Early Life Stress (dimensional)
Dimensional Approaches: Definitions of Threat, deprivation, and unpredictability
Dimensional models are an alternate approach to measuring and conceptualizing the impact of adversity on neurobiological development and subsequent health and well-being. These models focus on dimensions of underlying experiences shared across multiple forms of adversity (McLaughlin et al., 2020). Multiple researchers have proposed dimensional models (Belsky et al., 2011; Humphreys & Zeanah, 2015; Sheridan & McLaughlin, 2014) that have converged on three dimensions (threat, deprivation, and unpredictability) that capture a number of aspects of adversity experiences. Theories of exposure to harshness or threat capture experiences of violence in childhood (e.g., abuse, domestic violence, and community violence) and suggest that children with this type of exposure are likely to exhibit increased emotional reactivity and decreased regulation as well as accelerated biological aging (Belsky et al., 2011; McLaughlin et al., 2014). The deprivation domain includes an absence of expected social and cognitive stimulation—particularly in the context of caregiver interactions (e.g., neglect, institutionalization, lack of consistent caregiver interactions, and material deprivation. Deprivation or a lack of caregiver input has been theoretically linked with cognitive and social functioning (Sheridan & McLaughlin, 2016). Unpredictability involves a lack of stability in caregiving and other aspects of the early environment (Baram et al., 2012). It is more challenging to assess unpredictability and less agreement exists about how to do so (Young et al., 2020). Here we propose approaches for measuring threat and deprivation but only briefly describe measures of unpredictability given the more nascent nature of that work.
To address some of these complexities, we propose the following herein. First, we separately outline measures that can be used to assess threat, deprivation, and unpredictability. We propose measures of several experiences that capture each of these dimensions individually. Second, we outline measures that could be used in childhood for prospective assessments of adversity experiences and then complementary measures that can be used in adulthood. Many measures collect information directly from children and, in a modified form, directly from adults. Including self-report both early and late in life eliminates one source of variance in reporting across the lifespan. However, there are issues with both retrospective and prospective measures, including memory bias and lack of agreement (see Newbury et al., 2018; Baldwin et al., 2019 for studies and discussions of this issue). As is the case in many other domains, information from different reporters (e.g., parents, children) does not always align well (Skar et al., 2021), as each may have various motivations for sharing or not sharing experiences (e.g., privacy, shame/embarrassment, desire to share or seek help, fear of consequences, etc.) and/or may not all be aware of the same events. As of yet, only a limited amount of evidence documents associations between dimensions of adversity and outcomes in mid to late life (Geoffroy et al., 2016; Pereira et al., 2019). This enterprise is complicated because evidence suggests that the overlap between who are identified in early life as having experienced adversity versus those who report these experiences in adulthood is relatively low (Baldwin et al., 2019). Additionally, adult psychopathology is more strongly associated with self-reported maltreatment in adulthood than observed maltreatment in early childhood (Newbury et al., 2018).
Below we recommend specific measures to assess threat (TABLE 1) and deprivation (TABLE 2). We then describe each measure in depth in the addendum. Much previous work has conceptualized named exposures (e.g., maltreatment or community violence), and thus most measures are designed to capture a child’s experience of a particular exposure. In contrast, when conceptualizing dimensions of exposure, we focus on experiences (e.g., interpersonal violence) that may occur within a number of named exposures (see McLaughlin et al., 2020 for a complete discussion). Because of this mismatch, we suggest assessing threat and deprivation broadly using a variety of measures and creating dimensional variables from them (see Machlin et al., 2019; Miller et al., 2018, 2020) for examples of ways to do this.
Alternately, if the information collected is more limited, another approach is to count the number of exposures within a specific dimension, essentially creating a cumulative risk score for each dimension. Both approaches approximate assessing the underlying dimensions of experience, and future measurement work should focus on measuring the dimensions of threat and deprivation and, to get more data, also including unpredictability when possible.
Table 1: Threat Measures
Table 2: Deprivation Measures
Below we go into more detail about each measure under the dimensional categories of threat, deprivation, and unpredictability
Threat exposure is defined as direct experiences or witnessing interpersonal violence and trauma where they believe their life or the life of a close other may be in danger (e.g., a life-threatening accident). Most instruments focus on one form of exposure to violence (e.g., partner violence, abuse, or community violence). Because each questionnaire proposed here may assess a mixture of deprivation and threat we specify which subscales would be included in the appropriate dimension below.
Caregiver Report of Threat Experiences in Childhood
The Violence Exposure Scale for Children-Revised (VEX-R). The VEX-R is an interview-based measure that was originally designed to be administered to children (Raviv et al., 2001; Raviv et al., 1999); however the interview can also be administered to parents to obtain parental report of children’s exposure to various forms of violence (Fox & Leavitt, 1995; Shahinfar et al., 2000). Subscales appropriate for including in the threat dimension are those assessing severe witnessing and direct experiences of violence
The Juvenile Victimization Questionnaire (JVQ). The JVQ (Finkelhor et al., 2005) is a 34-item measure of victimization experiences from ages 2-17. Subcales: conventional Crime, child maltreatment, sexual victimization, and witnessing
The Conflict Tactic Scales-Parent Child (CTS-PC). This is a relatively brief measure (27 questions; 6-8 minutes to complete) administered to caregivers regarding current or recent abuse and maltreatment within the family or home environment. Only subscales assessing corporal punishment, physical abuse, and sexual abuse should be used to measure threat (Straus et al. 1997). Subscales: corporal punishment, physical abuse, and sexual abuse.
The Conflict Tactic Scales-2 (CTS-2). The CTS-2 is designed to measure intimate partner aggression, as reported by a caregiver. This is conceptualized as an adversity exposure to the children of this partnership because of ample evidence that children experience intimate partner violence as an instance of traumatic violence (Straus et al., 1996). Subscales: physical assault, sexual coercion, and an injury subscale
Self-Report of Threat Exposure Reported in Childhood
Children can be asked about their experiences of threat exposure directly, and this can serve as a compliment to parent report.
The Violence Exposure Scale for Children-Revised (VEX-R). As noted above, the VEX-R was originally designed to be administered to children directly, including young children (e.g., 4-10 years) (Fox & Leavitt, 1995). Subscales: severe witnessing and direct experiences of violence.
The Juvenile Victimization Questionnaire (JVQ). The JVQ can be administered as an interview with children ages 8-17 and as a self-report questionnaire for children above the age of 12 (Finkelhor et al., 2005). Subcales: conventional Crime, child maltreatment, sexual victimization, and witnessing
Parent-Child Conflict Tactics Scale – Revised (CTSPC-R). This scale was developed to assess psychological and physical abuse from the children’s perspective (Straus et al. 1997). Subscales: corporal punishment, physical abuse, and sexual abuse.
Assessing violence exposure in children younger than 18.
Asking about family violence prospectively (when the study participants are younger than 18 years of age) has clinical, ethical and legal ramifications. In clinical use, any non-negative score on a family violence questionnaire may warrant further investigation to safeguard the victim. In research use there are questionnaires which assess potential abuse experiences directly (e.g., the CTS-PC asks specific questions about experiences which would be very likely or would clearly be defined as physical or sexual abuse). Other questionnaires (e.g., the CTS, VEX-R or JVQ) ask more general questions which are not clearly an assessment of abuse. When working with populations younger than 18 years, it is the responsibility of the researcher to make sure they have the clinical expertise to handle cases where evidence of abuse is uncovered during the course of research. This may affect which kinds of questions researchers feel capable of asking.
Self-Report of Childhood Threat Experiences Reported in Adulthood
Assessing threat exposure in adulthood requires that adults accurately recall experiences prior to the age of 18 that involved harm or threat of harm. While it seems likely that these are salient events, there are myriad differences in how these events are reported across age (see Baldwin et al., 2019 for a review and meta-analysis) and recall bias is a particular concern with older adults. One way to reduce the degree of variance is to use the same measures and informants across ages. To increase the likelihood that could happen we provide suggestions for measures that can be used across ages and informants. In addition, we provide some additional examples of measures designed for retrospective self-report.
The Juvenile Victimization Questionnaire (JVQ). The JVQ can be adapted to assess the entire lifespan and with adults for retrospective reporting of childhood adversity exposure. A second revision with a reduced number items, the JVQ-R2 (Finkelhor et al., 2005) is also available as an adult retrospective screener for childhood adversity experiences before the age of 18. Subcales: conventional Crime, child maltreatment, sexual victimization, and witnessing.
Maltreatment and Abuse Chronology of Exposure (MACE). The MACE (Teicher & Parigger, 2015) is a 52-question self-report measure, was designed to be used retrospectively with adults. Subscales: non-verbal emotional abuse, parental physical maltreatment, parental verbal abuse, peer physical bullying, sexual abuse, witnessing interparental violence and witnessing violence to siblings
Deprivation exposure is defined as a lack of expected experiences of caretaking and cognitive and social stimulation during childhood. Exposures in this dimension include neglect, institutionalization, and a lack of invested caregiving due to low resources or caregiver capacity. Conceptually this is an index of a lack of caregiver interactions which is reflected in our choice of measures. It is possible that investment in cognitive development which occurs outside of the home, such as in schools would compensate for deficits experienced at home. However, to date few self, parent, or teacher report questionnaires exist which assess the amount of cognitive scaffolding provided to children in the classroom so we do not touch on this form of enrichment or deprivation here.
Many instruments that measure family violence include variables assessing neglect, including parent report measures such as the CTS-PC and self-report measures such as the MACE. We recommend those measures here using measures that assess many aspects of adversity reduces overall burden on participants. However, these scales are limited in scope and assess specific behaviors (e.g., not bringing a child to the doctor when she is sick) that constitute neglect, but do not capture the broader range of caregiving experiences that reflect deprivation. Thus, we additionally suggest measures that assess a range of caregiving behaviors across the deprivation dimension. For example, a wider range of neglect behaviors are assessed in the Multidimensional Neglectful Behavior Scale (MNBS; Harrington et al., 2002; Kaufman Kantor et al., 2004; Straus et al., 2011).
Additionally, an important theoretical aspect of deprivation concerns cognitive stimulation and scaffolding as assessed in the Home Observation for Measurement of the Environment (HOME; Bradley et al., 2001; Bradley & Caldwell, 1977) and the StimQ (Mendelsohn et al., 1999). Generally, these measures are for use with young children and are not validated for use as retrospective reporting tools although some recent studies have attempted to use them in this way.
Parent Report of Deprivation in childhood
The Conflict Tactic Scales-Parent Child (CTS-PC). The CTS-PC contains a 5-item neglect subscale that assesses the presence of five neglectful behaviors (e.g., left your child alone at home even though you thought they were too young) during the child’s lifetime. The neglect subscale is the only one which is appropriate for use in the deprivation dimension.
Multidimensional Neglectful Behavior Scale (MNBS). The MNBS measures the extent to which the child’s environment meets four basic developmental needs: physical (food, clothing, shelter, medical care); emotional (e.g., affection, companionship, support); supervisory (e.g., limit setting, attending to misbehavior, knowing child’s activities); and cognitive (e.g., reading to child, explaining things). A parent-report version of the MNBS can be administered as an interview or self-administered questionnaire (Straus et al., 2011). The entire MNBS scale is appropriate for inclusion in the deprivation dimension
Home Observation for Measurement of the Environment (HOME). The HOME (Caldwell & Bradley, 1984; Bradley et al., 2001). The HOME was originally designed as an in-person interview and observation and has several versions for use from toddlerhood through middle childhood. All parts of the HOME and HOME short form except the questions about physical discipline are appropriate for use in the deprivation dimension.
StimQ. The StimQ (Mendelsohn et al., 1999) is a caregiver interview designed for use in both clinical and research settings to assess the role of the child’s primary caregiver and the home environment in providing cognitive stimulation. Versions vary by age but this measure is only available for infants and children ages 5 – 72 months of age. All subscales of the StimQ are appropriate for use in the deprivation dimension.
Self-Report of Deprivation Experiences Reported in Childhood
Multidimensional Neglectful Behavior Scale (MNBS). The MNBS, originally developed for use with adults, has been adapted for retrospective recall with older youth (e.g., ages 12-14; Dubowitz et al., 2011). The entire MNBS scale is appropriate for inclusion in the deprivation dimension
Self-Report of Deprivation Experiences Reported in Adulthood
Multidimensional Neglectful Behavior Scale (MNBS). The MNBS-A (Straus et al., 2011) was originally developed for use with adolescents and adults to retrospectively report on their experience of neglect of children’s developmental needs across four 5-item subscales assessing physical, emotional, supervisory, and cognitive domains. The entire MNBS scale is appropriate for inclusion in the deprivation dimension
Maltreatment and Abuse Chronology of Exposure (MACE). The Maltreatment and Abuse Chronology of Exposure (MACE; Teicher & Parigger, 2015) is a 52-question self-report measure, was designed to be used retrospectively with adults. The MACE assesses 10 types of adversity exposure in childhood, the physical neglect subscales would be appropriate for measuring deprivation.
Potential Future Directions. As described above, assessment of adversity exposure in adult populations is rife with complications, where previous exposures can both be missed early in development and reported on later or reported on accurately early in development but not described later. Carmel & Widom, 2020 recently developed measure to address this concern in the area of severe neglect. Development of this measure included Support Vector Machine (SVM), a machine learning algorithm, to select an optimal set of items. The final measure consists of 10 items to retrospectively assess neglect experiences and identify adults who suffered severe neglect who may not have been identified or treated at the time. The scale assessed the domains of medical neglect (e.g., dental problems, lacking hygiene); nutritional neglect (e.g., untreated food spoilage), shelter (e.g., unfixed broken windows); guardianship (e.g., left home alone). This measure also collects information about severity and diversity, and propensity (likelihood of having an experience) of experiences. Propensity scores demonstrated strong predictive, construct, and discriminant validity, while the severity and diversity scores each only passed 2 of the 3 validity tests. Thus far, this measure has been used and cited in one 2021 peer-reviewed publication (Morris et al., 2021).
Another dimension of experience currently being explored as it relates to subsequent outcomes is caregiver unpredictability (See Young et al., 2020) for review of environmental unpredictability theory and measurement). Conceptually, unpredictability could include intermittent unavailability of a primary caregiver, changes in caregivers, or changes in living circumstances and other substantial aspects of the environment. This approach to conceptualizing unpredictability is taken by some prominent researchers (Belsky et al., 2011). However, equally possible is that unpredictability is primarily an aspect of caregiver behavior, as in caregiver behavior is unexpected, non-contingent, or similarly difficult to predict, an approach other researchers have taken (Davis et al., 2017) and which has conceptually been linked with processes of aging (Short & Baram, 2019). Some measures to assess both global unpredictability (the Family Unpredictability Scale; FUS; Ross & Hill, 2000) and unpredictability of maternal signals (the Questionnaire of Unpredictability in Childhood; QUIC; Glynn et al., 2018) exist but they have not been widely used in concert with each other or other measures of adversity thus we do not strongly recommend either here. However, we hope that future research elucidates the level at which unpredictability should be measured and identifies the pathways through which it comes to impact health and well-being across the lifespan.
Authors and Reviewer(s):
This summary was prepared by Margaret Sheridan and reviewed by Stefanie Mayer, Megan Gunnar, Elissa Epel, and Darwin A. Guevarra.
Measuring Early Life Adversity:
Prospective and Retrospective Measures using a dimensional approach
One common approach to measuring early-life adversity is a cumulative risk approach (Evans et al., 2013). In this approach, multiple forms of adversity ranging in severity and type are assessed together and conceptualized as examples of various indicators of increasing risk. Thus, many kinds of childhood adversity are assessed, and the number of exposures endorsed is summed to compute a risk score. The primary proposed mechanism for the impact of cumulative risk on a wide variety of outcomes is via allostatic load (Danese & McEwen, 2012; McEwen & Gianaros, 2010). The stress measurement network has excellent articles suggesting best practices for taking this cumulative risk approach. Please see the sections on “Early Life Stress” or “Major Life Stress” for additional information and specific measure recommendations.