This posting provides an overview of the ACE Study to initiate a running commentary on the implications and applications of ACEs. Think of this introductory post as a “crash course” on ACEs with an ongoing repository of resources built in, which we hope will encourage you to learn more. Please check back regularly for news, commentary, and updates in connection with our current ACE-related work.
The impetus for the ACE Study began with the clinical curiosity of an internist, Dr. Vincent Felitti, founder of the Department of Preventive Medicine at Kaiser Permanente, a large, managed health care organization located in San Diego, California. Consequently, this interest led to a startling, scientific discovery with huge implications for health and wellness. While running a very effective, nonsurgical weight loss program at Kaiser, Dr. Felitti observed that the patients who were the most successful at losing weight were also the most likely to drop out of the program. Dr. Felitti wondered why. He talked with one of his patients who had shed hundreds of pounds and then left the weight loss program suddenly only to regain the weight more rapidly than she had lost it. Her disclosure of childhood sexual abuse was the catalyst for Dr. Felitti to talk with other patients who had dropped out of the program, often after significant weight loss. They shared similar histories of sexual abuse. A larger investigation confirmed Dr. Felitti’s earlier observations. Dr. Felitti learned that obesity was a defense mechanism for many trauma survivors and eating was an unconscious solution to cope with the trauma.
This unexpected finding of the connection between childhood sexual abuse and obesity became the foundation for the ACE Study, ground-breaking research that would ultimately transform our thinking about the origin of leading health problems and risk behaviors in America. Dr. Felitti collaborated with Dr. Robert Anda at the Centers of Disease Control and Prevention (CDC) to conduct an epidemiological study to measure the impact of adverse childhood experiences over the human lifespan. Adverse childhood experiences include child abuse, neglect and several forms of household dysfunction such as domestic violence, substance abuse, mental illness, and criminal behavior. The study population was over 17,000 men and women enrolled with Kaiser Permanente. Participants were predominantly Caucasian and college-educated with middle class incomes. They answered questions about adverse childhood experiences on a health history form that was mailed to them. The ACE data was linked with participants’ health records, which often spanned decades.
The findings from the initial ACE Study represent one of the most important discoveries of twentieth century health research (Felitti et al, 1998). The study showed how common ACEs were in a population that would not typically be considered as “high-risk” (see Table 1). Another defining moment in the ACE Study was the number and strength of associations between ACEs and health problems. A history of ACEs increased the risk of ischemic heart disease, cancer, chronic lung disease, fractures and liver disease. ACEs had a dose-response relationship, which indicates a causal connection, with adult health risk behaviors. This means that the more ACEs a person experienced, the more likely he/she was to have adverse health outcomes. As a result, researchers found that adults with 4 or more ACEs were more likely to have:
- a 4- to 12-fold increase risk for alcoholism, drug abuse, depression, and attempted suicide
- 50 or more sexual intercourse partners
- a 1.4- to 1.6-fold increase in severe obesity
The landmark ACE Study in 1998 and many publications since then have taught us some key characteristics about ACEs that have major implications for clinical medicine and every avenue of behavioral and public health. We have learned that ACEs:
- are very common
- come in groups/clusters (rarely occur alone)
- are strong predictors of health behaviors in adolescence and adult life
- are leading determinants of health and social well-being
- are intergenerational
The discovery of ACEs coincided with a revolution in neuroscience that has transformed our thinking about the long-term effects of childhood trauma. Early emotional experiences and a child’s environment become embedded in the architecture of children’s brains (National Scientific Council on the Developing Child, 2006). The combination of research on ACEs and the latest neuroscience has advanced our understanding of the pathway of disease and the mind-body connection. More than 70 studies have been published about ACEs since 1998.
As professionals working within the ACE community and widening world of ACE-informed practice, our challenge is to translate ACEs research into policy and practice. At Kaiser Permanente, ACEs are an integral part of routine health assessment and a trauma-informed health care response. There are growing efforts to address ACEs in a wide range of health care settings, including pediatrics where the emphasis is on early identification and intervention with families to interrupt the cycle of intergenerational ACEs. Futures Without Violence is developing an ACEs safety card for patients that health care providers can use to facilitate assessment and universal education.
The implications and applications of ACEs seem infinite and extend far beyond health care and public health, with webinars, teleseminar series, DVDs, and ACE research being conducted around the globe. In fact, it is unusual to see a conference related to trauma that does not have a presentation on ACEs. If you do a PubMed search on “adverse childhood experiences,” it will yield more than two hundred peer-reviewed publications with related content. As awareness and opportunities to network about ACEs continue to expand, the spread and scope of applications and innovative ACE responses will help to plant the seed in other venues. Examples of ACE responses include:
- Washington State, the first state to enact legislation to reduce ACEs, has a capacity-building initiative that promotes a resiliency framework to address ACEs in a wide range of settings including schools, social services, and the criminal justice system
- Content about ACEs is being incorporated into parenting programs including a parenting class for prison inmates in Alaska
- The Arizona Think Tank has partnered with PBS to raise awareness about ACEs and response strategies
- At least eighteen states have added ACE questions to the Behavioral Risk Factor Surveillance System (BRFSS) questionnaire in their respective states
- The World Health Organization has urged policymakers to address ACEs in order to promote public health, and pilot ACE studies are being conducted in several countries
- The Institute for Safe Families in Philadelphia is leading an initiative to develop a pediatric ACEs assessment tool
Over the next year, this blog will feature content on research, policies and practices on ACEs that have major relevance for behavioral and public health. We will also follow the innovative work being done by the Institute for Safe Families and partners to develop an ACEs assessment tool for the pediatric setting. We would like to hear your perspectives and insights about ACEs. We hope the following questions will provide a starting point for an ongoing dialogue about ACEs:
1) How is research on ACEs influencing the work you do?
2) What is happening with ACEs in your work/community that you would add to the list of “ACE Responses” in this blog?
We look forward to hearing from you and learning more about the implications and applications of ACEs in your world.
To learn more about ACEs:
- Visit http://www.cdc.gov/nccdphp/ace/publications.htm for a list of publications
- Go to www.aceresponse.org to obtain information about webinars, teleseminars, and an extensive list of website links
- Visit the Academy on Violence and Abuse at www.avahealth.org to obtain a DVD on 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.
National Scientific Council on the Developing Child. 2006. Children’s Emotional Development is Built into the Architecture of Their Brains. Working Paper #2. http://www.developingchild.net
World Health Organization. 2009. Addressing adverse childhood experience to improve public health. Expert Consultation, 4-5 May 2009. Download at http://www.aceresponse.org/documents/who_aces_2009.pdf