Conceptual Refinement of the Phenomenon of Adverse Childhood Experiences
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Abstract
Adverse childhood experiences (ACEs) are stressful and/or traumatic events that happen during the first 18 years of a person’s life. Researchers estimate that at least 50% of the U.S. adult population have experienced at least one ACE. Consequences of early traumatic experiences include higher rates of disease in adulthood. ACEs and their effect on later-life outcomes have gained considerable attention in the past 20 years; nevertheless, the research on ACEs lacks a clear conceptual structure. To advance a conceptual understanding of ACEs, this dissertation aimed to identify the role of different dimensions of ACEs, such as timing or frequency, and their relevance for research and practice. In the first study, I reviewed quantitative, empirical journal articles on ACEs published after the groundbreaking ACE Study in 1998. The goal of this literature synthesis was to provide an overview of the conceptual landscape of ACEs related to different dimensions of adversity. I used a PRISMA methodology to identify articles that assessed at least two of the 10 original ACE domains and at least two ACE dimensions. A standardized data extraction spreadsheet was used to record basic article information and specifics on ACE domains and dimensions. I identified four primary dimensions used for most ACE domains: frequency, timing, perception, and the role of the perpetrator. Additionally, I found several secondary and domain-specific dimensions, which relate to the intensity of the adverse event. The purpose of the second study was to develop a standardized measurement approach for five ACE dimensions identified in Study 1, related to the 10 original ACE domains. Sixteen subject matter experts (SMEs) were asked to rate (1) the relative importance of dimensions for the 10 original ACE domains; (2) how dimension items and response options should be worded; (3) how dimension items should be anchored; and (4) how dimensions response options should be ranked based on their intensity. SMEs agreed that the five proposed dimensions are relevant for all except one ACE domain. The proposed wording of dimension items and response options was revised based on survey feedback. Most SMEs agreed that we should anchor participant responses on the adverse event most relevant to the participant. SMEs generally agreed on the ranking of response options in terms of the least to the most impactful response. Based on our results, a new instrument, the ACE dimensions questionnaire (ACE-DQ), was developed which has a minimum of 10 questions (the 10 original ACE domain items) if each domain stem question is answered with "no." If all original ACE domain stem questions are answered with "yes," the new ACE-DQ has a maximum of 48 items. In the third study, I conducted a cross-sectional online survey using Amazon’s MTurk to pilot test the ACE-DQ to determine its predictive validity and compare scoring approaches. I compared ACE exposure as assessed with the ACE index and the ACE-DQ, and their associations with depression outcomes. When using perception weighted ACE-DQ scores, participants had smaller, yet significant odds of reporting depression outcomes compared to the ACE index; thus suggesting that the original ACE index may overestimate the impact of ACEs and the effects of ACEs on depression outcomes. Further, the addition of the comprehensive set of conceptual dimensions to more fully weight participants’ experience of adverse events might increase the accuracy of ACE measurement but would also increase participant burden considerably. I recommend including items to assess a person’s perception of each adverse event for improved screening efforts and for research focused on cumulative adversity.