Discussion
Assessing the sensitive topics of ACEs and resilience was acceptable to our racial/ethnically- and socioeconomically-diverse cohort of childhood and AYA cancer patients and their caregivers. Feasibility and participant acceptance are common concerns in research with sensitive subject matter, such as ACEs. Prior research has shown that even in well-documented cases of serious childhood abuse, retrospective studies likely provide underestimates of their incidence.12However, certain survey methodology choices, such as the utilization of anonymous surveys and the creation of perceived confidential environments to disclose ACEs have been shown to improve accuracy of reports.13 This provided rationale for administering electronic surveys to assess ACEs and resilience. Results from our study showed most participants were comfortable and prepared to answer survey questions following informed consent. This suggests that future studies of ACEs and resilience in larger cancer populations are feasible.
For our descriptive results, 50% of patients reported at least one ACE, similar to larger general population cohorts.4,14,15Those with ACEs were older compared to those without. Though most of the ACE literature uses retrospective cohorts of adults,16prospective accounts of ACEs from children less than 18 years old retain the ability to predict poor health outcomes in their futures.12 Participants with prior ACEs were more likely to endorse mental health issues and substance misuse compared to those without. Prior studies investigating relationships between ACEs and mental health demonstrated that repeated exposures to high-stress experiences in early childhood can lead to long-term disruptions in neuropsychiatric development.17,18 Though previous studies show childhood cancer survivors engage in similar rates of substance misuse compared to peers,19 AYA cancer patients who report multi-drug use are more likely to report mental health issues as well.20 Participants with ACEs also had lower resilience scores compared to those without. Research has demonstrated that early adversity can be mitigated through teaching resilience.21,22 Though studies mapping neurobiological pathways connecting ACEs, resilience, and health outcomes are ongoing,23 research in the general population using “strength-based” interventions (e.g. those that focus on positive attributes of a person/group rather than negative) to cultivate resilience in children and AYAs with ACEs have shown increased health-promoting behaviors.24,25
Limitations include the cross-sectional design of this study as well as our use of a convenience sample. Future studies utilizing larger, well-characterized cohorts of childhood and AYA cancer patients and survivors could better delineate associations of ACEs and resilience with long-term health outcomes. Assessment of ACEs could also be incorporated into future pediatric and AYA clinical trials to examine their associations with various poor health outcomes. These data would inform interventions to aid those who have experienced ACEs to reduce additional morbidity and premature mortality for this high-risk population.