Adverse Childhood Experiences Study

The Adverse Childhood Experiences Study (ACE Study) is a research study conducted by Kaiser Permanente health maintenance organization and the Centers for Disease Control and Prevention (CDC).^[1] Participants were recruited to the study between 1995 and 1997 and have been in long-term follow up for health outcomes. The study has demonstrated an association of adverse childhood experiences (ACEs) with health and social problems as an adult. The study has been analyzed extensively,^[2] is frequently cited as a notable landmark in epidemiological research,^[3] and has produced more than 50 scientific articles and more than 100 conference and workshop presentations that look at the prevalence and consequences of ACEs.^[1]

Background

In the 1980s, the dropout rate of participants at Kaiser Permanente’s obesity clinic in San Diego was about 50%; but what was perplexing was that all of the dropouts had been successfully losing weight before they left the clinic.^[4] Dr. Vincent Felitti conducted interviews with individuals who had left the program, and discovered that a majority of 286 people he interviewed had experienced childhood sexual abuse.^[4] The interview findings suggested to Felitti that weight gain might be a coping mechanism for depression, anxiety, and fear.^[4]

Felitti and Dr. Robert Anda from the CDC went on to survey childhood trauma experiences of over 17,000 Kaiser Permanente patient volunteers.^[4]

Findings

Mechanisms by which Adverse Childhood Experiences influence health and well-being throughout the lifespan.

The 17,337 participants were volunteers from approximately 26,000 consecutive Kaiser Permanente members. About half were female; 74.8% were white; the average age was 57; 75.2 had attended college; all had jobs and good health care, because they were members of the Kaiser HMO.^[5] Participants were asked about 10 types of childhood trauma that had been identified in earlier research literature: physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, mother treated violently, household substance abuse, household mental illness, parental separation or divorce, and incarcerated household member.^[6] About two-thirds of individuals reported at least one of these Adverse Childhood Experiences (ACE); 87% of individuals who reported one ACE reported at least one additional ACE.^[6] The prevalence of emotional abuse was 10.6%, physical abuse 28.3%, sexual abuse 20.7%, emotional neglect 14.8%, physical neglect 9.9%, mother treated violently 12.7%, household substance abuse 26.9%, household mental illness 19.4%, parental separation or divorce 23.3%, incarcerated household member 4.7%.

The number of ACEs was strongly associated with adulthood high-risk health behaviors such as smoking, alcohol and drug abuse, promiscuity, and severe obesity, and correlated with ill-health including depression, heart disease, cancer, chronic lung disease and shortened lifespan.^[6][7][8] Compared to an ACE score of zero, having four adverse childhood experiences was associated with a seven-fold increase in alcoholism, a doubling of risk of being diagnosed with cancer, and a four-fold increase in emphysema; an ACE score above six was associated with a 30-fold increase in attempted suicide.^[3]

Impact

The ACE Study has produced more than 50 articles that look at the prevalence and consequences of ACEs.^[2] It has been influential in several areas. Subsequent studies have confirmed the high frequency of adverse childhood experiences, or found even higher incidences in urban or youth populations. The original study questions have been used to develop screening tools that evaluate adverse childhood experience scores. Cognitive and neuroscience researchers have examined possible mechanisms that might explain the negative consequences of adverse childhood experiences on adult health. The ACEs Study and related data has an influence on public policy.

Subsequent surveys

The original study questions have been used to develop a 10 item screening questionnaire.^[1][9] Numerous subsequent surveys have confirmed that adverse childhood experiences are frequent.

State ACEs Study surveys diagram color coded from the year 2009 to 2014.

The CDC runs the Behavioral Risk Factor Surveillance System (BRFSS),^[10] an annual survey conducted by individual state health departments in all 50 states. An expanded survey instrument in several states found each state to be similar.^[11] Some states have collected additional local data.^[12][13] Adverse childhood experiences were even more frequent in studies in urban Philadelphia^[14] and in a survey of young mothers (mostly younger than 19).^[15]

Internationally, an ACE International Questionnaire (ACE-IQ) is undergoing validation testing.^[16] Surveys of adverse childhood experiences have been conducted in Romania,^[17] the Czech Republic,^[18] the Republic of Macedonia,^[19] Norway, the Philippines, the United Kingdom, Canada, China and Jordon.^[20] Child Trends used data from the 2011/12 National Survey of Children's Health (NSCH) to analyze ACEs prevalence in children nationally, and by state. The NSCH's list of "adverse family experiences" includes a measure of economic hardship and shows that this is the most common ACE reported nationally.^[21]

Consequences

Cognitive and neuroscience researchers have examined possible mechanisms that might explain the negative consequences of adverse childhood experiences on adult health.^[22] Adverse childhood experiences can alter the structural development of neural networks and the biochemistry of neuroendocrine systems^{[23][24][25][26]} and may have long-term effects on the body, including speeding up the processes of disease and aging and compromising immune systems.^[27][28][29]

Additionally, epigenetic transmission may occur due to stress during pregnancy or during interactions between mother and newborns. Maternal stress, depression, and exposure to partner violence have all been shown to have epigenetic effects on infants.^[26]

Implementing practices

As knowledge about the prevalence and consequences of adverse childhood experiences increases, trauma-informed and resilience-building practices based on the research is being implemented in communities, education, public health departments, social services, faith-based organizations and criminal justice. A few states are considering legislation.

Communities

As knowledge about the prevalence and consequences of ACEs increases, more communities seek to integrate trauma-informed and resilience-building practices into their agencies and systems. Tarpon Springs, Florida, became the first trauma-informed community in 2011.^[30][31] Trauma-informed initiatives in Tarpon Springs include trauma-awareness training for the local housing authority, changes in programs for ex-offenders, and new approaches to educating students with learning difficulties.^[32]

Education

Children who are exposed to many adverse childhood experiences may be overloaded with stress hormones, leaving them in a constant state of fight or flight, and unable to focus at school. One in approximately three or four children have experienced significant ACEs.^[33] A study by the Area Health Education Center of Washington State University found that students with at least three ACEs are three times as likely to experience academic failure, six times as likely to have behavioral problems, and five times as likely to have attendance problems.^[33] These students may have trouble trusting teachers and other adults, and may have difficulty creating and maintaining relationships.^[34] The trauma-informed school movement aims to train teachers and staff to help children self-regulate, and to help families that are having problems that result in children’s normal response to trauma, rather that simply jumping to punishment. It also seeks to provide behavioral consequences that will not re-traumatize a child. Punishment is often ineffective, and better results can often be achieved with positive reinforcement.^[35] Out-of-school suspensions can be particularly bad for students with difficult home lives; forcing students to remain at home may increase their distrust of adults.

Trauma-sensitive, or compassionate, schooling has becoming increasingly popular in Washington, Massachusetts and California. Lincoln High School in Walla Walla, Washington, adapted a trauma-informed approached to discipline and reduced its suspensions by 85%.^[36] Rather than standard punishment, students are taught to recognize their reaction to stress and learn to control it. Spokane, Washington schools conducted a research study that demonstrated that academic risk was correlated with students’ experiences of traumatic events known to their teachers.^[33][37] The same school district has begun a study to test the impact of trauma-informed intervention programs, in an attempt to reduce the impact of toxic stress. In Brockton, Massachusetts a community-wide meeting led to a trauma-informed approach being adopted by the Brockton School District.^[35] So far, all of the elementary schools have implemented trauma-informed improvement plans, and there are plans to do the same in the middle school and high school. About one-fifth of the district teachers have participated in a course on teaching traumatized students. Police alert schools when they have arrested someone or visited at a student’s address. Massachusetts state legislation has sought to require all schools to develop plans to create “safe and supportive schools.”^[35] At El Dorado, an elementary school in San Francisco, California, trauma-informed practices were associated with a suspension reduction of 89%.^[38]

Social services

Social service providers—including welfare systems, housing authorities, homeless shelters, and domestic violence centers – are adopting trauma-informed approaches that help to prevent ACEs or minimize their impact. Utilizing tools that screen for trauma can help a social service worker direct their clients to interventions that meet their specific needs.^[39] Trauma-informed practices can also help social service providers look at how trauma impacts the whole family.^[40]

Trauma-informed approaches can improve child welfare services by 1) openly discussing trauma and 2) addressing parental trauma.^[41] The New Hampshire Division for Children Youth and Families (DCYF) is taking a trauma-informed approach to their foster care services by educating staff about childhood trauma, screening children entering foster care for trauma, using trauma-informed language to mitigate further traumatization, mentoring birth parents and involving them in collaborative parenting, and training foster parents to be trauma-informed.^[39]

In Albany, New York the HEARTS Initiative has led to local organizations developing trauma-informed practice.^[41] Senior Hope Inc., an organization serving adults over the age of 50, began implementing the 10-question ACE survey and talking with their clients about childhood trauma. The LaSalle School, which serves orphaned and abandoned boys, began looking at delinquent boys in from a trauma-informed perspective and began administering the ACE questionnaire to their clients.

Housing authorities are also becoming trauma-informed. Supportive housing can sometimes recreate control and power dynamics associated with clients’ early trauma.^[42] This can be reduced through trauma-informed practices, such as training staff to be respectful of clients’ space by scheduling appointments and not letting themselves into clients’ private spaces, and also understanding that an aggressive response may be trauma-related coping strategies.^[42] The housing authority in Tarpon Springs provided trauma-awareness training to staff so they could better understand and react to their clients’ stress and anger resulting from poor employment, health, and housing.^[32]

A survey of 200 homeless individuals in California and New York demonstrated that more than 50% had experienced at least four ACEs.^[43] In Petaluma, California, the Committee on the Shelterless (COTS) uses a trauma-informed approach called Restorative Integral Support (RIS) to reduce intergenerational homelessness.^[44] RIS increases awareness of and knowledge about ACEs, and calls on staff to be compassionate and focus on the whole person. COTS now consider themselves ACE-informed and focus on resiliency and recovery.

Health care services

ACEs are especially relevant to pediatric work. Screening for or talking about ACEs with parents and children can help to foster healthy physical and psychological development and can help doctors understand the circumstances that children and their parents are facing. By screening for ACEs in children, pediatric doctors and nurses can better understand behavioral problems. Some doctors have questioned whether some behaviors resulting in ADHD diagnoses are in fact reactions to trauma. Children who have experienced four or more ACEs are three times as likely to take ADHD medication when compared with children with less than four ACEs.^[45] Screening parents for their ACEs allows doctors to provide the appropriate support to parents who have experienced trauma, helping them to build resilience, foster attachment with their children, and prevent a family cycle of ACEs.^[46][47] Trauma-informed pediatric care also allows doctors to develop a more trusting relationship with parents, opening the lines of communication.^[48] At Montefiore Medical Center ACEs screenings will soon be implemented in 22 pediatric clinics. In a pilot program any child with one parent who has an ACE score of four or higher is offered enrollment and receive a variety of services. For families enrolled in the program parents report fewer ER visits and children have healthier emotional and social development, compared with those not enrolled.^[46][49]

Public health

Some public health centers see ACEs as an important part of accessing health, especially in mothers and children. A life course framework suggests that social, cultural, and individual factors must be examined to understand health risks.^[50] Once these are better understood, health interventions can target individuals during sensitive periods of development early in their life, or even in utero.^[50] Jefferson Country Public Health clinic in Port Townsend, Washington, now screens pregnant women, their partners, parents of children with special needs, and parents involved with CPS for ACEs.^[51] This allows the clinic to inform individuals of the health risks associated with their ACEs, just as they would with other health risks, like smoking or alcohol consumption. It also helps them intervene in what can be intergenerational health problems.

Criminal justice

Since research suggests that incarcerated individuals are much more likely to have been exposed to violence and suffer from PTSD,^[52] a trauma-informed approach may better help to address some of these criminogenic risk factors and can create a less traumatizing criminal justice experience. Programs, like Seeking Safety, are often used to help individuals in the criminal justice system learn how to better cope with trauma, PTSD, and substance abuse.^[53] Juvenile courts better help deter children from crime and delinquency when they understand the trauma many of these children have experienced.^[54] The criminal justice system itself can also retraumatize individuals.^[55] This can be prevented by creating safer facilities where correctional and police officers are properly trained to keep incidents from escalating.^[52] Partnerships between police and mental health providers can also reduce the possible traumatizing effects of police intervention and help provide families with the proper mental health and social services.^[56] The Women’s Community Correctional Center of Hawaii began a Trauma-Informed Care Initiative that aims to train all employees to be aware and sensitive to trauma, to screen all women in their facility for trauma, to assess those who have experienced trauma, and begin providing trauma-informed mental health care to those women identified.^[55] Restorative justice programs, like Resolve to Stop the Violence, can also help to bring offenders together with victims and those affected in the community to stop the cycle of violence.^[57]

Faith Based Organizations

Many in faith based organizations recognize that the traumas identified in the ACE Study are traumas to the inner heart, or the spirit of the person. They understand that spiritual issues require spiritual solutions. Accordingly many organizations are turning to the Holy Scriptures of their respective faiths for wisdom and direction on how to care for the spirits of those who've been affected by early life trauma. ACE Overcomers is one such organization. The founder of this ministry combined the epidemiology of ACEs, the neurobiology of toxic stress and principles of the Bible into a workbook and 12-week course that's being used by clergy in several states.^[58] Other active participants representing faith based organizations participate in the online group - ACES Connection Network. The Faith and Health Connection ministry addresses issues of whole person health and provides teaching on the care of the spirit and resiliency according to principles of Christian theology.

Legislation

ACEs are beginning to impact state legislation. Vermont has proposed a bill, H. 762, The Adverse Childhood Experience Questionnaire, which seeks wide use of ACE screening by health providers and aims to educate medical and health school students about ACEs.^[59] Previously Washington State passed legislation to set up a public-private partnership to further community development of trauma-informed and resilience-building practices that had begun in that state; but it was not adequately funded.^[59] On August 18, 2014, thanks to the advocacy efforts of Nadine Burke Harris of the Center for Youth Wellness, California lawmakers unanimously passed ACR No. 155, which encourages policies reducing children's exposure to adverse experiences.^[60] Recent Massachusetts legislation supports a trauma-informed school movement as part of The Reduction of Gun Violence bill (No. 4376). This bill aims to create “safe and supportive schools” through services and initiatives focused on physical, social, and emotional safety.^[61]

See also

• Abuse
• Alcoholism in family systems
• Child abuse
• Domestic violence
• Dysfunctional family
• Effects of domestic violence on children
• Neglect
• Post-traumatic stress disorder
• Psychological abuse
• Social determinants of health
• Verbal abuse

References

External links

• Adverse Childhood Experiences (ACE) Study - Publications on Major Findings. Centers for Disease Control and Prevention
• ACEsConnection.com