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What Do Adverse Childhood Experiences (ACEs) Have to Do with Health?

When I joined i.b.mee. Enterprises this summer, I did not realize I would be part of something so important and undiscovered. I never thought I would be reading studies that would change the way medical professionals look at the top ten leading causes of death. I would argue that most people are aware that the research has found for many years that the leading causes of morbidity and mortality in the United States are related to health behavior and life style factors. Many people know a friend or a relative who has died from lung cancer after smoking for years, or a friend who has high cholesterol due to a poor diet. We know that these lifestyle choices have a lot to do with their health outcomes.

However, there are other key variables that come into play that effect a person’s health. One of these variables is the level of emotional trauma a child endures. In 1998, Kaiser Permanente’s San Diego Health Appraisal Clinic looked into the relationship between exposures to Adverse Childhood Experiences (ACEs) and adult health. The ACE study correlates children’s exposure to psychological, physical and contact sexual abuse, and household dysfunction to risky health behaviors and disease in adults.

To learn about the ACE study, I first took their questionnaire on my exposure to adverse childhood experiences. As I answered, I was curious as to how my childhood experiences correlated to my current and future health. Some of the questions were easier than others to answer. – “Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?” No, there was never a drug or even a drop of wine in my house. “Did you often or very often feel that your family didn’t look out for each other, feel close to each other or support each other?” Mmmm, Yes. This answer did not thrill me, however, it did make me think about how it may be affecting my behaviors and health.

The ACE questionnaire was designed from a variety of published surveys and “childhood exposures”. Exposures include three categories of childhood abuse and four categories of household dysfunction. Specific questions were grouped to fit into seven categories of Adverse Childhood Exposures: Psychological abuse (2 questions), Physical abuse (2 questions), Contact sexual abuse (4 questions), Expose to substance abuse (2 questions), mental illness (2 questions), Violence from mother (4 question) and criminal behavior (1 question). Because I answered “Yes” to one of the “Psychological abuse” questions my ACE score is one. The scale is from 0 (unexposed) to 7 (exposed to all categories) in order to allow the comparison of number of exposers to adult health risk behaviors and disease.

The ACE study assesses, retrospectively and prospectively, the long-term impact of abuse and household dysfunction during childhood. This information is then used to describe the relationship between the number of categories of exposures in children to diseases that underline many of the leading causes of death in adults. Out of the 13,494 Kaiser Health Plan members who received the mail-in questionnaire, 9,508 completed the survey making a response rate of 70.5%. Through the ACE questionnaire and the Health Appraisal Clinic’s questionnaire, ten risk factors were chosen that contributed to the leading causes of morbidity and mortality in the United States. These risk factors included smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, any drug abuse, parental drug abuse, a high life time number of sexual partners (>50) and a history of STDs.

There was a strong correlation found in the number of ACEs and health risk factors. For example, 56% of the individuals with an ACE score of zero had none of the ten risk factors; in comparison 14% with a score of 4+ had no risk factors. In contrast, only 1% of people who scored zero on the ACE questionnaire had four or more risk factors, yet 7% of people with a score of 4+ had four or more risk factors. To me this is stating that children with higher levels of adverse childhood exposures are more likely to have a higher chance of developing risky health behavior as an adult.

These ten risk factors were chosen for the study because they contribute to the diseases with the highest mortality rates in the United States. Specifically, the diseases studied included; ischemic heart disease, any form of cancer, stroke, chronic bronchitis or emphysema and diabetes. The data suggests that the higher number of ACEs an individual has, a higher chance of disease in adults occurs. For example, only 3.7% of people with a score of zero have been diagnosed with ischemic heart disease in comparison to a rate of 5.6% in people with an ACE score of four or more. This is logical due to the increased health risk behaviors with a score of four or above.

The findings also suggest that the impact of ACES on adult health status is strong and cumulative. These exposures may affect attitudes and behaviors towards health and health care, sensitivity to internal situations, and ultimately physiological functioning in the brain centers and neurotransmitter systems.

As a personal example, my best friend Sara has an ACE score of six and she is just now starting to see the effects of those exposures as she comes into her early twenties. Because she had many adverse childhood exposures, she experienced high levels of stress. Many young people who have ACEs are not shown how to deal with their stress (who would teach them?), and Sarah was one of these individuals. She was never able to fully process her stress and disempowering emotions and positively cope to her challenges. She did however learn to cope in disempowering and unhealthy ways such as using cigarettes to help with stress, sex to give her immediate satisfaction, and food so she could take control over something in her life. Through the years, I have unknowingly watched the after-effects of her ACEs control her life and ultimately lead her to six of the ten health risk behaviors by twenty years old. I worry about Sara’s health, as she has already seen some physiological effects such as weight and hair loss and chest pains; however, I worry more about mental health issues in her future.

Overall, the research is clear that Adverse Childhood Experiences lead to health risk behaviors that correlate with chronic diseases and eventually death. That is the bad news. The good news is that the research and information is now out there for the public to learn from! The simple pyramid graph shows how ACEs influence health and well being over a lifespan. I believe that this information is crucial to understand especially for medical professionals, parents, teachers and/or any adult that influences and mentors children.

In order to prevent health risk behaviors, there needs to be an understanding about the reasons someone would take part in a risky action to begin with. It is time to stop lecturing kids and teens to “just say no”, and teach them how to cope with their challenges before the behavior begins. In order to create the next generation as a healthy and well one, caregivers need to understand the effects of their actions on a child’s life. Doctors and medical professional should start looking beyond the medications and numbing techniques to the root of the health risk behaviors. Although this information will continue to be researched, I believe this is a crucial beginning to understanding the correlation of adverse childhood exposures (ACEs) and disease in adulthood.

Written by Susannah Crawford – Senior, University of North Carolina Asheville, Health and Wellness Promotion Major