Assessment and screening of positive childhood experiences along with childhood adversity in research, practice, and policy

ABSTRACT

Despite empirical evidence documenting the role of positive childhood experiences in predicting adaptation over the lifespan and across generations, this research has not yet been fully integrated into public health and policy efforts. We argue that adults' benevolent childhood experiences (BCEs) should be measured in large-scale data collection efforts, such as statewide surveys, alongside more routinely collected adverse childhood experiences (ACEs). We also outline several recommended strategies in which the assessment and screening of positive childhood experiences could be implemented as a counterpart to community health and primary care screening for childhood adversity in adults, with short- and long-term benefits. Pediatric physicians should screen children and adolescents for their current positive childhood experiences as well. The assessment of positive childhood experiences is essential to empirically identifying resilience resources linked with better long-term adaptation, understanding how positive experiences may counteract the long-term effects of childhood adversity in underserved and traumatized individuals, informing medical providers' knowledge about patients' strengths in addition to challenges, and instilling hope in individuals and families experiencing stress.

KEYWORDS:

• Adverse childhood experiences (ACEs)
• benevolent childhood experiences (BCEs)
• resilience
• universal screening

Introduction

Decades of research have established that childhood experiences and relationships shape and predict development and outcomes across the lifespan (Cicchetti and Toth 2009; Masten 2006; Sroufe 1979). For instance, healthy or disrupted attachment relationships with primary caregivers beginning in infancy have well-documented, long-term effects on relationships into adulthood (Sroufe et al. 2009; Booth-LaForce and Roisman 2014). A large body of research on early experiences has also documented associations between childhood abuse, neglect, and other interpersonal adversities (e.g., exposure to parental domestic violence and household discord) and adulthood problems in the domains of physical and mental health, romantic relationships, and parenting (Belsky, Conger, and Capaldi 2009; CDC 2019a; Felitti et al. 1998; Labella et al. 2019; Narayan et al. 2014; Narayan, Englund, and Egeland 2013).

As this body of research has expanded, so too have the number policies and guidelines related to mitigating the long-term effects of adverse childhood experiences (ACEs; see Table 1) on adulthood maladaptation and preventing ACEs entirely in the next generation. For example, several statewide bills and resolutions related to ACEs in states such as Virginia and Illinois have encouraged state employees, such as school and healthcare personnel and child welfare workers, to educate themselves about the consequences of childhood adversity, identify ways to deter it and minimize its consequences, and implement appropriate interventions (e.g., H.J.R 652, 2017; S.J.R. 263, 2017; H.R. 304, 2017; S.R. 489, 2017). Other governmental policies in California and New York, respectively, have outlined programs to support children who have experienced ACEs (e.g., A.B. 11, 2018) and have required healthcare professionals to screen for ACEs to receive Medicaid reimbursement (e.g., A.B. 3427, 2017). Further, the Centers for Disease Control and Prevention (CDC 2019b, 2019c), the National Conference of State Legislatures (2018), and the Center for the Study of Social Policy (2020) have developed recommendations to guide future policy-related work on this topic. Together, the growing body of existing legislation, as well as recommendations for future policies on childhood adversity, demonstrate a governmental commitment to addressing the short- and long-term consequences of ACEs.

Table 1. Adverse Childhood Experiences (ACEs) items.

Type of ACE
1. Emotional abuse
2. Physical abuse
3. Sexual abuse
4. Emotional neglect
5. Physical neglect
6. Parental separation/divorce
7. Exposure to domestic violence
8. Household member substance abuse
9. Household member mental illness
10. Household member incarceration

Note: For exact wording of scale items for complete ACEs scale, see Felitti et al. (1998).

Positive childhood experiences as a counterpart to childhood adversity

Although less established in the area of public policy, an emerging body of literature has begun to examine the role of positive childhood experiences, beyond parent–child attachment relationships, on development and adaptation across the lifespan (Narayan et al. 2019; Ungar and Liebenberg 2011). Broadly, this research has shown associations between higher levels of positive childhood experiences and lower levels of psychopathology symptoms, stress, and health problems (e.g., Bellis et al. 2017, 2018; Bethell et al. 2019; Chung et al. 2008; Hillis et al. 2010; Merrick et al. 2020b; Narayan et al. 2018). Many of the long-term benefits of positive childhood experiences have been documented in the context of ACEs (e.g., Bellis et al. 2017, 2018; Bethell et al. 2019; Merrick et al. 2020b; Narayan et al. 2018). These findings demonstrate that adverse and positive experiences can occur concurrently and that positive experiences in childhood may play a role in promoting later adaptation, even in the context of childhood adversity.

While some studies have examined the predictive power of individual childhood resources (e.g., Bellis et al. 2017), others have examined composites of multiple positive childhood experiences (e.g., Bellis et al. 2018; Bethell et al. 2019; Chung et al. 2008; Hillis et al. 2010; Logan-Greene et al. 2014). This body of work, examining the positive effects of multiple childhood experiences at one point in time or accumulating supportive experiences across development, is consistent with cumulative resource models (e.g., Evans, Li, and Whipple 2013). Accumulation of resources often leads to more positive outcomes than any one resource on its own (Runyan et al. 1998).

Consistent with this cumulative resource approach, our group recently introduced the Benevolent Childhood Experiences (BCEs) scale (Narayan et al. 2018; see Table 2) as a brief, culturally sensitive measure of positive childhood experiences that can be used as a counterpart to the ACEs scale (CDC 2019a; Felitti et al. 1998). Ten items comprise the BCEs scale; these reflect adults’ retrospectively reported childhood experiences and resources drawn from family and other close relationships, aspects of personal identity, and a positive and predictable quality of life during childhood. The BCEs scale has been utilized in research across different samples, both in the U.S. and internationally, including with pregnant women, homeless parents, and in more normative samples of university students and representative adults across the U.S., with promising results linking adults’ BCEs to their present adaptation (Crandall et al. 2019; Gunay-Oge, Pehlivan, and Isikli 2020; Merrick et al. 2019; Narayan et al. 2018).

Table 2. Benvolvent Childhood Experiences (BCEs) items.

Type of BCE
1. At least one safe caregiver
2. At least one good friend
3. Beliefs that gave comfort
4. Enjoyment of school
5. At least one teacher who cared
6. Good neighbors
7. Another adult who provided support or advice
8. Opportunities to have a good time
9. Positive self-image
10. Predictable home routine

Note: For exact wording of scale items for complete BCEs scale, see Narayan et al. (2018).

Despite results indicating the key role that positive experiences in childhood can play in predicting later health and wellbeing in the context of adversity, this body of research has not been fully integrated into public health and policy. Alternatively, screening for adults’ histories of ACEs or their children’s current ACEs is more commonly recommended in some areas of primary care and pediatrics, particularly in communities where children might be at high risk for ACEs (Bright et al. 2015; Glowa, Olson, and Johnson 2016; Pardee et al. 2017). The inclusion of instruments to examine positive childhood experiences, in addition to the more common screening of adversity, is essential to better understanding the resilience resources linked to better long-term adaptation and the mechanisms through which both adverse and positive childhood experiences interplay to predict adulthood and intergenerational adaptation. In the sections that follow, we outline several recommended strategies in which the screening of positive childhood experiences could be implemented in conjunction with screening for childhood adversity and the potential short- and long-term benefits of this implementation.

Statewide screening of adults’ positive childhood experiences

The inclusion of indices of positive childhood experiences in large representative datasets and surveys is one ongoing strategy that shows promise in identifying and understanding the pathways from childhood experiences to adulthood outcomes. Beginning in 2009, the CDC included questions on childhood adversity in their Behavioral Risk Factors Surveillance System (BRFSS; CDC 2019d), a large-scale statewide survey administered across the U.S. The BRFSS broadly includes questions on health-risk behaviors, adulthood health outcomes, and health service utilization, and it is administered in all 50 states and Washington, D.C. (CDC 2019d). So far, 48 states and Washington, D.C., have included questions on ACEs in at least one year of their study (CDC 2019e), and some states have made efforts to include measures of positive experiences as well. For instance, when this survey was administered in Washington State, it included an index of adults’ reports of their current positive experiences (Foundation for Healthy Generations 2014-2015). Further, in Wisconsin, individuals were specifically asked about positive childhood experiences using questions drawn from the Child and Youth Resilience Measure (CYRM; Ungar and Liebenberg 2011). Results from Wisconsin indicated that higher levels of positive experiences in childhood were associated with lower levels of adulthood mental health problems, even after accounting for the effects of ACEs and supportive experiences in adulthood (Bethell et al. 2019).

Including questions on positive childhood experiences in large representative samples in addition to questions about childhood adversity provides an invaluable opportunity to identify how resilience processes may have operated across the lifespan in conjunction with pathways of risk. With the inclusion of both types of questions, researchers can understand both halves of the story—how childhood adversity contributes to adulthood risk and how positive childhood experiences may predict better outcomes in adulthood. Moreover, it is highly likely that these pathways of risk and resilience operate in tandem and are intertwined. In the vast majority of cases, individuals have both types of experiences, rather than only experiences of adversity or only positive experiences during childhood (Narayan et al. 2018, 2020).

Incorporating the assessment of positive childhood experiences into large-scale data collection efforts also informs understanding of resilience processes at play. Resilience is defined as the capacity of a dynamic system, such as a human organism, to endure, recover from, or transform during or in the aftermath of adversity that threatens the system’s viability and functioning (Masten 2014). As an illustration of resilience, in the original ACEs studies and many other studies on the long-term effects of severe adversities such as childhood maltreatment, the majority of individuals who report childhood adversity do not report negative outcomes in adulthood or parenthood (e.g., Felitti et al. 1998; Madigan et al. 2019). Positive childhood experiences may be a key factor in explaining why some individuals with high levels of childhood adversity display resilient functioning in adulthood and essentially “beat the odds” (Masten 2014). Thus, much more research on the long-term impacts of positive childhood experiences, using larger and representative samples, is crucial to better understanding the predictive power of childhood resources.

The inclusion of the ACEs screener in the BRFSS in 48 states enables policymakers to understand how ACEs may be differentially represented across communities and areas of the US. Examining the differential representation of positive childhood experiences would increase understanding of how the pathways of risk and resilience may present differently across samples and populations. Although initial pilot work on the BCEs scale in a small sample of 101 individuals demonstrated comparable rates of BCEs across racial/ethnic groups and Spanish- versus English-speaking women (Narayan et al. 2018), little research has examined other group differences, including differences in age, gender, socioeconomic status, and demographic region. Future research examining whether and how ACEs and BCEs may differ across various demographics and ethnically diverse populations is essential to understanding the cultural nuances of risk and resilience. Previous research on the BCEs scale has also demonstrated comparable rates of many individual BCE items across multiple samples (i.e., high-risk pregnant women and homeless parents; Merrick et al. 2019), but research is needed to determine whether similar patterns would be observed when examining associations between BCEs and adulthood outcomes in additional populations, such as community samples and individuals of different ages (e.g., young versus elderly adults).

Research using both the ACEs and BCEs could also examine the different ways that childhood adversity and positive childhood experiences may interact with one another depending on the context in which they are examined. In their sample of low-income, ethnically diverse pregnant women, Narayan and colleagues demonstrated three unique, within-sample groups: those characterized by (1) high BCES, (2) high BCEs and high ACEs, and (3) high ACEs. They noted that these groups differentially predicted adulthood outcomes, with the “high BCEs” group reporting the lowest level of psychopathology symptoms and stress exposure, and the “high BCEs and high ACEs” group reporting lower psychopathology symptoms and stress exposure than the “high ACEs” group, suggesting that BCEs at higher numbers may begin to offset the effects of high ACEs (Narayan et al. 2018). Future research that includes both ACEs and BCEs is necessary to further understand how ACEs and BCEs may operate in the context of one another, replicate the above effects, or address whether BCEs and ACEs cluster uniquely across different samples. The inclusion of BCEs, or other measures of positive childhood experiences in larger data collections, including statewide screenings, would allow researchers to begin to answer these questions, with important implications for informing future policy-related work and interventions.

Community provider screening of adults’ positive childhood experiences

Previous research has examined the feasibility and benefits of ACEs screening by community providers, including social workers, home visitors, and primary care physicians (Glowa, Olson, and Johnson 2016; Johnson et al. 2017; Kalmakis et al. 2018). Although it may be feasible and beneficial to assess for histories of ACEs in these types of settings, this practice is still not routine among community providers for a variety of reasons, including but not limited to constraints on time, billing, and available resources (e.g., Finkelhor 2018; Johnson et al. 2017; Weinreb et al. 2010). Even when screening for adversity does occur, it typically grants providers with an understanding of only an individual’s risks with no attention to the individual’s resources. The addition of an instrument designed to assess positive childhood experiences, such as the BCEs, to initial screenings by providers, including those working with parents and families, is key to understanding individuals’ full histories. The BCEs scale is extremely short and easy to administer. Although it may not address all the screening barriers, we argue that an understanding of a client’s childhood experiences is necessary for providers to have a complete understanding of the individuals with whom they work.

The inclusion of an instrument to assess positive childhood experiences could be used as a helpful tool to identify vulnerable individuals. While higher levels of positive experiences in childhood are an indicator of resources, lower levels of reported positive childhood experiences may be an indicator of risk (Narayan et al. 2018). In other words, while high levels of BCEs may signal the presence of resilience factors, lower levels of BCEs may be a risk factor in and of themselves. Thus, even in the absence of an ACEs screener, providers could use the BCEs as a means to identify adults who may be at risk for psychopathology symptoms and could benefit from interventions. When providers are unable to administer the ACEs screener for feasibility reasons or due to discomfort with asking about childhood adversities or lack of confidence in their ability to provide adequate referrals following positive screening of them, the inclusion of the BCEs scale may be all the more crucial. An understanding of an adult client’s childhood experiences might be valuable to most successfully supporting their wellbeing.

When providers working with adults are able to screen for childhood adversity, an index of positive childhood experiences should still be included in initial screening protocols. With more information on adults’ childhood experiences—both adverse and benevolent—providers can speak to clients and patients not only about mitigating risks but also about promoting resources. If the primary care provider in the example above were to have screened for both ACEs and BCEs, he or she could speak with the adult client about the role of childhood experiences in shaping experiences, relationships, and behavior across development and the ways in which different types of experiences may have interacted, built on one another, or counteracted one another. This comprehensive method of screening could also help to mitigate some of the barriers described above, including reducing provider and patient discomfort in screening for negative life events, as both parties would also be reflecting on favorable experiences.

In addition to primary care providers, there may be other community providers who could include the assessment of both ACEs and BCEs in their initial screening protocols. For instance, the assessment of both ACEs and BCEs with a parent involved with the child welfare system could inform a discussion about the ways in which an adult’s experiences in childhood—both adverse and benevolent—may have influenced and continue to influence their parenting (e.g., Bartlett and Easterbrooks 2012; Pereira et al. 2012). A caseworker could recommend interventions that address parents’ childhood experiences—helping to draw upon the positive experiences and recover from the adversity—and nurture the parent–child relationship (e.g., Lieberman, Ghosh Ippen, and Van Horn 2015; Narayan et al. 2019). Similarly, a caseworker working with homeless adults could use information gained from the screening of both ACEs and BCEs to identify individuals at risk for specific outcomes. Previous research on the BCEs scale in homeless parents noted that adults’ higher levels of ACEs predicted higher levels of sociodemographic risk and higher levels of BCEs predicted lower odds of psychological distress (Merrick et al. 2019). In this case, information on the types of experiences that adults had in childhood may guide caseworkers in determining an individual’s needs. Again, by collecting information on both adverse and positive childhood experiences, providers can better understand both sides of their clients’ childhood histories. Further, through a comprehensive method of screening that includes positive factors in addition to the more routinely assessed adversities, providers can communicate their desire to give attention to and promote client wellbeing.

Previous research on the associations between BCEs and pregnancy-related outcomes (i.e., Merrick et al. 2020b; Narayan et al. 2018), points to the importance of not only including screeners of positive childhood experiences in more routine provider visits, but specifically in prenatal screening. According to this research, higher levels of childhood maltreatment predicted higher levels of PTSD symptoms during pregnancy; lower levels of childhood family dysfunction and higher levels of BCEs predicted lower levels of stressful life events during pregnancy; and higher levels of BCEs predicted lower levels of risky reproductive planning, including experiences of unwanted, unplanned, and teenage pregnancies (Merrick et al. 2020b). Because different types of childhood experiences differentially predict pregnancy-related outcomes, including both ACEs and BCEs in prenatal screening could help in identifying individuals most at risk for specific outcomes of interest and in implementing targeted interventions (Merrick et al. 2020b). For instance, given that higher levels of childhood maltreatment predict higher levels of PTSD symptoms during pregnancy, a woman who screens positively for high levels of childhood maltreatment early on in pregnancy could be provided with a preventive intervention to deter prenatal PTSD. If providers are able to screen for women’s adverse and benevolent childhood experiences early in pregnancy, they may be able to better anticipate and deter negative perinatal outcomes before they emerge.

Screening for children’s own positive childhood experiences

In addition to the importance of screening adults’ own histories of positive childhood experiences, there is a need to accurately assess accumulating positive experiences in the lives of their children. Thus far, we have focused on the importance of screenings and surveys that assess adults’ positive childhood experiences, but it is essential to also document the prospective, protective effects of positive childhood experiences as they are occurring in the lives of children. Although a thorough assessment of adults’ histories of risks and resources is central to understanding pathways to their current wellbeing, adults’ own experiences have already occurred and cannot be changed. Examining risks and resources, including positive childhood experiences, during childhood, provides an opportunity to help promote resources and counteract risk factors before they pile up.

Research on the developmental timing of positive childhood experiences indicates that experiences that begin earlier in childhood are more predictive of adulthood outcomes than experiences that begin later in childhood or adolescence (Merrick et al. 2020b). More specifically, higher levels of BCEs that began in early childhood (ages 0–5) significantly predicted lower levels of risky reproductive planning and less stress exposure during pregnancy, whereas BCEs that began later in childhood did not predict these outcomes. These findings point to the importance of bolstering children’s positive experiences beginning in early childhood to prevent a variety of negative adulthood outcomes. Screening for children’s own positive experiences may be one method by which to ensure that positive experiences are being promoted from a young age. Parent and self-report measures of children’s assets, resources, and positive experiences currently exist (e.g., CYRM, Ungar and Liebenberg 2011; Developmental Assets Profile [DAP], Search Institute 2005); to our knowledge, however, such instruments have not yet been routinely integrated into policy efforts or practice, such as pediatric care.

Just as primary care providers should screen adults for their histories of positive childhood experiences, so too should physicians screen children and adolescents to assess their current levels of positive childhood experiences. The same benefits of adulthood screening of positive childhood experiences apply to the screening of positive experiences in children. For instance, if a parent reported that their child had low overall levels of positive experiences and resources, supportive services could be provided to the family to help them create those positive experiences. Providers may then work to help the family implement positive time and structure in the home and connect the family with community services to increase the child’s opportunities to develop additional supportive relationships outside the home. Further, some measures of children’s positive childhood experiences, such as the CYRM, examine the types of experiences, including those pertaining to the individual (e.g., awareness of strengths, feeling supported by friends), caregiver (e.g., feeling safe with caregivers, talking to caregivers about feelings), and context (e.g., a sense of belonging at school, having people to look up to) resources (Liebenberg, Ungar, and Van de Vijver 2012; Ungar and Liebenberg 2016). If providers using the CYRM learned that certain types of experiences were not present in a child’s life, they could provide families with more targeted suggestions or talk more directly with parents about the barriers to specific opportunities and resources. For instance, if a provider noticed that a parent endorsed high levels of individual and caregiver resources but low levels of contextual resources (e.g., resources related to culture, education, and spirituality), a provider could speak directly with parents about the importance of increasing contextual resources via the child’s school or other community activities.

It is important to acknowledge that the prospective screening of children’s own positive childhood experiences is also limited by barriers and biases within the screening process. For example, providers may consider their goal to be determining the areas of a child’s life that are going poorly, rather than assessing aspects that are going well. As recommended above, however, identifying the absence of positive experiences may be as informative as identifying the presence of adverse experiences, so providers may wish to choose which type of assessment they conduct if only one type is feasible.

Parental biases may also exist when reporting on their children’s experiences. Previous research on parent-reported child adversity has noted that parents’ own histories of adversity affect how they report on their children’s adverse experiences (Cohodes et al. 2016). Research has also noted that parental reports of how much their children’s cumulative life adversity is weighing on their children are only moderately correlated with parents’ reports of the total number of adverse events their children have experienced. That is, even though a parent may report that his or her child has experienced many adversities, the parent may not report that the child has been strongly affected by them (Merrick et al. 2020a).

Similar reporting biases may apply to parental reports of children’s positive experiences. Parents may be hesitant to acknowledge that their child has a low level of ongoing positive experiences or resources for fear of social judgment or unwanted intervention. Parents may also view their children’s availability of positive experiences and resources in light of their own history of childhood experiences (or lack thereof) from their families of origin. Screening efforts to assess parental report of children’s positive experiences may guard against these biases by using assessments, such as the CYRM, that are multidimensional and allow for nuanced reporting across the type of experience (e.g., individual, caregiver, and contextual). Future research on instruments that could prospectively be used to examine positive childhood experiences, as well as the possible barriers and biases that may limit their use, is therefore necessary before implementing such a policy.

Conclusion

There are multiple short- and long-term benefits to including the assessment and screening of positive childhood experiences in future research, practice, and policy-related endeavors. As outlined above, when health care and community providers are acutely aware of an individual’s full history of childhood experiences, they can provide more individualized, tailored referrals to address the consequences and benefits of these experiences and capitalize on clients’ strengths. The addition of an instrument that focuses on positive experiences in community care settings could also help to instill hope in patient and client alike. Drawing from the growing evidence base that higher levels of BCEs predict lower levels of mental health problems and stress exposure in adulthood, even in individuals with high ACEs (e.g., Crandall et al. 2019; Merrick et al. 2019; Narayan et al. 2018), community providers could communicate and emphasize the predictive power of positive childhood experiences, particularly to clients with histories of childhood adversity. Furthermore, past studies have found that the vast majority of individuals experienced at least one BCE during childhood—a message that could be used to instill hope and help clients draw upon their existing positive childhood moments.

Assessment and screening of positive childhood experiences have many intergenerational implications. Ideally, providers would ask parents about their history of positive childhood experiences, and then ask parents’ offspring about the extent to which positive childhood experiences are present in the next generation. In pediatric care, providers may subsequently wish to engage in direct conversation with patients and families about the importance of bolstering positive experiences during childhood. By also including assessments of positive experiences in prenatal screenings, providers could initiate opportunities to provide resources to clients with low levels of reported positive childhood experiences and provide psychoeducation to parents-to-be about strategies to increase positive childhood experiences in the next generation. This multi-generational approach to screening could help to mitigate the intergenerational transmission of risk and adversity and promote resilience in generations to come. The assessment and screening of positive experiences is essential in the areas of research, practice, and policy, as work in each field informs work in the others. Instituting the policies outlined above is the first step in further promoting and understanding positive childhood experiences.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes on contributors

Jillian S. Merrick, M.A., is a doctoral student in clinical child psychology at the University of Denver. Her research focuses on the role of protective factors, such as positive childhood experiences and parenting, in promoting resilient outcomes for families experiencing adversity. She is also interested in how parents can capitalize on these protective influences to deter the intergenerational transmission of risk and shape a positive trajectory of intergenerational resilience for their children.

Angela J. Narayan, Ph.D., L.P., is an assistant professor in the Department of Psychology at the University of Denver and a licensed clinical psychologist. Her current research investigates the intergenerational transmission of risk and resilience through the perinatal period, with an emphasis on how mothers’ and fathers’ childhood experiences influence their transition to parenthood.