THE ADVERSE CHILDHOOD EXPERIENCES STUDY (CDC, 2014)
A partnership between Kaiser Permanente and the US Centers for Disease Control and Prevention produced one of the largest studies ever conducted to assess the connections between chronic, toxic stress caused by early adversity and health throughout the lifespan. The Adverse Childhood Experiences Study (ACES) looked at multiple categories of childhood physical and emotional abuse and neglect, along with measures of household dysfunction (such as domestic violence, parental mental illness, substance abuse), and separation/abandonment/divorce.
The study followed the medical status of 17,337 Kaiser Permanente HMO members who underwent a physical exam and also chose to provide information about their childhood experiences of abuse, neglect, and family dysfunction. These data were gathered between 1995-1997. Since that initial phase of the study, the results so far have been the basis of more than 50 scientific articles and more than 100 conferences and workshop presentations. The results of this landmark study have also spurred the collection of ACES data in other states.
The high prevalence of childhood emotional, physical, and sexual abuse; neglect; and household dysfunction – and their lasting effects – found in this study may surprise you:
PREVALANCE OF INDIVIDUAL ADVERSE CHILDHOOD EXPERIENCES (given as percentages)
Emotional abuse 13.1 7.6
Physical abuse 27.0 29.9
Sexual abuse 24.7 16.0
Emotional neglect 16.7 12.4
Physical neglect 9.2 10.7
Mother treated violently 13.7 11.5
Household substance abuse 29.5 23.8
Household mental illness 23.3 14.8
Parental separation or divorce 24.5 21.8
Incarcerated household member 5.2 4.1
NUMBER OF ADVERSE CHILDHOOD EXPERIENCES (ACE SCORE)
0 34.5 38.0
1 24.5 27.9
2 15.5 16.4
3 10.3 8.6
4 or more 15.2 9.2
Below are the gender, racial, age, and education characteristics of the 17,337 San Diegans who participated in the ACE Study. I’ve included these demographics in case you thought that childhood abuse only happens in poor, non-white families. Most of the study’s participants were white, middle or upper-middle class, college-educated, with good jobs and comprehensive health care from Kaiser-Permanent’s HMO.
The Three Types of ACEs Studied: Abuse, Neglect and Household Dysfunction
“Childhood abuse, neglect, and exposure to other traumatic stressors which we term adverse childhood experiences (ACE) are common. Almost two-thirds of our study participants reported at least one ACE, and more than one of five reported three or more ACE. The short- and long-term outcomes of these childhood exposures include a multitude of health and social problems.
“The ACE Study uses the ACE Score, which is a total count of the number of ACEs reported by respondents. The ACE Score is used to assess the total amount of stress during childhood and has demonstrated that as the number of ACE increase, the risk for the following health problems increases in a strong and graded fashion:”
Alcoholism and alcohol abuse
Chronic obstructive pulmonary disease (COPD)
Health-related quality of life
Illicit drug use
Ischemic heart disease (IHD)
Risk for intimate partner violence
Multiple sexual partners
Sexually transmitted diseases (STDs)
Early initiation of smoking
Early initiation of sexual activity
The ACE Study findings convincingly demonstrate that harsh childhood experiences negatively affect children into adulthood. The chronic, toxic stress resulting from these experiences is seen in their difficulties in school and life. Unlike manageable stress, toxic stress “refers to the long-term changes in brain architecture and organ systems that develop after extreme, prolonged and repeated stress goes untreated. Exposure to ACEs may put our children at higher risk for learning difficulties, emotional problems, developmental issues and long-term health problems.” (emphasis added) (Center for Youth Wellness, 2015-A)
Levels & Consequences of Stress
The ACE Study results have focused attention on two very important findings:
ADVERSE CHILDHOOD EXPERIENCES ARE VERY COMMON. 67% (2 out of 3 people) of the study population had at least one ACE and 13% (1 out of 8 people) had four or more ACEs.
THERE IS A DOSE-RESPONSE RELATIONSHIP BETWEEN ACES AND NUMEROUS HEALTH PROBLEMS. The more ACEs a child has, the higher the risk of developing chronic illnesses such as heart disease, chronic obstructive pulmonary disease (COPD), depression, and cancer.
– Center for Youth Wellness (2015-A)
NADINE BURKE HARRIS, MD
Nadine Burke Harris, MD, MPH, FAAP is a Pediatrician and Founder/Chief Executive Officer of the Center for Youth Wellness in the Bayview Hunters Point neighborhood of San Francisco. Dr Burke has earned international attention for her innovative approach to addressing the mental and physical health effects of toxic stress resulting from adverse childhood experiences.
From the Center for Youth Wellness website:
“The Center for Youth Wellness is part of a national effort to revolutionize pediatric medicine and transform the way society responds to kids exposed to significant adverse childhood experiences and toxic stress.
“Led by founder and CEO Dr. Nadine Burke Harris, we are a health organization within a pediatric home that serves children and families in the Bayview Hunters Point neighborhood of San Francisco. We were created to respond to an urgent public health issue: early adversity harms the developing brains and bodies of children.
“We screen every young person we see for Adverse Childhood Experiences (ACEs) that we know can lead to toxic stress and lifelong problems with health, wellness and learning. We heal children’s brains and bodies by piloting treatments for toxic stress and sharing our findings nationally. We prevent toxic stress by raising awareness among those who can make a difference: from parents and pediatricians to policy makers.
Our mission is to improve the health of children and adolescents exposed to Adverse Childhood Experiences.”
– Center for Youth Wellness (2015-B)
In September 2014, Dr Harris gave a TEDMed talk on the lifetime effects of toxic stress on children. This is from the description of her talk:
“Childhood trauma isn’t something you just get over as you grow up. Pediatrician Nadine Burke Harris explains that the repeated stress of abuse, neglect and parents struggling with mental health or substance abuse issues has real, tangible effects on the development of the brain. This unfolds across a lifetime, to the point where those who’ve experienced high levels of trauma are at triple the risk for heart disease and lung cancer. An impassioned plea for pediatric medicine to confront the prevention and treatment of trauma, head-on.”
As childhood trauma expert Na’ama Yehuda eloquently puts it:
“What if there is an exposure that affects health and development dramatically and is more prevalent than HIV, cancer, and Hepatitis combined and yet most doctors do not screen for it? What if you knew of an exposure that increases the risk for heart disease, diabetes, early death, inflammatory diseases, premature birth, metabolic syndrome, depression, anxiety, suicide, and more? What if that exposure was at the base of many learning disabilities, attention issues, and behavior issues and if there was a lot to do to help reduce this risk?
“Wouldn’t you want to know about it?
“Wouldn’t you want it to be treated as a priority in healthcare and public interest? I know I would, and do. Nadine Burke Harris is sure, too. Listen to her amazing Ted Talk–this is a brief talk that you’ll want to pass along!”
– Na’ama Yehuda, 2015
You can listen to Dr Harris’s excellent talk here.
CALCULATE YOUR OWN ACE SCORE (Stevens, 2015)
In case you’re interested in calculating your own ACE score or are just interested in knowing more about the study, here are the questions (slightly modified) the ACE Study asked its 17,337 participants.
Prior to your 18th birthday:
Did a parent or other adult in the household often or very often: Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? No__ If Yes, enter 1 __
Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? No__ If Yes, enter 1 __
Did an adult or person at least 5 years older than you ever: Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? No__ If Yes, enter 1__
Did you often or very often feel that: No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other? No__ If Yes, enter 1 __
Did you often or very often feel that: You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? No__ If Yes, enter 1 __
Was a biological parent ever lost to you through divorce, abandonment, or other reason ? No__ If Yes, enter 1 __
Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? No__ If Yes, enter 1 __
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? No__ If Yes, enter 1 __
Was a household member depressed or mentally ill, or did a household member attempt suicide? No__ If Yes, enter 1 __
Did a household member go to prison? No__ If Yes, enter 1 __
Now add up your “Yes” answers: ___. This is your ACE Score.
Information on the childhood trauma measures:
“There are 10 types of childhood trauma measured in the ACE Study. Five are personal — physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to other family members: a parent who’s an alcoholic, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment. Each type of trauma counts as one. So a person who’s been physically abused, with one alcoholic parent, and a mother who was beaten up has an ACE score of three.
“There are, of course, many other types of childhood trauma — watching a sibling being abused, losing a caregiver (grandmother, mother, grandfather, etc.), homelessness, surviving and recovering from a severe accident, witnessing a father being abused by a mother, witnessing a grandmother abusing a father, etc. The ACE Study included only those 10 childhood traumas because those were mentioned as most common by a group of about 300 Kaiser members; those traumas were also well studied individually in the research literature.
“The most important thing to remember is that the ACE score is meant as a guideline: If you experienced other types of toxic stress over months or years, then those would likely increase your risk of health consequences.”
See the Got Your ACE Score? page on ACEs Too High News for fuller information on the questions and the results from the study. There’s also an interesting RESILIENCE questionnaire there.
Many thanks to Rebeca Scherman, PsyD, & Na’ama Yehuda, MSC, SLP, for bringing Dr Nadine Burke Harris’s TEDMed talk to my attention.