Keywords
Adverse Childhood Experiences (ACE), Post Traumatic Stress Disorder (PTSD), Abuse, Neglect
Abstract
Global evidence has demonstrated that Adverse Childhood Experiences (ACEs) from the childhood significantly increase the risk of mental and physical health for an adult. The research linking ACE with health and wellbeing over past 2 decades has confirmed a dose-response relationship between the number of ACE experienced and the extent of impact on wellbeing. The source of ACE is the family, community, and the immediate environment and it causes long term risk for mental health with the potential to carry it over beyond the present generation. The findings are consistent across the developed and developing countries, and the evidence highlights the need for new elements beyond the 10 ACE elements in the pathbreaking original study.
India, with a population of more than 0.4 billion children and adolescents, and with one out seven Indians being affected by mental health issues, need urgent intervention in identifying, managing, and preventing the ACEs. This commentary reviews global research, summarizes the limited evidence available in India on ACE elements’ impact on mental health, and proposes a multi-pronged approach to identify, manage and prevent the mental health implications of ACE in India to preempt a major public health challenge.
References
Bellis MA, Hughes K, Ford K, Rodriguez GR, Sethi D, Passmore J. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. The Lancet Public Health. 2019 Oct 1;4(10):e517-28.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Marks JS. 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 of preventive medicine. 1998 May 1;14(4):245-58.
Larkin H, Felitti VJ, Anda RF. Social work and adverse childhood experiences research: Implications for practice and health policy. Social work in public health. 2014 Jan 2;29(1):1-6.
Wade Jr R, Cronholm PF, Fein JA, Forke CM, Davis MB, Harkins-Schwarz M, Pachter LM, Bair-Merritt MH. Household and community-level adverse childhood experiences and adult health outcomes in a diverse urban population. Child abuse & neglect. 2016 Feb 1;52:135-45.
Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, Dua T, Ganguli A, Varghese M, Chakma JK, Kumar GA. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017. The Lancet Psychiatry. 2020 Feb 1;7(2):148-61.
Center for Disease Control & Prevention Website https://www.cdc.gov/vitalsigns/aces/index.html (Last accessed, Aug 24, 2020)
Organization WHO. Adverse Childhood Experiences International Questionnaire (ACE-IQ) 2012. Available from: http://www.who.int/violence_injury_prevention/violence/activities/adverse_childhood_experiences/en/
Chang X, Jiang X, Mkandarwire T, Shen M. Associations between adverse childhood experiences and health outcomes in adults aged 18–59 years. PloS one. 2019 Feb 7;14(2):e0211850.
Lee H, Kim Y, Terry J. Adverse childhood experiences (ACEs) on mental disorders in young adulthood: latent classes and community violence exposure. Preventive medicine. 2020 Feb 22:106039.
Centre of Disease Control- Kaiser’s ACE questionnaire- (Last accessed, Aug 31, 2020)
https://www.cdc.gov/violenceprevention/acestudy/index.html
Adverse Childhood Experiences International Questionnaire (ACE-IQ)- (Last accessed Aug 31, 2020)https://www.who.int/violence_injury_prevention/violence/activities/adverse_childhood_experiences/guidance_for_analysing.pdf?ua=1
Finkelhor D, Shattuck A, Turner H, Hamby S. A revised inventory of adverse childhood experiences. Child abuse & neglect. 2015 Oct 1;48:13-21.
Walsh D, McCartney G, Smith M, Armour G. Relationship between childhood socioeconomic position and adverse childhood experiences (ACEs): a systematic review. J Epidemiol Community Health. 2019 Dec 1;73(12):1087-93.
Choi NG, DiNitto DM, Marti CN, Choi BY. Association of adverse childhood experiences with lifetime mental and substance use disorders among men and women aged 50+ years. International psychogeriatrics. 2017 Mar;29(3):359-72.
Herzog JI, Schmahl C. Adverse childhood experiences and the consequences on neurobiological, psychosocial, and somatic conditions across the lifespan. Frontiers in psychiatry. 2018 Sep 4;9:420.
Ege MA, Messias E, Thapa PB, Krain LP. Adverse childhood experiences and geriatric depression: results from the 2010 BRFSS. The American Journal of Geriatric Psychiatry. 2015 Jan 1;23(1):110-4.
Von Cheong E, Sinnott C, Dahly D, Kearney PM. Adverse childhood experiences (ACEs) and later-life depression: perceived social support as a potential protective factor. BMJ open. 2017 Sep 1;7(9).
Metzler M, Merrick MT, Klevens J, Ports KA, Ford DC. Adverse childhood experiences and life opportunities: Shifting the narrative. Children and youth services review. 2017 Jan 1;72:141-9.
Ramiro LS, Madrid BJ, Brown DW. Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country setting. Child abuse & neglect. 2010 Nov 1;34(11):842-55.
Almuneef M, Qayad M, Aleissa M, Albuhairan F. Adverse childhood experiences, chronic diseases, and risky health behaviors in Saudi Arabian adults: a pilot study. Child abuse & neglect. 2014 Nov 1;38(11):1787-93.
Chang X, Jiang X, Mkandarwire T, Shen M. Associations between adverse childhood experiences and health outcomes in adults aged 18–59 years. PloS one. 2019 Feb 7;14(2):e0211850.
Bellis MA, Hughes K, Ford K, Rodriguez GR, Sethi D, Passmore J. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. The Lancet Public Health. 2019 Oct 1;4(10):e517-28
Fox BH, Perez N, Cass E, Baglivio MT, Epps N. Trauma changes everything: Examining the relationship between adverse childhood experiences and serious, violent and chronic juvenile offenders. Child abuse & neglect. 2015 Aug 1;46:163-73.
McLennan JD, MacMillan HL, Afifi TO. Questioning the use of adverse childhood experiences (ACEs) questionnaires. Child Abuse & Neglect. 2020 Mar 1;101:104331.
Oral R, Ramirez M, Coohey C, Nakada S, Walz A, Kuntz A, Benoit J, Peek-Asa C. Adverse childhood experiences and trauma informed care: the future of health care. Pediatric research. 2016 Jan;79(1):227-33.
K Damodaran D, Rapheal J, Paul V. Child maltreatment in the Indian context. Child Maltreatment in the Indian Context (July 5, 2015). The International Journal of Humanities and Social Studies. 2014 Oct;4(10):333-9.
Pandey R, Gupta S, Upadhyay A, Gupta RP, Shukla M, Mishra RC, Arya YK, Singh T, Niraula S, Lau JY, Kumari V. Childhood maltreatment and its mental health consequences among Indian adolescents with a history of child work. Australian & New Zealand Journal of Psychiatry. 2020 May;54(5):496-508.
Singh S, Manjula M, Philip M. Suicidal risk and childhood adversity: A study of Indian college students. Asian journal of psychiatry. 2012 Jun 1;5(2):154-9.
Pillai A, Andrews T, Patel V. Violence, psychological distress and the risk of suicidal behaviour in young people in India. International journal of epidemiology. 2009 Apr 1;38(2):459-69.
Esser MB, Rao GN, Gururaj G, Murthy P, Jayarajan D, Sethu L, Jernigan DH, Benegal V, Collaborators Group on Epidemiological Study of Patterns and Consequences of Alcohol Misuse in India. Physical abuse, psychological abuse and neglect: Evidence of alcohol‐related harm to children in five states of India. Drug and alcohol review. 2016 Sep;35(5):530-8.
Mishra K, Ransing R, Khairkar P, Gajanan S. Association between childhood abuse and psychiatric morbidities among hospitalized patients. Indian journal of social psychiatry. 2016;32(1).
Choudhry V, Dayal R, Pillai D, Kalokhe AS, Beier K, Patel V. Child sexual abuse in India: A systematic review. PloS one. 2018 Oct 9;13(10):e0205086.
Chandra PS, Carey MP, Carey KB, Shalinianant A, Thomas T. Sexual coercion and abuse among women with a severe mental illness in India: an exploratory investigation. Comprehensive psychiatry. 2003 May 1;44(3):205-12.
Bhilwar M, Upadhyay RP, Rajavel S, Singh SK, Vasudevan K, Chinnakali P. Childhood experiences of physical, emotional and sexual abuse among college students in South India. Journal of tropical pediatrics. 2015 Oct 1;61(5):329-38.
Patel V, Varma J, Nimbalkar S, Shah S, Phatak A. Prevalence and profile of bullying involvement among students of rural schools of anand, Gujarat, India. Indian Journal of Psychological Medicine. 2020 Jun;42(3):268-73.
Pandey R, Gupta S, Upadhyay A, Gupta RP, Shukla M, Mishra RC, Arya YK, Singh T, Niraula S, Lau JY, Kumari V. Childhood maltreatment and its mental health consequences among Indian adolescents with a history of child work. Australian & New Zealand Journal of Psychiatry. 2020 May;54(5):496-508.
Gilmoor AR, Adithy A, Regeer B. The cross-cultural validity of post-traumatic stress disorder and post-traumatic stress symptoms in the Indian context: a systematic search and review. Frontiers in psychiatry. 2019;10:439.
Mushtaq R, Shah T, Mushtaq S. Post-Traumatic stress disorder (PTSD) in children of conflict region of Kashmir (India): a review. Journal of clinical and diagnostic research: JCDR. 2016 Jan;10(1):VE01.
Patel V, Xiao S, Chen H, Hanna F, Jotheeswaran AT, Luo D, Parikh R, Sharma E, Usmani S, Yu Y, Druss BG. The magnitude of and health system responses to the mental health treatment gap in adults in India and China. The Lancet. 2016 Dec 17;388(10063):3074-84.
Narasimhan L, Gopikumar V, Jayakumar V, Bunders J, Regeer B. Responsive mental health systems to address the poverty, homelessness and mental illness nexus: The Banyan experience from India. International Journal of Mental Health Systems. 2019 Dec;13(1):1-0.
Gautham MS, Gururaj G, Varghese M, Benegal V, Rao GN, Kokane A, Chavan BS, Dalal PK, Ram D, Pathak K, Lenin Singh RK. The National Mental Health Survey of India (2016): Prevalence, socio-demographic correlates and treatment gap of mental morbidity. International Journal of Social Psychiatry. 2020 Mar 4:0020764020907941.
Srivastava K, Chatterjee K, Bhat PS. Mental health awareness: The Indian scenario. Industrial psychiatry journal. 2016 Jul;25(2):131.
Ministry of Health and Family Welfare, Government of India. National Mental Health Survey of India; 2016. Available from: http://www.indianmhs.nimhans.ac.in/Docs/Summary.pdf. [Last accessed on 2020 Aug 06].
Hossain MM, Purohit N. Improving child and adolescent mental health in India: Status, services, policies, and way forward. Indian Journal of Psychiatry. 2019;61(4):415.
John TJ, Vashishtha VM. Eradicating poliomyelitis: India's journey from hyperendemic to polio-free status. The Indian journal of medical research. 2013 May;137(5):881.
Narasimhan L, Gopikumar V, Jayakumar V, Bunders J, Regeer B. Responsive mental health systems to address the poverty, homelessness and mental illness nexus: The Banyan experience from India. International Journal of Mental Health Systems. 2019 Dec;13(1):1-0.
John TJ, Vashishtha VM. Eradicating poliomyelitis: India's journey from hyperendemic to polio-free status. The Indian journal of medical research. 2013 May;137(5):881.
Sethi D, Yon Y, Parekh N, Anderson T, Huber J, Rakovac I, Meinck F. European status report on preventing child maltreatment.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Marks JS. 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 of preventive medicine. 1998 May 1;14(4):245-58.
Larkin H, Felitti VJ, Anda RF. Social work and adverse childhood experiences research: Implications for practice and health policy. Social work in public health. 2014 Jan 2;29(1):1-6.
Wade Jr R, Cronholm PF, Fein JA, Forke CM, Davis MB, Harkins-Schwarz M, Pachter LM, Bair-Merritt MH. Household and community-level adverse childhood experiences and adult health outcomes in a diverse urban population. Child abuse & neglect. 2016 Feb 1;52:135-45.
Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, Dua T, Ganguli A, Varghese M, Chakma JK, Kumar GA. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017. The Lancet Psychiatry. 2020 Feb 1;7(2):148-61.
Center for Disease Control & Prevention Website https://www.cdc.gov/vitalsigns/aces/index.html (Last accessed, Aug 24, 2020)
Organization WHO. Adverse Childhood Experiences International Questionnaire (ACE-IQ) 2012. Available from: http://www.who.int/violence_injury_prevention/violence/activities/adverse_childhood_experiences/en/
Chang X, Jiang X, Mkandarwire T, Shen M. Associations between adverse childhood experiences and health outcomes in adults aged 18–59 years. PloS one. 2019 Feb 7;14(2):e0211850.
Lee H, Kim Y, Terry J. Adverse childhood experiences (ACEs) on mental disorders in young adulthood: latent classes and community violence exposure. Preventive medicine. 2020 Feb 22:106039.
Centre of Disease Control- Kaiser’s ACE questionnaire- (Last accessed, Aug 31, 2020)
https://www.cdc.gov/violenceprevention/acestudy/index.html
Adverse Childhood Experiences International Questionnaire (ACE-IQ)- (Last accessed Aug 31, 2020)https://www.who.int/violence_injury_prevention/violence/activities/adverse_childhood_experiences/guidance_for_analysing.pdf?ua=1
Finkelhor D, Shattuck A, Turner H, Hamby S. A revised inventory of adverse childhood experiences. Child abuse & neglect. 2015 Oct 1;48:13-21.
Walsh D, McCartney G, Smith M, Armour G. Relationship between childhood socioeconomic position and adverse childhood experiences (ACEs): a systematic review. J Epidemiol Community Health. 2019 Dec 1;73(12):1087-93.
Choi NG, DiNitto DM, Marti CN, Choi BY. Association of adverse childhood experiences with lifetime mental and substance use disorders among men and women aged 50+ years. International psychogeriatrics. 2017 Mar;29(3):359-72.
Herzog JI, Schmahl C. Adverse childhood experiences and the consequences on neurobiological, psychosocial, and somatic conditions across the lifespan. Frontiers in psychiatry. 2018 Sep 4;9:420.
Ege MA, Messias E, Thapa PB, Krain LP. Adverse childhood experiences and geriatric depression: results from the 2010 BRFSS. The American Journal of Geriatric Psychiatry. 2015 Jan 1;23(1):110-4.
Von Cheong E, Sinnott C, Dahly D, Kearney PM. Adverse childhood experiences (ACEs) and later-life depression: perceived social support as a potential protective factor. BMJ open. 2017 Sep 1;7(9).
Metzler M, Merrick MT, Klevens J, Ports KA, Ford DC. Adverse childhood experiences and life opportunities: Shifting the narrative. Children and youth services review. 2017 Jan 1;72:141-9.
Ramiro LS, Madrid BJ, Brown DW. Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country setting. Child abuse & neglect. 2010 Nov 1;34(11):842-55.
Almuneef M, Qayad M, Aleissa M, Albuhairan F. Adverse childhood experiences, chronic diseases, and risky health behaviors in Saudi Arabian adults: a pilot study. Child abuse & neglect. 2014 Nov 1;38(11):1787-93.
Chang X, Jiang X, Mkandarwire T, Shen M. Associations between adverse childhood experiences and health outcomes in adults aged 18–59 years. PloS one. 2019 Feb 7;14(2):e0211850.
Bellis MA, Hughes K, Ford K, Rodriguez GR, Sethi D, Passmore J. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. The Lancet Public Health. 2019 Oct 1;4(10):e517-28
Fox BH, Perez N, Cass E, Baglivio MT, Epps N. Trauma changes everything: Examining the relationship between adverse childhood experiences and serious, violent and chronic juvenile offenders. Child abuse & neglect. 2015 Aug 1;46:163-73.
McLennan JD, MacMillan HL, Afifi TO. Questioning the use of adverse childhood experiences (ACEs) questionnaires. Child Abuse & Neglect. 2020 Mar 1;101:104331.
Oral R, Ramirez M, Coohey C, Nakada S, Walz A, Kuntz A, Benoit J, Peek-Asa C. Adverse childhood experiences and trauma informed care: the future of health care. Pediatric research. 2016 Jan;79(1):227-33.
K Damodaran D, Rapheal J, Paul V. Child maltreatment in the Indian context. Child Maltreatment in the Indian Context (July 5, 2015). The International Journal of Humanities and Social Studies. 2014 Oct;4(10):333-9.
Pandey R, Gupta S, Upadhyay A, Gupta RP, Shukla M, Mishra RC, Arya YK, Singh T, Niraula S, Lau JY, Kumari V. Childhood maltreatment and its mental health consequences among Indian adolescents with a history of child work. Australian & New Zealand Journal of Psychiatry. 2020 May;54(5):496-508.
Singh S, Manjula M, Philip M. Suicidal risk and childhood adversity: A study of Indian college students. Asian journal of psychiatry. 2012 Jun 1;5(2):154-9.
Pillai A, Andrews T, Patel V. Violence, psychological distress and the risk of suicidal behaviour in young people in India. International journal of epidemiology. 2009 Apr 1;38(2):459-69.
Esser MB, Rao GN, Gururaj G, Murthy P, Jayarajan D, Sethu L, Jernigan DH, Benegal V, Collaborators Group on Epidemiological Study of Patterns and Consequences of Alcohol Misuse in India. Physical abuse, psychological abuse and neglect: Evidence of alcohol‐related harm to children in five states of India. Drug and alcohol review. 2016 Sep;35(5):530-8.
Mishra K, Ransing R, Khairkar P, Gajanan S. Association between childhood abuse and psychiatric morbidities among hospitalized patients. Indian journal of social psychiatry. 2016;32(1).
Choudhry V, Dayal R, Pillai D, Kalokhe AS, Beier K, Patel V. Child sexual abuse in India: A systematic review. PloS one. 2018 Oct 9;13(10):e0205086.
Chandra PS, Carey MP, Carey KB, Shalinianant A, Thomas T. Sexual coercion and abuse among women with a severe mental illness in India: an exploratory investigation. Comprehensive psychiatry. 2003 May 1;44(3):205-12.
Bhilwar M, Upadhyay RP, Rajavel S, Singh SK, Vasudevan K, Chinnakali P. Childhood experiences of physical, emotional and sexual abuse among college students in South India. Journal of tropical pediatrics. 2015 Oct 1;61(5):329-38.
Patel V, Varma J, Nimbalkar S, Shah S, Phatak A. Prevalence and profile of bullying involvement among students of rural schools of anand, Gujarat, India. Indian Journal of Psychological Medicine. 2020 Jun;42(3):268-73.
Pandey R, Gupta S, Upadhyay A, Gupta RP, Shukla M, Mishra RC, Arya YK, Singh T, Niraula S, Lau JY, Kumari V. Childhood maltreatment and its mental health consequences among Indian adolescents with a history of child work. Australian & New Zealand Journal of Psychiatry. 2020 May;54(5):496-508.
Gilmoor AR, Adithy A, Regeer B. The cross-cultural validity of post-traumatic stress disorder and post-traumatic stress symptoms in the Indian context: a systematic search and review. Frontiers in psychiatry. 2019;10:439.
Mushtaq R, Shah T, Mushtaq S. Post-Traumatic stress disorder (PTSD) in children of conflict region of Kashmir (India): a review. Journal of clinical and diagnostic research: JCDR. 2016 Jan;10(1):VE01.
Patel V, Xiao S, Chen H, Hanna F, Jotheeswaran AT, Luo D, Parikh R, Sharma E, Usmani S, Yu Y, Druss BG. The magnitude of and health system responses to the mental health treatment gap in adults in India and China. The Lancet. 2016 Dec 17;388(10063):3074-84.
Narasimhan L, Gopikumar V, Jayakumar V, Bunders J, Regeer B. Responsive mental health systems to address the poverty, homelessness and mental illness nexus: The Banyan experience from India. International Journal of Mental Health Systems. 2019 Dec;13(1):1-0.
Gautham MS, Gururaj G, Varghese M, Benegal V, Rao GN, Kokane A, Chavan BS, Dalal PK, Ram D, Pathak K, Lenin Singh RK. The National Mental Health Survey of India (2016): Prevalence, socio-demographic correlates and treatment gap of mental morbidity. International Journal of Social Psychiatry. 2020 Mar 4:0020764020907941.
Srivastava K, Chatterjee K, Bhat PS. Mental health awareness: The Indian scenario. Industrial psychiatry journal. 2016 Jul;25(2):131.
Ministry of Health and Family Welfare, Government of India. National Mental Health Survey of India; 2016. Available from: http://www.indianmhs.nimhans.ac.in/Docs/Summary.pdf. [Last accessed on 2020 Aug 06].
Hossain MM, Purohit N. Improving child and adolescent mental health in India: Status, services, policies, and way forward. Indian Journal of Psychiatry. 2019;61(4):415.
John TJ, Vashishtha VM. Eradicating poliomyelitis: India's journey from hyperendemic to polio-free status. The Indian journal of medical research. 2013 May;137(5):881.
Narasimhan L, Gopikumar V, Jayakumar V, Bunders J, Regeer B. Responsive mental health systems to address the poverty, homelessness and mental illness nexus: The Banyan experience from India. International Journal of Mental Health Systems. 2019 Dec;13(1):1-0.
John TJ, Vashishtha VM. Eradicating poliomyelitis: India's journey from hyperendemic to polio-free status. The Indian journal of medical research. 2013 May;137(5):881.
Sethi D, Yon Y, Parekh N, Anderson T, Huber J, Rakovac I, Meinck F. European status report on preventing child maltreatment.