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.