While I was aware of the connection between adverse childhood experiences (ACEs) and substance abuse since the landmark ACE Study was published in 1998, it was only recently that I delved more deeply into the ACEs literature on alcohol abuse. The connection between ACEs and alcohol problems illustrates many key characteristics about traumatic stress during early childhood while challenging us to look at substance abuse through a trauma-informed lens to understand the role of ACEs and the implications for intervention and prevention.
According to data from the original ACE Study, approximately 1 out of 4 adults grew up in a household with someone who had problems with alcohol dependence (Felitti et al., 1998). Study participants were primarily Caucasian, middle income patients at Kaiser Permanente in California who were willing to disclose this information on a medical questionnaire. Another 4.9% disclosed having lived in a household with someone who used street drugs. Substance abuse demonstrated the powerful influences that ACEs have on health and risk behaviors. We know that ACEs often produce a clustering effect and substance abuse is no exception. Of the 69% of households in which substance abuse was a problem, participants identified that a second ACE had occurred and 40% had two additional ACEs (Felitti et al, 1998). One-third of households that experienced substance abuse also experienced co-occurring sexual abuse (34%) or mental illness (34%). The total number of ACEs experienced during childhood had a graded relationship with the likelihood of considering oneself an alcoholic as an adult and a person with 4 or more ACEs was 7.4 times more likely to self-identify as an alcoholic compared to an adult with no ACEs.
A key insight from the ACEs research that Dr. Felitti emphasizes in each ACE presentation is that what we commonly view as problem behavior may instead be an adult survivor’s attempt at coping behavior to self-manage the childhood trauma that he or she experienced. These coping strategies such as self-medicating with alcohol can become an addiction. Dube and colleagues (2002) reported that there was a strong relationship between ACEs and personal alcohol abuse as an adult with and without a history of parental alcoholism. In other words, ACEs had an effect on the risk of alcohol abuse that was independent of family history. Early identification and treatment of alcohol abuse and children exposed to ACEs can therefore be strategic in preventing lifelong substance abuse.
The elevated risk of alcohol problems associated with ACEs starts well before adulthood. Children exposed to ACEs are more likely to initiate alcohol use at an earlier age and report that they drank to cope during their first year of drinking (Dube et al., 2006). Children who experienced 3 or more ACEs were 2.1 times more likely to start drinking before age 15 instead of age 21 compared to children with no ACEs (Rothman et al., 2008).
What are the implications of ACEs for treatment and prevention of alcohol-related problems? First and foremost, it puts trauma-informed care and treatment programs front and center. Lessons learned from the Women, Co-Occurring Disorders & Violence Study helped us to understand that the most effective programs are trauma-informed and integrated (SAMSHA, 2004).
In a large study that examined the relationships between ACEs and adult alcohol abuse by gender, psychological distress explained a significant proportion of self-reported alcohol problems associated with ACEs for both men and women (Strine et al., 2012). The authors emphasize the importance of identifying early childhood trauma and addressing the psychological distress associated with ACEs as part of substance abuse treatment programs.
In an article published in a German medical journal that raised considerable controversy, Dr. Felitti challenged commonly held concepts about root causes of addiction by suggesting that the basic cause of addiction is predominantly experience-dependent during childhood versus substance-dependent (Felitti, 2003). He recommended that substance abuse treatment programs and clinicians in the medical setting routinely screen at the earliest possible point for ACEs. All adult members of Kaiser Health Plan are screened as part of their comprehensive medical evaluation and “yes” answers receive follow-up during history taking by acknowledging the disclosure and asking, “Tell me how that has affected you later in your life.” An evaluation of screening and follow-up for ACEs with a cohort of patients at Kaiser showed a 35% reduction in doctor office visits during the year subsequent to screening.
To push the prevention envelope, we need to screen for ACEs even earlier. In my field of work, which focuses on children exposed to domestic violence, there are children who start self-medicating at a very young age. The first time may be when a child is given some cough syrup for a cold and realizes that he or she feels a little bit better about themselves. Then that 7- or 8-year old may start finding other ways to self-medicate with the rest of the cough syrup and when that’s all gone, a few sips of some brandy or whatever is available before getting on the school bus in the morning. Children who are alcoholics before they reach puberty are being seen in schools and health care settings and nobody knows about the ACEs in their world and how they learned to cope.
There are tremendous windows of opportunity for prevention and early intervention through a trauma-informed approach to ACES and substance abuse treatment. It starts with educating service providers, survivors, and communities about the connection between ACEs and alcohol dependence. Routine screening for ACEs that connects with families earlier is also a key step. We need to think broadly about how to integrate ACEs into interventions that work with parents and children to interrupt the intergenerational transmission of ACEs. This includes home visitation programs that educate parents about ACEs, parenting curricula that include content on how childhood trauma can affect parenting, and school-based programs to support children who are immersed in ACEs and may develop coping behaviors that lead to addictions.
What innovative applications have you seen in addressing ACEs as part of alcohol abuse treatment and prevention? Are there strategies that you feel could be a tipping point on a trauma-informed, integrated approach to ACEs and substance abuse? We look forward to your comments and insights.
Read Dr. Chamberlain's previous blog post: The Widening World of ACEs
Felitti VJ, Anda RF, Nordenberg et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998;14(4):245-258.
Felitti VJ. The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study. Praxis der Kinderpsychologie und Kinderpsychiatrie. 2003;523:547-559.
Strine TW, Dube SR, Edwards VJ, Witt Prehn A, Rasmussen S, Wagenfeld M, Dhingra S, Croft JB. Associations between adverse childhood experiences, psychological distress and adult alcohol problems. American Journal of Health Behavior. 2012;36(3):408-423.