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Child Abuse & Neglect 34 (2010) 842855

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Child Abuse & Neglect

Adverse childhood experiences (ACE) and health-risk behaviors among


adults in a developing country setting
Laurie S. Ramiro a, , Bernadette J. Madrid b , David W. Brown c
a
b
c

Department of Behavioral Sciences, College of Arts and Sciences, University of the Philippines Manila, Padre Faura st., Ermita, Manila, Philippines
Child Protection Unit, Philippine General Hospital, University of the Philippines Manila, Ermita, Manila, Philippines
Decatur, GA, USA

a r t i c l e

i n f o

Article history:
Received 23 May 2009
Received in revised form 19 February 2010
Accepted 25 February 2010

Keywords:
Adverse childhood experiences
Health-risk behaviors
Chronic diseases
Developing country
Philippines

a b s t r a c t
Objective: This study aimed to examine the association among adverse childhood experiences, health-risk behaviors, and chronic disease conditions in adult life.
Study population: One thousand and sixty-eight (1,068) males and females aged 35 years
and older, and residing in selected urban communities in Metro Manila participated in the
cross-sectional survey.
Methods: A pretested local version of the Adverse Childhood Experiences Questionnaires
developed by the Centers for Disease Control and Prevention, USA, was used. Data were
collected through self-administration of the questionnaire. Prevalence and estimates of
odds ratio were computed to obtain a measure of association among variables. Logistic
regression analysis was employed to adjust for the potential confounding effects of age,
sex, and socio-economic status.
Results: The results indicated that 75% of the respondents had at least 1 exposure to adverse
childhood experiences. Nine percent had experienced 4 or more types of abuse and household dysfunctions. The most commonly reported types of negative childhood events were
psychological/emotional abuse, physical neglect, and psychological neglect of basic needs.
Majority of respondents claimed to have experienced living with an alcoholic or problem
drinker and where there was domestic violence. Health-risk behavior consequences were
mostly in the form of smoking, alcohol use, and risky sexual behavior. The general trend
shows that there was a relatively strong graded relationship between number of adverse
childhood experiences, health-risk behaviors, and poor health.
Conclusion: This study provided evidence that child maltreatment is a public health problem even in poorer environments. Prevention and early intervention of child maltreatment
were recommended to reduce the prevalence of health-risk behavior and morbidity in later
life.
2010 Published by Elsevier Ltd.

Introduction
Much is known about the lifetime effects of childhood trauma. An earlier review of the literature by Browne and Filkenhor
(1986) shows that depression, feelings of isolation and stigma, poor self-esteem, distrust, substance abuse, and sexual maladjustment are the most frequently reported long-term effects of child abuse and neglect. More recent ndings point to the

Research supported by the Prevention of Violence, Department of Injuries and Violence of the World Health Organization through its coordinator, Dr
Alex Butchart, World Health Organization-Philippines, and the Department of Health.
Corresponding author.
0145-2134/$ see front matter 2010 Published by Elsevier Ltd.
doi:10.1016/j.chiabu.2010.02.012

L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842855

843

same consequences but include a variety of other psychopathological disorders such as suicide, panic disorder, dissociative
disorders, post-traumatic stress disorder, and antisocial behaviors (Bensley, Van Eenwyk, & Simmons, 2000; De Bellis, &
Thomas, 2003; English, Widom, & Brandford, 2004; Johnson & Leff, 1999; Sher,Walitzer, Wood, & Brent, 1991; Silverman,
Reinherz, & Giaconia, 1996; Springer, Sheridan, Kuo, & Carnes, 2007; Teicher, 2000; Zeitlen, 1994). Child abuse and neglect
also result in impaired brain development with long-term consequences for cognitive, language, and academic abilities
(Watts-English, Fortson, Gibler, Hooper, & De Bellis, 2006; Zolotor, Kotch, Dufort, Winsor, & Catellier, 1999).
In particular, many of the past studies focused on the prospective impact of sexual abuse (Beitchman et al., 1992; Briere
& Runtz, 1988; Finkelhor, Hotaling, Lewis, & Smith, 1990; Windle, Windle, Scheidt, & Miller, 1995, to name a few). Jejeebhoy
and Bolt (2003) found that those who experience coercive sex are more likely to experience both subsequent non-consensual
sex and risky consensual sexual behaviors including abortion in adolescence and early adulthood. Child sexual abuse was
shown to be associated with lifetime risks of depression, alcohol or drug dependence, panic disorders, post-traumatic stress
disorders, and suicides (Dube et al., 2001, 2005). Furthermore, adult women with a history of childhood sexual abuse show
greater evidence of sexual disturbance or dysfunction, homosexual experiences in adolescence or adulthood, and are more
likely than non-abused women to be re-victimized. Beitchman et al. (1992) afrmed that the extent of impact depends on
the duration of abuse and the threat or use of force. Moreover, greater harm is inicted if the father (or stepfather) is the
perpetrator and if sexual abuse involves penetration.
Similarly, physical maltreatment can result in bruises, broken bones, visual and auditory impairment, brain damage,
contusions, burns, and death (Oates, 1996). In particular, the violent shaking of a baby (Shaken Baby Syndrome) has been
found to be associated with bleeding of the brain, which may lead to permanent, severe brain damage or death (National
Institute of Neurological Disorders & Stroke, 2001). Physical maltreatment was also found to be associated with an array of
psychological problems that include major depression, alcohol dependence, and externalizing problems (Brownridge, Cox,
& Sareen, 2006; Miller-Perrin, Perrin, & Kocur, 2009). In addition, adults who were physically maltreated during childhood
are at increased risk of harming their own children who, in turn, tend to exhibit insecure attachment patterns (Belsky,
1993; Kaufman & Zigler, 1987; Newcomb & Locke, 2001; Simons, Whitbeck, Conger, & Wu, 1991; Van Ijzendoorn, 1995).
Adolescents with a history of physical maltreatment may even participate in dating relationships that are characterized by
violence as well (Wekerle & Wolfe, 1998; Wekerle et al., 2001).
Akin to physical violence and sexual abuse, psychological maltreatment appears to be as destructive as it puts its victims
at equal risk of developing physical and mental health problems (Egeland & Erickson, 1987; OLeary, 1999). Individuals who
underwent psychological abuse are more prone to develop chronic physical and mental illnesses such as depression, injury,
drug addiction, and alcoholism (National Research Council, 1996; Tomison & Tucci, 1997). Psychological maltreatment may
also result in poor self-esteem that may lower capacities to combat the effects of future abusive events (Walker, 1994).
In the Philippines, a community study indicated that depression, feelings of embarrassment, suicidal ideations, and having
broken families are most common among psychologically abused men and women (Philippines Department of Health, 2000a,
2000b).
Directly or indirectly, household insufciencies and dysfunctions may also lead to negative psychosocial and health
outcomes (Flaherty et al., 2006; Springer et al., 2007). Such household insufciencies include general poverty specic to
lack of basic necessities such as food, shelter, clothing, education, and health. Children from families that report multiple
experiences of food insufciency and hunger are more likely to show behavioral, emotional, and academic problems than
children whose families do not report such conditions in life (Kleinman et al., 1998). Moreover, household dysfunctions such
as living with a family member who is an alcoholic, drug addict, mentally ill, or one who has been incarcerated for certain
crimes and offenses may also inuence future life outcomes. For instance, children with family histories of substance abuse
had higher levels of aggression, delinquency, sensation-seeking, hyperactivity, impulsivity, anxiety, negative affectivity, and
difculties in self-differentiation compared to children with no such histories (Dore, Kauffman, Nelson-Zlupko, & Gran-fort,
1996; Giancola & Parker, 2001; Maynard, 1997). Family history of alcohol dependence has also predicted poor adolescent
neuropsychological functioning (Anda et al., 2006; Dube et al., 2006; Tapert & Brown, 2000). The same is true with situations
where a child grew in a family where domestic violence is a common experience, or where parents are separated or divorced.
Studies have shown that children who lived under an environment of domestic violence exhibit clinical levels of anxiety
or post-traumatic stress disorder (Graham-Bermann & Levendosky, 1998). These children are at signicant risk for law
breaking, substance abuse, school inattendance, and relationship problems.
Aside from its psychosocial consequences, child abuse and neglect have become a serious public health problem. The
health outcomes usually occur in highly inter-related forms. A strong, graded relationship between the number of adverse
experiences in childhood, and self-reports of cigarette smoking, alcoholism, drug abuse, obesity, attempted suicide, and
sexual promiscuity in later life was reported (Anda et al., 1999; Dietz et al., 1999; Felitti et al., 1998). Similarly, the likelihood
that a person develops physical and mental health conditions such as heart disease, cancer, and depression in adulthood is
greater, the more childhood adverse experiences were experienced (Chapman et al., 2004; Dong, Anda, Dube, Felliti, & Giles,
2003; Dong et al., 2005; Hillis, Anda, Felliti, Nordenberg, & Marchbanks, 2000).
In reality, child abuse and neglect do not usually occur as single incidents but rather, they are experienced repeatedly
and simultaneously in various forms (Trickett, 1998). The experience of multiple types of maltreatment is associated with
greater impairment than experiencing a single form of maltreatment (Higgins & McCabe, 2000). Child maltreatment can
become recurrent or repetitive, especially if the child is not withdrawn from the same environment where initial abuses
occurred. This is also compounded by the fact that in some cultures, parents and other caregivers regard physical punishment

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L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842855

and psychological reprimands as a necessary form of discipline for their children (Lansford & Dodge, 2008; Orhon, Ulukol,
Bingoler, & Gulnar, 2006; Plan Philippines, 2005).
Current knowledge of the effects of negative life events in childhood is mostly focused on experiences in the developed
world. Very few pieces of evidence in developing countries are noted. Denitely, poverty and associated environmental and
social concerns serve as compounding factors that prevent children in developing countries from attaining their maximum
potential. Walker et al. (2007) posited that stunting, nutrition and inadequate cognitive stimulation which are common
among children in developing countries, entail exposure to several factors including less opportunities for learning, polluted
environment, heavy metal poisoning, and household crowding.
The Philippines is one country in the developing world with fewer resources for health but with a high prevalence of
infectious and non-communicable diseases such as TB, cardiovascular diseases, cancers, unintentional injuries, and diabetes
(Philippine Health Statistics, 2009). The prevalence of smoking is high at 40%, and alcohol use at 37% among male youth
(Domingo & Marquez, 1999). Moreover, the number of abused children reported to the Department of Social Welfare and
Development increased 5-fold from 1998 to 2002, although in a population-based study (BSNOH, 2000), it was reported
that nearly 90% of the 2,700 adolescent-respondents claimed to have been physically maltreated while about 60% were
psychologically abused at least once in their lifetime. About 12% reported having been sexually molested. The main question,
therefore, is: In the Philippine setting, are these statistics interrelated? How, if at all, do these ndings relate to one another?

Objectives of the study


This study aimed to determine the interrelationship among adverse childhood experiences, health-risk behaviors and
health outcomes in a developing country setting. It sought to examine associations among a number of adverse childhood
experiences and health-risk behaviors. Associations between childhood trauma and occurrence of common major diseases
were also studied.

Methodology
Research design
This general population survey made use of the cross-sectional design to assess signicant associations among adverse
childhood experiences, health-risk behaviors and the occurrence of certain diseases during adulthood. It was conducted in
selected urban barangays (villages) in Quezon City in Metro Manila from September to November 2007.

Study population and sampling scheme


The study population consisted of 535 males and 533 females, aged 35 years and older, residing in the sample urban
barangays in Quezon City. From each community, sample households were chosen randomly using systematic sampling.
Sample households were given equal probabilities of being selected.
In each selected household, a household roster was initially established. The names, sex, and age of all household members were taken where eligible respondents were marked. From all eligible household members, the nal respondent was
randomly chosen using a Kish table. Only one respondent was drawn from each household. If the selected household member
was not available during the visit, an appointed date of interview was made either by phone, or through another household
member. If the selected household member refused to participate or was not available for interview after three callbacks,
another eligible household member was randomly drawn.
To produce a statistically valid sample, 1,068 respondents (d = 0.03, p = 50%, CI = 95%) were asked to participate in the
study. Almost an equal number of males and females from different socio-economic classes were represented.

Instrumentation
The Adverse Childhood Experiences (ACE) Questionnaires were used for this study (Centers for Disease Control and
Prevention, 2008). These questionnaires, developed by the US Centers for Disease Control and Prevention and Kaiser Permanente in 1997, came in separate versions for male and female respondents and was composed of two parts: Family Health
History questionnaire and Physical Health Appraisal questionnaire (www.cdc.gov/nccdphp/ace).
The Family Health History questionnaire consisted of 68 questions examining various types of child maltreatment,
childhood adversities rooted in household dysfunctions, and other risk factors.
The Physical Health Appraisal questionnaire had questions on the respondents self-rated health, and items asking about
a history of ischemic heart disease, any cancer, stroke, COPD, diabetes, hepatitis or jaundice, any skeletal fractures, and other
types of diseases and pains.
The ACE Questionnaires were translated into the Filipino language, and were pre-tested among Filipino adult samples.

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Data collection
As approved by an ethical review board, data-collection conformed to certain technical and ethical standards appropriate
to the study setting. Interviewers experienced in conducting child abuse studies were recruited for this study. They were
oriented and trained with regard to data-collection using the ACE questionnaires. Aside from sampling issues, ethics as well
as data quality assurance were part of their training.
In the context of the Filipino culture, talking face-to-face about adverse childhood experiences, especially with regard to
sexual abuse, sexual promiscuity and to some extent, illegal drug use, may be taboo or may encourage a social desirability
bias. Such a behavior may be due in part to the cultural emphasis on social acceptance (pakikisama, pakikipagkapwa)
as well as the common Filipino trait of being non-confrontational in negotiating with issues in the social environment
(Enriquez, 1978; Rodell, 2002). Hence, this household survey made use of the self-administered data-collection strategy. The eld assistant started by introducing the objectives and mechanics of the study, and also assured the would-be
respondents that all their responses will be kept with utmost condentiality, and that there was no way that they could
be identied since answers from all respondents would be analyzed as group data. Respondents were also told that they
would be given privacy in answering the questions. Participation in the study was made known to be voluntary, and if
respondents could refuse or discontinue participation and the researcher would respect that decision. After all questions
from respondents were answered, they were asked to sign an informed consent form, which consisted of statements noting respondents fully understood the purpose and mechanics of the survey and acknowledged their participation was
voluntary.
For those who agreed to participate, eld assistants distributed a sealed envelope containing the ACE questionnaire. Each
respondent was then respectfully asked to go to a private place in the house and answer the questions by herself/himself.
The eld assistant told respondents that he/she would be around to clarify any questions or concerns. For respondents who
found it difcult to read and/or write, eld assistants asked if he/she could do the reading and/or writing for the respondent.
Those who refused with this system were dropped and were replaced by another randomly sampled eligible respondent
from the same household. In case respondents felt that home was not the best place to answer the questionnaire, they were
given the freedom to choose the venue, where they were accompanied by the eld assistant. To encourage more openness,
the gender of both respondent and eld assistant was matched such that male respondents were attended to by male eld
assistants; and female respondents, by female eld assistants.
Upon submission of the questionnaire to the eld assistant, the latter, in front of the respondent, went quickly through
the completed forms to see if all questions were answered. If not, the eld assistant asked the respondent to reconsider
responding to the unanswered items. Once again, the eld assistant re-assured the respondents of the condentiality of
their answers.
Data analysis
The prevalence of adverse childhood experiences and health-risk behaviors were determined. Estimates of odds ratio
were computed to obtain a measure of association between adverse childhood experiences and health-risk behaviors, as well
as with chronic disease conditions. Logistic regression analysis was employed to adjust for the potential confounding effects
of age, sex, and socio-economic status on the relationship among adverse childhood experiences, health-risk behaviors, and
chronic health conditions.
Results
Socio-demographic characteristics of respondents
A total of 1,068 respondents agreed to participate in the survey. An almost equal number of male and female respondents
from different socio-economic classes were noted. The mean age of the respondents was 46.7 9.2 years. Only 12% had no
school attendance while 44% were not working at the time of the survey (Table 1).
History of exposure to adverse childhood experiences
Among the various types of childhood abuse, psychological and physical neglect of needs as well as psychological/emotional abuse were the most commonly reported forms of childhood adverse experiences (Table 2). In terms of
neglect, almost half felt they had never been loved while about a fourth felt they had not been taken cared of. About 23% of
respondents reported that they were psychologically abused as they were often or very often insulted, swore at, or threatened when they were children. Five percent claimed to be sexually abused or molested. Surprisingly, only a small proportion
(1.3%) of the 1,068 respondents reported having been physically maltreated.
Among the household dysfunctions, a third (36.2%) of respondents experienced living with an alcoholic or problem
drinker. About 18% saw their mother being treated violently. Ten percent had separated parents.
Overall, 75% of the respondents (women = 74.5%; men = 72%) had at least 1 exposure to adverse childhood experiences.
About 9% had experienced 4 or more types of childhood abuse. Those who experienced 4 or more categories of exposure

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L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842855


Table 1
Socio-demographic characteristics of 1,068 study participants, Philippines, 2007.
Characteristic

n (%)

Age in years, mean (SD)


3539
4044
4554
5592

46.7 (9.2)
298 (27.9)
224 (21.0)
317 (29.7)
229 (21.4)

Gender
Men
Women

535 (50.1)
533 (49.9)

Civil status
Married
Not married but with live-in partner
Widowed/separated
Single, never married

788 (73.8)
80 (7.5)
96 (9.0)
104 (9.7)

Socioeconomic classa
Lower
Middle
Upper

378 (35.4)
380 (35.6)
310 (29.0)

Education
No formal high school attendance
Some high school
High school graduate
Vocational graduate/some college
College graduate

129 (12.1)
75 (7.0)
272 (25.5)
254 (23.8)
338 (31.7)

Work status
Full-time (35 hours per week)
Part-time (<35 hours per week)
No paid work

415 (38.9)
179 (16.8)
474 (44.4)

a
Socioeconomic class was dened according to residence location/type of dwelling (i.e., respondents residing in
publicly acknowledged (a) exclusive Class A & B villages (upper class), (b) Class C subdivisions (middle class), (c) slum
areas (lower class). One qualier was that they should be owners of the residential house.

were mostly males, aged 3539 years, married, belonging to the lower socio-economic class, high school level, and those
with no paid work.
Interrelationships among categories of adverse childhood experiences
Table 3 shows the interrelationships among categories of adverse childhood experiences. More than half of the respondents who had experienced all categories of abuse (psychological, physical, and sexual) also felt psychologically neglected
(i.e., felt that they were not loved). Similarly, among those who have been physically maltreated, 92.9% also experienced
emotional or psychological abuse. Psychological neglect cuts across all forms of abuse and household dysfunctions. The most
common household dysfunctions experienced by those who were exposed to childhood abuse were alcohol use and domestic violence (i.e., mother treated violently). There was a high co-occurrence between domestic violence and physical and
sexual abuse. About 64% of those who reported physical abuse and 41.1% of those who reported sexual abuse also reported
witnessing domestic violence. The same triad of psychological abuse, feelings of not being loved and feelings of physical
neglect, were common among those who experienced dysfunctional households. Many of those who reported to come from
households with members who are mentally ill or illicit drug users also claimed to be psychologically neglected. Having an
incarcerated family member was associated with alcohol abuse in 61.5% of cases.
Prevalence and odds of health-risk behaviors by type of adverse childhood exposures
Table 4 indicates that smoking and alcohol use were most common health-risk behavior consequences. A third of the
1,068 respondents reported to be smokers at the time of the survey where 12% initiated smoking at age 15 or younger.
Similarly, 36.5% of the 1,068 respondents claimed to be current drinkers. Among these, 5.5% reported to have driven a car
while drunk. About 12% had ever used illicit drugs. In terms of risky sexual behavior, almost 10% had engaged in early sex
and 18% had sex with 3 or more partners. About 13% got pregnant at age 18 years or younger, and a third were considered as
unintended rst pregnancies. Other health-risk behaviors were being obese or overweight (10.7%), and attempted suicide
(3.8%).
Adjusting for age, sex, and socio-economic status, Table 4 also shows that early smoking and use of illicit drugs were
common among individuals who had been physically maltreated, psychologically abused, and sexually abused during childhood. In addition, those who were psychologically and sexually abused were more likely to also have sex with multiple

L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842855

847

Table 2
Denition and prevalence of adverse childhood experiences (ACEs) during the rst 18 years of life by sex: Philippines, 2007.
Categories

Women, %
(n = 533)

Childhood Abuse
Psychological/Emotional (Did a parent or other adult in the household . . .)
19.3
(1) Often or very often swear at you, insult you, or put you down?
(2) Sometimes, often, or very often act in a way that made you feel that you might be physically hurt?

Men, %
(n = 535)

Both, %
(n = 1068)

26.4

22.8

Physical (Did a parent or other adult in the household . . .)


(1) Often or very often push, grab, slap, or throw something at you?
(2) Often or very often hit you so hard that you had marks or were injured?

1.5

1.1

1.3

Sexual (Did an adult or person at least 5 years older ever . . .)


(1) Touch or fondle you in a sexual way?
(2) Have you touch their body in a sexual way?
(3) Attempt oral, anal, or vaginal intercourse with you?
(4) Actually have oral, anal, or vaginal intercourse with you?

6.0

4.5

5.2

21.2

23.7

22.5

42.8

44.5

43.6

8.4

6.7

7.5

35.8

36.5

36.2

7.1

5.4

6.2

13.5

21.9

17.7

4.3

5.2

4.8

11.8

8.2

10.0

25.5
27.2
21.6
11.4
8.3

28.0
22.2
16.1
16.3
10.1

26.8
24.7
18.8
13.8
9.2

Physical neglect
(1) Ever did not have enough to eat?
(2) Ever had to wear dirty clothes?
(3) Someone to take you to the doctor if you needed it?
Psychological neglect
(1) Never felt loved
(2) Ever felt that someone in your family hated you?
(3) Ever thought your parents wished you had never been born?
Household dysfunctions
Illicit drug use
(1) Live with anyone who used street drugs?
Alcohol abuse
(1) Live with anyone who was a problem drinker or alcoholic?
Mental Illness
(1) Was a household member depressed or mentally ill?
(2) Did a household member attempt suicide?
Mother treated violently (Was your mother (or stepmother) . . .)
(1) Sometimes, often, or very often pushed, grabbed, slapped or had something thrown at her?
(2) Sometimes, often, or very often kicked, bitten, hit
with a st, or hit with something hard?
(3) Ever repeatedly hit over at least a few minutes?
(4) Ever threatened with or hurt by a knife or gun?
Incarcerated household member
(1) Did a household member go to prison?
Parental separation or divorce
(1) Were your parents ever separated or divorced?
Categories of adverse childhood experiences, Number
0
1
2
3
4 or more

Respondents were dened as exposed to a category if they responded yes to one or more of the questions in that category.

partners, experience rst unintended pregnancy, and attempt suicide. In particular, those who were sexually abused were
12 times more likely to engage in early sex, 9 times more likely to have early pregnancy, and 5 times more likely to attempt
to commit suicide.
Moreover, childhood physical neglect was associated with a two-fold increased likelihood that the individual would use
alcohol and illicit drugs during adolescence or adulthood, and attempt to smoke early in life. Individuals who had felt that
they were not loved during childhood were almost twice more likely to smoke, use illicit drugs, have early sex, and have
multiple sex partners.
Having a family member who either used illicit drugs, had a mental illness, or had been incarcerated increased the odds
for several risky behaviors. Those who lived with a family member who used illicit drugs were 3 times more likely to use
illicit drugs themselves, and had a 5-point chance of attempting suicide. Similarly, individuals who lived with a mentally ill
household member were 5 times more likely to use illicit drugs, about 4 times more likely to be sexually risky, and have 12
times probability of attempting to commit suicide.
The odds that an individual would smoke early, use alcohol, use illicit drugs, be sexually risky, and be pregnant early
were also found signicantly high if the mother had been treated violently. Moreover, a person with an incarcerated family
member was 5 times more likely to use illicit drugs. Coming from a broken home where parents were separated may also

848

Table 3
Relationship between categories of adverse childhood exposures, Philippines, 2007.

Sample
sizea

Psych
Abuse

Phys
Abuse

Sexual
Abuse

Physical
Neglect

Psych
neglect

Drug
use

Alcohol Mental
Illness

Mother
Violence

Childhood abuse
Psychological abuse
Physical abuse
Sexual abuse
Physical neglect
Psychological neglect

244
14
56
240
466

92.9*
37.5
42.1
37.8

5.3

3.6
3.7
2.8

8.6
14.3

7.9
6.4

41.4
64.3
33.9

33.5

72.1
92.9
53.6
65.0

11.9
14.3
19.6
10.8
10.5

49.6
50.0
41.1
50.8
43.8

9.0
14.3
19.6
11.3
10.1

37.3
64.3
41.1
28.7
25.7

7.0
28.6
12.5
9.6
6.4

Household dysfunction
Illicit drug use
Alcohol abuse
Mental illness
Mother treated violently
Incarcerated HH member
Parental separation

81
386
67
189
51
107

35.8
31.3
32.8
48.1
34.6
34.6

2.5
1.8
3.0
4.8
7.7
1.9

13.6
6.0
16.4
12.2
13.5
7.5

32.1
31.6
40.3
36.5
44.2
33.6

60.5
52.9
70.1
63.5
59.6
55.1

11.4
20.9
11.6
21.1
16.8

54.3

43.3
46.6
61.5
46.7

17.3
7.5

7.9
25.0
10.3

27.2
22.8
22.4

34.6
30.8

13.6
8.0
13.6
9.0

6.5

See Table 2 for denitions of adverse childhood exposures.


a
Number exposed to rst category. For example, among persons who were physically abused, 92.9% also experienced psychological or emotional abuse.

Prison Parent
Divorce

Any 1
additionl
category

Any 2
additionl
categories

15.2
14.3
14.3
15.0
12.7

93.9
100.0
83.9
91.7
80.3

75.8
100.0
75.0
71.7
54.3

22.2
12.9
16.4
17.5
13.5

93.8
77.5
95.5
92.6
94.1
85.1

79.0
54.7
77.6
73.5
74.5
60.7

L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842855

First category of childhood exposure Percent (%) exposed to another category

Current
smoker

Early
smoking
initiation
(15 years
or younger)

Current
alcohol use

Driving
drunk

Illicit drug
use

Early sex
(age 16 or
younger)

Multiple
partners
(>3)

Early
pregnancya

Unintended
Pregnancya

(age < 18 years)


Prevalence, % (n)
30.0 (320)
Psychological abuse
1.7 (1.22.3)
Physical maltreatment
2.8 (0.98.7)
Sexual abuse
1.9 (1.03.4)
Physical neglect
1.1 (0.81.5)
Psychological neglect
1.3 (1.01.7)
Illicit drug use
2.3 (1.43.7)
Alcohol abuse
0.8 (0.61.1)
Mental illness
1.4 (0.82.5)
Mother treated violently 1.3 (0.91.9)
Incarcerated HH member 1.6 (0.82.9)
Parental separation
1.4 (0.92.2)

12.0 (128)
36.5 (390)
5.5 (59)
2.1 (1.43.2)
1.0 (0.71.4)
1.2 (0.72.2)
11.2 (2.942.6) 1.1 (0.34.2) NA
2.1 (1.04.7)
1.4 (0.72.9)
1.7 (0.64.8)
1.6 (1.12.5)
2.1 (1.53.1)
1.4 (0.72.7)
1.8 (1.22.6)
1.2 (0.91.6)
0.9 (0.51.6)
1.8 (0.93.5)
1.1 (0.62.0)
1.2 (0.43.3)
1.4 (0.92.1)
1.2 (0.81.6)
0.9 (0.51.6)
1.4 (0.63.0)
1.1 (0.62.0)
2.3 (0.95.9)
2.4 (1.63.7)
1.7 (1.22.6)
1.3 (0.72.5)
0.7 (0.31.8)
1.6 (0.83.1)
1.0 (0.33.6)
2.1 (1.23.9)
1.7 (1.02.7)
1.1 (0.52.8)

Odds ratios adjusted for age, sex, SES, education.


a
Among 533 women.

12.1 (129)
9.5 (101)
18.3 (196)
2.1 (1.33.1)
1.1 (0.71.8)
2.1 (1.53.0)
3.8 (1.014.4) 1.5 (0.37.0)
2.8 (0.99.1)
2.9 (1.45.9) 11.6 (6.321.4) 2.6 (1.44.9)
2.0 (1.33.2)
1.0 (0.61.7)
1.9 (1.32.7)
1.6 (1.12.3)
1.5 (1.02.3)
2.0 (1.52.7)
3.1 (1.75.6)
1.1 (0.52.4)
1.8 (1.03.0)
1.4 (0.92.1)
1.1 (0.71.8)
1.1 (0.81.5)
5.1 (2.69.7)
3.8 (2.07.1)
2.3 (1.34.1)
1.7 (1.12.7)
1.2 (0.72.0)
1.5 (1.02.1)
5.0 (2.510.0) 1.0 (0.42.5)
1.1 (0.62.2)
2.1 (1.23.8)
1.6 (0.92.9)
1.7 (1.12.7)

12.6 (67)
34.9 (186)
0.8 (0.41.6)
2.2 (1.43.4)
2.0 (0.410.8) 1.2 (0.35.0)
8.5 (3.918.6) 1.1 (0.52.2)
0.9 (0.51.8)
1.6 (1.02.4)
0.7 (0.41.3)
1.2 (0.91.8)
0.5 (0.21.9)
2.0 (1.13.7)
1.0 (0.61.7)
1.3 (0.91.8)
3.8 (1.78.2)
2.3 (1.24.4)
2.1 (1.14.1)
1.5 (0.92.4)
0.9 (0.23.2)
2.1 (0.94.9)
1.0 (0.42.3)
2.1 (1.23.5)

Weight

Suicide
attempt

>170 lbs
10.7 (114)
1.1 (0.71.7)
0.7 (0.15.7)
2.2 (1.04.8)
1.0 (0.61.7)
1.0 (0.71.5)
1.8 (0.93.6)
0.9 (0.61.4)
0.6 (0.21.6)
1.1 (0.71.9)
0.9 (0.32.4)
1.3 (0.72.4)

3.8 (41)
2.1 (1.14.1)
2.1 (0.316.9)
5.2 (2.212.3)
1.8 (0.93.6)
5.0 (2.310.5)
4.6 (2.29.7)
1.7 (0.93.2)
11.9 (5.923.9)
1.8 (0.93.9)
2.4 (0.87.2)
1.4 (0.63.6)

L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842855

Table 4
Prevalence and adjusted relative odds of health-risk behaviors by type of adverse childhood exposures, Philippines, 2007.

849

850

L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842855

Table 5
Prevalence and adjusted relative odds of health-risk behaviors by number of adverse childhood exposures, Philippines, 2007.
Health-risk behavior

Number of adverse childhood exposures


1 (n = 264)

2 (n = 201)

3 (n = 148)

>4 (n = 169)

Current smoker

Prevalence, %
OR (95% CI)a

None (n = 286)
26.9
1.0 (referent)

25.0
1.0 (0.71.5)

27.9
1.1 (0.71.8)

35.1
1.3 (0.82.1)

40.8
1.7 (1.12.7)

Early smoking initiation

Prevalence, %
OR (95% CI)a

7.0
1.0 (referent)

10.2
1.8 (0.93.3)

10.5
2.0 (1.04.0)

17.6
2.7 (1.45.2)

20.1
3.7 (1.96.9)

Current alcohol use

Prevalence, %
OR (95% CI)a

31.8
1.0 (referent)

31.1
1.2 (0.81.9)

38.3
2.0 (1.33.2)

44.6
1.8 (1.12.9)

43.8
1.8 (1.12.9)

Driving drunk

Prevalence, %
OR (95% CI)a

5.2
1.0 (referent)

4.5
1.1 (0.52.5)

5.0
1.3 (0.53.0)

8.8
1.9 (0.94.4)

5.3
1.0 (0.42.6)

Illicit drug use

Prevalence, %
OR (95% CI)a

4.5
1.0 (referent)

6.8
1.8 (0.93.9)

17.4
5.7 (2.811.6)

14.2
3.4 (1.67.3)

24.9
7.0 (3.514.2)

Early sex

Prevalence, %
OR (95% CI)a

4.2
1.0 (referent)

10.6
2.9 (1.45.9)

9.5
2.7 (1.35.9)

13.5
3.5 (1.77.5)

13.0
3.4 (1.67.2)

Multiple partners, >3

Prevalence, %
OR (95% CI)a

26.2
1.0 (referent)

26.9
1.3 (0.92.0)

32.3
1.9 (1.22.9)

38.5
1.9 (1.23.0)

50.3
3.6 (2.35.7)

Early pregnancyb

Prevalence, %
OR (95% CI)a

7.3
1.0 (referent)

11.7
1.5 (0.73.5)

14.8
2.0 (0.84.6)

19.7
2.5 (1.06.4)

14.5
1.7 (0.74.3)

Unintended 1st pregnancyb

Prevalence, %
OR (95% CI)a

24.3
1.0 (referent)

28.3
1.2 (0.72.1)

50.0
2.8 (1.64.8)

34.4
1.7 (0.93.3)

48.7
3.1 (1.75.8)

Weight > 170 lbs

Prevalence, %
OR (95% CI)a

12.2
1.0 (referent)

10.2
1.0 (0.61.7)

6.5
0.6 (0.31.2)

12.2
1.1 (0.62.0)

12.4
1.1 (0.62.0)

Suicide attempt

Prevalence, %
OR (95% CI)a

7.4
18.3 (4.967.5)

9.5
24.1 (6.786.5)

0.0

1.1
1.0 (referent)

5.5
10.5 (2.938.5)

OR, odds ratio; CI, condence interval.


a
Adjusted for age, gender, education, SES.
b
Among 533 women.

result in early smoking initiation, alcohol use, illicit drug use, and sexual risks including experience of unintended rst
pregnancy.
In sum, the ndings afrmed that being exposed to a negative circumstance during childhood would result in a number
of risky lifestyle habits in adolescence and adulthood.

Prevalence and odds of health-risk behaviors by number of adverse childhood exposures


In Table 5, the prevalence and adjusted relative odds of health-risk behaviors by number of adverse childhood exposures
are shown. The general trend indicates that there was a relatively strong graded relationship between health-risk behaviors
and number of adverse childhood experiences. Signicantly, suicide attempt was found to be 24 times more likely as the
number of adverse childhood experiences reaches 4 or more. The odd of using illicit drugs was also found higher as the
number of adverse experiences increases to 4 or more (OR = 7.0, 95% CI = 3.514.2). Early smoking initiation (OR = 3.7, 95%
CI = 1.96.9), and engaging in sexually risky behaviors (OR = 3.6, 95% CI = 2.35.7) followed the same trend.
However, associations between the number of adverse childhood experiences and certain health-risk behaviors such as
driving while drunk, engaging in early sex, having an unintended rst pregnancy, and being overweight or obese were not
as clear.

Prevalence and odds of disease/poor health by number of adverse childhood experiences


There was a strong graded relationship between number of exposures to adverse childhood experiences and poor health
(Table 6). This was true for diseases and health conditions such as asthma, ischemic heart disease, skin diseases, digestive
disorders, and mental health among others. However, the results indicated that less number of exposures could result in
other diseased conditions such as hypertension, stroke, and peptic ulcers.
In general, perceptions of poor health were directly proportional to the number of exposures. The higher the number of
exposures, the poorer are perceptions of general health. Also, perceptions of current nancial problems worsened with the
increase in the number of adverse childhood experiences.

L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842855

851

Table 6
Prevalence and adjusted relative odds of prevalent diseases, health conditions and symptoms by number of adverse childhood exposures, Philippines, 2007.
Disease/health condition

Number of adverse childhood exposures


None (n = 286)

1 (n = 264)

2 (n = 201)

3 (n = 148)

4 (n = 169)

Prevalence, %
OR (95% CI)a

1.4
1.0 (referent)

1.1
0.8 (0.23.6)

1.5
1.1 (0.24.9)

3.4
2.5 (0.79.7)

Asthma

Prevalence, %
OR (95% CI)a

10.8
1.0 (referent)

11.4
0.8 (0.61.8)

15.4
1.1 (1.03.0)

13.5
2.5 (0.72.5)

14.2
5.5 (0.92.8)

Ischemic heart disease

Prevalence, %
OR (95% CI)a

10.1
1.0 (referent)

19.7
2.2 (1.33.5)

20.4
2.6 (1.64.5)

22.3
2.9 (1.75.1)

24.3
3.5 (2.16.0)

Hypertension

Prevalence, %
OR (95% CI)a

31.5
1.0 (referent)

36.7
1.3 (0.91.9)

39.8
1.8 (1.22.7)

44.6
2.0 (1.33.1)

35.5
1.6 (1.12.5)

Stroke

Prevalence, %
OR (95% CI)a

3.1
1.0 (referent)

5.3
1.7 (0.74.2)

3.5
1.3 (0.53.8)

1.3
0.4 (0.12.0)

3.0
1.2 (0.43.8)

Tuberculosis

Prevalence, %
OR (95% CI)a

2.5
1.0 (referent)

3.4
1.5 (0.54.1)

3.5
1.5 (0.54.6)

4.7
1.7 (0.65.1)

4.1
1.7 (0.65.0)

Diabetes

Prevalence, %
OR (95% CI)a

7.3
1.0 (referent)

8.7
1.2 (0.62.3)

4.0
0.7 (0.31.7)

5.4
0.9 (0.42.2)

7.1
1.5 (0.73.4)

Skin problems

Prevalence, %
OR (95% CI)a

5.6
1.0 (referent)

6.8
1.2 (0.62.4)

6.0
1.0 (0.52.2)

10.1
1.9 (0.94.0)

16.6
3.5 (1.86.8)

Frequent back pain

Prevalence, %
OR (95% CI)a

26.2
1.0 (referent)

36.0
1.5 (1.12.0)

34.3
1.4 (1.12.0)

36.5
1.7 (1.12.6)

39.6
2.0 (1.33.1)

Urinary tract infections

Prevalence, %
OR (95% CI)a

10.5
1.0 (referent)

16.3
1.7 (1.02.3)

15.9
1.7 (1.02.9)

17.6
2.1 (1.23.3)

24.9
3.4 (2.05.8)

Gall bladder problems

Prevalence, %
OR (95% CI)a

4.2
1.0 (referent)

3.7
1.3 (0.62.9)

4.0
1.0 (0.42.4)

3.3
2.4 (1.13.6)

12.4
3.8 (1.33.2)

Liver problems/hepatitis

Prevalence, %
OR (95% CI)a

1.4
1.0 (referent)

1.9
1.5 (0.45.6)

2.5
1.9 (0.57.5)

2.7
1.8 (0.47.3)

Ulcers

Prevalence, %
OR (95% CI)a

8.4
1.0 (referent)

18.9
2.5 (1.54.3)

16.4
2.2 (1.23.8)

17.6
2.4 (1.34.4)

Sexually transmitted diseases

Prevalence, %
OR (95% CI)a

0.3
1.0 (referent)

Indigestion/
heartburn

Prevalence, %

8.4

OR (95% CI)a

1.0 (referent)

1.4 (0.82.5)

2.0 (1.13.5)

1.9 (1.03.6)

2.4 (1.34.3)

Persistent diarrhea

Prevalence, %
OR (95% CI)a

4.2
1.0 (referent)

6.8
1.6 (0.83.4)

13.9
3.5 (1.77.2)

12.2
3.2 (1.57.0)

13.0
3.6 (1.77.6)

Constipation

Prevalence, %
OR (95% CI)a

7.3
1.0 (referent)

14.4
2.0 (1.13.6)

17.9
2.9 (1.63.3)

20.9
3.9 (2.17.2)

19.5
3.3 (2.17.0)

Depression

Prevalence, %
OR (95% CI)a

7.3
1.0 (referent)

11.7
1.6 (0.92.8)

15.9
2.4 (1.34.3)

17.6
3.2 (1.76.0)

18.3
3.3 (1.86.2)

Frequent headaches

Prevalence, %
OR (95% CI)a

19.2
1.0 (referent)

29.2
1.6 (1.12.4)

37.8
2.4 (1.63.7)

25.7
1.6 (1.02.7)

33.1
2.3 (1.43.6)

Insomnia

Prevalence, %
OR (95% CI)a

9.8
1.0 (referent)

23.5
2.7 (1.74.4)

23.4
2.9 (1.74.8)

22.3
2.8 (1.64.9)

28.4
4.1 (2.46.9)

Fair or poor health

Prevalence, %
OR (95% CI)a

63.3
1.0 (referent)

67.8
1.1 (0.81.6)

65.2
1.1 (0.71.6)

72.3
1.5 (0.92.3)

74.0
1.7 (1.12.8)

Current nancial problems

Prevalence, %
OR (95% CI)a

21.7
1.0 (referent)

40.1
2.2 (1.53.3)

46.3
2.6 (1.73.9)

47.3
2.9 (1.84.5)

58.6
4.6 (3.07.0)

1.5
4.3 (0.538.9)
11.7

1.5
4.4 (0.444.6)
14.9

0.7
1.5 (0.124.1)
13.5

7.1
5.5 (1.717.9)

4.1
3.0 (0.810.7)
29.0
4.6 (2.78.0)
1.2
2.9 (0.333.3)
16.0

Odds ratios adjusted for age, gender, education and SES.

Discussion of results
This is a survey of 1,068 urban residents aged 35 years and older to describe their adverse childhood experiences and
demonstrate how these experiences may be associated with adult health-risk behaviors and morbidity. About 75% of the
1,068 respondents reported to have experienced negative childhood events. Nine percent claimed to have been exposed
to 4 or more adverse events in childhood. The results conrmed conclusions of previous studies that childhood trauma
is associated with disease and poor health in later life. In general, the more adverse experiences one has encountered in

852

L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842855

childhood, the higher the probability that an individual engages in risky lifestyle habits and consequently suffers from poor
health.
Current ndings indicate that psychological abuse and neglect, as well as physical neglect of basic needs were the most
frequently reported forms of childhood adverse experiences. This is not unusual since psychological violence is considered
the underpinning of all forms of abuse (Navarre, 1987). If a person is physically maltreated or sexually molested, he or she
naturally experiences emotional distress. Additionally, parents in developing countries may also tend to neglect the basic
needs of their children, not necessarily by intention, but because of poverty and its concomitant social costs. Poverty by itself
is a great stressor and may lead to poor health and delays in development. This is a critical issue in resource-poor countries
where the line between poverty and neglect remains ambiguous. The immature child may interpret material deprivation
as lack of parental care and love. Ney, Fung, and Wickett (1994) have also suggested that not having ones biological needs
met may make other types of maltreatment even more devastating when they occur. Neglect appears to make the child
vulnerable to subsequent adverse experiences.
This study has also shown that the various forms of childhood maltreatment and household dysfunctions co-occur.
This is in consonance with the ndings of Arata, Langhinrichsen-Rohling, Bowers, and OBrien (2007) where they found
that co-occurring maltreatment was more common than single type maltreatment. Individuals who experience multi-type
maltreatment especially physical abuse, sexual abuse, and neglect are considered the most symptomatic. Growing research
evidence reveal that the total number of lifetime victimization is as important, if not more important, than individual
categories of victimization in predicting psychological distress (Finkelhor, Omrod, &Turner, 2007; Richmond, Elliot, Pierce,
Aspelmeier, & Alexander, 2009).
Surprisingly, exposure to physical maltreatment was reportedly low in this study. This may be due to the type of behavioral
indicators used in the present survey which focused on slapping, hitting, pushing, throwing something and getting injured.
In a previous study, Ramiro, Madrid, and Amarillo (2004) found that while about 40% of respondents reported to be physically
harmed during childhood, spanking with a stick, belt, or any hard material was the most common method used. Only 7%
were slapped, and 3% were hit or beaten repeatedly.
In terms of health-risk behaviors, most respondents reported smoking, alcohol use, and risky sexual activities. About half
of the 1,068 respondents had ever smoked and ever used alcohol. This was consistent with past ndings that among Filipino
male youth, smoking is high at 40%, and alcohol use at 37% (Domingo & Marquez, 1999). Furthermore, this study showed
that more than a third of the respondents had engaged in sex with more than 1 partner while 35% had unintended rst
pregnancy. These ndings were consistent with the results of another local study showing that about 35% of young people
(48.9% for males and 10.6% for females) had multiple sexual partners. By the age of 19 years, 12% of these young people were
already sexually active, and by age 24 years, 45% of women were already mothers (www2.doh.gov.ph/noh2007).
A relatively strong doseresponse relationship was observed between the number of ACE exposures and most (but not all)
health-risk behaviors. As the number of adverse childhood experiences increases, suicide attempts, use of illicit drugs, early
smoking initiation, and engaging in sexually risky behaviors also became more prevalent. Associations were unclear with
select health-risk behaviors such as driving while drunk, engaging in early sex, having an unintended rst pregnancy, and
being overweight or obese. These ndings may, therefore, imply that while the number of adverse childhood experiences is
highly associated with the development of health-risk behaviors, there are other factors as well that can inuence behavioral
and health outcomes in adulthood.
In a developing country like the Philippines, it could be surmised that people may have become more exposed to these type
of negative experiences, partly or mainly because of poverty and its social concomitants. However, socio-cultural factors can
also be cited as important reasons for the development of certain risk behaviors in developing countries. In the Philippines,
for example, peer inuence was found to be the strongest single factor why people initiate and continue to smoke and take
alcohol. Alcohol drinking is generally a form of socialization that binds relationships among friends (Ramiro, 1999). There
is also a cultural belief that big body size is indicative of health and economic progress (Ramiro et al., 2000). On the other
hand, early sex and having multiple partners may be inuenced by the inux of liberalized ideas on sexuality and sexual
behavior (Raymundo & Cruz, 2004). Therefore, in a developing country setting, the issue of health and health behavior has
become more complex and multi-factorial.
What is the mechanism involved in childhood trauma that can affect future cognitions and behavior? Recent studies
on the neurobiological processes accompanying or underlying observed behavior show that maltreatment can result in
changes in the brain structure itself (Perry, 2000). Many of these changes in brain functioning are related to ones response
to stress. Although moderate and predictable stress in childhood can help develop ways of coping with life in general, severe,
repetitive, or chronic stress hampers normal brain functioning. Neural pathways are sensitized and regions of the brain (e.g.,
hippocampus, sub-cortical and limbic systems) that deal with anxiety and fear responses become overdeveloped. Studies
have also shown that repeated abuse with its resulting stress can affect the neuro-chemical system resulting in changes
in attention, impulse control, sleep patterns, and ne motor control (Perry, 2000). In particular, children who have been
subjected to abuse have abnormal secretions of cortisol (Hart, Gunnar, & Cicchetti, 1995).
The tendency, therefore, is for individuals who are in constant threat of abuse to focus their brains resources on survival
and threat avoidance, to the detriment of other parts of the brain that are involved in more productive activities that include
language development and active learning. If children are in a persistent state of hyper-arousal and hyper-vigilance, then
they are likely to have difculties with normally responding to stimulations in daily life. These groups of children turn to
high risk behaviors to deal with stress and adverse life events.

L.S. Ramiro et al. / Child Abuse & Neglect 34 (2010) 842855

853

The results of this study are subject to certain limitations. Responses were based on self-reports. The percentage of
adults disclosing adverse childhood experience of abuse is lower than those of previous local surveys (e.g., BSNOH, 2000)
although some differences in the way questions were asked in different surveys were noted. Disease conditions were also
self-disclosed and therefore may be subject to over-or under-reporting. Future research may help address these issues by
including more objective measures such as laboratory results and clinical diagnosis.
A potential weakness of studies with retrospective reporting of childhood experiences is the possibility of recall bias.
Difculty recalling childhood events likely results in misclassication (i.e., classifying people who were truly exposed to
ACEs as unexposed) that would bias results toward the null. This means that if adverse childhood experiences were underestimated, then this would result in a downward bias and suggest an even stronger relationship between adverse childhood
experiences and adult risk behaviors and diseases than that observed in this study. It may also be possible that there was
differential recall, depending upon the nature and signicance of the events (e.g., sexual abuse compared with emotional
neglect).
Despite the debate that problems in adult life, which may stimulate a focus on the negative aspects of childhood, would
increase the reporting of ACEs, our study setting was based on data collected from a general population sample, not a clinical
population where respondents would be more likely to reect back on their childhood for reasons why they might have
their current problems. By sampling from a general population, there is no reason to believe that any one individual would
reect more or less on their childhood (and negative aspects therein) than the next sampled individual.
Perhaps, the most important contribution of this study is to provide evidence that child maltreatment is a public health
problem even in poorer environments. This is in contrast to the common notion in many societies that child abuse and
neglect is simply a social problem. As borne by the ndings, childhood abuse and neglect are major risk factors that may lead
to disabilities, morbidities and other health outcomes during adulthood. Hence, these ndings may impact on how health
care is delivered to the people. Prevention and early intervention are crucial if we want to improve the childs chances of
developing optimally and prevent the long-term consequences. To increase the chance of success, prevention should start
even before the child is born, during rst pregnancy, when anticipatory guidance will have a better chance to be followed.
Screening for domestic violence and child maltreatment should be part of every visit. Physicians should be just as adept
in the management of abuse, alcoholism and what was traditionally thought as social work matters as they are in the
common diseases. The practice of medicine clearly should follow the biopsychosocial and ecological model.
Greater efforts must also be exerted to let parents and the communities as well, understand the long-term implications of
child abuse and neglect. Regular parenting seminars, organization of community support groups, and continuous exposures
to media messages are as important as regular home visits of professionals and other health and social workers. National
laws and policies on child protection must be well-monitored and evaluated to ensure that they are effectively implemented
at the local level. With poverty as a major culprit, livelihood programs must be part of any form of psychosocial intervention.
References
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