Adverse childhood experiences - Agenda for International Development

Child Abuse & Neglect 34 (2010) 842–855

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Child Abuse & Neglect

Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country setting夽 Laurie S. Ramiro a,∗ , Bernadette J. Madrid b , David W. Brown c a b c

Department of Behavioral Sciences, College of Arts and Sciences, University of the Philippines Manila, Padre Faura st., Ermita, Manila, Philippines Child Protection Unit, Philippine General Hospital, University of the Philippines Manila, Ermita, Manila, Philippines Decatur, GA, USA

a r t i c l e

i n f o

Article history: Received 23 May 2009 Received in revised form 19 February 2010 Accepted 25 February 2010

Keywords: Adverse childhood experiences Health-risk behaviors Chronic diseases Developing country Philippines

a b s t r a c t Objective: This study aimed to examine the association among adverse childhood experiences, health-risk behaviors, and chronic disease conditions in adult life. Study population: One thousand and sixty-eight (1,068) males and females aged 35 years and older, and residing in selected urban communities in Metro Manila participated in the cross-sectional survey. Methods: A pretested local version of the Adverse Childhood Experiences Questionnaires developed by the Centers for Disease Control and Prevention, USA, was used. Data were collected through self-administration of the questionnaire. Prevalence and estimates of odds ratio were computed to obtain a measure of association among variables. Logistic regression analysis was employed to adjust for the potential confounding effects of age, sex, and socio-economic status. Results: The results indicated that 75% of the respondents had at least 1 exposure to adverse childhood experiences. Nine percent had experienced 4 or more types of abuse and household dysfunctions. The most commonly reported types of negative childhood events were psychological/emotional abuse, physical neglect, and psychological neglect of basic needs. Majority of respondents claimed to have experienced living with an alcoholic or problem drinker and where there was domestic violence. Health-risk behavior consequences were mostly in the form of smoking, alcohol use, and risky sexual behavior. The general trend shows that there was a relatively strong graded relationship between number of adverse childhood experiences, health-risk behaviors, and poor health. Conclusion: This study provided evidence that child maltreatment is a public health problem even in poorer environments. Prevention and early intervention of child maltreatment were recommended to reduce the prevalence of health-risk behavior and morbidity in later life. © 2010 Published by Elsevier Ltd.

Introduction Much is known about the lifetime effects of childhood trauma. An earlier review of the literature by Browne and Filkenhor (1986) shows that depression, feelings of isolation and stigma, poor self-esteem, distrust, substance abuse, and sexual maladjustment are the most frequently reported long-term effects of child abuse and neglect. More recent findings point to the

夽 Research supported by the Prevention of Violence, Department of Injuries and Violence of the World Health Organization through its coordinator, Dr Alex Butchart, World Health Organization-Philippines, and the Department of Health. ∗ Corresponding author. 0145-2134/$ – see front matter © 2010 Published by Elsevier Ltd. doi:10.1016/j.chiabu.2010.02.012

L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842–855

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same consequences but include a variety of other psychopathological disorders such as suicide, panic disorder, dissociative disorders, post-traumatic stress disorder, and antisocial behaviors (Bensley, Van Eenwyk, & Simmons, 2000; De Bellis, & Thomas, 2003; English, Widom, & Brandford, 2004; Johnson & Leff, 1999; Sher,Walitzer, Wood, & Brent, 1991; Silverman, Reinherz, & Giaconia, 1996; Springer, Sheridan, Kuo, & Carnes, 2007; Teicher, 2000; Zeitlen, 1994). Child abuse and neglect also result in impaired brain development with long-term consequences for cognitive, language, and academic abilities (Watts-English, Fortson, Gibler, Hooper, & De Bellis, 2006; Zolotor, Kotch, Dufort, Winsor, & Catellier, 1999). In particular, many of the past studies focused on the prospective impact of sexual abuse (Beitchman et al., 1992; Briere & Runtz, 1988; Finkelhor, Hotaling, Lewis, & Smith, 1990; Windle, Windle, Scheidt, & Miller, 1995, to name a few). Jejeebhoy and Bolt (2003) found that those who experience coercive sex are more likely to experience both subsequent non-consensual sex and risky consensual sexual behaviors including abortion in adolescence and early adulthood. Child sexual abuse was shown to be associated with lifetime risks of depression, alcohol or drug dependence, panic disorders, post-traumatic stress disorders, and suicides (Dube et al., 2001, 2005). Furthermore, adult women with a history of childhood sexual abuse show greater evidence of sexual disturbance or dysfunction, homosexual experiences in adolescence or adulthood, and are more likely than non-abused women to be re-victimized. Beitchman et al. (1992) affirmed that the extent of impact depends on the duration of abuse and the threat or use of force. Moreover, greater harm is inflicted if the father (or stepfather) is the perpetrator and if sexual abuse involves penetration. Similarly, physical maltreatment can result in bruises, broken bones, visual and auditory impairment, brain damage, contusions, burns, and death (Oates, 1996). In particular, the violent shaking of a baby (Shaken Baby Syndrome) has been found to be associated with bleeding of the brain, which may lead to permanent, severe brain damage or death (National Institute of Neurological Disorders & Stroke, 2001). Physical maltreatment was also found to be associated with an array of psychological problems that include major depression, alcohol dependence, and externalizing problems (Brownridge, Cox, & Sareen, 2006; Miller-Perrin, Perrin, & Kocur, 2009). In addition, adults who were physically maltreated during childhood are at increased risk of harming their own children who, in turn, tend to exhibit insecure attachment patterns (Belsky, 1993; Kaufman & Zigler, 1987; Newcomb & Locke, 2001; Simons, Whitbeck, Conger, & Wu, 1991; Van Ijzendoorn, 1995). Adolescents with a history of physical maltreatment may even participate in dating relationships that are characterized by violence as well (Wekerle & Wolfe, 1998; Wekerle et al., 2001). Akin to physical violence and sexual abuse, psychological maltreatment appears to be as destructive as it puts its victims at equal risk of developing physical and mental health problems (Egeland & Erickson, 1987; O’Leary, 1999). Individuals who underwent psychological abuse are more prone to develop chronic physical and mental illnesses such as depression, injury, drug addiction, and alcoholism (National Research Council, 1996; Tomison & Tucci, 1997). Psychological maltreatment may also result in poor self-esteem that may lower capacities to combat the effects of future abusive events (Walker, 1994). In the Philippines, a community study indicated that depression, feelings of embarrassment, suicidal ideations, and having broken families are most common among psychologically abused men and women (Philippines Department of Health, 2000a, 2000b). Directly or indirectly, household insufficiencies and dysfunctions may also lead to negative psychosocial and health outcomes (Flaherty et al., 2006; Springer et al., 2007). Such household insufficiencies include general poverty specific to lack of basic necessities such as food, shelter, clothing, education, and health. Children from families that report multiple experiences of food insufficiency and hunger are more likely to show behavioral, emotional, and academic problems than children whose families do not report such conditions in life (Kleinman et al., 1998). Moreover, household dysfunctions such as living with a family member who is an alcoholic, drug addict, mentally ill, or one who has been incarcerated for certain crimes and offenses may also influence future life outcomes. For instance, children with family histories of substance abuse had higher levels of aggression, delinquency, sensation-seeking, hyperactivity, impulsivity, anxiety, negative affectivity, and difficulties in self-differentiation compared to children with no such histories (Dore, Kauffman, Nelson-Zlupko, & Gran-fort, 1996; Giancola & Parker, 2001; Maynard, 1997). Family history of alcohol dependence has also predicted poor adolescent neuropsychological functioning (Anda et al., 2006; Dube et al., 2006; Tapert & Brown, 2000). The same is true with situations where a child grew in a family where domestic violence is a common experience, or where parents are separated or divorced. Studies have shown that children who lived under an environment of domestic violence exhibit clinical levels of anxiety or post-traumatic stress disorder (Graham-Bermann & Levendosky, 1998). These children are at significant risk for law breaking, substance abuse, school inattendance, and relationship problems. Aside from its psychosocial consequences, child abuse and neglect have become a serious public health problem. The health outcomes usually occur in highly inter-related forms. A strong, graded relationship between the number of adverse experiences in childhood, and self-reports of cigarette smoking, alcoholism, drug abuse, obesity, attempted suicide, and sexual promiscuity in later life was reported (Anda et al., 1999; Dietz et al., 1999; Felitti et al., 1998). Similarly, the likelihood that a person develops physical and mental health conditions such as heart disease, cancer, and depression in adulthood is greater, the more childhood adverse experiences were experienced (Chapman et al., 2004; Dong, Anda, Dube, Felliti, & Giles, 2003; Dong et al., 2005; Hillis, Anda, Felliti, Nordenberg, & Marchbanks, 2000). In reality, child abuse and neglect do not usually occur as single incidents but rather, they are experienced repeatedly and simultaneously in various forms (Trickett, 1998). The experience of multiple types of maltreatment is associated with greater impairment than experiencing a single form of maltreatment (Higgins & McCabe, 2000). Child maltreatment can become recurrent or repetitive, especially if the child is not withdrawn from the same environment where initial abuses occurred. This is also compounded by the fact that in some cultures, parents and other caregivers regard physical punishment

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and psychological reprimands as a necessary form of discipline for their children (Lansford & Dodge, 2008; Orhon, Ulukol, Bingoler, & Gulnar, 2006; Plan Philippines, 2005). Current knowledge of the effects of negative life events in childhood is mostly focused on experiences in the developed world. Very few pieces of evidence in developing countries are noted. Definitely, poverty and associated environmental and social concerns serve as compounding factors that prevent children in developing countries from attaining their maximum potential. Walker et al. (2007) posited that stunting, nutrition and inadequate cognitive stimulation which are common among children in developing countries, entail exposure to several factors including less opportunities for learning, polluted environment, heavy metal poisoning, and household crowding. The Philippines is one country in the developing world with fewer resources for health but with a high prevalence of infectious and non-communicable diseases such as TB, cardiovascular diseases, cancers, unintentional injuries, and diabetes (Philippine Health Statistics, 2009). The prevalence of smoking is high at 40%, and alcohol use at 37% among male youth (Domingo & Marquez, 1999). Moreover, the number of abused children reported to the Department of Social Welfare and Development increased 5-fold from 1998 to 2002, although in a population-based study (BSNOH, 2000), it was reported that nearly 90% of the 2,700 adolescent-respondents claimed to have been physically maltreated while about 60% were psychologically abused at least once in their lifetime. About 12% reported having been sexually molested. The main question, therefore, is: In the Philippine setting, are these statistics interrelated? How, if at all, do these findings relate to one another?

Objectives of the study This study aimed to determine the interrelationship among adverse childhood experiences, health-risk behaviors and health outcomes in a developing country setting. It sought to examine associations among a number of adverse childhood experiences and health-risk behaviors. Associations between childhood trauma and occurrence of common major diseases were also studied.

Methodology Research design This general population survey made use of the cross-sectional design to assess significant associations among adverse childhood experiences, health-risk behaviors and the occurrence of certain diseases during adulthood. It was conducted in selected urban barangays (villages) in Quezon City in Metro Manila from September to November 2007.

Study population and sampling scheme The study population consisted of 535 males and 533 females, aged 35 years and older, residing in the sample urban barangays in Quezon City. From each community, sample households were chosen randomly using systematic sampling. Sample households were given equal probabilities of being selected. In each selected household, a household roster was initially established. The names, sex, and age of all household members were taken where eligible respondents were marked. From all eligible household members, the final respondent was randomly chosen using a Kish table. Only one respondent was drawn from each household. If the selected household member was not available during the visit, an appointed date of interview was made either by phone, or through another household member. If the selected household member refused to participate or was not available for interview after three callbacks, another eligible household member was randomly drawn. To produce a statistically valid sample, 1,068 respondents (d = 0.03, p = 50%, CI = 95%) were asked to participate in the study. Almost an equal number of males and females from different socio-economic classes were represented.

Instrumentation The Adverse Childhood Experiences (ACE) Questionnaires were used for this study (Centers for Disease Control and Prevention, 2008). These questionnaires, developed by the US Centers for Disease Control and Prevention and Kaiser Permanente in 1997, came in separate versions for male and female respondents and was composed of two parts: Family Health History questionnaire and Physical Health Appraisal questionnaire (www.cdc.gov/nccdphp/ace). The Family Health History questionnaire consisted of 68 questions examining various types of child maltreatment, childhood adversities rooted in household dysfunctions, and other risk factors. The Physical Health Appraisal questionnaire had questions on the respondent’s self-rated health, and items asking about a history of ischemic heart disease, any cancer, stroke, COPD, diabetes, hepatitis or jaundice, any skeletal fractures, and other types of diseases and pains. The ACE Questionnaires were translated into the Filipino language, and were pre-tested among Filipino adult samples.


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Data collection As approved by an ethical review board, data-collection conformed to certain technical and ethical standards appropriate to the study setting. Interviewers experienced in conducting child abuse studies were recruited for this study. They were oriented and trained with regard to data-collection using the ACE questionnaires. Aside from sampling issues, ethics as well as data quality assurance were part of their training. In the context of the Filipino culture, talking face-to-face about adverse childhood experiences, especially with regard to sexual abuse, sexual promiscuity and to some extent, illegal drug use, may be taboo or may encourage a social desirability bias. Such a behavior may be due in part to the cultural emphasis on social acceptance (“pakikisama,” “pakikipagkapwa”) as well as the common Filipino trait of being non-confrontational in negotiating with issues in the social environment (Enriquez, 1978; Rodell, 2002). Hence, this household survey made use of the self-administered data-collection strategy. The field assistant started by introducing the objectives and mechanics of the study, and also assured the would-be respondents that all their responses will be kept with utmost confidentiality, and that there was no way that they could be identified since answers from all respondents would be analyzed as group data. Respondents were also told that they would be given privacy in answering the questions. Participation in the study was made known to be voluntary, and if respondents could refuse or discontinue participation and the researcher would respect that decision. After all questions from respondents were answered, they were asked to sign an informed consent form, which consisted of statements noting respondents fully understood the purpose and mechanics of the survey and acknowledged their participation was voluntary. For those who agreed to participate, field assistants distributed a sealed envelope containing the ACE questionnaire. Each respondent was then respectfully asked to go to a private place in the house and answer the questions by herself/himself. The field assistant told respondents that he/she would be around to clarify any questions or concerns. For respondents who found it difficult to read and/or write, field assistants asked if he/she could do the reading and/or writing for the respondent. Those who refused with this system were dropped and were replaced by another randomly sampled eligible respondent from the same household. In case respondents felt that home was not the best place to answer the questionnaire, they were given the freedom to choose the venue, where they were accompanied by the field assistant. To encourage more openness, the gender of both respondent and field assistant was matched such that male respondents were attended to by male field assistants; and female respondents, by female field assistants. Upon submission of the questionnaire to the field assistant, the latter, in front of the respondent, went quickly through the completed forms to see if all questions were answered. If not, the field assistant asked the respondent to reconsider responding to the unanswered items. Once again, the field assistant re-assured the respondents of the confidentiality of their answers. Data analysis The prevalence of adverse childhood experiences and health-risk behaviors were determined. Estimates of odds ratio were computed to obtain a measure of association between adverse childhood experiences and health-risk behaviors, as well as with chronic disease conditions. Logistic regression analysis was employed to adjust for the potential confounding effects of age, sex, and socio-economic status on the relationship among adverse childhood experiences, health-risk behaviors, and chronic health conditions. Results Socio-demographic characteristics of respondents A total of 1,068 respondents agreed to participate in the survey. An almost equal number of male and female respondents from different socio-economic classes were noted. The mean age of the respondents was 46.7 ± 9.2 years. Only 12% had no school attendance while 44% were not working at the time of the survey (Table 1). History of exposure to adverse childhood experiences Among the various types of childhood abuse, psychological and physical neglect of needs as well as psychological/emotional abuse were the most commonly reported forms of childhood adverse experiences (Table 2). In terms of neglect, almost half felt they had never been loved while about a fourth felt they had not been taken cared of. About 23% of respondents reported that they were psychologically abused as they were often or very often insulted, swore at, or threatened when they were children. Five percent claimed to be sexually abused or molested. Surprisingly, only a small proportion (1.3%) of the 1,068 respondents reported having been physically maltreated. Among the household dysfunctions, a third (36.2%) of respondents experienced living with an alcoholic or problem drinker. About 18% saw their mother being treated violently. Ten percent had separated parents. Overall, 75% of the respondents (women = 74.5%; men = 72%) had at least 1 exposure to adverse childhood experiences. About 9% had experienced 4 or more types of childhood abuse. Those who experienced 4 or more categories of exposure

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L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842–855 Table 1 Socio-demographic characteristics of 1,068 study participants, Philippines, 2007. Characteristic

n (%)

Age in years, mean (SD) 35–39 40–44 45–54 55–92

46.7 (9.2) 298 (27.9) 224 (21.0) 317 (29.7) 229 (21.4)

Gender Men Women

535 (50.1) 533 (49.9)

Civil status Married Not married but with live-in partner Widowed/separated Single, never married

788 (73.8) 80 (7.5) 96 (9.0) 104 (9.7)

Socioeconomic classa Lower Middle Upper

378 (35.4) 380 (35.6) 310 (29.0)

Education No formal high school attendance Some high school High school graduate Vocational graduate/some college College graduate

129 (12.1) 75 (7.0) 272 (25.5) 254 (23.8) 338 (31.7)

Work status Full-time (≥35 hours per week) Part-time (3)

Early pregnancya

Unintended Pregnancya

(age < 18 years) Prevalence, % (n) 30.0 (320) Psychological abuse 1.7 (1.2–2.3) Physical maltreatment 2.8 (0.9–8.7) Sexual abuse 1.9 (1.0–3.4) Physical neglect 1.1 (0.8–1.5) Psychological neglect 1.3 (1.0–1.7) Illicit drug use 2.3 (1.4–3.7) Alcohol abuse 0.8 (0.6–1.1) Mental illness 1.4 (0.8–2.5) Mother treated violently 1.3 (0.9–1.9) Incarcerated HH member 1.6 (0.8–2.9) Parental separation 1.4 (0.9–2.2)

12.0 (128) 36.5 (390) 5.5 (59) 2.1 (1.4–3.2) 1.0 (0.7–1.4) 1.2 (0.7–2.2) 11.2 (2.9–42.6) 1.1 (0.3–4.2) NA 2.1 (1.0–4.7) 1.4 (0.7–2.9) 1.7 (0.6–4.8) 1.6 (1.1–2.5) 2.1 (1.5–3.1) 1.4 (0.7–2.7) 1.8 (1.2–2.6) 1.2 (0.9–1.6) 0.9 (0.5–1.6) 1.8 (0.9–3.5) 1.1 (0.6–2.0) 1.2 (0.4–3.3) 1.4 (0.9–2.1) 1.2 (0.8–1.6) 0.9 (0.5–1.6) 1.4 (0.6–3.0) 1.1 (0.6–2.0) 2.3 (0.9–5.9) 2.4 (1.6–3.7) 1.7 (1.2–2.6) 1.3 (0.7–2.5) 0.7 (0.3–1.8) 1.6 (0.8–3.1) 1.0 (0.3–3.6) 2.1 (1.2–3.9) 1.7 (1.0–2.7) 1.1 (0.5–2.8)

Odds ratios adjusted for age, sex, SES, education. a Among 533 women.

12.1 (129) 9.5 (101) 18.3 (196) 2.1 (1.3–3.1) 1.1 (0.7–1.8) 2.1 (1.5–3.0) 3.8 (1.0–14.4) 1.5 (0.3–7.0) 2.8 (0.9–9.1) 2.9 (1.4–5.9) 11.6 (6.3–21.4) 2.6 (1.4–4.9) 2.0 (1.3–3.2) 1.0 (0.6–1.7) 1.9 (1.3–2.7) 1.6 (1.1–2.3) 1.5 (1.0–2.3) 2.0 (1.5–2.7) 3.1 (1.7–5.6) 1.1 (0.5–2.4) 1.8 (1.0–3.0) 1.4 (0.9–2.1) 1.1 (0.7–1.8) 1.1 (0.8–1.5) 5.1 (2.6–9.7) 3.8 (2.0–7.1) 2.3 (1.3–4.1) 1.7 (1.1–2.7) 1.2 (0.7–2.0) 1.5 (1.0–2.1) 5.0 (2.5–10.0) 1.0 (0.4–2.5) 1.1 (0.6–2.2) 2.1 (1.2–3.8) 1.6 (0.9–2.9) 1.7 (1.1–2.7)

12.6 (67) 34.9 (186) 0.8 (0.4–1.6) 2.2 (1.4–3.4) 2.0 (0.4–10.8) 1.2 (0.3–5.0) 8.5 (3.9–18.6) 1.1 (0.5–2.2) 0.9 (0.5–1.8) 1.6 (1.0–2.4) 0.7 (0.4–1.3) 1.2 (0.9–1.8) 0.5 (0.2–1.9) 2.0 (1.1–3.7) 1.0 (0.6–1.7) 1.3 (0.9–1.8) 3.8 (1.7–8.2) 2.3 (1.2–4.4) 2.1 (1.1–4.1) 1.5 (0.9–2.4) 0.9 (0.2–3.2) 2.1 (0.9–4.9) 1.0 (0.4–2.3) 2.1 (1.2–3.5)

Weight

Suicide attempt

>170 lbs 10.7 (114) 1.1 (0.7–1.7) 0.7 (0.1–5.7) 2.2 (1.0–4.8) 1.0 (0.6–1.7) 1.0 (0.7–1.5) 1.8 (0.9–3.6) 0.9 (0.6–1.4) 0.6 (0.2–1.6) 1.1 (0.7–1.9) 0.9 (0.3–2.4) 1.3 (0.7–2.4)

3.8 (41) 2.1 (1.1–4.1) 2.1 (0.3–16.9) 5.2 (2.2–12.3) 1.8 (0.9–3.6) 5.0 (2.3–10.5) 4.6 (2.2–9.7) 1.7 (0.9–3.2) 11.9 (5.9–23.9) 1.8 (0.9–3.9) 2.4 (0.8–7.2) 1.4 (0.6–3.6)


Table 4 Prevalence and adjusted relative odds of health-risk behaviors by type of adverse childhood exposures, Philippines, 2007.

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Table 5 Prevalence and adjusted relative odds of health-risk behaviors by number of adverse childhood exposures, Philippines, 2007. Health-risk behavior

Number of adverse childhood exposures 1 (n = 264)

2 (n = 201)

3 (n = 148)

>4 (n = 169)

Current smoker

Prevalence, % OR (95% CI)a

None (n = 286) 26.9 1.0 (referent)

25.0 1.0 (0.7–1.5)

27.9 1.1 (0.7–1.8)

35.1 1.3 (0.8–2.1)

40.8 1.7 (1.1–2.7)

Early smoking initiation


7.0 1.0 (referent)

10.2 1.8 (0.9–3.3)

10.5 2.0 (1.0–4.0)

17.6 2.7 (1.4–5.2)

20.1 3.7 (1.9–6.9)

Current alcohol use


31.8 1.0 (referent)

31.1 1.2 (0.8–1.9)

38.3 2.0 (1.3–3.2)

44.6 1.8 (1.1–2.9)

43.8 1.8 (1.1–2.9)

Driving drunk


5.2 1.0 (referent)

4.5 1.1 (0.5–2.5)

5.0 1.3 (0.5–3.0)

8.8 1.9 (0.9–4.4)

5.3 1.0 (0.4–2.6)

Illicit drug use


4.5 1.0 (referent)

6.8 1.8 (0.9–3.9)

17.4 5.7 (2.8–11.6)

14.2 3.4 (1.6–7.3)

24.9 7.0 (3.5–14.2)

Early sex


4.2 1.0 (referent)

10.6 2.9 (1.4–5.9)

9.5 2.7 (1.3–5.9)

13.5 3.5 (1.7–7.5)

13.0 3.4 (1.6–7.2)

Multiple partners, >3


26.2 1.0 (referent)

26.9 1.3 (0.9–2.0)

32.3 1.9 (1.2–2.9)

38.5 1.9 (1.2–3.0)

50.3 3.6 (2.3–5.7)

Early pregnancyb


7.3 1.0 (referent)

11.7 1.5 (0.7–3.5)

14.8 2.0 (0.8–4.6)

19.7 2.5 (1.0–6.4)

14.5 1.7 (0.7–4.3)

Unintended 1st pregnancyb


24.3 1.0 (referent)

28.3 1.2 (0.7–2.1)

50.0 2.8 (1.6–4.8)

34.4 1.7 (0.9–3.3)

48.7 3.1 (1.7–5.8)

Weight > 170 lbs


12.2 1.0 (referent)

10.2 1.0 (0.6–1.7)

6.5 0.6 (0.3–1.2)

12.2 1.1 (0.6–2.0)

12.4 1.1 (0.6–2.0)

Suicide attempt


7.4 18.3 (4.9–67.5)

9.5 24.1 (6.7–86.5)

0.0

1.1 1.0 (referent)

5.5 10.5 (2.9–38.5)

OR, odds ratio; CI, confidence interval. a Adjusted for age, gender, education, SES. b Among 533 women.

result in early smoking initiation, alcohol use, illicit drug use, and sexual risks including experience of unintended first pregnancy. In sum, the findings affirmed that being exposed to a negative circumstance during childhood would result in a number of risky lifestyle habits in adolescence and adulthood.

Prevalence and odds of health-risk behaviors by number of adverse childhood exposures In Table 5, the prevalence and adjusted relative odds of health-risk behaviors by number of adverse childhood exposures are shown. The general trend indicates that there was a relatively strong graded relationship between health-risk behaviors and number of adverse childhood experiences. Significantly, suicide attempt was found to be 24 times more likely as the number of adverse childhood experiences reaches 4 or more. The odd of using illicit drugs was also found higher as the number of adverse experiences increases to 4 or more (OR = 7.0, 95% CI = 3.5–14.2). Early smoking initiation (OR = 3.7, 95% CI = 1.9–6.9), and engaging in sexually risky behaviors (OR = 3.6, 95% CI = 2.3–5.7) followed the same trend. However, associations between the number of adverse childhood experiences and certain health-risk behaviors such as driving while drunk, engaging in early sex, having an unintended first pregnancy, and being overweight or obese were not as clear.

Prevalence and odds of disease/poor health by number of adverse childhood experiences There was a strong graded relationship between number of exposures to adverse childhood experiences and poor health (Table 6). This was true for diseases and health conditions such as asthma, ischemic heart disease, skin diseases, digestive disorders, and mental health among others. However, the results indicated that less number of exposures could result in other diseased conditions such as hypertension, stroke, and peptic ulcers. In general, perceptions of poor health were directly proportional to the number of exposures. The higher the number of exposures, the poorer are perceptions of general health. Also, perceptions of current financial problems worsened with the increase in the number of adverse childhood experiences.


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Table 6 Prevalence and adjusted relative odds of prevalent diseases, health conditions and symptoms by number of adverse childhood exposures, Philippines, 2007. Disease/health condition

Number of adverse childhood exposures None (n = 286)

1 (n = 264)

2 (n = 201)

3 (n = 148)

≥4 (n = 169)


1.4 1.0 (referent)

1.1 0.8 (0.2–3.6)

1.5 1.1 (0.2–4.9)

3.4 2.5 (0.7–9.7)

Asthma


10.8 1.0 (referent)

11.4 0.8 (0.6–1.8)

15.4 1.1 (1.0–3.0)

13.5 2.5 (0.7–2.5)

14.2 5.5 (0.9–2.8)

Ischemic heart disease


10.1 1.0 (referent)

19.7 2.2 (1.3–3.5)

20.4 2.6 (1.6–4.5)

22.3 2.9 (1.7–5.1)

24.3 3.5 (2.1–6.0)

Hypertension


31.5 1.0 (referent)

36.7 1.3 (0.9–1.9)

39.8 1.8 (1.2–2.7)

44.6 2.0 (1.3–3.1)

35.5 1.6 (1.1–2.5)

Stroke


3.1 1.0 (referent)

5.3 1.7 (0.7–4.2)

3.5 1.3 (0.5–3.8)

1.3 0.4 (0.1–2.0)

3.0 1.2 (0.4–3.8)

Tuberculosis


2.5 1.0 (referent)

3.4 1.5 (0.5–4.1)

3.5 1.5 (0.5–4.6)

4.7 1.7 (0.6–5.1)

4.1 1.7 (0.6–5.0)

Diabetes


7.3 1.0 (referent)

8.7 1.2 (0.6–2.3)

4.0 0.7 (0.3–1.7)

5.4 0.9 (0.4–2.2)

7.1 1.5 (0.7–3.4)

Skin problems


5.6 1.0 (referent)

6.8 1.2 (0.6–2.4)

6.0 1.0 (0.5–2.2)

10.1 1.9 (0.9–4.0)

16.6 3.5 (1.8–6.8)

Frequent back pain


26.2 1.0 (referent)

36.0 1.5 (1.1–2.0)

34.3 1.4 (1.1–2.0)

36.5 1.7 (1.1–2.6)

39.6 2.0 (1.3–3.1)

Urinary tract infections


10.5 1.0 (referent)

16.3 1.7 (1.0–2.3)

15.9 1.7 (1.0–2.9)

17.6 2.1 (1.2–3.3)

24.9 3.4 (2.0–5.8)

Gall bladder problems


4.2 1.0 (referent)

3.7 1.3 (0.6–2.9)

4.0 1.0 (0.4–2.4)

3.3 2.4 (1.1–3.6)

12.4 3.8 (1.3–3.2)

Liver problems/hepatitis


1.4 1.0 (referent)

1.9 1.5 (0.4–5.6)

2.5 1.9 (0.5–7.5)

2.7 1.8 (0.4–7.3)

Ulcers


8.4 1.0 (referent)

18.9 2.5 (1.5–4.3)

16.4 2.2 (1.2–3.8)

17.6 2.4 (1.3–4.4)

Sexually transmitted diseases


0.3 1.0 (referent)

Indigestion/ heartburn

Prevalence, %

8.4

OR (95% CI)a

1.0 (referent)

1.4 (0.8–2.5)

2.0 (1.1–3.5)

1.9 (1.0–3.6)

2.4 (1.3–4.3)

Persistent diarrhea


4.2 1.0 (referent)

6.8 1.6 (0.8–3.4)

13.9 3.5 (1.7–7.2)

12.2 3.2 (1.5–7.0)

13.0 3.6 (1.7–7.6)

Constipation


7.3 1.0 (referent)

14.4 2.0 (1.1–3.6)

17.9 2.9 (1.6–3.3)

20.9 3.9 (2.1–7.2)

19.5 3.3 (2.1–7.0)

Depression


7.3 1.0 (referent)

11.7 1.6 (0.9–2.8)

15.9 2.4 (1.3–4.3)

17.6 3.2 (1.7–6.0)

18.3 3.3 (1.8–6.2)

Frequent headaches


19.2 1.0 (referent)

29.2 1.6 (1.1–2.4)

37.8 2.4 (1.6–3.7)

25.7 1.6 (1.0–2.7)

33.1 2.3 (1.4–3.6)

Insomnia


9.8 1.0 (referent)

23.5 2.7 (1.7–4.4)

23.4 2.9 (1.7–4.8)

22.3 2.8 (1.6–4.9)

28.4 4.1 (2.4–6.9)

Fair or poor health


63.3 1.0 (referent)

67.8 1.1 (0.8–1.6)

65.2 1.1 (0.7–1.6)

72.3 1.5 (0.9–2.3)

74.0 1.7 (1.1–2.8)

Current financial problems


21.7 1.0 (referent)

40.1 2.2 (1.5–3.3)

46.3 2.6 (1.73.9)

47.3 2.9 (1.8–4.5)

58.6 4.6 (3.0–7.0)

a

1.5 4.3 (0.5–38.9) 11.7

1.5 4.4 (0.4–44.6) 14.9

0.7 1.5 (0.1–24.1) 13.5

7.1 5.5 (1.7–17.9)

4.1 3.0 (0.8–10.7) 29.0 4.6 (2.7–8.0) 1.2 2.9 (0.3–33.3) 16.0

Odds ratios adjusted for age, gender, education and SES.

Discussion of results This is a survey of 1,068 urban residents aged 35 years and older to describe their adverse childhood experiences and demonstrate how these experiences may be associated with adult health-risk behaviors and morbidity. About 75% of the 1,068 respondents reported to have experienced negative childhood events. Nine percent claimed to have been exposed to 4 or more adverse events in childhood. The results confirmed conclusions of previous studies that childhood trauma is associated with disease and poor health in later life. In general, the more adverse experiences one has encountered in

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childhood, the higher the probability that an individual engages in risky lifestyle habits and consequently suffers from poor health. Current findings indicate that psychological abuse and neglect, as well as physical neglect of basic needs were the most frequently reported forms of childhood adverse experiences. This is not unusual since psychological violence is considered the underpinning of all forms of abuse (Navarre, 1987). If a person is physically maltreated or sexually molested, he or she naturally experiences emotional distress. Additionally, parents in developing countries may also tend to neglect the basic needs of their children, not necessarily by intention, but because of poverty and its concomitant social costs. Poverty by itself is a great stressor and may lead to poor health and delays in development. This is a critical issue in resource-poor countries where the line between poverty and neglect remains ambiguous. The immature child may interpret material deprivation as lack of parental care and love. Ney, Fung, and Wickett (1994) have also suggested that not having one’s biological needs met may make other types of maltreatment even more devastating when they occur. Neglect appears to make the child vulnerable to subsequent adverse experiences. This study has also shown that the various forms of childhood maltreatment and household dysfunctions co-occur. This is in consonance with the findings of Arata, Langhinrichsen-Rohling, Bowers, and O’Brien (2007) where they found that co-occurring maltreatment was more common than single type maltreatment. Individuals who experience multi-type maltreatment especially physical abuse, sexual abuse, and neglect are considered the most symptomatic. Growing research evidence reveal that the total number of lifetime victimization is as important, if not more important, than individual categories of victimization in predicting psychological distress (Finkelhor, Omrod, &Turner, 2007; Richmond, Elliot, Pierce, Aspelmeier, & Alexander, 2009). Surprisingly, exposure to physical maltreatment was reportedly low in this study. This may be due to the type of behavioral indicators used in the present survey which focused on slapping, hitting, pushing, throwing something and getting injured. In a previous study, Ramiro, Madrid, and Amarillo (2004) found that while about 40% of respondents reported to be physically harmed during childhood, spanking with a stick, belt, or any hard material was the most common method used. Only 7% were slapped, and 3% were hit or beaten repeatedly. In terms of health-risk behaviors, most respondents reported smoking, alcohol use, and risky sexual activities. About half of the 1,068 respondents had ever smoked and ever used alcohol. This was consistent with past findings that among Filipino male youth, smoking is high at 40%, and alcohol use at 37% (Domingo & Marquez, 1999). Furthermore, this study showed that more than a third of the respondents had engaged in sex with more than 1 partner while 35% had unintended first pregnancy. These findings were consistent with the results of another local study showing that about 35% of young people (48.9% for males and 10.6% for females) had multiple sexual partners. By the age of 19 years, 12% of these young people were already sexually active, and by age 24 years, 45% of women were already mothers (www2.doh.gov.ph/noh2007). A relatively strong dose–response relationship was observed between the number of ACE exposures and most (but not all) health-risk behaviors. As the number of adverse childhood experiences increases, suicide attempts, use of illicit drugs, early smoking initiation, and engaging in sexually risky behaviors also became more prevalent. Associations were unclear with select health-risk behaviors such as driving while drunk, engaging in early sex, having an unintended first pregnancy, and being overweight or obese. These findings may, therefore, imply that while the number of adverse childhood experiences is highly associated with the development of health-risk behaviors, there are other factors as well that can influence behavioral and health outcomes in adulthood. In a developing country like the Philippines, it could be surmised that people may have become more exposed to these type of negative experiences, partly or mainly because of poverty and its social concomitants. However, socio-cultural factors can also be cited as important reasons for the development of certain risk behaviors in developing countries. In the Philippines, for example, peer influence was found to be the strongest single factor why people initiate and continue to smoke and take alcohol. Alcohol drinking is generally a form of socialization that binds relationships among friends (Ramiro, 1999). There is also a cultural belief that big body size is indicative of health and economic progress (Ramiro et al., 2000). On the other hand, early sex and having multiple partners may be influenced by the influx of liberalized ideas on sexuality and sexual behavior (Raymundo & Cruz, 2004). Therefore, in a developing country setting, the issue of health and health behavior has become more complex and multi-factorial. What is the mechanism involved in childhood trauma that can affect future cognitions and behavior? Recent studies on the neurobiological processes accompanying or underlying observed behavior show that maltreatment can result in changes in the brain structure itself (Perry, 2000). Many of these changes in brain functioning are related to one’s response to stress. Although moderate and predictable stress in childhood can help develop ways of coping with life in general, severe, repetitive, or chronic stress hampers normal brain functioning. Neural pathways are sensitized and regions of the brain (e.g., hippocampus, sub-cortical and limbic systems) that deal with anxiety and fear responses become overdeveloped. Studies have also shown that repeated abuse with its resulting stress can affect the neuro-chemical system resulting in changes in attention, impulse control, sleep patterns, and fine motor control (Perry, 2000). In particular, children who have been subjected to abuse have abnormal secretions of cortisol (Hart, Gunnar, & Cicchetti, 1995). The tendency, therefore, is for individuals who are in constant threat of abuse to focus their brain’s resources on survival and threat avoidance, to the detriment of other parts of the brain that are involved in more productive activities that include language development and active learning. If children are in a persistent state of hyper-arousal and hyper-vigilance, then they are likely to have difficulties with normally responding to stimulations in daily life. These groups of children turn to high risk behaviors to deal with stress and adverse life events.


853

The results of this study are subject to certain limitations. Responses were based on self-reports. The percentage of adults disclosing adverse childhood experience of abuse is lower than those of previous local surveys (e.g., BSNOH, 2000) although some differences in the way questions were asked in different surveys were noted. Disease conditions were also self-disclosed and therefore may be subject to over-or under-reporting. Future research may help address these issues by including more objective measures such as laboratory results and clinical diagnosis. A potential weakness of studies with retrospective reporting of childhood experiences is the possibility of recall bias. Difficulty recalling childhood events likely results in misclassification (i.e., classifying people who were truly exposed to ACEs as unexposed) that would bias results toward the null. This means that if adverse childhood experiences were underestimated, then this would result in a downward bias and suggest an even stronger relationship between adverse childhood experiences and adult risk behaviors and diseases than that observed in this study. It may also be possible that there was differential recall, depending upon the nature and significance of the events (e.g., sexual abuse compared with emotional neglect). Despite the debate that problems in adult life, which may stimulate a focus on the negative aspects of childhood, would increase the reporting of ACEs, our study setting was based on data collected from a general population sample, not a clinical population where respondents would be more likely to reflect back on their childhood for reasons why they might have their current problems. By sampling from a general population, there is no reason to believe that any one individual would reflect more or less on their childhood (and negative aspects therein) than the next sampled individual. Perhaps, the most important contribution of this study is to provide evidence that child maltreatment is a public health problem even in poorer environments. This is in contrast to the common notion in many societies that child abuse and neglect is simply a social problem. As borne by the findings, childhood abuse and neglect are major risk factors that may lead to disabilities, morbidities and other health outcomes during adulthood. Hence, these findings may impact on how health care is delivered to the people. Prevention and early intervention are crucial if we want to improve the child’s chances of developing optimally and prevent the long-term consequences. 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