Adverse Childhood Experiences (ACE) and Adult Health
“When I was a child, I talked like a child, I thought like a child, I reasoned like a child. When I became a man, I put the ways of childhood behind me.” This quotation from the writings of Saint Paul speaks to the ideal because, sadly, many people do not have the power to expel certain childhood experiences, such as childhood trauma, from their lives as they move into adulthood. Adverse childhood experiences (ACE) , also referred to as childhood trauma, are such experiences. We know now that childhood traumas have the potential to shape physical and mental well-being in adulthood. The discovery of this relationship is attributed to Dr. Vincent Felitti, director of the California Institute of Preventive Medicine in San Diego.
A few years ago, in the course of writing my first health and wellness book, my research took me to a study done by Dr Felitti. He had stumbled on an interesting finding while assisting severely obese patients to lose weight.
Each of his morbidly obese patients lost as much as 300 pounds in a year on a new liquid diet treatment. But something strange also happened. The patients quickly regained the pounds—and faster than they had lost them—or they simply quit the program altogether. Dr. Felitti started asking questions and he found an interesting connection between past childhood experience and adult health.
First, one patient told him she’d been sexually abused as a child. Then another patient. More than half of the patients claimed they had been abused.
Felitti, joining with Anda from the Centers for Disease Control and Prevention, designed a test composed of ten questions to measure adverse childhood experience (ACE). Of the severely obese patients surveyed, out of ten patients grew up with domestic violence. Two out of ten had been sexually abused. Three out of ten had been physically abused.
Now here comes the hook.
As these patients grew up, diseases such as cancer, addiction, diabetes, and stroke occurred more often among the patients with a high ACE score. Certainly, there was some kind of connection between childhood trauma and adult health.
What are ACEs?
Dr. Felitti and his colleagues isolated the 10 most common types of trauma that children encounter and which were shown in the short- or long-term “to cause negative effects on physiological, cognitive, behavioral, and psychological functions.”
These 10 ACEs are:
- emotional child abuse
- physical child abuse
- sexual child abuse
- emotional child neglect
- physical child neglect
- domestic violence
- substance abuse
- mental illness
- criminal activity
- parental absence
Since Dr. Felitti’s study over two decades ago, other adverse childhood experiences or childhood trauma have been identified:
- extreme economic adversity
- school violence
- community violence
- traumatic loss of a loved one
- sudden and frequent relocations
- serious accidents
- life-threatening childhood illness/injury
- pornography (exposure or participation)
- natural disaster
- refugee camps
- growing up in poverty
- peer rejection and lack of friends
- poor school performance
- property crime
- witnessing community violence
ACEs have been linked to:
- risky health behaviors,
- chronic health conditions,
- low life potential, and
- early death.
They affect how children and adults attach to others, weigh consequences, problem solve, and value themselves. They have been shown to increase the risk of a wide range of health conditions, namely,
- heart disease
- respiratory disease
- substance abuse
How could childhood trauma lead to mental illness, physical illness, or cognitive impairment many years later?
According to Resmiye Oral et al., in a study published online in Pediatric Research, the culprit is traumatic toxic stress which results from “chronic/sustained stressors in the absence of a supportive environment.” Stress can be classified according to the response it engenders in the individual:
- Physiologic/Positive Stress: e.g. flight or fight stressors that can help survival and growth;
- Tolerable Stress: “multiple invasive interventions” due to sickness but within a supportive environment;
- Traumatic Toxic Stress.
Where there is traumatic toxic stress, the body’s natural response to positive or tolerable stress is prolonged and exaggerated and can lead to “disruption of the structure and function of the neuroendocrine and immune systems.”
Thus, excess cortisol level in the circulation is sustained with subsequent chronic activation of the HPA axis (3). In the short term, this overactivation can result in an overload of cortisol, and in the long term, a relative lack of cortisol (2).
Both of these deviations may lead to negative health consequences (10). Too much cortisol suppresses the immune response and increases the chance of infection, while too little cortisol leads to the inflammatory response persisting after it is no longer needed (3).
The presence of ACEs does not mean that a child will experience poor mental, physical or cognitive health as an adult. A 2015 study on the Long Term Physical Health Consequences of Adverse Childhood Experiences was designed to “identify the unique association of each ACE with adult health.” Therefore the study examined “the relationships between nine different ACEs [physical abuse, verbal abuse, sexual abuse, domestic violence, depression, alcohol abuse, drug abuse, incarceration, and parental divorce] and three different physical health outcomes [functional limitation, diabetes, and heart attack], while controlling for the potential confounding effect of experiencing multiple adverse conditions during childhood.”
The results revealed two caveats with respect to interpreting the relationship between ACEs and adult well-being. One, “the associations between ACEs and adult health were not universal; some ACEs were associated with certain health outcomes but not others. For example, experiencing childhood physical abuse was significantly and substantively associated with all four health outcomes [self-rated health, functional limitation, diabetes, and heart attack] while verbal abuse was associated only with self-rated health and functional limitations and witnessing parental domestic violence was associated only with odds of a diabetes diagnosis.” Two, “adult SES [socioeconomic status] helps to explain the relationship between ACEs and physical health outcomes.… Given the well-established role of SES as a social determinant of health (Link and Phelan 1995) adult economic disadvantage stemming from adverse conditions during childhood may then result in worse health outcomes in adulthood.”
What does this relationship between adverse childhood experiences and adult well-being mean for the way we care for the elderly, mentally ill, disabled, and adults suffering with chronic diseases or lifestyle diseases?
ACE offers several implications for the delivery of health care.
1. Health care providers should be aware that “early-life adversities lay a critical foundation for long-term health trajectories”;
2. A first line of care that primary care physicians should consider providing is just to listen and implicitly accept patients’ stories.
3. Patients should be screened for ACE.
4. Health care providers should develop a plan to address the long-term effects of childhood trauma and not focus only on treating the patient’s symptoms, such as diabetes, with medication.
5. Public health measures should be instituted—both to prevent child maltreatment in the first place and to provide trauma-informed care for survivors.
Trauma-informed Care (TIC)
Trauma-informed care is considered a “comprehensive multilevel approach” to dealing with trauma. According to the Substance Abuse and Mental Health Services Administration (SMHSA), trauma-informed care possesses these attributes:
A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization.
The six key principles fundamental to a trauma-informed approach to health care are:
1. Safety. Promoting a sense of safety involves a conscious effort to ensure that all members and clients of an organization are physically and emotionally safe.
2. Trustworthiness and transparency. Organizations must approach decisions with transparency and engender trust of staff and their clientele.
3. Peer support. Peers, which include family of traumatized children as well as individuals who have lived with histories of trauma, can be critical resources for support.
4. Collaboration and mutuality. All members of an organization can equally contribute to the healing of children impacted by adverse experiences.
5. Empowerment, voice, and choice. Developing plans of action for clients requires patient-centered approaches that empower clients.
6. Cultural, historical and gender issues. Efforts must be culturally sensitive and free of prejudices based on biases and stereotypes.
Healthcare providers and systems that are aware of the potential role of ACEs in the physical and mental health and cognitive development of their clients can choose to incorporate trauma-informed care as a part of their program. They are thereby likely to return to their clients some of the power they need to “put away” some of the ways of childhood.