American Academy of Developmental Medicine and Dentistry Developmental Medicine and Dentistry Reviews & Reports

BY H. BARRY WALDMAN, DDS, MPH, PHD; STEVEN P. PERLMAN, DDS, MSCD; AND DEBRA A. CINOTTI, DDS

Adverse childhood experiences are major risk factors for the leading causes of illness and death as well as poor quality of life in the United States. That is the finding from The Adverse Childhood Experiences (ACE) Study, one of the largest investigations ever conducted on the links between childhood maltreatment and later-life health and well-being. The ACE study is a collaborative effort between the Centers for Disease Control and Prevention and Kaiser Permanente’s Health Appraisal Clinic in San Diego, Health Maintenance Organization (HMO). HMO members undergoing a comprehensive physical examination provided detailed information about their childhood experience of abuse, neglect, and family dysfunction. Over 17,000 members chose to participate.1

Childhood abuse, neglect and other traumatic stressors are common. “Almost two-thirds of the study participants reported at least one ACE, and more than one in five reported three or more ACE.”2 The risk for the following health problems escalate with increasing adverse childhood experiences.

• alcoholism and alcohol abuse
• chronic obstructive pulmonary disease
• depression
• fetal death
• health-related quality of life
• illicit drug use
• ischemic heart disease
• liver disease
• risk for intimate partner violence
• multiple sexual partners
• sexually transmitted diseases
• smoking
• suicide attempts
• unintended pregnancies2

As the number of adverse childhood experiences increases the number of co-occurring or “co-morbid” conditions increases.

The proportion of individuals who had experienced adverse childhood experiences in each of the sub-categories was greater for women than men, except for physical abuse and physical neglect. Among women, household substance abuse, physical abuse, sexual abuse and parental separation or divorce were the most frequently reported ACE. Among men, physical abuse, household substance abuse and parental separation or divorce were the most frequently reported ACE. (Table 1)

CONSEQUENCES
More than half of adult respondents reported at least one adverse childhood experience. One-fourth reported two or more categories of ACE. “…a strong …relationship (was reported) between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.”4 Adult risk factors  included: alcoholism, drug abuse, depression, suicide attempt, smoking, fifty or more sexual intercourse partners, sexually transmitted diseases and severe obesity.4

“Intimate partner violence damages a woman’s physical and mental well-being and indicates that her children are likely to experience abuse, neglect and other traumatic experiences.”5 Compared to persons who grew up with no domestic violence, the rate for any adverse childhood experience was two to six times greater.5 “…exposure to parental alcohol abuse is highly associated with experiencing adverse childhood experiences.”6 Increased numbers of adverse childhood experiences is related strongly to:

1) initial illicit drug use in early adolescence into adulthood and drug addiction,
2) lifetime depression,
3) attempted suicide, and
4) adolescent pregnancy. (7-10)

A cursory review of the National Library of Medicine (Pub Med) website reveals more than 600 published articles (including those drawn from the ACE study) relating adverse childhood experiences and the impact on subsequent adult physical and mental conditions.

THE GENERAL TREND PRESENTED IN THE ACE STUDY IS:

Adverse Childhood Experiences -> Social, Emotional & Cognitive Impairment -> Adoption of Health-risk Behaviors - > Disease, Disability and Social Problems -> Early Death.11 Additional information from the Longitudinal Studies of Child Abuse and Neglect (a consortium of research studies on the etiology and impact of child mistreatment12) affords another perspective on adverse environment exposures and the impact on youngsters. “…child abuse and other household dysfunction are associated with poor child health at an early age (as young as 4 to 6 years of age).”13

MALTREATMENT OF CHILDREN – 2006

The Children’s Bureau of the U.S. Department of Health and Human Services reported that “an estimated 905,000 children were victims of maltreatment in 2006.”14 Whereas the Adverse Childhood Experiences (ACE) Study was based on recall by adults, the Children’s Bureau report is based on present day information from Child Protective Services agencies in the 50 states, the District of Columbia and the Commonwealth of Puerto Rico.14

Each State has its own definitions of child abuse and neglect based on standards set by federal law. Child protective services agencies respond to the needs of children who are alleged to have been maltreated to ensure that they are safe. During federal fiscal year 2006:

• Nationally, the rate of victimization was 12.1 per 1,000 children in the population.

• Eight states (Arizona, Idaho, Kansas, Missouri, New Hampshire, Pennsylvania, Virginia and Washington) had the lowest rates of child victimization (0.0 – 5.0 victims per 1,000 children).

• Five jurisdictions (Florida, Iowa, Massachusetts, West Virginia and the District of Columbia) had the highest rates (>20.1 victims per 1,000 children).

• Nearly 3.6 million children received a child protective services agency investigation or assessment.

Approximately 64% of the victims experienced neglect, 16% were physically abused, 9% were sexually abused, 7% were psychologically maltreated, and 2% were medically neglected. In addition 15% of the victims experienced “other” types of maltreatment, such as “abandonment,” “threats of harm to the child,” or “congenital drug addiction.” Of the victims of physical abuse, 24% were reported by teachers, 23% were reported by police and 12% were reported by medical staff members.

Black, Native American and multiple race children had the highest rates of victimization. Asian children had the lowest rate. 49% of the victims were white, 23% were black and 18% were Hispanic. For all race categories except Native Hawaiian and Pacific Islanders, the largest percentage of victims suffered \from neglect.

 Nearly 83% of the victims were abused by a parent acting alone or with another person. Approximately 40% of child victims were maltreated by their mother acting alone, 18% were maltreated by their fathers acting alone, and 18% were abused by both parents.14

CHILDREN WITH SPECIAL NEEDS

The unfortunate reality is that there are youngsters, teens and older individuals with disabilities who also are subjected to abuse, neglect and reside in dysfunctional households.15-18 As a result children with disabilities could be affected by the same consequences reported in the ACE, Longitudinal Studies of Child Abuse and Neglect, and the Children’s Bureau studies, but which may well be magnified given the underlying disabling difficulties that they and their families face.

FAMILY CENTERED CARE AND A PATIENT-CENTERED MEDICAL HOME
Family-centered care is an approach to planning, delivery, and evaluation of health care where the cornerstone is active participation between families and professionals.19 A medical home is an approach to providing comprehensive primary care for children, youth and adults.20 (See previous issues of EP Magazine for the 12 installment Medical Home series.) The patient-centered medical home is a model of health care delivery that is based on an ongoing personal relationship with a physician. This personal patient/physician relationship provides a mechanism for continuous and comprehensive health care.

The 2005-2006 National Survey of Children with Special Health Care Needs reported that 44% of “children who usually/ always are affected or are affected a great deal (by a special health care need) are most likely to receive care that is not family- centered.” Similarly, 55% of “children with special health care needs who are uninsured are most likely to receive care that is not-family-centered.”19

At issue is the need to develop coordinated care across all elements of the complex health care system. The medical home concept offers the added opportunity to monitor the household setting within which a child (with and without special health care needs) is being raised. Family-centered care in a medical home arrangement could improve the foundation for a more favorable outlook for a child with a disability who faces abuse, neglect and a dysfunctional household situation. •

References
1. Centers for Disease Control and Prevention. Adverse Childhood Experiences Study: Welcome. Web site: mhtml:file://F:ACE%20Study%20-%20Adverse%20Childhood%20Experiences.mht Accessed May 27, 2008.

2. Centers for Disease Control and Prevention. Adverse Childhood Experiences Study: Major findings. Web site http://www.cdc.gov/nccdphp/ACE/findings.htm Accessed May 28, 2008

3. Centers for Disease Control and Prevention. Adverse Childhood Experiences Study: Data and statistics Web site: http://www.cdc.gov/nccdphp/ace/prevalence.htm Accessed May 27, 2008.

4. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of child abuse and household dysfunction to many of the leading causes of death in adults. Am J Prev Med 1998;14(4):245-258.

5. Dube SR, Anda RF, Felitti VJ. Exposure to abuse, neglect, and household dysfunction among adults who witnessed intimate partner violence as children: implications for health and social services. Violence Vict 2002;17(1):3-17.

6. Dube SR, Anda RF, Felitti VJ, et al. Growing up with parental alcohol abuse: exposure to childhood abuse, neglect, and household dysfunction. Child Abuse Negl 2001;25(12):1627-1640.

7. Dube SR, Felitti VJ, Dong M, et al. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics 2003:111(3):564-572.

8. Chapman DP, Whitfield CL, Felitti VJ., Adverse childhood experiences and the risk of depressive  disorders in adulthood. J Affect Disord 2004;82(2)217-225.

9. Dube SR, Anda RD, Felitti VJ, et al. Childhood abuse, household dysfunction and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA 2001;286(24):3126-3127

10.Hillis SD, Anda RF, Dube SR, et al. The association between adverse childhood experiences and adolescent pregnancy, long –term psychological consequences, and fetal death. Pediatrics 2004;113(2):320-327.

11. Centers for Disease Control and Prevention. Adverse Childhood Experiences Study: Pyramid. Web site: http://www.cdc.gov/nccdphp/ACE/pyramid.htm Accessed May 27, 2008.

12. Longitudinal Studies of Child Abuse and Neglect. Web site: http://www.iprc.unc.edu/longscan/ Accessed May 27, 2008.

13. Flaherty EG, Thompson R, Litrownik AJ, et al. Effect of early childhood adversity on child health. Arch Pediatr Adolesc Med 2006;160(12):1232-1238.

14. Administration for Children and Families. Children’s Bureau. Child Maltreatment 2006. Web site: http://www.acf.hhs.gov/programs/cb/pubs/cm06/chapter3.htm#sex Accessed May 28, 2008.

15. Hibbard RA, Desch LW. American Academy of Pediatrics Committee on Child Abuse and Neglect. Maltreatment of children with disabilities. Pediatrics 2007;119(5):1018-1025.

16. Kvam MH. Is sexual abuse of children with disabilities disclosed? A retrospective analysis of child disability and the likelihood of sexual abuse among those attending Norwegian hospitals.Child Abuse Negl 2000;24(8):1073-1084.

17. Hershkowitz I, Lamb ME, Horowitz D. Victimization of children with disabilities. Am J Orthopsychiatry 2007;77(4):629-635.

18. Sobsey D, Randall W, Parrila RK. Gender differences in abused children with and without disabilities. Child Abuse Negl 1997;21(8):707-720.

19. Maternal and Child Health Bureau. The National Survey of Children with Special Health Care Needs Chartbook 2005-2006. Rockville, MD: Department of Health and Human Services, 2007.

20. American Academy of Family Physicians. What is a patient centered medical home? Web site:
whttp://www.aafp.org/online/en/home/membership/initiatives/pcmh.htmlww Accessed May 27, 2008
.
21. H. Barry Waldman, DDS, MPH, PhD is a Distinguished Teaching Professor in the Department of General Dentistry at the School of Dental Medicine, Stony Brook University, NY.

22. Steven P. Perlman, DDS, MScD is the Global Clinical Director, Special Olympics, Special Smiles, and a Clinical Professor of Pediatric Dentistry at The Boston University School of Dental Medicine. He also has a private pediatric dentistry practice in Lynn, MA.

23. Debra A. Cinotti, DDS is a Clinical Associate Professor and Associate Dean for Admission and Student Affairs for the Department of General Dentistry at Stony Brook University, NY.