Child Abuse & Neglect 103 (2020) 104440

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Child Abuse & Neglect

journal homepage: www.elsevier.com/locate/chiabuneg

Research article

Adverse childhood experiences: Assessing the impact on physical

T
and psychosocial health in adulthood and the mitigating role of
resilience
Nancy Rossa,*, Robert Gilbertb, Sara Torresc, Kevin Dugasa, Phil Jefferiesd,
Sheila McDonalde, Susan Savagef, Michael Ungard
a
School of Social Work, Dalhousie University, Halifax, Nova Scotia, Canada
b
School of Health Sciences, Dalhousie University, Halifax, Nova Scotia, Canada
c
School of Social Work, Laurentian University, Sudbury, Ontario, Canada
d
Resilience Research Centre, Dalhousie University, Halifax, Nova Scotia, Canada
e
Maternal Child Health—Research and Innovation Population, Public and Indigenous Health Alberta Health Services/University of Calgary, Nova
Scotia Health, Canada
f
Nova Scotia Health Authority, Nova Scotia, Canada

A R T IC LE I N F O ABS TRA CT

Keywords: Background: More than 2000 studies demonstrate adverse childhood experiences ACEs are uni-
Adult versal and that experiencing multiple ACEs increases risk for developing physical and psycho-
Adverse childhood experiences social health problems in adulthood. A challenge faced by clinicians is identifying those most at
Social ecological resilience risk. Recent evidence suggests socio-ecological resilience may mitigate the consequences ACEs.
Prevention
We hypothesize that integrated assessment of ACEs and resilience might improve identification of
Health and social
those at highest risk.
Risk assessment
Rural population Objectives: We examined ACEs among adults attending a rural family practice clinic and explored
associations between ACE, socio-ecological resilience and health.
Methods: A cross-sectional survey measured ACEs, resilience, and health in adult patients at-
tending a collaborative family health care centre in Lunenburg, Nova Scotia, Canada. Correlation
analyses were used to determine associations between the measures. The impact of socio-eco-
nomic status, level of education and gender was considered.
Results: Two hundred and twenty-six persons participated in this study.
Approximately 73 % of participants had experienced at least one ACEs and 31 % experienced
4 or more. Overall with increasing numbers of ACEs prevalence of health problems increased.
However, individuals with high resilience scores had lower prevalence of health problems.
Regression analyses indicated that the number of ACEs were slightly more important predictor of
health issues than level of resilience, though both were important. Social economic status,
education level and gender were not significant predictors of the impact of ACEs on person's
health. Conclusion: The results suggest integrated assessment for resilience and ACEs may fa-
cilitate identification of those at higher risk and in need of preventative intervention.

⁎
Corresponding author.
E-mail address: nancy.ross@dal.ca (N. Ross).

https://doi.org/10.1016/j.chiabu.2020.104440
Received 22 September 2019; Received in revised form 24 February 2020; Accepted 27 February 2020
0145-2134/ © 2020 Published by Elsevier Ltd.
N. Ross, et al. Child Abuse & Neglect 103 (2020) 104440

1. Introduction

A systematic search of PubMed will reveal more than 2000 studies conducted in the past decade that demonstrate adverse
childhood experiences (ACEs) are pervasive and associated with the development of numerous physical and psychosocial health
issues across the lifespan (Hughes et al., 2017). Specifically research has demonstrated that the more ACEs a person experiences, the
higher their risk of developing physical health challenges (e.g. chronic stress, increased rates of heart disease, chronic pain and
difficulty sleeping), unhealthy lifestyle behaviours (e.g. severe obesity, a high lifetime number of sexual partners and a history of
having a sexually transmitted disease), mental health challenges (e.g. depressed mood, anxiety, suicide attempts, substance abuse),
and social underachievement (e.g. lower educational achievement and economic productivity) (Anda et al., 2006; Douglas et al.,
2010; Dube et al., 2003; Edwards et al., 2001; Felitti et al., 1998; Logan-Greene, Green, Nurius, & Longhi, 2014; McDonald, Kingston,
Bayrampour, & Tough, 2015).
The largest North American ACEs longitudinal study (Felitti et al., 1998) began in 1998 and explores the relationships between
ACEs and the development of physical and psychosocial health issues in adulthood among 17, 000 participants. This study has found
that 67 percent of the study population had at least 1 ACE and 13 percent of the population had 4 or more ACEs. This research has
also demonstrated that persons who experience 1 ACE are potentially at risk for long term health and social consequences and that
there is a dose-response relationship between the number of ACEs a person has had and the risk for development of physical and
psychosocial health issues in adulthood. For example, when compared with adults reporting no ACEs, persons with a total ACEs score
of 4 are twice as likely to be smokers, 7 times more likely to be alcoholic, at 400 percent increased risk of emphysema and 1200
percent more likely to attempt suicide. Persons with an ACEs score of 6 or higher are at risk of shortening their lifespan by 20 years
(Felitti et al., 1998). Furthermore, a recent meta-analysis that examined the health outcomes of adults with 4 or more ACEs de-
monstrated physical inactivity had the weakest relationship with multiple ACEs (odds ratio of 1.25) (1.03-1-02) while suicide at-
tempts had the strongest relationship (OR 30.13) (14.73–61.67) (Hughes et al., 2017). It is also important to note that different ACEs
can be more impactful than others. For example, Roos et al. (2016) conducted research in a nationally representative sample in the
United States that investigated the link between ACEs and adult incarceration and concluded that childhood typologies with mal-
treatment were specifically associated with adult incarceration. Collectively these studies demonstrate that ACEs are a risk factor for
long term health and psychosocial consequences in adulthood and that individuals with high ACEs scores are at increased risk.
Recognition of the impact of ACEs on physical and psychosocial health led researchers to explore potential interventions that
might mitigate their negative consequences. Numerous preventative interventions have been investigated and, as illustrated in a
recent systematic review, psychosocial approaches can improve mental health and reduce health-risk behaviours in adults with high
ACEs scores (Korotana, Dobson, Pusch, & Josephson, 2016). Unfortunately, despite these opportunities, adults are infrequently
assessed for ACEs in primary care settings and recommendations for assessment and treatment are not described in clinical practice
guidelines (Poole, Dobson, & Pusch, 2018).
One can hypothesize why adults are infrequently assessed for ACEs in primary care settings. First, there is a misunderstanding that
screening for adversity in childhood explores a distal factor that cannot be altered in adulthood. However, research conducted in
primary health care settings in Alberta indicate that emotional regulation and interpersonal difficulties, often a consequence of ACEs,
are modifiable with appropriate treatment (Poole et al., 2018). Second, as described above, the number of people with high total
ACEs scores is considerable. If we were to assign preventative interventions based solely on total ACEs scores it might add con-
siderable burden to our already stressed health care systems. For example, in Nova Scotia approximately 50,000 individuals or 5.4 %
of the population are without a family physician and this percentage increases for individuals living in rural areas (Schneidereit,
2019). Third, not all persons with high total ACEs scores suffer ACEs associated physical and psychosocial health problems in
adulthood and ascribing preventative intervention to persons not truly at risk would be wasteful. Collectively these facts demonstrate
a need for knowledge that would allow more precise prediction of the level of risk a person with a high total ACEs score has. Such
knowledge would support the judicious direction of persons towards preventative interventions and hopefully support the integration
of ACEs assessment into clinical practice.
Recent evidence suggests that persons with high ACEs scores and positive interpersonal traits (i.e. social, emotional, and cognitive
functioning or adaptive coping strategies) are less likely to experience the physical and psychosocial health problems associated with
ACEs (Poole et al., 2018). Findings suggest that such traits serve as protective factors capable of countering the effects of ACEs.
Resilience research demonstrates that beneficial experiences can help persons acquire positive intrapersonal traits. Investigators
have identified several beneficial experiences, such as having a trusted caregiver, healthy attachment bonds, effective parenting
behaviors, and resources within communities and societies, as key contributors to resilience (Narayan, Rivera, Bernstein, Harris, &
Lieberman, 2018). Ungar and Liebenberg (2011) define social-ecological resilience as: 1. The capacity of individuals to navigate their
way to resources that sustain well-being; 2. The capacity of individuals’ physical and social ecologies to provide those resources; and
3. The capacity of individuals, their families and communities to negotiate culturally meaningful ways for resources to be shared
(Ungar & Liebenberg, 2011).
This study examines the associations between total ACEs scores, associated physical and psychosocial health problems and, socio-
ecological resilience (Bellis, Hughes, Leckenby, Perkins, & Lowey, 2014; Dube et al., 2003; Narayan et al., 2018; Roy, Carli, &
Sarchiapone, 2011; Ungar & Liebenberg, 2011), in a rural Nova Scotia population. Specifically it seeks to: 1) Define the types and
extent of ACEs in adult Nova Scotians, attending a family practice health care clinic; 2) Examine associations between the total
numbers of ACEs and physical and psychosocial health issues; and 3) Examine associations between socio-ecological resilience and
physical and psychosocial health problems in persons with high total ACEs scores.
Better understanding of the degree to which socio-ecological resilience might mitigate the physical and psychosocial problems

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commonly experienced by persons with high total ACEs scores may support the development of approaches that allow greater
precision in the determination of actual risk in high total ACEs score individuals (Korotana et al., 2016; McDonald et al., 2015).

2. Methods

2.1. Study population

This study recruited participants over the age of 18 years who attend the Lunenburg Family Health Centre LFHC. The purpose of
the survey was to assess persons ACEs, current ACEs associated physical and psychosocial health problems and, socio-ecological
resilience. The LFHC is a rural collaborative family practice that serves approximately 7000 patients. Lunenburg County is one of 18
counties in Nova Scotia with a population of 47, 591 Lunenburg County Community Fund, 2010). The median age in Lunenburg
County is higher than provincial and national levels at 46.0 years (Lunenburg County Community Fund, 2013). Incomes in Nova
Scotia are lower than the national average and urban residents earn more than rural residents. Fifty-six percent of the people living in
Lunenburg County have either a post-secondary certificate, diploma or university degree (One Nova Scotia, 2013). Average hourly
income rates were $23.65 in Canada; $20.90 in Nova Scotia, and $17.68 in Lunenburg County (Lunenburg County Community Fund,
2010). One in five children live in poverty in Lunenburg County (One Nova Scotia, 2013). In 2012, 31.4 % over 18 were obese, 9.6 %
over 12 years had diabetes and 23.1 % over 12 smoked cigarettes (One Nova Scotia, 2013).

2.2. Study design and materials

This cross-sectional survey was approved by the Research Ethics Board at the Nova Scotia Health Authority. A focus group (n = 4)
of patients at the LFHC was conducted prior to launching the study. Data gained from this focus group was used to ensure that the
survey tools were context appropriate.
Recruitment posters were placed within the LFHC waiting room and individuals were offered a gift card for a local coffee shop as
an incentive for participating. Clerical staff in the clinic provided interested individuals with a consent form, an information letter
describing the study, and the questionnaire.
The survey tool took an average of eight minutes to complete and incorporated previously validated tools for assessing ACEs (The
ACE Questionnaire; Felitti et al., 1998) and socio- ecological resilience (Adult Resilience Measure-12 (Liebenberg, Ungar, & LeBlanc,
2013; Ungar & Liebenberg, 2011)).
The ACE Questionnaire is a 10-item measure and includes the 10 ACEs most commonly reported in the research literature. These
are physical, sexual, emotional abuse, physical and emotional neglect, exposure to domestic violence, household substance abuse,
household mental illness, parental separation/divorce, and having a household member become incarcerated (Felitti et al., 1998).
Participants were asked to indicate which of these ACEs they had and a score indicating their total number of ACEs assigned. The
Adult Resilience Scale-12 is a brief measure of adult resilience was used to measure participants psycho-social resilience. This Likert
scale, derived from the 28-item measure of resilience by Ungar and Liebenberg (2011), is a validated tool for measuring individual’s,
18 years of age and older, socio-ecological resilience. Persons with a total scale score of > 36 are considered to possess good socio-
ecological resilience.
Also included in the survey were socio-demographic questions (age, gender, education level, family size, employment status,
religious affiliation, and place of birth). To assess participants current physical and psychosocial health problems questions informed
by the findings of prior ACEs studies, were included (Anda et al., 2006; Douglas et al., 2010; Dube et al., 2003; Edwards et al., 2001;
Felitti et al., 1998; Logan-Greene et al., 2014; McDonald et al., 2015). For example, participants were asked to indicate if they have
sought treatment for any of the following ACEs associated health problems: high blood pressure, diabetes, irritable bowel syndrome/
Crohn’s disease, chronic pain, back pain, asthma, allergies, chronic fatigue syndrome/fibromyalgia, anxiety disorder, major de-
pressive disorder, alcohol dependency, drug dependency, gambling problems, ischemic heart disease, ulcers, headaches, cancer,
stroke, high-risk sexual behavior, and sleep disturbances.
The survey was conducted for 5 consecutive months beginning in January 2018.

2.3. Data analysis

The internal reliability of the ARM-12 was checked prior to use. Frequencies were calculated for the number of ACEs in the
sample. Correlation analyses (Spearman rho, 95 % CI, one tailed) were used to investigate relationships between study variables. All
data were analysed using SPSS v21 (IBM Corp, 2012).

3. Results

3.1. Participant demographics

Table 1 describes the demographics of the study population. Approximately 65 % of the sample (n = 226) were female. Four
participants did not indicate their gender. The participants ranged in age from 18 to 86 years (x̄ = 48.87, SD = 18.08). Ninety- four
% of the study population were Caucasian.

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Table 1
Participant Demographics.
Sex
Male 75
Female 147
Did not disclose 4
Total 226

Ethnic background
White (Caucasian) 212
First Nations 5
Black 1
Metis 2
Chinese 2
Latin American 1
Other 3

Marital status
Single 47
Married 110
Common-law/live-in 26
Divorced or separated 32
Widowed 9
Did not disclose 2

Highest level of education

No schooling 1
Junior high 3
High school 60
College/Technical instit. 73
Some university 29
Bachelor’s degree 47
Postgraduate degree 12
Did not disclose 1

Born in Canada
Yes 197
No 28
Did not disclose 1

Born in Nova Scotia

Yes 72
No 152
Did not disclose 2

Age
Range: 18 years to 86 years
Average: 48.4 years of age
Mode = 55 years of age
Employment Status
29 % employed full time
6 % unemployed
4 % students
31 % retired
6 % on disability
1 % on maternity leave

3.2. Adult childhood experiences

Seventy-three % of survey respondents reported 1 ACE and 31 % reported 4 or more (Fig. 1). The three types of ACEs most
commonly reported (shown in Table 2) were living with someone who abused drugs and alcohol (39.8 %, n = 90); living with a
household member who was mentally ill or attempted suicide (39.4 %, n = 89) and parents separated or divorced (34.5 %, n = 78).

3.3. Adverse childhood experiences, resilience and health outcomes

A one-tailed correlational analysis was used to test the hypothesis that individuals with low total ACEs scores would report higher
levels of resilience (ARM-12 scores). The results of these analyses are presented in Table 3. We further explored this relationship by
dividing our sample into approximately evenly sized younger and older age groups (18–54 years, 55–86 years). Although the same
significant inverse relationship was found in both groups (p < .001), it was moderately stronger for the younger age group (r =

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Fig. 1. Frequency of Total ACEs Among the Study Participants.

Table 2
Types of ACE Reported by Study Participants.
Type of ACE Number Percentage

Live with someone who abused drugs and alcohol 90 39.8

Member of household mentally ill or attempted suicide 89 39.4
Parents separated or divorced 78 34.5
Verbal abuse and afraid to be physically hurt 74 32.7
Lack of family support and love 72 31.9
Physical abuse 55 24.3
Sexual abuse 52 23
Parent experienced physical abuse 38 16.8
Member of household incarcerated 24 10.6
Neglect 18 8

Table 3
Coefficients for the Model Predicting Overall Health Problems.
Variable Unstandardized Coefficients Standardized Coefficients t Sig. 95.0 % Confidence Interval for B

(B) (Std. Error) (Beta) (Lower Bound) (Upper Bound)

(Constant) 7.06 1.22 – 5.78 < .001 4.65 9.46

ARM-12 total score −.11 .03 −.30 −4.23 < .001 −.15 −.06
ACE total score .45 .08 .37 5.33 < .001 .28 .62
Gender −.45 .40 −.07 −1.13 .26 −1.23 .34
Age .01 .01 .03 .43 .67 −.02 .03
Level of education −.04 .15 −.02 −.28 .78 −.34 .25

-0.61) than the older (r = -0.40). To test the hypothesis that lower total ACEs scores would correlate with better health in adulthood,
we ran a correlational analysis using total ACEs scores and the number of self-reported health issues. The analysis confirmed a
positive relationship (r = .49, p < .001), such that lower total ACEs scores were associated with fewer health problems. When health
problems was divided into physical and psychosocial, positive significant associations were also detected (see Table 4), with psy-
chosocial issues sharing a slightly stronger relationship with total ACEs scores (r = 0.49, p < .001) compared to physical health (r =
0.38, p < .001). Exploration of these relationships based on the age groupings found significantly positive associations in both the

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Table 4
Model Results for Predicting Physical and Psychosocial Health Problems.
Model R R Square Adjusted R Square S.E.

Overall health .585a .342 .324 2.539

Physical health .459a .211 .190 2.132
Psychosocial health .635a .403 .387 .996

older and younger cohorts (p < .001). Again, the relationships were moderately stronger for the younger age group (physical health: r
= 0.41; psychosocial health: r = o.56) relative to the older group (physical health: r = 0.35; psychosocial health: r = 0.39).
We compared the relationship between persons with high total ACEs scores (> 3) and high socio-ecological resilience (> 36) n =
31 against those with high total ACEs scores (> 3) and low resilience (< 36) (n = 55). People with high total ACEs scores and high
resilience reported significantly fewer health problems compared with those who had high total ACEs scores and low resilience (mean
of 6.59 vs 4.94 respectively). Broken down according to physical and psychosocial health problems persons with low resilience and
high total ACEs scores reported more psychosocial issues (x̄ = 1.95 versus 0.97). In persons with high total ACEs scores socio-
ecological resiliency was not associated with difference in physical health issues.
This study also sought to explore the capacity of a model involving total ACEs scores, socio-ecological resilience, and socio-
demographic variables (gender, age, and level of education) to predict the number of reported health issues. The model was sig-
nificant (F = 19.73, p < .001) in predicting a good proportion (32 %) of the variance in reported health issues (Table 2). The
sociodemographic variables were not found to be significant predictors in the model, but resilience (p < .001) and ACEs were
(p < .001), with ACEs being a significantly better predictor (β = 0.37) of health outcomes than resilience (β = -0.30). A similar
outcome was found when the predictors were used in separate models predicting physical and psychosocial health issues (Table 3).
However, although the model predicted 39 % of the variance of psychosocial health issues, it only accounted for 19 % of the variance
for physical health issues.

4. Discussion

As depicted in Fig. 1, 73 % of survey respondents reported one ACE and 31 % reported 4 or more. These results vary significantly
from ACEs surveys in both the United States and Canada where typically the range of survey respondents reporting 4 or more ACEs is
between 13 % (Felitti et al., 1998) and 18 % (Poole et al., 2018).
The three top ACEs most commonly reported in this study (shown in Table 2) were living with someone who abused drugs and
alcohol, a household member who was mentally ill or attempted suicide and parent’s separation or divorced are similar to other
Canadian surveys (McDonald et al., 2015; Poole et al., 2018).
Very few studies have examined the impact of ACEs on the physical and psychosocial health of adults living in rural communities
and as such it is difficult to provide comparison against other Canadian province’s experiences. One can, however, compare these
results against those obtained in urban settings. For example, a study conducted in Calgary examined ACEs in an urban population of
adults at primary care clinics (Poole et al., 2018). When compared to the rural Lunenburg population the frequency of individuals
reporting experiencing at least one ACE were similar. Furthermore, the three most commonly experienced ACEs in both populations
were: having lived with a household member who was depressed, mentally ill or attempted suicide; living with a person who was a
problem drinker or used illicit drugs; and separation or divorce of parents (Poole et al., 2018). Interestingly, reports of experiencing
four or more ACEs were almost double in the rural population, 31 % versus 18.1 %.
However, Iniguez and Stankowski (2016) measured ACEs and health in adulthood among a rural population-based sample in the
United States. They analysed data collected from a telephone survey of 800 participants in rural regions of Wisconsin and found that
overall 62 % reported at least one ACE and 15 % reported four or more. Those reporting four or more ACEs in the Lunenburg study
are more than double in this U.S. rural study, 31 % versus 15 %.
This discrepancy may be attributed in part, to the larger sample size (n = 800) and the fact that this survey was not conducted in
a healthcare facility.
Future studies which examine ACEs across urban and rural populations within a same regional jurisdiction (e.g. province) are
necessary if we are to gain better perspective on the differences between rural and urban experiences.
The social ecological model of resilience suggests that persons who have access to community and relational resources are less
likely to be impacted by adverse experiences (Narayan et al., 2018). The results of this Lunenburg ACEs Study have provided greater
insight into the relationship between resiliency and ACEs suggesting high levels of resilience may act to circumvent the negative
physical and psychosocial consequence of ACEs in adulthood. Specifically, a prognostic model developed through this, albeit small,
dataset has demonstrated that in populations with higher resilience the incidence of negative ACEs associated outcomes is lower. This
model has also shown that age, gender and level of education do not appear to be predictive of ACEs mediated risk. Although based
on a small and homogeneous sample this work demonstrates the potential for such research to support the development of ap-
proaches that might better predict the consequences of ACEs in individuals. Furthermore, given that ACEs are interpersonal one
might hypothesize that interventions grounded in a social-ecological model of resilience may be effective in circumventing the
consequences of ACEs across one’s lifespan.

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5. Limitations

The results from this cross-sectional pilot study, while statistically significant, cannot inform accurate predictions. They do
however provide evidence to support further investigation. A multi-centred cohort study, that engages a larger sample and greater
diversity, might provide evidence that leads to more precise ways of assessing ACEs risk and, support closure of the current
knowledge to practice gap.

6. Conclusions

The association between ACEs and the development of negative physical health and psychosocial issues across the lifespan has
been well established (Hughes et al., 2017). A number of studies have demonstrated intervention programs can reduce these negative
life term consequences of ACEs in adults (Korotana et al., 2016). Despite this vast body of research little effort has been made to assess
adults for past ACEs in primary healthcare settings and then assign them to intervention programs. One of the reasons for lack of
screening for ACEs among adults in primary healthcare may be the recognition of the magnitude of this public health problem.
However, not every individual who experiences ACEs suffers negative physical and psychosocial issues (Narayan et al., 2018).
This pilot study has shown that pairing resilience and ACEs measures better predicts those who may experience significant health
challenges and be in most need of intervention programs. While preliminary, the data clearly demonstrates a resilience effect. Our
findings signal the need for those in the helping professions to engage in the assessment of ACEs. Combining measurement of ACEs
with resilience provides a mechanism of triage to better assess those who are at greater risk and to make informed referrals to
treatment interventions.

Source of funding

Nova Scotia Health Research Foundation.

Acknowledgement

We would like to acknowledge the support of staff at the Lunenburg Family Health Clinic and Dr. Tara Sampalli, Director of
Research and Innovation, Primary Health Care, Nova Scotia Health Authority.

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