M. Jackson Group Update – October 2019 – Positive Childhood Experiences

This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:
JAMA: Pediatrics includes a study: “Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample: Associations Across Adverse Childhood Experiences Levels.”
The authors are Christina Bethell, PhD, MBA, MPH1; Jennifer Jones, MSW2; Narangerel Gombojav, MD, PhD1; Jeff Linkenbach, EdD3; & Robert Sege, MD, PhD4.
Here’s how it opens:
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Research demonstrates that both positive and adverse experiences shape brain development and health across the life span.1-5. Understanding human development requires a model that incorporates both risks (factors that decrease the likelihood of successful development) and opportunities (factors that increase the likelihood of successful development). On the positive side, successful child development depends on secure attachment during the first years of life.6,7 As the child grows, exposure to spoken language8 and having the presence of safe, stable, nurturing relationships and environments are important factors for optimal development.9,10 On the other hand, children with adverse childhood experiences (ACEs) are at risk for observable changes in brain anatomy,11 gene expression,12,13 and delays in social, emotional, physical, and cognitive development lasting into adulthood.3-5,14-17
According to standardized measures, an estimated 61.5% of adults18 and 48% of children19 in the United States have been exposed to ACEs, with more than one-third of these having multiple exposures.18,19 The wide-ranging negative associations between exposure to multiple ACEs and diminished adult and child health are well documented.14,19-22 Most notable is the especially strong evidence linking ACEs with adult mental health problems including depression.22-28 A robust literature also exists regarding the effect of ACEs on adult relational health (often assessed by whether adults report that they get the social and emotional support they need) and how diminished adult social and emotional support contributes to poorer adult physical and mental health.29-56
Beyond the extensive and growing body of research dealing with lifelong correlates of adversity, many prior studies identify resiliency factors and adaptive skills and interventions associated with improved child development and child and adult health outcomes.2,3,16,17,25-55 For example, the Search Institute developed a list of “40 Developmental Assets” and demonstrated associations between the number of assets and both positive and negative outcomes.52 A national population-based study53 on child flourishing and resilience shows strong associations with levels of family resilience and parent-child connection for children with exposures to greater ACEs, poverty, and chronic conditions. Similar studies, such as those assessing the US Centers for Disease Control and Prevention (CDC)’s “safe, stable, and nurturing relationships” model, show similar findings.55
Despite these advances, standardized measures and the prevalence of positive childhood experiences (PCEs) at the population level for adults or children are still unknown. Yet prior studies, using data from small or nonrepresentative samples, have explored interactions between PCEs and ACEs.25,41,56 For example, 1 study,41 conducted by Kaiser Permanente and CDC investigators, analyzed a cohort of 4648 women. They found that adult reports of specific positive family experiences in childhood (including closeness, support, loyalty, protection, love, importance, and responsiveness to health needs) were associated with lower rates of adolescent pregnancy across all ACEs exposure levels.41 The protective effects of reported interpersonal PCEs against mental health problems in adulthood have also been found among pregnant women25 and young adults56 exposed to ACEs. Despite these findings, few subsequent studies on ACEs have simultaneously evaluated PCEs.
Collectively, prior studies on child development point to the importance of research focusing on PCEs, especially those associated with parent-child attachment, positive parenting (eg, parental warmth, responsiveness, and support), family health, and positive relationships with friends, in school, and in the community. Knowledge of whether retrospectively reported PCEs co-occur with ACEs and how PCEs interact with ACEs to effect adult mental and relational health is needed to inform the nation’s growing focus on addressing early life and social determinants of healthy development and lifelong health.
This study used data from the 2015 Wisconsin Behavioral Risk Factor Survey (WI BRFS), a representative, population-based survey,57 to assess the prevalence of PCEs in an adult sample and evaluate hypothesized associations with adult mental and relational health across 4 ACEs exposure levels. This study builds on a 2017 Health Outcomes of Positive Experiences report58 featuring bivariate findings from the 2015 WI BRFS associating individual PCEs with negative adult health outcomes. Here, we construct a PCEs cumulative score measure and use multivariable regression methods to assess the magnitude and significance of associations between this PCEs score and (1) adult depression and/or poor mental health (D/PMH) and (2) adults’ reported social and emotional support (ARSES). Separate assessment of associations was conducted for each of 4 ACEs exposure levels.
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Another excerpt: “Positive childhood experiences demonstrate a dose-response association with adult D/PMH and ARSES after adjustment for ACEs; assessing and proactively promoting PCEs may reduce adult mental and relational health problems, even in the concurrent presence of ACEs.”
Here’s how the Discussion section opens:
[begin excerpt]
This study examined the prevalence of adult reports of both PCEs and ACEs in a statewide sample and found that PCEs both co-occur with and operate independently from ACEs in their associations with the adult health outcomes evaluated here. Findings also confirm the hypotheses that PCEs may exert their association with D/PMH through their association with ARSES. However, PCEs maintained an association with D/PMH independent from ARSES. Findings are both consistent with prior research showing that relational experiences in childhood are associated with adult social and relational skills and health3,15,56,68 and also point to enduring effects of PCEs on D/PMH separate from their influence on adult ARSES.
While PCEs associations with D/PMH were substantial and similar for adults reporting ACEs, associations were not statistically significant for those reporting no ACEs. Insignificant findings may be owing to low sample sizes for respondents with no ACEs and fewer PCEs. Results still raise questions for further exploration. We hypothesize that PCEs may have a greater influence in promoting positive health, such as getting needed social and emotional support or flourishing as an adult. In turn, these positive health attributes may reduce the burden of illness even if the illness is not eliminated. This is consistent with prior research demonstrating a dual continuum of health whereby flourishing is found to be present for many adults despite concurrent mental health conditions.69
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Here’s how it concludes:
[begin excerpt]
Overall, study results demonstrate that PCEs show a dose-response association with adult mental and relational health, analogous to the cumulative effects of multiple ACEs. Findings suggest that PCEs may have lifelong consequences for mental and relational health despite co-occurring adversities such as ACEs. In this way, they support application of the World Health Organization’s definition of health emphasizing that health is more than the absence of disease or adversity.71 The World Health Organization’s positive construct of health is aligned with the proactive promotion of positive experiences in childhood because they are foundational to optimal childhood development and adult flourishing. Including PCEs as well as positive health outcomes measures in routinely collected public health surveillance systems, such as the National Survey of Children’s Health and state Behavioral Risk Factor Surveillance Surveys, may advance knowledge and allow the nation to track progress in promoting flourishing despite adversity or illness among children and adults in the United States.
Even as society continues to address remediable causes of childhood adversities such as ACEs, attention should be given to the creation of those positive experiences that both reflect and generate resilience within children, families, and communities. Success will depend on full engagement of families and communities and changes in the health care, education, and social services systems serving children and families. A joint inventory of ACEs and PCEs, such as the positive experiences assessed here, may improve efforts to assess needs, target interventions, and engage individuals in addressing the adversities they face by leveraging existing assets and strengths.72 Initiatives to conduct broad ACEs screening, such as those ensuing in California’s Medicaid program, may benefit from integrated assessments including PCEs.73
Recommendations and practice guidelines included in the National Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents74 and the CDC’s Essentials for Childhood initiative9 encourage policies and initiatives to help child-serving professionals and programs to adopt effective approaches to promote the type of PCEs evaluated in this study. The Health Outcomes of Positive Experiences framework48 and the Prioritizing Possibilities national agenda for promoting child health and addressing ACEs75 each seek to advance existing and emerging evidence-based approaches44,45,47,48,50,54,76,77 that promote a positive construct of health in clinical, public health, and human services settings. This study adds to the growing evidence that childhood experiences have profound and lifelong effects. Results hold promise for national, state, and community efforts to achieve positive child and adult health and well-being by promoting the largely untapped potential to promote positive experiences and flourishing despite adversity.53,78
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“Everything should be made as simple as possible, but not simpler.”
—Albert Einstein