Recently, Anales de Pediatría published an editorial titled “Are adverse childhood experiences the hidden iceberg of emotional distress in children and adolescents?”1 defining adverse childhood experiences (ACEs) and describing their classification, the physiological hypothesis of their impact and their multiple effects on children, concluding that “ACEs are a preventable risk factor that requires a response from the health care system from 2 complementary intervention frameworks: the toxic stress framework (…) and the relational health framework, which defines the solution”.

The subject of the editorial is quite relevant, as it shifts the focus of our perspective on disease from the biomedical paradigm to the determinants of health, at least in part, as I am about to discuss.

“Life is childhood, and everything else is addenda.” Few sentences are as apt in stating the importance of childhood in our lives and our health as this verse quoted by a noted congressman in pursuit of health promotion,2 for, as the editorial explains, everything that happens in the first years of life has a considerable impact on our health and all other dimensions of development. Adverse childhood experiences, classified into the categories of abuse and neglect, household dysfunction, social adversity and other ACEs, are closely related, and one ACE may cause or be associated with other ACEs, as is the case of low socioeconomic status, social exclusion, unsafe neighborhoods, substance use in the family or the different types of violence. Given the diversity of these experiences, their varying severity and the different times at which they can affect children, it would be complicated to prove, with the current scientific evidence, that they all lead to the same toxin or neurohormonal imbalance.

Adverse childhood experiences are not the base of the iceberg, but consequences of determinants of health3 (Fig. 1) and the model of social determinants of health and health inequities4 (Fig. 2). The theoretical framework is based on the events of the course of life, searching “upstream” for the causes of the causes, from where social, economic, environmental and biological factors shape the health of individuals and populations, factors such as socioeconomic status, education, employment, housing, access to health care and working conditions, among others. These are the factors that give rise and shape adverse experiences in general and require a response not only from the health care system, but also in the form of public policy aimed at the prevention of health inequities.

Figure 1.

Model of the determinants of health of the Pan American Health Organization.

(0.53MB).

Source: developed by PAHO/WHO.3

Figure 2.

Conceptual framework of social determinants of health and health inequities.

(0.57MB).

Source: Committee to Reduce Social Inequities in Health in Spain4 (based on the model developed by Solar and Irwin).

As Rudolf Virchow stated, “medicine is social science and politics nothing but medicine on a grand scale.” Thus, medicine has to be practiced on a grand scale, and care delivered with eyes on the world beyond, not solely through the lens of biomedicine, to recognize, raise awareness of and fight the causes of ACEs.