This year marks the 20th anniversary of publication in this journal of the first of many articles on the adverse childhood experiences (ACEs) research by Drs. Felitti, Anda, and colleagues. As we celebrate the impact of this seminal research, it is also imperative to assess critically its serious limitations: an unrepresentative study population and narrow operationalization of childhood adversity lead to undercounting adverse experiences and misrepresenting their social distribution. Placing ACEs research—and the movement it has generated—in the wider contexts provided by the social determinants of health framework, and by the rapidly growing biology and neuroscience of early child- hood adversity, can enrich ACEs research and extend its impact to shaping primary prevention policies that address social and economic conditions producing adversity.
The research by Felitti and Anda demonstrated a strong relationship between the number of childhood adversities that a sample of predominantly white, middle-class, adult, Kaiser Permanente patients reported experiencing, and the likelihood of a wide range of health and behavioral outcomes, including chronic diseases, depression, and substance abuse. Their work has catalyzed a large body of research and inspired an influential movement on behalf of trauma-informed institutions and resilience-building efforts. It has been popularized through hundreds of trainings, statewide ACE networks, a formidable web presence through www.acesonnection.com and www.acestoohigh.com, a film (Resilience), and a recently televised 60 Minutes segment with Oprah Winfrey.
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