Staff Perspective: Lessons From the ACEs Study
"It's not just 'them'. It's us." ~Robert Anda
Once upon a time, in the post-disco 1980’s, Madonna was singing about material girls and Vincent Felitti was trying to figure out why so many people were prematurely dropping out of his weight loss program at Kaiser Permanente’s Department of Preventative Medicine in San Diego. The weight loss clinic was a state-of-the-art program designed to help those who were 100 to 600 pounds overweight. Inexplicably, many were dropping out even though they had successfully been losing weight.
In searching for factors that might play a role, Dr. Felitti asked about all sorts of experiences including sexual experiences, that might vary with age and weight gain. Almost by accident, though some would call it fate, he asked a woman about when she first became sexually active, and learned that she was four years old, and had been molested by her father. At the time he considered her experience rare, having only had one other patient who reported incest in over 20 years of medical practice. However, as he began asking more methodically, he was astonished to learn that many patients reported similar experiences, and that weight gain might be a way of coping with the depression, anxiety, and fear that had haunted them their entire lives. As one of his patients put it,” Overweight is overlooked, and that is the way I need to be.”
By 1990, Dr. Felitti was ready to share his insights with the medical community. He presented his findings on 286 patients to the North American Association for the Study of Obesity. He was roundly criticized for believing his patients. Instead, it was suggested, his patients were inventing excuses for their problems. Fortunately, not everyone at the conference was dismissive. An epidemiologist from the Center for Disease control, David Williamson, encouraged him to collect data from a more general population. Dr. Felitti began collaborating with Robert Anda, a physician and epidemiologist from the CDC.
Together, Drs. Felitti and Anda interviewed almost 17,500 patients who were part of Kaiser’s preventive medicine clinic. Every person who came through the clinic already filled out a detailed biopsychosocial (biomedical, psychological, social) medical questionnaire, received a complete physical examination, and underwent extensive laboratory tests. To this extensive data set, if the patients consented, they added a set of questions about early experiences that could be considered traumatic or stressful. These 10 categories of experiences have come to be called adverse childhood experiences, or ACEs. They include sexual, physical, and verbal abuse, family dysfunction, such as a mentally ill or addicted parent, domestic violence in the home, incarceration of a family member, loss of a parent through divorce or abandonment, and emotional and physical neglect. Patients were then followed throughout their care, some for as long as 15 years. This was the first time that researchers had looked at the effects of so many types of trauma, rather than the consequences of just one. The data was clear and shocking, even to the researchers who were stunned by the implications of their study.
Three key findings are particularly relevant.
- ACEs were found to be alarmingly common. For example, more than one fourth of the participants experienced physical abuse and one fifth experienced sexual abuse.
- ACEs often cluster together. Roughly two thirds of the respondents experienced one or more ACEs; almost 40% of the participants experienced 2 or more ACEs; and 12.5% experienced 4 or more.
- There was a direct and cumulative relationship between the number of ACEs and several negative health, social and behavioral outcomes. As the number of ACEs increased so did the likelihood of high-risk behaviors like smoking, drinking alcohol, and drug abuse, multiple sex partners and obesity. People with high ACE scores were more likely to have violent relationships, more marriages, unintended pregnancy, pregnancy loss, more broken bones, sexually transmitted diseases, more drug prescriptions, more depression, more auto-immune diseases,substance abuse, and more work absences. Higher ACEs were also associated with increased risk of several medical conditions, and early death. Compared to people with no ACEs, those with 4 or more ACEs were 12 times more likely to have attempted suicide. People with six or more ACEs died nearly 20 years earlier on average than those without ACEs (Anda et al., 2010; Middlebrooks & Audage, 2008). These myriad problems take a toll not only from the individual but from society as a whole. The Centers for Disease Control and Prevention (CDC) estimates that the yearly lifetime costs associated with child maltreatment alone are $124 billion (Fang et al., 2012).
Perhaps the most understated, and most important takeaway from the study, these were ordinary people, average, middle-class, middle-aged, Americans with good jobs and a healthcare plan. Most were college educated. Eighty percent were white or Latino, 10% were Black and 10% were Asian. They were not recruited because of trauma or illness, but rather were recruited because they were members of the huge HMO that was Kaiser Permanente. The original ACEs study has been replicated and extended in peer reviewed studies over 1500 times. More than 30 other ACEs have been added since the 1998 study include bullying, racism, gender discrimination, unsafe neighborhoods, deportation experiences, community violence, and homelessness and researchers continue to identify links between these devastating childhood experiences and later health outcomes.
The immediate and often devastating effects of ACEs cannot fully explain the long-term effects described in the Adverse Childhood Experiences study. To understand how childhood experiences can reach forward in time to devastate lives after the acute danger is past we need to consider how ACEs remain active in the lives of people. For all of us, stressful experiences, ubiquitous in human life, are met with increases in heart rate, hormonal fluctuations, and other physiological changes. These changes are part of the fight or flight system of managing threat and are helpful in the short-term for mobilizing the person to act as needed to return to “safety.” As children navigate normal stressors with the help of supportive adults and their own propensity to learn and grow from experiences, they become competent to manage stressors and develop resiliency. Even some normal but extremely stressful experiences can be overcome with care and support. However, for those who experience toxic stress such as those investigated in the ACEs study, the stress is sustained over a long period of time, support is often absent, and the individual doesn’t have the ability to manage by themselves. This is especially true for children as their rapidly developing brains are sensitive and ill equipped to manage sustained stress. Physiological responses become chronic, brains are changed, immune functions are suppressed, and emotions are dysregulated. But that isn’t the end of the story. Chronic disease states such as autoimmune disorders, heart disease, and diabetes are the result. The implications are wide ranging, as Dr. Anda has frequently stated, “Every aspect of human functioning is affected by adverse childhood experiences.”
Experts recommend trauma-informed approaches to help health care providers engage their patients more effectively, thereby offering the potential to improve outcomes and reduce avoidable costs for both health care and social services. According to SAMHSA, “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” (Substance Abuse and Mental Health Services Administration, 2014).
At the most basic level, professionals working from a trauma-informed perspective will be aware of the acute and chronic physical, psychological, social, and economic effects of trauma and understand the high prevalence of trauma and trauma-related distress among those seeking care, particularly mental health care. From this perspective, trauma is viewed not as a singular event but as a formative experience that may significantly contribute to the person’s current health/mental health status and the way in which they interact with the world, including caregivers and systems of care. Symptoms are understood in context, with an appreciation for the person’s culture and life experiences. Butler et al., (2011) succinctly describes this point-of-view as a shift in clinical understanding from one emphasizing “What happened to the person,” rather than the implied judgment of, “What is wrong with the person.”
Systems of care are designed from this perspective to reduce barriers to care and to facilitate client participation and collaboration. Every aspect of care from clinical practices, policies, procedures, and even the look and feel of the environment is organized to accommodate the client’s needs and vulnerabilities, maximize safety, and minimize the possibility of injury or retraumatization (C. Wilson & Pence, 2013).
When you watch the news tonight, or more likely scroll through your news feed, you will hear about ACEs. This isn’t what they will be called by the talking heads who tell you about children being separated from parents, people living in dangerous or dehumanizing conditions, communities devastated by violent acts, individuals robbed of autonomy and self-determination, and forced to sink further into poverty. The root causes of these events are complex, but even a cursory look will uncover conditions that perpetuate and facilitate ACEs. The events themselves heap fuel on the flames, new ACEs to add to lives already devastated. Our work as trauma-informed clinicians, helping individuals overcome the effects of trauma or ACEs, cannot be divorced from the context in which trauma occurs. Even those of us who do not work with trauma, but with other psychosocial or health related problems do not work in a vacuum. The impact of ACEs can be recognized in patients with heart disease, depression, addiction, autoimmune disorders - you can fill in the blank with your preferred area of expertise. Turns out the individual really isn’t separate from the community and the context in which they live the past is very much present for many people, and the personal actually is political. We can ignore these facts and treat each person as a singular mystery, or we can widen our view, take in the landscape, and attend to the whole story. Treat your patients, but don’t forget to organize, resist, and vote.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Kelly Chrestman, Ph.D., is a Senior Military Behavioral Health Psychologist at the Center for Deployment Psychology. She provides training, support and consultation in Cognitive Behavioral Therapy and in the Assessment and Treatment of PTSD.
References
Anda, R. F., Butchart, A., Felitti, V. J., & Brown, D. W. (2010). Building a Framework for Global Surveillance of the Public Health Implications of Adverse Childhood Experiences. American Journal of Preventive Medicine, 39(1), 93–98. https://doi.org/10.1016/J.AMEPRE.2010.03.015
Anda, R. F. & Felitti, V. J., (2003). ACE Reporter: Origins and Essence of the Study. Ace Reporter, 1(1), 1–4. http://thecrimereport.s3.amazonaws.com/2/94/9/3076/acestudy.pdf
Butler, L. D., Critelli, F. M., & Rinfrette, E. S. (2011). Trauma-Informed Care and Mental Health. Directions in Psychiatry, 31, 197–210. https://www.researchgate.net/publication/234155324
Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P., Williamson, D. F., & Giles, W. H. (2001). Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: Findings from the adverse childhood experiences study. Journal of the American Medical Association, 286(24), 3089–3096. https://doi.org/10.1001/jama.286.24.3089
Fang, X., Brown, D. S., Florence, C. S., & Mercy, J. A. (2012). The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse and Neglect, 36(2), 156–165. https://doi.org/10.1016/j.chiabu.2011.10.006
Middlebrooks, J. S., & Audage, N. C. (2008). The Effects of Childhood Stress on Health Across the Lifespan. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Samhsa. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.
Stevens, J.E. (2012, October 8). The Adverse Childhood Experiences Study -- The largest public health study you never heard of, part three. The Huffington Post. https://www.huffpost.com/entry/the-adverse-childhood-exp_7_b_1944199
Wilson, A., Hutchinson, M., & Hurley, J. (2017). Literature review of trauma-informed care: Implications for mental health nurses working in acute inpatient settings in Australia. In International Journal of Mental Health Nursing (Vol. 26, Issue 4, pp. 326–343). Blackwell Publishing. https://doi.org/10.1111/inm.12344
Wilson, C., & Pence, D. M. (2013). Trauma Informed Care. In Encyclopedia of Social Work (Vol. 23, pp. 1–23). https://doi.org/10.1093/acrefore/9780199975839.013.1063
"It's not just 'them'. It's us." ~Robert Anda
Once upon a time, in the post-disco 1980’s, Madonna was singing about material girls and Vincent Felitti was trying to figure out why so many people were prematurely dropping out of his weight loss program at Kaiser Permanente’s Department of Preventative Medicine in San Diego. The weight loss clinic was a state-of-the-art program designed to help those who were 100 to 600 pounds overweight. Inexplicably, many were dropping out even though they had successfully been losing weight.
In searching for factors that might play a role, Dr. Felitti asked about all sorts of experiences including sexual experiences, that might vary with age and weight gain. Almost by accident, though some would call it fate, he asked a woman about when she first became sexually active, and learned that she was four years old, and had been molested by her father. At the time he considered her experience rare, having only had one other patient who reported incest in over 20 years of medical practice. However, as he began asking more methodically, he was astonished to learn that many patients reported similar experiences, and that weight gain might be a way of coping with the depression, anxiety, and fear that had haunted them their entire lives. As one of his patients put it,” Overweight is overlooked, and that is the way I need to be.”
By 1990, Dr. Felitti was ready to share his insights with the medical community. He presented his findings on 286 patients to the North American Association for the Study of Obesity. He was roundly criticized for believing his patients. Instead, it was suggested, his patients were inventing excuses for their problems. Fortunately, not everyone at the conference was dismissive. An epidemiologist from the Center for Disease control, David Williamson, encouraged him to collect data from a more general population. Dr. Felitti began collaborating with Robert Anda, a physician and epidemiologist from the CDC.
Together, Drs. Felitti and Anda interviewed almost 17,500 patients who were part of Kaiser’s preventive medicine clinic. Every person who came through the clinic already filled out a detailed biopsychosocial (biomedical, psychological, social) medical questionnaire, received a complete physical examination, and underwent extensive laboratory tests. To this extensive data set, if the patients consented, they added a set of questions about early experiences that could be considered traumatic or stressful. These 10 categories of experiences have come to be called adverse childhood experiences, or ACEs. They include sexual, physical, and verbal abuse, family dysfunction, such as a mentally ill or addicted parent, domestic violence in the home, incarceration of a family member, loss of a parent through divorce or abandonment, and emotional and physical neglect. Patients were then followed throughout their care, some for as long as 15 years. This was the first time that researchers had looked at the effects of so many types of trauma, rather than the consequences of just one. The data was clear and shocking, even to the researchers who were stunned by the implications of their study.
Three key findings are particularly relevant.
- ACEs were found to be alarmingly common. For example, more than one fourth of the participants experienced physical abuse and one fifth experienced sexual abuse.
- ACEs often cluster together. Roughly two thirds of the respondents experienced one or more ACEs; almost 40% of the participants experienced 2 or more ACEs; and 12.5% experienced 4 or more.
- There was a direct and cumulative relationship between the number of ACEs and several negative health, social and behavioral outcomes. As the number of ACEs increased so did the likelihood of high-risk behaviors like smoking, drinking alcohol, and drug abuse, multiple sex partners and obesity. People with high ACE scores were more likely to have violent relationships, more marriages, unintended pregnancy, pregnancy loss, more broken bones, sexually transmitted diseases, more drug prescriptions, more depression, more auto-immune diseases,substance abuse, and more work absences. Higher ACEs were also associated with increased risk of several medical conditions, and early death. Compared to people with no ACEs, those with 4 or more ACEs were 12 times more likely to have attempted suicide. People with six or more ACEs died nearly 20 years earlier on average than those without ACEs (Anda et al., 2010; Middlebrooks & Audage, 2008). These myriad problems take a toll not only from the individual but from society as a whole. The Centers for Disease Control and Prevention (CDC) estimates that the yearly lifetime costs associated with child maltreatment alone are $124 billion (Fang et al., 2012).
Perhaps the most understated, and most important takeaway from the study, these were ordinary people, average, middle-class, middle-aged, Americans with good jobs and a healthcare plan. Most were college educated. Eighty percent were white or Latino, 10% were Black and 10% were Asian. They were not recruited because of trauma or illness, but rather were recruited because they were members of the huge HMO that was Kaiser Permanente. The original ACEs study has been replicated and extended in peer reviewed studies over 1500 times. More than 30 other ACEs have been added since the 1998 study include bullying, racism, gender discrimination, unsafe neighborhoods, deportation experiences, community violence, and homelessness and researchers continue to identify links between these devastating childhood experiences and later health outcomes.
The immediate and often devastating effects of ACEs cannot fully explain the long-term effects described in the Adverse Childhood Experiences study. To understand how childhood experiences can reach forward in time to devastate lives after the acute danger is past we need to consider how ACEs remain active in the lives of people. For all of us, stressful experiences, ubiquitous in human life, are met with increases in heart rate, hormonal fluctuations, and other physiological changes. These changes are part of the fight or flight system of managing threat and are helpful in the short-term for mobilizing the person to act as needed to return to “safety.” As children navigate normal stressors with the help of supportive adults and their own propensity to learn and grow from experiences, they become competent to manage stressors and develop resiliency. Even some normal but extremely stressful experiences can be overcome with care and support. However, for those who experience toxic stress such as those investigated in the ACEs study, the stress is sustained over a long period of time, support is often absent, and the individual doesn’t have the ability to manage by themselves. This is especially true for children as their rapidly developing brains are sensitive and ill equipped to manage sustained stress. Physiological responses become chronic, brains are changed, immune functions are suppressed, and emotions are dysregulated. But that isn’t the end of the story. Chronic disease states such as autoimmune disorders, heart disease, and diabetes are the result. The implications are wide ranging, as Dr. Anda has frequently stated, “Every aspect of human functioning is affected by adverse childhood experiences.”
Experts recommend trauma-informed approaches to help health care providers engage their patients more effectively, thereby offering the potential to improve outcomes and reduce avoidable costs for both health care and social services. According to SAMHSA, “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” (Substance Abuse and Mental Health Services Administration, 2014).
At the most basic level, professionals working from a trauma-informed perspective will be aware of the acute and chronic physical, psychological, social, and economic effects of trauma and understand the high prevalence of trauma and trauma-related distress among those seeking care, particularly mental health care. From this perspective, trauma is viewed not as a singular event but as a formative experience that may significantly contribute to the person’s current health/mental health status and the way in which they interact with the world, including caregivers and systems of care. Symptoms are understood in context, with an appreciation for the person’s culture and life experiences. Butler et al., (2011) succinctly describes this point-of-view as a shift in clinical understanding from one emphasizing “What happened to the person,” rather than the implied judgment of, “What is wrong with the person.”
Systems of care are designed from this perspective to reduce barriers to care and to facilitate client participation and collaboration. Every aspect of care from clinical practices, policies, procedures, and even the look and feel of the environment is organized to accommodate the client’s needs and vulnerabilities, maximize safety, and minimize the possibility of injury or retraumatization (C. Wilson & Pence, 2013).
When you watch the news tonight, or more likely scroll through your news feed, you will hear about ACEs. This isn’t what they will be called by the talking heads who tell you about children being separated from parents, people living in dangerous or dehumanizing conditions, communities devastated by violent acts, individuals robbed of autonomy and self-determination, and forced to sink further into poverty. The root causes of these events are complex, but even a cursory look will uncover conditions that perpetuate and facilitate ACEs. The events themselves heap fuel on the flames, new ACEs to add to lives already devastated. Our work as trauma-informed clinicians, helping individuals overcome the effects of trauma or ACEs, cannot be divorced from the context in which trauma occurs. Even those of us who do not work with trauma, but with other psychosocial or health related problems do not work in a vacuum. The impact of ACEs can be recognized in patients with heart disease, depression, addiction, autoimmune disorders - you can fill in the blank with your preferred area of expertise. Turns out the individual really isn’t separate from the community and the context in which they live the past is very much present for many people, and the personal actually is political. We can ignore these facts and treat each person as a singular mystery, or we can widen our view, take in the landscape, and attend to the whole story. Treat your patients, but don’t forget to organize, resist, and vote.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Kelly Chrestman, Ph.D., is a Senior Military Behavioral Health Psychologist at the Center for Deployment Psychology. She provides training, support and consultation in Cognitive Behavioral Therapy and in the Assessment and Treatment of PTSD.
References
Anda, R. F., Butchart, A., Felitti, V. J., & Brown, D. W. (2010). Building a Framework for Global Surveillance of the Public Health Implications of Adverse Childhood Experiences. American Journal of Preventive Medicine, 39(1), 93–98. https://doi.org/10.1016/J.AMEPRE.2010.03.015
Anda, R. F. & Felitti, V. J., (2003). ACE Reporter: Origins and Essence of the Study. Ace Reporter, 1(1), 1–4. http://thecrimereport.s3.amazonaws.com/2/94/9/3076/acestudy.pdf
Butler, L. D., Critelli, F. M., & Rinfrette, E. S. (2011). Trauma-Informed Care and Mental Health. Directions in Psychiatry, 31, 197–210. https://www.researchgate.net/publication/234155324
Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P., Williamson, D. F., & Giles, W. H. (2001). Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: Findings from the adverse childhood experiences study. Journal of the American Medical Association, 286(24), 3089–3096. https://doi.org/10.1001/jama.286.24.3089
Fang, X., Brown, D. S., Florence, C. S., & Mercy, J. A. (2012). The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse and Neglect, 36(2), 156–165. https://doi.org/10.1016/j.chiabu.2011.10.006
Middlebrooks, J. S., & Audage, N. C. (2008). The Effects of Childhood Stress on Health Across the Lifespan. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Samhsa. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.
Stevens, J.E. (2012, October 8). The Adverse Childhood Experiences Study -- The largest public health study you never heard of, part three. The Huffington Post. https://www.huffpost.com/entry/the-adverse-childhood-exp_7_b_1944199
Wilson, A., Hutchinson, M., & Hurley, J. (2017). Literature review of trauma-informed care: Implications for mental health nurses working in acute inpatient settings in Australia. In International Journal of Mental Health Nursing (Vol. 26, Issue 4, pp. 326–343). Blackwell Publishing. https://doi.org/10.1111/inm.12344
Wilson, C., & Pence, D. M. (2013). Trauma Informed Care. In Encyclopedia of Social Work (Vol. 23, pp. 1–23). https://doi.org/10.1093/acrefore/9780199975839.013.1063