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New Article Finds Different Effects of Protective versus Adverse Childhood Events


In a new article, my former nursing honors student Linda Driscoll Powers wrote about the measurement properties of a survey called PACES -- standing for Positive and Adverse Childhood Experiences Survey -- developed by Dr. Laurie Leitch. The instrument combines items from the widely used ACEs (Adverse Childhood Experiences) measure with a set of protective factors such as having a supportive family, having a positive relationship with an adult outside the family, or belonging to social groups like a team or a church. ACEs items have been found to predict a variety of health outcomes in adulthood, either directly or by way of social support, but positive childhood experiences are under-studied. 

Besides having satisfactory psychometric properties (a stable factor structure, good internal consistency reliability, no evidence of response bias), the PACES items split cleanly into two independent subscales, one measuring positive experiences and the other measuring negative ones. The fact that these subscales were orthogonal (independent) to one another means that a person could have had negative experiences as a child, positive experiences as a child, both, or neither -- in other words, positive experiences aren't the same as just an absence of negative ones. There was also some suggestion in preliminary analyses that items measuring positive relationships within the family could be differentiated from positive relationships outside the family, but ultimately it made the most sense to group those items together for analysis, meaning that any positive relationship has about the same benefits, regardless of who it's with.

To me, the most interesting piece of Linda's paper was the comparison of positive vs. negative early experiences with a range of other measures. The data were gathered in a large sample (n = 589) of clients seen in rural Colorado treatment programs for opioid use disorder over about a year's time. In this group, a higher number of ACEs correlated with having more symptoms of depression, medical problems, and pain, more alcohol and other substance use, more current legal problems, and more psychological distress, as well as more family conflict, housing problems, and fewer economic and social resources. All of these relationships were expected based on prior literature about the later-life risks associated with ACEs. People with a history of childhood adverse experiences were also more likely to report having been victims of physical, sexual, or emotional abuse over the past 30 days, which in a previous paper we found to be associated with higher pain scores and therefore perhaps a higher risk for opioid use relapse.

We also found that the positive childhood experiences subscale was linked to less depression, a lower chance of hospitalization, more social and economic resources, a lower likelihood of legal problems, and less family-related distress. A couple of surprising effects were relationships between positive childhood experiences and current physical pain or health concerns, which we interpreted to mean that perhaps people were more in tune with their bodies and willing to ask for help. People with more positive childhood experiences were also more likely to be using prescription pain medication (e.g., as opposed to heroin or other street drugs). Nevertheless, the greater attention to current pain among people with more positive childhood experiences might suggest a unique risk factor for relapse. 

Overall, the most important conclusion from this study is that it's important for clinicians to ask about positive as well as negative experiences that people might have had in childhood. The different pattern of relationships with other variables for the positive and adverse experience subscales, and the fact that these scales were independent of one another, suggest that the two subscales of the PACES are likely to convey non-overlapping information. Asking about positive childhood experiences also can help clinicians to avoid an exclusive focus on deficits or problems, highlighting what has gone right in a person's life and what resources they might bring to current challenges. This fits with a strengths-focused approach to clinical care, and can help clinicians to support patients on their road to recovery.

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