The Impact of Adverse Childhood Experiences and Community Violence Exposure on a Sample of Anxious, Treatment-Seeking Children

Abstract

Screening for adverse childhood experiences (ACEs) can help prevent and reduce adverse outcomes on child development, including increased risk for anxiety disorders. Emerging studies strongly support the inclusion of community-level adversities in ACE screeners to consider diverse contexts and populations. Recent studies suggest that community violence exposure (CVE) may have a distinct impact on youth mental health. Although recent studies have examined the association between ACEs, CVE, and mental health in primary care settings, this association has not been examined on treatment-seeking children in urban mental health settings. The present study employs a mediation model using the PROCESS macro to examine community violence exposure mediating the effect on the association between ACEs and somatic symptoms (SS) on a sample of anxious treatment-seeking children. A total of 98 participants (Mage = 11.7, SD = 3.79, 51.6% males, 54.1% ethnic minority children) who sought services at a specialized anxiety clinic completed self-report measures. Results indicated that exposure to ACEs is associated with endorsement of somatic symptoms as a result of reporting hearing, witnessing, or experiencing CVE. Evidence of mediation was found in a statistically significant indirect effect of ACEs on SS through CREV (Effect = .17, 95% CI = .069–.294). These findings support recent evidence that CVE is a distinct ACE as it contributes to toxic stress similar to individual-level ACEs. The use of a comprehensive ACE screening that includes CVE is warranted, particularly when working with culturally and socioeconomically diverse populations, as it would better capture a broader range of adversities across demographic groups.

Adverse childhood experiences (ACEs) impact the health and wellbeing of children throughout the life course (Felitti et al., 1998; Di Lemma et al., 2019). Children who are exposed to adversity early in life including child abuse (emotional, physical, or sexual), child neglect (emotional or physical), separation or parental absence, domestic violence, substance abuse, mental illness, or incarceration of a caregiver, may not develop adequate coping mechanisms to face subsequent stressors through the lifespan (Gallo, 2009; Felitti et al., 1998; Krinner et al., 2021). Exposure to ACEs, particularly cumulative or chronic exposure, is associated with stable and long-lasting impact on children’s socio-emotional, health, and social areas (Burke et al., 2011; Halfon et al., 2017; Oh et al., 2018; Wade et al., 2016).

ACEs are significantly prevalent among children and adolescents. A national survey revealed that 34 million children ages 0 to 17 in the U.S. (46.3%) had experienced at least one ACE, and more than 20% have experienced two or more (Bethell et al., 2017a). Further, ACEs are strongly associated with psychopathology across the life span (McGrath et al., 2017). It is estimated that ACEs account for 26% to 32% of the risk for all adolescent and adult psychiatric disorders (Green et al., 2010). While more studies focus on the association between retrospective reports of ACEs (or “ACE score”) and internalizing behaviors (e.g., anxiety, depression) and externalizing behaviors (e.g., hyperactivity, conduct problems, substance abuse) (Henry et al., 2021; Hicks et al., 2021), further examination of somatic symptoms among children in relation to ACEs is warranted (Barnes et al., 2020; Kuhar & Zager Kocjan, 2021; Lin et al., 2020). Given that somatic symptoms can occur comorbidly with anxiety and depression (Creed et al., 2012; Dempster et al., 2020), more research is needed to examine the mechanism through which cumulative exposure to early adversities and community violence negatively impact the physical, emotional, and social responses of children (Burke et al., 2011; Finkelhor et al., 2013; Lai et al., 2018; Shonkoff et al., 2012).

Relative to the association between ACEs and anxiety disorders, mounting research strongly advocate for the use of measurement instruments that capture not only variations in exposure to individual-level or family-related adverse experiences but also to community-level adversity (Bethell et al., 2017b; Finkelhor et al., 2013, 2015a, b; Henry et al., 2021; Kysar-Moon, 2021; Thakur et al., 2020). As exposure to ongoing childhood adversity presents as a more discreet exposure to trauma, the use of a trauma-informed public health approach for early identification, provision of services, and linkage to referrals can reduce the harmful effects of ACEs on youth mental health (Merrick et al., 2018; Thakur et al., 2020). Among the number of pediatric ACE screenings available, comprehensive assessments (e.g., PEARLS, Koita et al., 2018) are critical to addressing more broadly the detrimental effects of individual and community-level factors on youth development (Chung et al., 2016; Goldenson et al., 2021; Koita et al., 2018; World Health Organization, 2017). Despite the growing research on trauma-informed assessment of childhood adversities in pediatric settings (Harris et al., 2017; Thakur et al., 2020), the use of comprehensive ACE screeners in urban mental health settings is needed to inform prevention and early intervention for children impacted by adversities and trauma (Greeson et al., 2014).

The Relevance of Somatic Symptoms (SS) in Anxiety Disorders

Pediatric anxiety disorders are associated with SS, which is linked to symptom severity and functional impairment across domains (Agorastos et al., 2019; Campo et al., 2004; Ginsburg et al., 2006). The autonomic nervous system (ANS) is the main conductor of bodily stress responses in the presence of both conscious (e.g., fear, pain) and unconscious stressors (hypoglycemia) (Shonkoff et al., 2012). Ongoing activation of the stress response system can lead to dysregulation of stress response processes (e.g., sympathetic-adrenomedullary functioning and limbic-hypothalamic-pituitary-adrenocortical functioning), which leads to altered physiological responses to stressful situations (Agorastos et al., 2019; Kuhlman et al., 2018; Shonkoff et al., 2012). Somatic symptoms play a role in classifying anxiety disorders as physiological complaints are required for the diagnosis of panic disorder, generalized anxiety disorder, and posttraumatic stress disorder (American Psychiatric Association, 2013). Studies suggest that increased somatic symptoms in youth with anxiety disorders may be associated with more psychopathology, affecting their functioning across domains (Benarous et al., 2017; Ginsburg et al., 2006; Kristensen et al., 2014).

Somatic symptoms (SS) are common symptoms among children with anxiety, with more than half reporting at least one somatic complaint (Crawley et al., 2014) and on average six SS (Ginsburg et al., 2006). The SS most reported by children are the following: restlessness, headaches, stomachaches, muscle tension, shaking, racing heart, sweating, blushing, difficulty breathing, and fatigue (Campo et al., 2004; Hofflich et al., 2006). Several studies indicate that SS emerges after experiencing adversity or traumatic experiences (Lai et al., 2018; Kuhar & Zager Kocjan, 2021). Anxiety is related to increased arousal symptoms following exposure to adversities (Creed et al., 2012; Kugler et al., 2012). A study found that improvement in anxiety symptoms was negatively associated with the number and severity of somatic symptoms at posttreatment, regardless of age and treatment condition (Crawley et al., 2014). Because anxiety is linked to SS, examining other factors that may exacerbate this association is critical to developing prevention and therapeutic intervention to reduce these symptoms.

Differences have been found in the number of somatic symptoms children and adolescents report and the type of effects observed in behavior (Lavigne et al., 2013). A study conducted on Dutch adolescents found that the influence of family disruption on SS was partially explained by internalizing symptoms (Van Gils et al., 2014). A clinical study conducted in youth ages 7 to 17 years found that the number of somatic symptoms was associated with anxiety symptoms, with more endorsed SS associated with anxiety severity (Crawley et al., 2014). Similarly, research that examined demographic characteristics shows mixed results. Studies using community and clinical samples found that female adolescents endorse more somatic complaints than younger girls and their male counterparts (Crawley et al., 2014; Delisle et al., 2012; Romero-Acosta et al., 2014; Ruchkin & Schwab-Stone, 2014). Girls may be at higher risk due to endorsing more internalizing symptoms compared to boys (Martel, 2013). Conversely, other studies showed no gender differences (Creed et al., 2012; Ginsburg et al., 2006) or a significant rate of SS among females (Lai et al., 2018; Van Geelen et al., 2015).

Adverse Childhood Experiences (ACEs) and Somatic Symptoms (SS)

A wealth of studies supports the association between ACEs and somatic symptoms (SS) (Green et al., 2010; Lai et al., 2018; Lin et al., 2020; Sachs-Ericsson et al., 2017; Thakur et al., 2020). Exposure to ACEs is associated with profound and enduring neurobiological consequences that alter interoceptive processes (i.e., perception of bodily sensations), which, in turn, leads to increased dysregulation in involuntary stress responses, such as somatic symptoms (Agorastos et al., 2019; Dempster et al., 2020; Schulz & Vögele, 2015). Notably, children with anxiety disorders who had been exposed to ACEs have an earlier age at onset, greater symptom severity, more comorbidity, and poorer treatment response than children with the same diagnosis with no history of ACEs (Teicher & Samson, 2013). Other studies pinpointed that the association between ACEs and altered physiological and stress response among children increases exponentially in the absence of stable and nurturing relationships (Lin et al., 2020; Shonkoff et al., 2012).

The cumulative risk framework suggests that accumulating levels of adversity hinder development and functioning across domains (Anda et al., 2010; Felitti et al., 1998; Henry et al., 2021). A growing body of research is examining the mechanisms through which ACEs may result in physical and behavioral impairment (Gustafsson et al., 2014; Kuhar & Zager Kocjan, 2021; James et al., 2021; Thakur et al., 2020). For instance, a recent study found eight individual-level ACEs associated with internalizing symptoms (Henry et al., 2021). Similarly, exposure to threat (e.g., interpersonal and community violence) predicted higher internalizing symptoms in children (Finkelhor et al. 2015a, b; Lai et al., 2018; Miller et al., 2018). These findings suggest different pathways through which different types of ACEs affect children’s socio-emotional and health outcomes (Lee et al., 2020).

Community Violence Exposure (CVE) and Somatic Symptoms (SS)

CVE has been associated with internalizing behaviors given that adolescents undergo significant biological and social changes during this developmental period (Hardaway et al., 2016; Schwab-Stone et al., 2013). Specifically, several studies shed light on the association between community-level adversity and somatic symptoms (Lai et al., 2018; Wade et al., 2016). Research conducted on urban low-income adolescents has found that perceived stress and CVE were associated with trouble breathing, numbness, stomachaches, feeling weak, and heart pain (Kim et al., 2021), as well as decreased appetite and difficulties sleeping (Bailey et al., 2005; Mayne et al., 2021). In a community study conducted on school children, exposure to community violence was associated with clinically significant somatic symptoms, including headaches (66.5%) and stomachaches (62.5%) (Hart et al., 2013). A recent study using a national dataset of young adults found a distinct path from CVE to anxiety disorders (Lee et al., 2020). Despite the link between community violence exposure and distress reactions in children (McGill et al., 2014), community violence exposure is not regularly screened in pediatric settings (Goldstein et al., 2017).

Much of the child victimization research focuses on specific areas, including the home (domestic violence, abuse), school (bullying), social media (cyberbullying), and community (Finkelhor et al., 2015a, b; Turner et al., 2016). Recently, more emphasis has been placed on understanding the cumulative impact of community violence exposure (CVE) on children (Kennedy & Ceballo, 2014; Lee et al., 2020). CVE consists of either experiencing, witnessing, or learning about serious fights, gunshots, or stabbing, which generally occurs outside the home (Krug et al., 2002). Children are more likely to be exposed to community violence than to other types of violence (Hardaway et al., 2016; Margolin et al., 2010) and are more likely to be affected by community violence compared to adults (Hillis et al., 2017).

There is strong evidence that CVE, among other adverse situations, also has a long-term developmental impact on children (Finkelhor et al., 2013, 2015a, b; Wolff et al., 2018). Literature on ACEs and mental health indicated that childhood adversities experienced in the community may distinctly impact youth mental health (Corcoran & McNulty, 2018). Recent studies on young adults have confirmed the link between CVE and ACEs (Lee et al., 2020). A study found that adolescents who have been exposed to community violence had a higher probability of being victimized by non-relative adult perpetrators, had lower family support, and had higher trauma symptoms scores than those victims of home or school violence (Turner et al., 2016). Similarly, a study examining the effects of cumulative violence exposure found an increased risk of more than 50% for internalizing symptoms and a 10% to 25% increased risk for somatic complaints (Margolin et al., 2010). The above results are noteworthy given that the study used a community sample of children and not a seeking-treatment sample. The prevalence and significant impact of CVE on youth mental health support its inclusion as part of the ACEs screening to understand the contribution of community-level adversity to youth’s anxiety symptomatology.

Efforts to screen for childhood adversities can help prevent and reduce negative outcomes on child development, including increased risk for internalizing disorders (Gillespie, 2019; Goldenson et al., 2021; Teicher & Samson, 2013). The cumulative risk framework (Evans et al., 2013; Felitti et al., 1998) has become the most common model for assessing risk for psychopathology based on the sum of exposure to individual adversities or cumulative risk score (Henry et al., 2021). Finkelhor et al. (2013) seminal work illustrated the value of adding related life events not considered in the original ACE study, increasing its predictive ability. The use of screenings to generate a total risk score (e.g., the PEdiatric ACEs and Related Life Event Screener tool – PEARLS, Koita et al., 2018) has been instrumental in identifying youth who are more likely to endure poor mental health outcomes for intervention (Shonkoff, 2016). In sum, there is the need to examine the unique contribution of CVE on the association between ACEs and somatic symptoms to inform prevention and intervention efforts in urban mental health clinics (World Health Organization, 2017).

The Present Study

Challenges posed by early adverse events and toxic stress can disrupt the architecture of the developing brain, which, in turn, influences behavioral, educational, and health outcomes (Shonkoff, 2010). Drawn on the cumulative risk framework (Felitti et al., 1998) and the Socio-ecological model (Bronfenbrenner, 1979) that examines interactions among individual and ecological factors that impact behavior and health across the lifespan (Bethell et al., 2017a, b; Harris et al., 2017), the proposed study aims to test the cumulative effect of ACEs, including community violence exposure (CVE) on somatic symptoms (SS) reported by children seeking for anxiety treatment. Specifically, the present study aims to examine whether community violence exposure (CVE) plays a role in the association between adverse childhood experiences (ACEs) and somatic symptoms (SS).

Methods

Participants

Participants in this study were part of an ongoing IRB-approved study of risk and protective factors associated with youth anxiety. A total of 98 children and their parents/ caregivers were recruited from a university mental health clinic specializing in treating pediatric anxiety disorders and trauma located in a large Midwestern city. Trauma-informed care is provided by a multidisciplinary team composed of psychologists, psychiatrists, and master-level clinicians. Baseline and follow-up data, including self-report measures, are collected from children, parents/guardians, and teachers.

The sample was composed of 52.1% females and 47.9% males, ranging from 4 to 17 years, with a mean age of 11.7 years (SD ± 3.73). Almost half of the participants (46%) were White, followed by 31.6% Latinx, 18.3% African American, and 1.1% of Asian descent. More than half of the participants (57%) lived with both biological parents, and 25.3% lived with their biological mother. At the time of the interview, 58% of parents/guardians reported being married, 10.5% reported being divorced, and 6.3% separated. The average annual income per household is $65,000. Nearly two-thirds of participants reported having experienced at least one ACE and related life events. Selected demographic information is presented in Tables 1 and 2.

Table 1.

Demographic Characteristics of the Selected Sample (N = 98)

	Mean (SD)
Age	11.7 (3.73)
	Percentage (n)
Gender
Female	52.1 (51)
Male	47.9 (47)
Ethnic Background
Caucasian	45.9 (45)
Latinx	31.6 (31)
African American	18.3 (18)
Asian	2.1 (2)
Other	2.1 (2)
Child’s Primary Residence
Father-mother	56.8 (54)
Biological mother	25.3 (24)
Biological father	1.1 (1)
Adoptive parents	1.1 (1)
Adoptive mother	1.1 (1)
Grandparents	1.1 (1)
With relatives	2.1 (2)
Caregiver Marital Status
Married	57.9 (55)
Divorced	10.5 (10)
Separated	6.3 (6)
Single	13.7 (13)
Widowed	1.1 (1)
Other	1.1 (1)
Household Income
Low (up to 39 k)	28.6 (28)
Middle (40 k-99 k)	35.8 (34)
High (100 K and up)	24.2 (23)
Parent’s Educational Status
Less than a high school	8.3 (8)
High School/GED	12.6 (12)
Some college-College diploma	39.1 (37)
Master’s Degree and beyond	26.3 (25)

Table 2.

Adverse Childhood Experiences (ACEs) and Community Violence Exposure (CVE)

(N = 98)	Mean (SD)	Range
Community Violence Exposure (CVE)
Media	9.1 (5.1)	0–19
Reported Stranger Victimization	4.6 (4.5)	1–15
Reported Family Member Victimization	1.89 (2.7)	0–10
Witnessing Stranger Victimization	1.0 (2.4)	0–15
Witnessing Family Member Victimization	0.7 (1.4)	0–7
Personal Victimization	0.3 (0.9)	0–6
	Percentage (n)
Adverse Childhood Experiences
Physical neglect	3.2 (3)
Emotional neglect	2.2 (2)
Emotional abuse	4.4 (4)
Physical abuse	10.9 (10)
Sexual abuse	12.0 (11)
Domestic violence	15.8 (15)
Substance abuse in the household	14.1 (13)
Impaired caregiver due to mental illness	37.0 (34)
Separation/divorce	32.6 (31)
Parent/caregiver incarceration	3.0 (3)
Death of a close family member	5.4 (5)
Victim/witness of a serious accident	6.5 (6)
Victim/witness of a natural disaster	2.1 (2)
Low-socioeconomic status	30.5 (43)
Interpersonal violence exposure	37.0 (34)
Total Number of ACEs
No ACEs	24.5 (24)
1 ACE	31.6 (30)
2 ACEs	21.1 (20)
3 ACEs	8.4 (8)
4 ACEs	10.5 (10)
5+ ACEs	6.4 (6)

Procedure

Families of children seeking treatment at the university-based clinic for anxiety and stress disorders were approached by a researcher at the end of the diagnostic intake to introduce the study. The research team is composed of doctorate-level and master-level clinicians trained in protecting human subjects in research. As part of the intake assessment, parents and children were asked to complete a package of questionnaires describing demographic information, psychological and physiological symptoms, and perception about community violence, among other factors. Parents/caregivers and their children were briefed by a member of the research team about the nature, purpose, and goals of the study. Of note, child and caregiver data used for the present research study were collected as part of routine clinical practice. Participants provided consent to share de-identified data for research. The principal investigator and some members of the research team were bicultural and bilingual (i.e.., English and Spanish) and clarified questions and concerns about the study in their language of preference. Informed consent from caregivers and assent from youth ages seven and above was a requirement for inclusion in the study. After reviewing the above information, parents and children who decided to participate in the study signed consents and assents, respectively. The study was approved by the University’s Institutional Review Board (IRB).

Measures

Demographics

A demographic questionnaire was used to obtain participants’ age, gender, ethnicity, household income, primary residence, parental education, and marital status of caregivers.

Adverse Childhood Experiences (ACEs)

The number and nature of adverse childhood experiences were obtained via chart review of all available medical and clinical records using the Trauma History Profile section from the UCLA PTSD Questionnaire Clinician Report (Steinberg et al., 2013) as a framework. The UCLA PTSD RI – 5 total scale scores showed optimal internal consistency (total scale α = .94) and evidence of diagnostic accuracy, supporting its utility for clinical assessment (Kaplow et al., 2020). A research assistant reviewed all clinical forms completed by clinicians and questionnaires completed by participants and their caregivers to determine whether they had been the victims, witnesses, or learned about any adversity that falls under one of the categories listed in the trauma history profile of the UCLA PTSD Questionnaire. A total of 15 items were selected, including the ten original ACE categories (Felitti et al., 1998), plus five related life events using the Revised ACE scale proposed by Finkelhor et al. (2013) and the Pediatric ACEs and Related Life Event Screener (PEARLS, Koita et al., 2018). A binary variable (0 = never experienced, 1 = experienced at any time in participant’s life) was created for each of the following ACE categories: physical and psychological neglect; physical, emotional, and sexual abuse; domestic violence; substance abuse in the household; household mental illness; parental separation/divorce; incarcerated household member; impaired caregiver, death of a close family member; victim/witness of a severe accident; victim/witness of natural disaster; and interpersonal violence exposure. Each of the variables created indicates whether participants reported exposure to a specific ACE. For the present study, an ACEs score was generated from the sum of the ACE variables, with higher values indicating more adversities experienced by each participant.

Community Violence Exposure

The Children’s Report of Community Violence (CREV; Cooley et al., 1995), Parent Version - is a 29-item, 5-point Likert scale (0 = never to 4 = every day), self-administered instrument that assesses exposure to community violence. Four subscales measure a) exposure to violence through media reports, b) hearing about/reported incidents of violence, c) witnessing violence, and d) being a victim of violence. The total score ranges from 0 to 116, whereas the reported and witnessed scale ranges from 0 to 40, and the victim scale ranges from 0 to 16. Higher scores indicate a greater amount of exposure to violence. The CREV has good internal consistency, (total scale α = .81; Cooley et al., 1995), construct validity, and test–retest reliability (Cooley et al., 1995). For the present study, the mean of the total score was used for the analysis.

Somatic Symptoms (SS)

The Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1991) is a 118-item, 3-point Likert scale (0 = not true, 1 = somewhat or sometimes true, and 2 = very true or often true) parent-report measure of child psychological adjustment and well-being. Questionnaires are scored using a computer program that norms results Factor-analytically-derived subscales assess internalizing, externalizing, and total child behavior problems. Reliability and validity are well-established for the CBCL (Achenbach & Edelbrock, 1991; Achenbach et al., 2001). The T-score from the Somatic Symptoms subscale (SS) subscale was used for the analysis.

Analysis Plan

Little’s MCAR test was performed to test for patterns of missing data. Preliminary analysis, using pairwise deletion was conducted to determine descriptive statistics. A mediation model using the SPSS PROCESS macro (Hayes, 2013), model 4 was applied to examine the mediating effect of community violence exposure (CREV) on the association between ACEs and somatic symptoms (SS) on children seeking treatment for anxiety. The PROCESS macro utilizes an ordinary least squares regression-based path analysis approach to estimate mediation models. Gender, ethnicity, and age were used as covariates and set bootstrap to 5,000 to calculate indirect effects and create 95% confidence intervals.

Results

Results from the little’s MCAR test indicated that no patterns were observed and that our data were randomly missed (χ² = 2.52, df = 5, p = .96). The final sample used for the model analysis contained 98 participants (52.1% female, 47.9% male) with a mean age of 11.7 years (SD = 3.73). Means, standard deviations, and correlations for all study variables are presented in Table 2. Bivariate correlations were conducted in the variables of interest. Results indicated that consistent with the model, the number of ACEs was positively correlated with community violence exposure (CVE) and somatic symptoms (SS). CVE was positively correlated with SS, being from an ethnic minority group, and age. Being female and age was positively associated with SS (Table 3).

Table 3.

Means, Standard Deviations, and Correlations among Study Variables

Measure	1	2	3	4	5	6
1. Number of ACEs	–
2. CREV	.34**	–
3. Somatic Symptoms (CBCL)	.27*	.46**	–
4. Age	.08	.26**	.40**	–
5. Gender	.06	-.08	.20**	.07	–
6. Ethnicity	.09	.24*	.19	.00	.07	–
M	1.74	10.5	63.2	11.7	.52	.54
SD	1.52	8.49	9.9	3.8	.50	.50
Range	0–5	1–50	50–87	3–17	0–1	0–1

The number of ACEs was derived from the UCLA PTSD-RI, Trauma History Section

Gender was coded 0  =  male, 1 =  female. Ethnicity was coded white  =  0, ethnic minority = 1

^*p < .05; ^**p < .01

Results from the proposed mediation model indicated that exposure to ACEs was significantly positively associated with CVE (b = .37, p = .0002), after controlling for gender, age, and ethnicity. Similarly, CVE was significantly positively associated with SS (b = .46, p < .001) after controlling for gender and age. In other words, for each one standard deviation (SD) increase in the number of ACEs, there is a .37 SD increase in CVE. Similarly, for each SD increase in CVE, there was a .31 SD increase in SS. Additionally, gender was significantly positively associated with SS (b = .46, p < .001) (See Fig. 1).

Fig. 1.

Moderation Model

Evidence of mediation was found in a statistically significant indirect effect of ACEs on SS through CVE (Effect = .173, 95% Bootstrap CI = .069–.294) after controlling for gender, ethnicity, and age. Then somatic symptoms increased by .17 standard deviation unit for every one unit increase of ACEs. Then, for one unit increase in ACEs, participants’ report of SS increased by .17 units (a seventeenth of a standard deviation) as a result of their increased exposure to community violence. This indirect effect is statistically different from zero, as revealed by a 95% bootstrap CI above zero. Results from the path model analysis also yielded a significant total effect of ACEs on SS (Effect = 1.58, SE = .66, p = .02), ∆R² = .15, F(3, 94) = 5.47, p = .001. A total effect is calculated by summing the direct and indirect effects or regressing SS on ACEs. Thus, to one unit increase in ACEs, there is an increase of 1.58 units in their reported SS.

Discussion

The aim of the study was to examine the link between cumulative individual and community-level adversity on treatment-seeking anxious children, such that community violence exposure (CVE) would significantly mediate the path between ACEs and somatic symptoms (SS). Examining the cumulative impact of childhood adversities on somatic symptoms allowed for a better understanding of the extent to which CVE impacts this association. Findings from this study support the proposed model.

Results indicated that, after controlling for age, gender, and ethnicity, dose–response risk generated ACEs is associated with SS via CVE in a sample of children seeking treatment for anxiety. A unique contribution of this study is that CVE mediates the association between ACEs and SS reported by a socioeconomically and ethnically diverse sample of children seeking treatment for anxiety in an urban mental health setting. This finding is consistent with mounting evidence that supports the inclusion of CVE as a separate ACE category (see Lai et al., 2018; Lee 2020; Thakur et al., 2020; WHO, 2016). These results are also consistent with emerging literature showing CVE -as a distinct ACE category- increasing the risk for somatic symptoms in children (Henry et al., 2021), above and beyond the cumulative impact of different forms of ACEs on this association (Finkelhor et al., 2015a, b; Lee et al., 2020). The use of a mediation model illustrated how ACEs and related life events exert their harmful effect on youth somatic symptoms.

Results from the current study are largely consistent with past studies demonstrating that community-level trauma contributes to toxic stress as individual-level ACEs do (Lee et al., 2020; Mayne et al., 2021). The inclusion of CVE to existing ACEs screeners increases its ability to identify cumulative toxic stress that affects physiological responses in children (Lee et al., 2020), the main path through which ACEs exert their public health impact (e.g., Anda et al., 2010; Zeanah et al., 2018). Toxic stress derived from CVE, or the prolonged activation of the body’s stress response system in the presence of community stressors (e.g., hearing, witnessing, experiencing), may lead to changes in the stress system, activating itself more frequently and for more extended periods of time (McEwen et al., 2015). As a result, dysregulation of the stress response system increases the likelihood of endorsing somatic complaints and physical and mental illness (Kerker et al., 2015; Shonkoff et al., 2012; Teicher et al., 2016). Together, these results confirm the importance of assessing for type and frequency of community violence exposure as part of the ACE screening (Afifi et al., 2020; Bethell et al., 2017a, b; Finkelhor et al., 2015a, b; Lee et al., 2020; Thakur et al., 2020).

Most importantly, this finding calls into question the perception that CVE is a phenomenon circumscribed to urban, low-income, and ethnic minority communities in that mounting evidence suggest the widespread of violence is impacting, to a certain degree, both urban and suburban children of diverse SES and ethnic backgrounds (Gaylord-Harden et al., 2016; Löfving-Gupta et al., 2015; Ozer et al., 2017). Although the prevalence of CVE in urban areas is higher, a substantial number of children from suburban middle-class communities have been found to report witnessing (34.5%) and experiencing (24%) community violence (Löfving-Gupta et al., 2015).

Results from the current study also indicate that females endorsed more somatic symptoms than males. This finding is consistent with previous research in pediatric samples that have found that females endorsed more somatic symptoms than males (Crawley et al., 2014; Romero-Acosta et al., 2014; Ruchkin & Schwab-Stone, 2014). Some studies suggest that this trend may be due to a physiological sensitivity among girls and gender expectations (Chaplin et al., 2009) as boys don’t openly endorse somatic symptoms nor is promoted by social norms (Kugler et al., 2012). Other studies suggest that advanced pubertal status in girls is associated with reporting somatic symptoms (Rhee et al., 2005). Future research should explore gender differences further by examining ACEs separately as unique risk indicators for psychopathology (Henry et al., 2021). Examining gender differences based on threat domains (i.e., physical and sexual abuse, community violence exposure, domestic violence) and deprivation domains (i.e., emotional and physical neglect, lack of resources) using other frameworks (DMAP; McLaughlin et al., 2012) may shed light on the associations between ACEs and internalizing behaviors among anxious children. Also, future studies need to include underserved and hard-to-reach populations that are at heightened risks, including non-binary participants who do not identify as either male or female and children who are involved in the criminal justice system.

The results from the present study demonstrate the need for implementing a comprehensive ACE screening in urban mental health settings. Furthermore, due to the association between ACEs and SS through CVE found in this study, it is critical that mental health providers are aware of the potential influence ACEs and related life events may have on preventative and intervention measures. Further prospective studies should examine the causal mechanisms through which ACEs and related life events increase physiological symptoms via toxic stress and the role of cross-agency collaboration to improve the mental, behavioral, and physical health of urban youth.

Implications

Findings from the present study suggest several implications. First, the use of comprehensive ACE screenings in urban mental health clinics where children may be more likely to report and seek support for somatic symptoms is critical for early intervention and prevention (McChesney et al., 2015). Notably, the use of well-designed culturally appropriate questionnaires for specific populations (e.g., PEARLS tool, WHO ACE-IQ) has been found to improve disclosure of traumatic experiences (Koita et al., 2018; Quinn et al., 2018). The systematic use of enhanced ACE screenings by researchers, healthcare and behavioral health providers in schools, clinics, and community-based organizations should inform the development and implementation of interventions that alleviate the effects of ACEs on children (Bethell et al., 2014; Larkin et al., 2012; Lee et al., 2020). Cross-agency collaboration is critical to coordinate care between first responders (i.e., law enforcement), schools, and community services. ACE screenings should only be conducted when a referral system is in place to adequately address the needs of children and their families identified as needing specific types of services (Soleimanpour et al., 2017). Changes in policies to share information among agencies are critical to avoid re-traumatization and remove barriers to trauma-informed services.

Second, ACE screenings that focus on the ecology of youth’s life by incorporating strength-oriented questions about the youth’s trust and sense of safety would help move the screening process beyond the negative (Goldernson et al., 2021; Van der Kolk, 2015). Caregivers and children may feel less guarded when questions are not only about their family but also about what children experience, witness, or hear in their communities, gathering contextual information needed to understand needs and connect children and families with services and resources (Bethell al., 2017a, b; Thakur et al., 2020). By the same token, a relationship-centered approach can be used when screening for ACEs to identify strengths, resources, and formal and informal support to address any trauma and toxic stress (Larkin et al., 2012).

There is the need to assess the effect of ACEs and CVE on youth’s behavioral and health outcomes overtime as well as to understand how ACE screening informs or enhances interventions to promote child resilience and reduce health disparities, particularly in underserved populations (Di Lemma et al., 2019; Goldenson et al., 2021). On clinical samples, the use of somatic (e.g., progressive muscle relaxation) and behavioral treatments (e.g., biofeedback, exposure) have been shown to be effective in increasing knowledge of the autonomous nervous system (ANS) functioning in anxious children (Seligman, & Ollendick, 2011; Van der Kolk, 2015). In sum, there is a need for interventions addressing emotion regulation and environmental stability (Suarez et al., 2012).

From a prevention lens, the use of a comprehensive ACE screening can inform the development, implementation, and evaluation of trauma-informed evidence-based prevention programs for children and their families (Hershberg & Briggs, 2016; Leitch, 2017). Particularly, prevention programs that promote resilience using a socio-ecological framework (Bronfenbrenner, 1979; Leventhal et al., 2005) have proven to be effective in promoting stable and supportive parent–child relationships (Positive Parenting Program; Bodenmann et al., 2008), informal social support (Dolan, 2011; Tolan et al., 2014), socio-emotional development and violence prevention programs in school settings (Durlak & Weissberg, 2011; Ross-Reed et al., 2019; Walsh et al., 2016), and neighborhood collective efficacy (Kirst et al., 2015; Sampson, 2017) that, in turn, foster resilience among those who experience childhood adversity, connect individuals with community services, and promotes a sense of community (Bellis et al., 2014; Gil-Rivas & Kilmer, 2016; Gouin et al., 2017; Hughes et al., 2018). Engaging service providers, community members, stakeholders, academics, and legislators in the development, implementation, and evaluation of strength-based programs is likely to be beneficial in reducing ACEs’ impact on children, families, and their communities (Harris et al., 2017).

Limitations

There were several limitations, including the cross-sectional nature of the present study does not allow for causal inferences. First, the ACE score used for the present study was obtained from a chart review using the trauma history section of the UCLA PTSD questionnaire as a framework. Although mental health providers conducting clinical assessments used psychometrically sounded measures (i.e., UCLA PTSD, CBCL) and received training in trauma-informed care, not having a formal ACE screening tool may introduce variability in how data is collected. Second, the ACEs score is a “cumulative risk score” and does not weigh adverse events based on severity, duration, and frequency. Third, although ACE screenings have been modified to assess for community-level adversity (e.g., witness/experience interpersonal violence, natural disasters, serious accidents), asking a single yes/no question requires a proper follow-up assessment of the type, severity, and frequency of the exposure. Fourth, the current study did not screen for participants’ experiences of racism and discrimination in their communities. Fifth, theories have hypothesized about specific adverse effects observed in children and the timing of stressor exposure (Andersen & Teicher, 2008; Fuhrmann et al., 2015). However, the current study did not stratify ACE exposure by age (e.g., 0–5, 6–12, 13–17) or the child’s family position. Sixth, self-report of ACEs may be biased as research suggests that recall of adverse situations is associated with underreporting due to fear of re-experiencing traumatic events (Di Lemma et al., 2019) or social desirability (Cronholm et al., 2015). Children may be aware that reporting adversity (e.g., physical or sexual abuse, neglect) may have legal consequences for their caregivers (e.g., DCFS involvement).

Conclusion

In summary, this study is the first in examining the additive impact of individual-level ACEs and community violence exposure (CVE) in a diverse, treatment-seeking pediatric population reporting anxiety symptoms. Findings from the current study support comprehensive ACE screening tools as they offer more sensitivity to identify adversities in youth. Further research should explore other adversities that children are constantly exposed to, including interpersonal violence and cyberbullying. Efforts should focus on examining adversity and resilience in children using prospective studies to capture better the contribution of individual, household, and community factors on children’s wellbeing.

Declarations

Conflict of Interest

The authors declare that there are no conflict of interests.