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Do safe, stable, and nurturing relationships work? New research has important findings for responding to ACEs


While we know that adverse childhood experiences (ACEs) can cause risk behaviors, research has told us that the presence of protective factors can help mitigate the effects of ACEs. Common risk behaviors such as smoking tobacco and alcohol misuse can be a result from the trauma of childhood disadvantage. In responding to ACEs, public health research proposes that protective factors such as safe, stable, nurturing relationships (SSNRs) with a caring adult can mitigate the long-term effects of ACEs, thus increasing resilience in children. 

In response to this, new research investigates whether the presence of an SSNR does reduce engagement in risk behaviors. By studying if tobacco and alcohol use would be weak or strong in adults whose basic living needs were met and felt safe and protected during childhood, the study further delved into the relationship between SSNRs and risk behaviors from ACEs (Srivastav, Davis, et al., 2020). This recent study revealed that these relationships do significantly decrease the odds of an adult engaging in unhealthy behaviors such as tobacco and alcohol use, further supporting SSNRs as playing a role in curbing risk behaviors. While SSNRs have proven to be effective, few studies have considered the inequities that racial minorities face and whether the presence of an SSNR is the best strategy for every population.

One study conducted in 2020 investigated this relationship between SSNRs and tobacco use among South Carolina adults and further examined the disproportionately worse health outcomes experienced by Black children and families (Srivastav, Strompolis, et al., 2020). The study found that SSNRs did not significantly buffer tobacco use among Black adults, whereas it did among White adults. 

Through this research, it is evident that protective factors such as SSNRs do have an impact on mitigating the long-term effects of ACEs. However, when examined by race, the effectiveness of SSNRs for minority children comes into question. It is important to consider the systemic racism and inequities faced by Black children that can cause strains in their relationships. Because of this study, SSNRs may not be sufficient to provide the support for racial/ethnic minorities who have been exposed to ACEs. Addressing the systemic racism in education, employment opportunities, health care, and housing to create equitable, tailored supports to addressing childhood trauma is important for the health and well-being of children of color. 


Srivastav, A., Davis, R. E., Strompolis, M., Crouch, E., Thrasher, J. F., & Spencer, M. (2020). Responding to Adverse Childhood Experiences: Understanding the Role of Safe, Stable, and Nurturing Relationships in Reducing Alcohol and Tobacco Related Risk Behaviors. Journal of Child & Adolescent Substance Abuse, 1-13.

Srivastav, A., Strompolis, M., Kipp, C., Richard, C. L., & Thrasher, J. F. (2020). Moderating the Effects of Adverse Childhood Experiences to Address Inequities in Tobacco-Related Risk Behaviors. Health Promotion Practice21(1_suppl), 139S-147S. 

Alyssa Koziarski, Children's Trust of South Carolina

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@Lisa Geath

Thanks so much for your comment. We agree that the NO ACEs and NO SSNRs group should not conceptually exist, so for the purposes of the analysis, we removed it. We were also limited to how we could conceptualize this, because we only had one year of data in which these items and the ACEs questions were asked. In the other approaches we tried, some of the groups became so small, that we could not do analyses. 

We had a long conversation with researchers across the country about how to conceptualize these items. I agree with you that the reverse order could be conceptualized as neglect. Several of my colleagues felt however, that those who reported these things as present, are also positive factors, that could be considered safe, stable nurturing relationships--a paper from 2018 (Crouch et al) which has been widely cited used this approach. 

It was this same discussion that led two of my co-authors to write a paper that is using these items as indicators of neglect (Crouch et al 2020). All in all, safe stable nurturing relationships are certainly important to understand, and while this research is preliminary and has some limitations, it is promising. 


I really appreciate the discussion!


I just wanted to point out that your January publication has a comparison group that just does not make sense....

This is your definition of a protective factor from the January article which appears to be the only article of the two listed that makes a racial distinction and only concerning tobacco use -


Protective Factor

Two questions were used to assess an SSNR in childhood: β€œFor how much of your childhood was there an adult who made you feel safe and protected?” and β€œFor how much of your childhood was there an adult who tried hard to make sure your basic needs were met?” Respondents who reported having an adult who made them feel safe and protected most of the time or all of the time were categorized as a β€œyes;” all other responses to this question were categorized as β€œno.” Respondents who had an adult who tried hard to make sure their basic needs were met most or all of the time were categorized as β€œyes,” while all other responses were categorized as β€œno.” These cut points are consistent with previous research using the SC-BRFSS (Crouch et al., 2019) and align with the broader protective factors’ literature (Shonkoff et al., 2012Wright & Masten, 2005). Responses to the two questions were then combined into an overall variable. If a respondent indicated β€œyes” to both items, they were classified as having an SSNR. If a respondent indicated yes to only one item or no to both items, they were classified as not having an SSNR."   


The paper, has a comparison group of No ACES and No SSNR (no protective factor) --- 

There can't logically be a comparison group with  No ACES and No SSNR as defined in the paper.   One would have to have at least one SSNR in order to be in the "No ACEs" group.   

If you don't have anyone in your childhood who "made you feel safe and protected" most or all of the time and / or you did not have "an adult who tried hard to make sure your basic needs were met"  that person has at least one ACE from Felitti and Anda's  ACE study.  That person experienced Neglect.   

Neglect is an incredibly damaging Adversity... but it is much harder for most people to define than the other adversities of the ACE Study.  Neglect certainly is difficult to define for most people using a retrospective questionnaire.    However, we know that severe neglect in infancy can kill a baby and is the most common reason that infants are taken into protective care.   



Last edited by Lisa Geath
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