Family health is “a resource at the level of the family unit that develops from the intersection of the health of each family member, their interactions and capacities, as well as the family’s physical, social, emotional, economic, and medical resources” [1]. Family health is shaped not only by genetics but also by family functioning and family experiences, including the ability of the family to adapt to internal and external challenges and experiences. Positive family health promotes belonging, caring, and the capacity to perform family responsibilities, which in turn, promotes the health of individual members [2].
Family health includes a variety of factors that transcend disciplinary boundaries, including family communication and problem-solving, family functioning and routines, emotional support, healthy behaviors, internal coping skills of the family, and access to external resources [1, 3]. Key domains of family health include: (1) family social and emotional health processes; (2) family healthy lifestyle; (3) family health resources; and (4) family external social support [3]. Family social and emotional health processes include family relationships, communication, support, and feelings of emotional safety and belonging that promote cohesion within the family. This aspect of family health aligns most closely with traditional measures of family functioning [3]. Family healthy lifestyle comprises a family’s collective healthy choices through regular physical activity, eating fruits and vegetables, following doctor’s recommendations, and seeking health care services as needed. Family health resources refer to financial and non-material assets that allow the family to carry out their functions and their normal daily activities. These include internal and external resources such as help-seeking efficacy, the ability to effectively cope with family challenges, financial resources and other basic needs, and access to health care. Finally, family external social supports refers to the presence of a social network or social capital outside of the family that the family can count on for advice, care, or assistance, whether financial or otherwise [3]. These domains offer protection against many physical and mental issues within families by creating stronger relationships and family functioning [4,5,6,7,8].
The measurement of family health is relatively new [1,2,3], and understanding how one’s family experiences in childhood affects family health in adulthood is not currently well understood. Therefore, in an effort to better understand the intergenerational transmissibility of family health, in this study we examine the effects of retrospectively reported adverse childhood experiences (ACEs) and positive childhood experiences (PCEs) that occurred before age 18 years on family health in adulthood. ACEs are potentially traumatic life events that occur before the age of 18, including child abuse (physical, emotional or sexual) and neglect, mental illness of family members, parental divorce or separation, and family member substance use [9]. PCEs (also referred to as benevolent childhood experiences (BCEs) or advantageous childhood experience (counter-ACEs) in other studies [10, 11]), are experiences before age 18 that are thought to be beneficial, such as positive relationships with parents and other adults, household routines, beliefs that provide comfort, and having good neighbors.
Childhood experiences and later health: resiliency and life course theories
Resiliency Theory and the Life Course Theory provide the theoretical framework for this study. Resiliency Theory focuses on promotive factors that independently lead to better health and may attenuate the effects of risk factors on developmental trajectories and outcomes [12]. Promotive factors allow for post-traumatic cognitive and social growth [13], which can equip individuals with coping skills, self-worth, self-efficacy, and optimism [14]. By applying Resiliency Theory to the current study, PCEs can be viewed as promotive factors that include healthy interactions with mentors, role models, and positive influences. In addition to internal skills, PCEs enable the individual to develop resilient functioning and continued growth even when traumatic events occur [13,14,15,16]. This resiliency and growth my help to promote better family health in adulthood.
Life Course Theory [17] offers a comprehensive intergenerational approach for understanding how the timing of life events, especially during sensitive developmental periods, have biopsychosocial consequences that could alter health trajectories [17,18,19], including family health. Human development, as viewed through the Life Course Theory, is comprised of interconnected biological changes at various life stages that interact with psychosocial factors over time. Thus, early experiences such as separation, family dysfunction, neglect, abuse, violence, and resource restrictions generate delayed pathology that influence subsequent health, including access to care and parental resilience [9, 18]. Where early adversity produces “distinct patterns of disadvantage or privilege” over time [18], having more positive childhood experiences allows for improved wellbeing in adulthood [14]. Forrest & Riley [20] attribute such effects on biopsychosocial processes that permit successful adaptation despite negative stressors.
Three key principles of the Life Course Theory provide a framework for understanding how childhood experiences can affect family health in adulthood: linked lives, human agency, and lifelong development and aging [17]. “Linked lives” is the interdependence of shared relationships and experiences that are most apparent in the family setting. For instance, ACEs and PCEs are strongly influenced by the circumstances in the family. Families that communicate well and do things together often facilitate healthy relationships for children, leading to more PCEs. On the other hand, families with fewer resources may have more difficulty in building healthy relationships and may have fewer coping resources. Thus, when stressors arise, family abuse and dysfunctionality may arise leading to more ACEs. ACEs and PCEs trigger a series of biopsychosocial mechanisms. ACEs can result in HPA axis dysfunction and chronic inflammation [21], with the effects of the initial trauma manifesting in adulthood in a variety of disorders and poor health outcomes, whereas PCEs can lead to adaptation and resilience [16, 22]. These early life events may work independently or together in affecting the quality of family health an individual is able to create in adulthood. On the other hand, “human agency” emphasizes how individuals and families can make choices in the presence of opportunities, constraints, and/or adversity. For example, even when families experience stress and trauma, they can still create safe, trusting relationships and stable routines for their children. Finally, “lifelong development and aging” is examining individual human development in terms of interconnected stages of physical, mental, social, and spiritual changes throughout the life span. For instance, the consequences of ACES that are transmitted across generations may be tempered by various factors over time such as the presence of PCEs.
Childhood experiences and family health in adulthood
Prior research has demonstrated that childhood experiences affect individual health in adulthood. For example, individuals who experience numerous ACEs early in their childhood are at risk for developing depression, anxiety, substance abuse habits, and detrimental health behaviors as they mature into adulthood [23]. Conversely, PCEs independently lead to better health and may offset the effects of ACEs on adult health [10, 11, 24, 25].
Although research on childhood experiences indicates their influence on adult health, little is known about how ACEs and PCEs affect family life. Research has demonstrated that parenting styles are often passed down to children who then parent their children using similar methods and traditions [26, 27]. Families develop through family patterns and life cycle events and processes [28]. For example, research indicates that individuals who were abused as children are more likely to abuse their own children [27], and parents who have unresolved emotional issues from childhood are more disorganized in their parent child attachments and exhibit more frightening parenting behaviors [8, 29]. On the other hand, parents that were raised in a home that had more positive coping strategies and parenting efficacy were more likely to perpetuate these positive coping strategies in their own families [26]. Other studies have shown that parents who have experienced more PCEs in their childhood are better able to provide a positive home life for their children [26] and have improved family function, family cohesion and overall health [5, 30, 31].
Aims and hypotheses
In this study, we examined the effects of ACEs and PCEs on a comprehensive measure of adult-reported family health. The aim of the study was to determine the association between childhood experiences, both adverse and advantageous, and family health in adulthood. We hypothesized that (1) ACEs would lead to worse family health outcomes across all four domains of family health; and (2) PCEs would improve family health across all domains. (3) Given that prior research has shown that PCEs have a direct positive effect on individual health irrespective of ACE score, and that the effects of ACEs on health is attenuated when PCEs are included in models [10], we also hypothesized that PCEs would have a stronger association with family health than ACEs.