Childhood Adversity Casts a Long Shadow

Megan Brooks

April 30, 2013

Childhood adversity harms children's physical and mental health and ultimately their ability to become competent and productive adults, and it deserves greater attention among physicians and policymakers, a researcher said today during a JAMA media briefing in New York City.

The good news is that if detected and addressed early, the impact of childhood adversity can be reversed, or at least attenuated, said David A. Brent, MD, of the University of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic, in Pittsburgh, Pennsylvania.

"David's lifelong work has been trying to understand the impact of childhood adversities on adolescent and adult life. For me personally, and I expect for him, it's been a gratifying decade, because there's been greater and greater acknowledgment that what happens in childhood has implications for adolescents and adults," said Howard Bauchner, MD, JAMA's editor-in-chief, who moderated the briefing.

Dr. Brent and Michael Silverstein, MD, MPH, of Boston University School of Medicine, are coauthors of a Viewpoint article, "Shedding Light on the Long Shadow of Childhood Adversity," published in the May 1 issue of JAMA, a theme issue on child health.

Lingering Effects

There is "increasingly strong" evidence that early child adversity related to parental psychiatric disorder, poverty, abuse, loss, neglect, or trauma can contribute to many chronic conditions associated with premature death, including smoking, substance abuse, obesity, cardiovascular disease, depression, and attempted suicide, Dr. Brent said.

It is thought that early adversity leads to epigenetic changes that can contribute to immune dysfunction, insulin resistance, and cognitive difficulties, which in turn lead to risky behavior and predispose to emotional instability and depression.

Individuals who suffer early adversity are burdened not only with a greater risk for chronic illness but also with an impaired ability to self-manage their condition, to engage in collaborative management, and to form trusting relationships with health providers, Dr. Brent explained. Eliminating childhood adversity would take a "huge bite" out of high-risk behaviors and chronic illness, he said.

A study published in the American Journal of Psychiatry in 2008 found that successful treatment of maternal depression leads to decreased psychiatric symptoms and improved functioning in offspring, Dr. Brent and Dr. Silverstein point out in their article.

A study in JAMA in 2003 found that economic interventions that provide local employment and that move parents out of poverty decreased risk for behavioral disorders in the children of the assisted families.

And a study in Pediatrics this year found that earlier foster placement can help reverse the harmful neurobiological and cognitive effects of extreme deprivation in infancy.

Dr. Brent and Dr. Silverstein say that what is now known about early adversity and its sequelae have important implications for research, practice, and policy.

"With regard to research, a better understanding of the pathoplastic effects of adversity, definition of the critical periods when such effects are particularly deleterious, and identification of effective approaches to their remediation or prevention are warranted," they write.

Call to Action

"We really should be addressing" childhood adversity in routine clinical care, Dr. Brent told reporters.

"Physicians must be taught about the effects of adversity, how to detect it, and what steps to take once identified. Screening, referral, and monitoring of the presence of adversity and its effects early in the child's life may prevent or attenuate the destructive multigenerational effects of dysfunctional parenting that occur as a consequence of untreated psychiatric disorder," Dr. Brent and Dr. Silverstein write in their article.

They call on physicians to be "advocates for social policies that can help families achieve what all parents want — a secure environment for their children to develop into competent adults."

"The economic cost — in excess health care utilization, nonresponse to treatment, incarceration, loss of employment, decrease in productivity, and disability — weighs heavily on families burdened with adversity but ultimately is borne by society as a whole. In the drive to improve quality of health care and contain costs, the huge price tag to society of early adversity cannot be neglected. Through research, clinical care, and advocacy, physicians can shine a light on the dark shadow of adversity and diminish its reach from generation to generation. Society can either invest in combating the effect of adversity on families now, or pay later," the investigators conclude.

Dr. Brent and Dr. Silverstein were supported by an endowed chair in suicide studies and grants from the National Institute of Mental Health. Dr. Brent reports receiving royalties from Guilford Press and from the electronic self-rated version of the Columbia Suicide Severity Rating Scale from ERT (eResearch Technology), receiving honoraria from Oxford Press, and serving as a psychiatry editor for UpToDate. Dr. Silverstein and Dr. Bauchner have reported no relevant financial relationships.

JAMA. 2013;309:1777-1778. Abstract

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