Protective factors can build resilience and potentially moderate the long-term impact of adverse childhood experiences (ACEs). To better understand the role of protective factors, this study examines the relationship of two protective factors focused on safe, stable and nurturing relationships, ACEs, and self-reported mental and physical health outcomes among a representative adult sample from the South Carolina Behavioral Risk Factor Surveillance System. Protective factors were assessed as potential moderators of ACEs and poor self-reported physical and mental health in multivariate logistic regression analyses. Respondents exposed to four or more ACEs who grew up with an adult who made them feel safe and protected were less likely to report frequent mental distress or poor health. The use of protective factors may be an effective prevention strategy for ACEs and its associated outcomes and may serve as a mechanism to “break the cycle” of childhood trauma.
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Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., . . . Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256(3), 174–186. https://doi.org/10.1007/s00406-005-0624-4.
Bethell, C., Gombojav, N., Solloway, M., & Wissow, L. (2016). Adverse childhood experiences, resilience and mindfulness-based approach: Common denominator issues for children with emotional, mental, or behavioral problems. Child and Adolescent Psychiatric Clinics of North America, 25(2), 139–156.
Bonnie, R. J., & Monahan, J. (Eds.). (1997). Mental disorder, work disability, and the law. Chicago: University of Chicago Press.
Brown, D. W., Anda, R. F., Tiemeier, H., Felitti, V. J., Edwards, V. J., Croft, J. B., & Giles, W. H. (2009). Adverse childhood experiences and the risk of premature mortality. American Journal of Preventive Medicine, 37(5), 389–396. https://doi.org/10.1016/j.amepre.2009.06.021.
Brown, D. W., Anda, R. F., Felitti, V. J., Edwards, V. J., Malarcher, A. M., Croft, J. B., & Giles, W. H. (2010). Adverse childhood experiences are associated with the risk of lung cancer: A prospective cohort study. BMC Public Health, 10, 20. https://doi.org/10.1186/1471-2458-10-20.
Center for the Study of Social Policy. (2017). Strengthening families: The protective factors framework. Retrieved from https://www.cssp.org/reform/strengthening-families/basic-one-pagers/Strengthening-Families-Protective-Factors.pdf.
Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R., Edwards, V. J., & Anda, R. F. (2004). Adverse childhood experiences and the risk of depressive disorders in adulthood. Journal of Affective Disorders, 82(2), 217–225. https://doi.org/10.1016/j.jad.2003.12.013.
Chapman, D. P., Liu, Y., Presley-Cantrell, L. R., Edwards, V. J., Wheaton, A. G., Perry, G. S., & Croft, J. B. (2013). Adverse childhood experiences and frequent insufficient sleep in 5 US states, 2009: A retrospective cohort study. BMC Public Health, 13(1), 3.
Child Information Gateway. (2014). Protective factors: approaches in child welfare (Issue Brief). Washington, DC: U.S. Department of Health and Human Services Retrieved from https://www.childwelfare.gov/pubPDFs/protective_factors.pdf.
Chung, E. K., Nurmohamed, L., Mathew, L., Elo, I. T., Coyne, J. C., & Culhane, J. F. (2010). Risky health behaviors among mothers-to-be: The impact of adverse childhood experiences. Academic Pediatrics, 10(4), 245–25.1. https://doi.org/10.1016/j.acap.2010.04.003.
Cronholm, P. F., Forke, C. M., Wade, R., Bair-Merritt, M. H., Davis, M., Harkins-Schwarz, M., et al. (2015). Adverse childhood experiences: Expanding the concept of adversity. American Journal of Preventive Medicine, 49(3), 354–361.
Crouch, E., Strompolis, M., Bennett, K. J., Morse, M., & Radcliff, E. (2017). Assessing the interrelatedness of multiple types of adverse childhood experiences and odds for poor health in South Carolina adults. Child Abuse & Neglect, 65, 204–211. https://doi.org/10.1016/j.chiabu.2017.02.007.
Dong, M., Anda, R. F., Felitti, V. J., Dube, S. R., Williamson, D. F., Thompson, T. J., . . . Giles, W. H. (2004). The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction. Child Abuse & Neglect, 28(7), 771–784. https://doi.org/10.1016/j.chiabu.2004.01.008.
Dube, S. R., Anda, R. F., Felitti, V. J., Edwards, V. J., & Croft, J. B. (2002). Adverse childhood experiences and personal alcohol abuse as an adult. Addictive Behaviors, 27(5), 713–725. https://doi.org/10.1016/S0306-4603(01)00204-0.
Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study. Pediatrics, 111(3), 564–572.
Dube, S. R., Miller, J. W., Brown, D. W., Giles, W. H., Felitti, V. J., Dong, M., & Anda, R. F. (2006). Adverse childhood experiences and the association with ever using alcohol and initiating alcohol use during adolescence. The Journal of Adolescent Health, 38, 444–4e1.
Durlak, J. A. (1998). Common risk and protective factors in successful prevention programs. The American Journal of Orthopsychiatry, 68(4), 512–520.
Edwards, V. J., Holden, G. W., Felitti, V. J., & Anda, R. F. (2003). Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: Results from the adverse childhood experiences study. The American Journal of Psychiatry, 160(8), 1453–1460.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal Preventive Medicine, 14(4), 245–258.
Fergus, S., & Zimmerman, M. A. (2005). Adolescent resilience: A framework for understanding healthy development in the face of risk. Annual Review of Public Health, 26, 399–419.
Ford, E. S., Anda, R. F., Edwards, V. J., Perry, G. S., Zhao, G., Li, C., & Croft, J. B. (2011). Adverse childhood experiences and smoking status in five states. Preventive Medicine, 53(3), 188–193. https://doi.org/10.1016/j.ypmed.2011.06.015.
Gilbert, L. K., Breiding, M. J., Merrick, M. T., Thompson, W. W., Ford, D. C., Dhingra, S. S., & Parks, S. E. (2015). Childhood adversity and adult chronic disease: An update from ten states and the District of Columbia, 2010. American Journal of Preventive Medicine, 48(3), 345–349. https://doi.org/10.1016/j.amepre.2014.09.006.
Green, J. G., McLaughlin, K. A., Berglund, P. A., Gruber, M. J., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2010). Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: Associations with first onset of DSM-IV disorders. Archives of General Psychiatry, 67(2), 113–123. https://doi.org/10.1001/archgenpsychiatry.2009.186.
Greenberg, M. T. (2006). Promoting resilience in children and youth. Annals of the New York Academy of Sciences, 1094(1), 139–150. https://doi.org/10.1196/annals.1376.013.
Greene, R. R. (2008). Risk and resilience theory: a Social Work perspective. In R. R. Greene (Ed.), Human behavior theory and social work practice (pp. 315–343). New Brunswick: Transaction Publishers.
Hardt, J., & Rutter, M. (2004). Validity of adult retrospective reports of adverse childhood experiences: Review of the evidence. Journal of Child Psychology and Psychiatry, 45(2), 260–273.
Harper Browne, C. (2014). The strengthening families approach and protective factors framework. In Branching out and reaching deeper. Washington, DC: Center for the Study of Social Policy.
Health Resources and Service Administration, Maternal Child Health. (2017). Home visiting. Rockville, MD: Health Resources and Services Administration. Retrieved from https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview.
Horwitz, A. V., Widom, C. S., McLaughlin, J., & White, H. R. (2001). The impact of childhood abuse and neglect on adult mental health: A prospective study. Journal of Health and Social Behavior, 42(2), 184–201.
Larkin, H., & Records, J. (2007). Adverse childhood experiences: Overview, response strategies, and integral theory. Journal of Integral Theory and Practice, 2, 1–25.
Larkin, H., Shields, J. J., & Anda, R. F. (2012). The health and social consequences of adverse childhood experiences (ACE) across the lifespan: An introduction to prevention and intervention in the community. Journal of Prevention & Intervention in the Community, 40, 263–270.
Larkin, H., Felitti, V. J., & Anda, R. F. (2014). Social work and adverse childhood experiences research: Implications for practice and health policy. Social Work in Public Health, 29(1), 1–16.
McElroy, S., & Hevey, D. (2014). Relationship between adverse early experiences, stressors, psychosocial resources and wellbeing. Child Abuse & Neglect, 38(1), 65–75.
Merrick, M. T., Leeb, R. T., & Lee, R. D. (2013). Examining the role of safe, stable, and nurturing relationships in the intergenerational continuity of child maltreatment--introduction to the special issue. The Journal of Adolescent Health, 53(4 Suppl), S1–S3. https://doi.org/10.1016/j.jadohealth.2013.06.017.
Metzler, M., Merrick, M. T., Klevens, J., Ports, K. A., & Ford, D. C. (2017). Adverse childhood experiences and life opportunities: Shifting the narrative. Child Youth Serv Review, 72, 141–149. https://doi.org/10.1016/j.childyouth.2016.10.021.
Moore, K.A. & N. Ramirez, A. (2016) Adverse childhood experience and adolescent well-being: Do protective factors matter? Child Ind Res, 9, 299, 316.
Morse, M., Strompolis, M., Priester, M. A., & Wooten, N. R. (2016). Adverse childhood experiences in South Carolina: A summary of individual demographics and individual ACEs. Retrieved from: https://www.researchgate.net/publication/303328647_Adverse_Childhood_Experiences_in_South_Carolina_A_Summary_of_Demographics_and_Individual_ACEs.
Morse, M., Strompolis, M., Priester, M. A., & Srivastav, A. (2017). Adverse childhood experiences in South Carolina: The interrelatedness of adversity. Research Brief No., 9 Retrieved from https://scchildren.org/public/files/docs/Prevention_Learning_Center/ACES-in-SC-Research-Brief-Interrelatedness.pdf.
National Survey of Children’s Health: NSCH 2011/12. (n.d.). Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Retrieved from www.childhealthdata.org.
Rich-Edwards, J. W., Mason, S., Rexrode, K., Spiegelman, D., Hibert, E., Kawachi, I., . . . Wright, R. J. (2012). Physical and sexual abuse in childhood as predictors of early-onset cardiovascular events in women. Circulation, 126(8), 920–927. https://doi.org/10.1161/circulationaha.111.076877.
Roxburgh, S., & MacArthur, K. R. (2014). Childhood adversity and adult depression among the incarcerated: Differential exposure and vulnerability by race/ethnicity and gender. Child Abuse & Neglect, 38(8), 1409–1420. https://doi.org/10.1016/j.chiabu.2014.02.007.
Roy, A., Janal, M. N., & Roy, M. (2010). Childhood trauma and prevalence of cardiovascular disease in patients with type 1 diabetes. Psychosomatic Medicine, 72(8), 833–838. https://doi.org/10.1097/PSY.0b013e3181eafc2d.
Schofield, T. J., Lee, R. D., & Merrick, M. T. (2013). Safe, stable, nuturing relationships as a moderator of intergenerational continuity of child maltreatment: A meta-analysis. The Journal of Adolescent Health, 53(4), S32–S38.
Shonkoff, J. P., & Garner, A. S. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. https://doi.org/10.1542/peds.2011-2663.
Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. JAMA, 301(21), 2252–2259.
Srivastav, A., Fairbrother, G., & Simpson, L. A. (2017). Addressing adverse childhood experiences through the affordable care act: Promising advances and missed opportunities. Academic Pediatrics, 17(7S), S136–S143. https://doi.org/10.1016/j.acap.2017.04.007.
Taloyan, M., Wajngot, A., Johansson, S. E., Tovi, J., & Sundquist, J. (2010). Poor self-rated health in adult patients with type 2 diabetes in the town of Sodertalje: A cross-sectional study. Scandinavian Journal of Primary Health Care, 28(4), 216–220. https://doi.org/10.3109/00016349.2010.501223.
Thornberry, T. P., Henry, K. L., Smith, C. A., Ireland, T. O., Greenman, S. J., & Lee, R. D. (2013). Breaking the cycle of maltreatment: The role of safe, stable, and nurturing relationships. The Journal of Adolescent Health, 53(4), S25–S31.
US Centers for Disease Control and Prevention. (1998). Self-reported frequent mental distress among adults--United States, 1993–1996. MMWR Morbility and Mortality Weekly Report, 47(16), 326.
US Centers for Disease Control and Prevention. (2014a). Behavior Risk Factor Surveillance System. Retrieved from http://www.cdc.gov/brfss/.
US Centers for Disease Control and Prevention (2014b). Safe, stable, and nurturing relationships may shield children against poor health later in life. Retrieved from. https://www.cdc.gov/violenceprevention/pub/healthy_infants.html.
Waite, R., Davey, M., & Lynch, L. (2013). Self-rated health and association with ACEs. Journal of Behavioral Health, 2(3), 198–205.
Walker, S. P., Wachs, T. D., Grantham-McGregor, S., Black, M. M., Nelson, C. A., Huffman, S. L., et al. (2011). Inequality in early childhood: Risk and protective factors for early child development. The Lancet, 378(9799), 1325–1338.
Zimmerman, M. A. (2014). Resiliency theory: A strengths-based approach to research and practice for adolescent health. Health Education & Behavior, 40(4), 381–383.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000.
Informed consent was obtained from all patients for being included in the study.
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Crouch, E., Radcliff, E., Strompolis, M. et al. Safe, Stable, and Nurtured: Protective Factors against Poor Physical and Mental Health Outcomes Following Exposure to Adverse Childhood Experiences (ACEs). Journ Child Adol Trauma 12, 165–173 (2019). https://doi.org/10.1007/s40653-018-0217-9
- Adverse childhood experiences
- Protective factors
- Physical abuse
- Sexual abuse