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Lars Crawford Drugs and Society, Nina Cesare November 20, 2011 Adverse Childhood Experience Theory on Illicit

Drug Use Drug use and abuse is an issue that has been debated for centuries, viewed differently in different cultures with unique social, political, and economic norms, and across different periods of time in history. However, in the article Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study, Shanta R. Dube et al describe a theory of drug use and abuse that seems to stem from a problem that [transcends] secular changes [over time] such as increased availability of drugs, social attitudes toward drugs, and recent massive expenditures and public information campaigns to prevent drug use. The Adverse Childhood Experiences Theory on drug use and abuse was substantiated by Dube and her colleagues through a study conducted in San Diego, California over multiple years. This study surveyed a group of adults, from 4 birth cohorts dating back to 1900, who received a standardized medical and biopsychosocial examination as members of the Kaiser Health Plan at Kaisers Health Appraisal Center, and was conducted in two waves. For the first wave of the study, conducted on members examined between August 1995 and March 1996, a questionnaire was sent out shortly after the examination that contained information and questions on adverse childhood experiences and their current drug use. For the second wave of the study, conducted on members examined between June and October 1997, a similar questionnaire was sent out that included the same and more in depth questions to acquire more thorough information on health topics that seemed to be pertinent upon analysis of wave

one data. As such, only wave two data was analyzed for relevance of adverse childhood experiences on patterns of drug use. An adverse childhood experience (ACE) is defined in their study as one of ten related phenomenon found in households with periodic or chronic familial dysfunction. These include physical, emotional, and/or sexual abuse, physical and/or emotional neglect, parental separation (and divorce), substance abuse, crime, and/or mental illness, and domestic violence. The participants of the study were assigned an ACE score, depending on how many of these experiences they had, which was seen to correlate with lifetime use of illicit drugs, problems with illicit drug use, addiction of illicit drugs, and parenteral drug use. According to the analysis of the study by Dube et al, the underlying cause of illicit drug use explained through this theory can be found in the traumatic childhood experiences of users. The data they collected showed a strong graded relationship between number of ACEs and the risk of young adolescent to adult drug initiation and drug use problems and addiction later in life. As ACEs appear to correlate strongly with drug abuse, Dube et al suggest that pediatricians screen the families of patients that display drug use behavior or symptoms for potential forms of abuse, and household dysfunction in order to treat them. This suggestion is helpful in terms of identifying the problem; however, Dube et al do not go in depth on how a pediatrician could screen a family for such issues or what steps could be taken to treat the child or to help with a stressful home environment. Although this suggestion has little backing, the idea that the problem of drug use and abuse should be targeted at its source, by reducing stressful childhood experiences as opposed to waiting until adulthood when the problem has already developed, is one that will have the most resounding effects. In analysis of the data from this study it seems the process that creates these

ACEs is cyclical in that ones traumatic experiences as a child can manifest themselves once they are a parent, in turn creating a potentially stressful home environment for their own children. If this problem is tackled early on by creating a friendlier and more loving home environment in these households, then the cycle could potentially be disrupted, effectively solving the problem. However this solution is not one that can be implemented easily, as Dube et al point out as pediatricians would need to be trained how to diagnose these symptoms and how to take appropriate action. Besides its limited solutions to the issue of drug use and abuse, this article, as it was written alongside a national study, is very credible. Not only does it have much data to report that help to bolster the claims made, but it also cites similar findings and data by several other studies such as those of the Epidemiologic Catchment Area Study and of Finkelhor et al. Its formal tone and included data tables also add to its credibility by taking a scientific stance that, in itself, leaves little room for debate about its claims. Though it also takes into consideration underestimations based on individuals forgetting all or parts of certain childhood events, this article does little to address counterclaims on drug use. This can be seen in the articles exclusion of information about those who had many ACEs that did not develop drug problems or drug users that had zero ACEs. In addition, the term street drugs, used in all of the questions about the participants current drug use posed in this study, lacks a definition or list of drugs that would qualify. These absences detract from the article by displaying bias against any drug use, as it is implied that all use is abuse. As such, the conclusions made by Dube et al, though extremely relevant to the data that is presented, demonstrate that correlation does not necessarily equal causation.

That being said however, the fact that this correlation of many ACEs with drug problems was found at the same rate of incidence across the 4 age cohorts dating back to 1900 suggests that the effect of these experiences on drug use behavior in individuals is more powerful than the social and cultural changes surrounding drug use, even over a century. That changes in availability of drugs, type of drugs used, and increased drug prevention aims over the past century have had little impact on this correlation indicates that more research should be conducted along these lines in order to understand the relationship between childhood experiences and drug use in later life. Besides this slight bit of bias, Dube and her collgese do make several intuitive analyses of the data such as in mention of parenteral drug use as a result of an individual having multiple ACEs. Though parenteral drug use was grouped with drug problems and addiction in the results of the survey, its inclusion demonstrates awareness, on behalf of the authors, of further problems that could be solved by recognizing this trend within the study. As several diseases, such as hepatitis B and C and HIV, can be transmitted through parenteral drug use, reducing stressful home environments, and thus drug use and abuse, will also help to reduce the transmission of such diseases. This insightful connection made by Dube et al show that, though the article may be a bit implicitly biased against all forms drug use, the conclusions presented are very relevant to not only the data, but the serious consequences of using and abusing certain drugs as well. The relationship of early drug use initiation age to number of ACEs in an individuals life is also shown to be strong according to the data from the study. The issue of age of initiation that is brought to light in this article is one that can be found in multiple different studies on abusive drug use. For example, in a study conducted by the National Institute on Drug Abuse (NIDA) on the age of onset of drug use, Lee N. Robins and Thomas R. Pryzbeck found that the youngest age

cohort (under 15) had the highest life time prevalence [of drug disorders]even though [they had] the fewest years at risk of developing one, such as alcoholism. In contrary however, this study reports that broken homes, with symptoms similar to a stressful home environment described in the ACE study, had little or no predictive power on illicit drug initiation age or patterns of use later in life. Having an alcoholic close relative on the other hand was associated with early onset of drug use, which is ironic as Dube et al refer only to street drugs, of which alcohol is by no definition. However, besides stating what is indicated by the data, Dube et al fail to answer and elaborate on deeper questions surrounding the relationship between early illicit drug initiation and drug use and abuse later in life. The conclusions made by Dube et al about the reasons why adolescents that were exposed to multiple adverse childhood experiences tend to have more problems with drugs and addiction relate to articles written by other prominent authors. Dube et al state that children who had many of these experiences may have feelings of helplessness, chaos, and impermanence and that their illicit drug use in early adolescence and in later life serve as an avenue to escape or dissociate from the deep emotional distress and general discomfort felt as a result. This idea that an individuals drug use is an act of escaping from the realities of life is similar to Samuel Friedmans sociopharmacological theory of drug use. Though Friedman states that disparate socio-economic factors are the root cause of such feelings of despair and anxiety, that both theories use escape as an explanation for illicit drug use indicates that there is potentially some truth behind it. However, that both of these causes are ultimately only signs that an individual may develop drug problems or addiction in later life shows again that correlation does not equal causation.

Another article that has similar concepts to the ACE article is Toby Miller and Marie Legers: A Very Childish Moral Panic: Ritalin. Though the Dube et al article is not about moral panics or Ritalin, the idea that children should be watched closely in a medical setting is very similar in both. However, the Dube et al write only about the protection of youth by society whereas Miller and Leger write about the simultaneous drive by society to protect and exploit youth. Taking this idea of exploitation into consideration thus makes for contradicting policy recommendations by Miller and Leger and Dube et al: that children themselves need to be monitored closely, almost policed, to prevent deviance, and that a childs family needs to be monitored closely to prevent stressful home environments, respectively. In an age where illicit drugs are increasingly easier to find by youths, this idea that new policies need to be put in place, that aim to affect more than just their supply within the United States or that preach complete abstinence, is one that a growing population of people agree with. These policies need to start attacking the problem at its source, taking into account children, their families, and the interactions between them. Trying to help an adult, or change their mind, about their problematic drug use is a very difficult task in itself, but one that is being attempted by society constantly. The problem with this solution though is that it does nothing to reduce demand as it does not prevent the rise of a successive generation of drug users and abusers, allowing the cycle to continue. This is precisely the reason why Dube et al state that the effects of ACEs transcend secular changes in American culture. Aiming efforts towards helping families create a healthy, loving environment for their children, with minimal adverse experiences, will produce adults do not feel the need to escape from society through drug use and abuse, ultimately breaking down the cycle.

As such, the suggestion made by Dube et al to involve pediatricians, who already play the role as family health advisors, further in the lives of children who live in dysfunctional households is very appropriate in that it attempts to change the culture in which drug abuse arises. This article and the associated ACE study pave the way for further studies to be conducted to obtain more information on the effects of childhood experiences on drug use and abuse later in life and to further solutions.

Bibliography: Dube, Shanta R. "Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study." Pediatrics. American Academy of Pediatrics, 2011. Web. 21 Nov. 2011. <http://www.pediatricsdigest.mobi/content/111/3/564.full>.

Robins, Lee N., and Thomas R. Pryzbeck. "Age of Onset of Drug Use as a Factor in Drug and Other Disorders." Etiology of Drug Abuse 56 (1985): 187-92. <http://www.documentacion.edex.es/docs/1101LAReti.pdf#page=187>

Friedman, Samuel. "Sociopharmacology of Drug Use." The American Drug Scene: an Anthology. By James A. Inciardi and Karen McElrath. New York: Oxford UP, 2011. 7179. Print.

Miller, Toby, and Marie C. Leger. "A Very Childish Moral Panic: Ritalin." The American Drug Scene: an Anthology. By James A. Inciardi and Karen McElrath. New York: Oxford UP, 2011. 312-330. Print.