The Ripple Effects of ACEs

By Keenia Tappin, MD

– Dr. Robert Block, former President of the American College of Pediatrics.

From 1995-1997, Dr. Felitti from Southern California Kaiser and Dr. Anda from the CDC conducted the landmark Adverse Childhood Experiences (ACE) Study. The study included ~17,000 Southern California Kaiser members who were 54% female, 46% male, 75% Caucasian, and 39% college educated. The study was designed to look for a correlation between exposure to abuse or family dysfunction during childhood and development of common deadly medical and public health problems in adulthood. The 10 ACEs included in the study were psychological, physical, and sexual abuse, emotional neglect, physical neglect, household substance abuse (alcohol or illicit drug use), mother treated violently, mental illness, depression in the household, parental separation or divorce, and having an incarcerated household member. The negative adult health outcomes assessed included: severe obesity, being a smoker, being an alcoholic, lack of physical activity, 2 or more weeks of depressed mood in a year, lifetime attempt at suicide, illicit drug use, ≥50 sexual intercourse partners, and history of sexually transmitted disease. Adult chronic diseases assessed included: ischemic heart disease, cancer, stroke, chronic bronchitis/ emphysema, diabetes, hepatitis, fair or poor self-rated health.

This landmark study revealed two unexpected and pivotal facts about trauma during childhood. Firstly, ACEs are common. 36% of the participants had no ACEs, 26% had 1 ACE, 16% had 2 ACEs, 9.5% had 3 ACEs, and 12% had 4 or more ACEs. The top 3 ACEs were physical abuse (28%), household substance use (27%), and parental separation or divorce (23%). Secondly, there is a graded dose-response relationship between number of ACEs and development of negative adult health outcomes. For instance, when participants with 0 ACEs were compared to those with 4 or more ACEs, the latter group was 2.2 times more likely to be a smoker, 7.4 times more likely to consider themselves an alcoholic, 10.3 times more likely to have illicit IV drug use, and 12.2 times more likely to have a prior suicide attempt. In terms of chronic disease, participants with 4 or more ACEs versus those with 0 ACEs were 2.2 times more likely to have ischemic heart disease, 2.4 times more likely to have a history of stroke, and 3.9 times more likely to have chronic bronchitis or emphysema. Once the results came in the next question became, how exactly are these ACEs linked to risky health behaviors and diseases in adulthood? Is it simply that people who experience trauma are more likely to cope in unhealthy ways or is it linked to changes in the brain and other organs that occur during development? The answer is, it may be a little bit of both.

In terms of unhealthy coping mechanisms, smoking is a prime example. Nicotine has been shown to have positive mood regulation effects. Also, when used alone or with other substances such as alcohol, it can stimulate the dopamine reward pathway via increased dopaminergic neuronal firing. Individuals exposed to repetitive trauma may find solace in the short term positive effects of smoking or alcohol. Unfortunately, chronic smoking predisposes to emphysema, heart disease, and malignancy. Chronic alcohol use is a factor in developing cancer, hepatitis, and cognitive impairment.

Looking at neurodevelopment, trauma can have

many long standing effects on the brain. First, it is well known that the brain is not structurally complete at birth. The infant’s brain is extremely adaptable and changes via pruning and strengthening of neuronal connection which occur based on interactions between the baby and their environment. According to the Harvard Center for the Developing Child, there are 3 types of stress responses which occur in the developing child. Positive stress is characterized by brief increases in heart rate and mild elevations in hormone levels. This is the type of stress that is essential for normal development. Examples include trying something new, first day of school, getting a vaccine. Tolerable stress is the next level up, where an individual may have time-limited activation of the fight or flight stress response that is tempered by supportive relationships with a caring adult. After a short period of time, the child comes back to their emotional baseline and suffers no long lasting effects. Examples include, death of a loved one, natural disaster, or experiencing a frightening event. Lastly, there is toxic stress, which is characterized by prolonged activation of the fight or flight stress response system without adequate supportive relationships to ameliorate its effects. Examples include any of the ACEs (abuse, neglect, household dysfunction) which occur repeatedly or an accumulation of multiple ACEs. This prolonged activation of the stress response leads to changes in the developing brain, hypothalamic pituitary axis, and other organs of the child. Changes can also be seen at the epigenetic level with modifications to the way one’s DNA is read and processed.

While the ground breaking ACEs study along with other key neurodevelopment research have helped us identify the problem and effects of ACEs, it does not offer us a solution. What do we do about children already exposed or the adults walking around with numerous ACEs suffering from the known long term consequences? Is there hope for them or are they simply a lost cause? Have faith, all is not lost! The solution to the riddle of ACEs lies in the building of resiliency. Resiliency is defined as the ability to recover from or adjust easily to adversity or change. While this skill is easier to develop in a child when compared to an adult, both can achieve this goal. It is accessible to all people at all ages. So how do we build resiliency? Interpersonal relationships and connection to community are key factors for adults. We can be part of the solution by creating a space of love, safety, and connection for our children, for one another, and for ourselves.

Figure 1: The ACES Pyramid: https://www.cdc.gov/violenceprevention/images/acestudy/ace_pyramid_lrg.png

References: 1. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). 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,14(4), 245-258. 2. American Academy of Pediatrics. (2019). Adverse childhood experiences and the lifelong consequences of trauma. 2014.

For more information on ACEs, effects, and solutions: 1. CDC: https://www.cdc.gov/violenceprevention/aces/index.html 2. Harvard Center for the Developing Child- Toxic stress: https://developingchild.harvard.edu/science/key-concepts/toxic-stress/ 3. Dr. Nadine Burke Harris ,California’s Attorney General, Ted Talk on ACEs: https://www.youtube.com/watch?v=95ovIJ3dsNk 4. ACEs connection network: https://www.acesconnection.com/ 5. For information on Trauma informed care, ACEs screening, and primary care training for government reimbursement for ACEs screening see California ACEs Aware Initiative: https:/www.acesaware.org/