Abstract Building

“Not all addictions are rooted in abuse or trauma, but I do believe they can all be traced to painful experience. A hurt is at the centre of all addictive behaviours. It is present in the gambler, the Internet addict, the compulsive shopper and the workaholic. The wound may not be as deep and the ache not as excruciating, and it may even be entirely hidden—but it’s there. As we’ll see, the effects of early stress or adverse experiences directly shape both the psychology and the neurobiology of addiction in the brain.”
― Gabor Mate, In the Realm of Hungry Ghosts: Close Encounters with Addiction

Adverse Childhood Experience Study

Childhood experiences, both positive and negative, have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity

What is ACEs science? ACEs science refers to the research on the prevalence and consequences of adverse childhood experiences, and what to do to prevent them. It comprises:

  1. The CDC-Kaiser Permanente ACE Study and subsequent surveys that show that most people in the U.S. have at least one ACE, and that people with four ACEs— including living with an alcoholic parent, racism, bullying, witnessing violence outside the home, physical abuse, and losing a parent to divorce — have a huge risk of adult onset of chronic health problems such as heart disease, cancer, diabetes, suicide, and alcoholism.

  2. Brain science (neurobiology of toxic stress) — how toxic stress caused by ACEs damages the function and structure of kids’ developing brains.

  3. Health consequences — how toxic stress caused by ACEs affects short- and long-term health, and can impact every part of the body, leading to autoimmune diseases, such as arthritis, as well as heart disease, breast cancer, lung cancer, etc.

  4. Historical and generational trauma (epigenetic consequences of toxic stress) — how toxic stress caused by ACEs can alter how our DNA functions, and how that can be passed on from generation to generation.

  5. Resilience research and practice — Building on the knowledge that the brain is plastic and the body wants to heal, this part of ACEs science includes evidence-based practice, as well as practice-based evidence by people, organizations and communities that are integrating trauma-informed and resilience-building practices. This ranges from looking at how the brain of a teen with a high ACE score can be healed with cognitive behavior therapy, to how schools can integrate trauma-informed and resilience-building practices that result in an increase in students’ scores, test grades and graduation rates.

 

What are ACEs?

ACEs are adverse childhood experiences that harm children’s developing brains and lead to changing how they respond to stress and damaging their immune systems so profoundly that the effects show up decades later. ACEs cause much of our burden of chronic disease, most mental illness, and are at the root of most violence.


“ACEs” comes from the CDC-Kaiser Adverse Childhood Experiences Study, a groundbreaking public health study that discovered that childhood trauma leads to the adult onset of chronic diseases, depression and other mental illness, violence and being a victim of violence, as well as financial and social problems. The ACE Study has published about 70 research papers since 1998. Hundreds of additional research papers based on the ACE Study have also been published.


The 10 ACEs the researchers measured:

  • Physical, sexual and verbal abuse.

  • Physical and emotional neglect.

  • A family member who is:

    • depressed or diagnosed with other mental illness;

    • addicted to alcohol or another substance;

    • in prison.

  • Witnessing a mother being abused.

  • Losing a parent to separation, divorce or other reason.

 

Subsequent to the ACE Study, other ACE surveys have expanded the types of ACEs to include witnessing a sibling being abused, witnessing violence outside the home, witnessing a father being abused by a mother, being bullied by a peer or adult, involvement with the foster care system, living in a war zone, living in an unsafe neighborhood, losing a family member to deportation, etc.
 

Resources:

 

Why are ACEs significant?

1. The ACE Study revealed six main discoveries:

  •  ACEs are common…nearly two-thirds (64%) of adults have at least one.

  •  They cause adult onset of chronic disease, such as cancer and heart disease, as well as mental illness, violence and being a victim of violence

  • ACEs don’t occur alone….if you have one, there’s an 87% chance that you have two or more.

  • The more ACEs you have, the greater the risk for chronic disease, mental illness, violence and being a victim of violence. People have an ACE score of 0 to 10. Each type of trauma counts as one, no matter how many times it occurs. You can think of an ACE score as a cholesterol score for childhood trauma. For example, people with an ACE score of 4 are twice as likely to be smokers and seven times more likely to be alcoholic. Having an ACE score of 4 increases the risk of emphysema or chronic bronchitis by nearly 400 percent, and attempted suicide by 1200 percent. People with high ACE scores are more likely to be violent, to have more marriages, more broken bones, more drug prescriptions, more depression, and more autoimmune diseases. People with an ACE score of 6 or higher are at risk of their lifespan being shortened by 20 years.

  • ACEs are responsible for a big chunk of workplace absenteeism, and for costs in health care, emergency response, mental health and criminal justice.  So, the fifth finding from the ACE Study is that childhood adversity contributes to most of our major chronic health, mental health, economic health and social health issues.

  • On a population level, it doesn’t matter which four ACEs a person has; the harmful consequences are the same. The brain cannot distinguish one type of toxic stress from another; it’s all toxic stress, with the same impact.

 

What’s particularly startling is that the 17,000 ACE Study participants were mostly white, middle- and upper-middle class, college-educated, and all had jobs and great health care (they were all members of Kaiser Permanente).

Resources:

 


Has anyone else done an ACE Study?
Thirty-five states and Washington, D.C. (infographic) have done one or more ACE surveys. Here are links to some of their reports (some states haven’t produced reports).
There are numerous other ACE surveys, including cities, such as Philadelphia; organizations, including the Crittenton Foundation; schools, including Spokane elementary schools; by pediatricians, including Dr. Nadine Burke Harris and Dr. Victor Carrion (2011 and 2013); several countries, including EnglandSaudi Arabia, and a World Health Organization ACE survey of university students in Romania,; and 64,000 juvenile offenders in the Florida juvenile justice system. You can find a list of ACE surveys, including expanded ACE surveys with more questions, in the Resources Section of ACEsConnection.com, the social network that accompanies ACEsTooHigh.com.

What’s the neurobiology of toxic stress?

Brain science shows that, in the absence of protective factors, toxic stress damages children’s developing brains. Stress is the body’s normal response to challenging events or environments. Positive stress — the first day of school, a big exam, a sports challenge — is part of growing up, and parents or caregivers help children prepare for and learn how to handle positive stress, which is moderate and doesn’t last long. It increases heart rate and the amount of stress hormones in the body, but they return to normal levels quickly.
But when events or the environment are threatening or harmful – we stumble across a bear in the woods – our brains instantly zap into fight, flight or freeze mode and bypass our thinking brains, which can be way too analytical to save us (Is the bear really mean? Is it more interested in berries or killing me? Should I wait until I see it charge?). With help from caring adults, children also recover from this tolerable stress.


Too much stress – toxic stress – occurs when that raging bear comes home from the bar every night, says pediatrician Nadine Burke Harris. Then a child’s brain and body will produce an overload of stress hormones — such as cortisol and adrenaline — that harm the function and structure of the brain. This can be particularly devastating in children, whose brains are developing at a galloping pace from before they are born to age three. Toxic stress is the kind of stress that can come in response to living for months or years with a screaming alcoholic father, a severely depressed and neglectful mother or a parent who takes out life’s frustrations by whipping a belt across a child’s body.


Resources:

 

What are the health effects of toxic stress?

Chronic toxic stress—living in a red alert mode for months or years — can also damage our bodies. In a red alert state, the body pumps out adrenaline and cortisol continuously. Over time, the constant presence of adrenaline and cortisol keep blood pressure high, which weakens the heart and circulatory system. They also keep glucose levels high to provide enough energy for the heart and muscles to act quickly; this can lead to type 2 diabetes. Too much adrenaline and cortisol can also increase cholesterol. Too much cortisol can lead to osteoporosis, arthritis, gastrointestinal disease, depression, anorexia nervosa, Cushing’s syndrome, hyperthyroidism and the shrinkage of lymph nodes, leading to the inability to ward off infections.
If the red alert system is always on, eventually the adrenal glands give out, and the body can’t produce enough cortisol to keep up with the demand. This may cause the immune system to attack parts of the body, which can lead to lupus, multiple sclerosis, rheumatoid arthritis, and fibromyalgia.

 

Cortisol is also extremely important in maintaining the body’s appropriate inflammation response. In a normal response to a bee sting or infection, the body rushes antibodies, white blood cells and other cell fighters to the site and the tissues swell while the battle rages. But too much swelling damages tissue. Cortisol controls this fine balance. So without the mediating effects of cortisol, the inflammatory response runs amok and can cause a host of diseases. If you’re chronically stressed and then experience an additional traumatic event, your body will have trouble returning to a normal state. Over time, you will become more sensitive to trauma or stress, developing a hair-trigger response to events that other people shrug off.
 

Biomedical researchers say that childhood trauma is biologically embedded in our bodies: Children with adverse childhood experiences and adults who have experienced childhood trauma may respond more quickly and strongly to events or conversations that would not affect those with no ACEs, and have higher levels of indicators for inflammation than those who have not suffered childhood trauma. This wear and tear on the body is the main reason why the lifespan of people with an ACE score of six or higher is likely to be shortened by 20 years.

Resources:

What’s epigenetics and how does that relate to historical or generational trauma? 

Most people believe that the DNA we’re born with does not change and that it determines all that we are during our lifetime. That’s true, but the research from epigenetics — the study of how social and other environments turn our genes on and off — shows that toxic stress can actually change how our genes function, which can lead to long-term changes in all parts of our bodies and brains. What’s more, these changes can be transferred from generation to generation.
Epigenetics means “above the genome” and refers to changes in gene expression that are not the result of changes in the DNA sequence (or mutations).


Resources:

Resilience research:

If you have a high ACE score, are you doomed? The good news is that the brain is plastic, and the body wants to heal. The brain is continually changing in response to the environment. If the toxic stress stops and is replaced by practices that build resilience, the brain can slowly undo many of the stress-induced changes. There is well documented research on how individuals’ brains and bodies become healthier through mindfulness practices, exercise, good nutrition, adequate sleep, and healthy social interactions.
 

Research on families shows that interventions — such as Nurse-Family PartnershipHealthy Steps, and Child First — can improve the lives of parents and children. Evidence-based parenting practices (Incredible YearsTriple P Parenting, etc.), increase the health of parents and children.
 

Research on communities and systems is emerging, but early data, especially from schools and juvenile detention centers, is showing promise.
Here’s a good article that weaves the unified science of human development together: Scars That Don’t Fade, from Massachusetts General Hospital’s Proto Magazine.


Who’s using ACEs science? Many people, organizations, agencies, systems, and communities are beginning to implement trauma-informed, resilience-building practices based on ACEs science.

 

Resources:

What does trauma-informed mean?
According to the Substance Abuse and Mental Health Services Administration (SAHMSA), part of the U.S. Department of Health and Human Services, a trauma-informed approach refers to how an organization or community thinks about and responds to children and adults who have experienced or may be at risk for experiencing trauma. In this approach, the whole community understands the prevalence and impact of ACEs, the role trauma plays in people’s lives, and the complex and varied paths for healing and recovery.

 

A trauma-informed approach asks: “What happened to you?” instead of “What’s wrong with you?” It is designed to avoid re-traumatizing already traumatized people, with a focus on “safety first” (including emotional safety), and a commitment to do no harm. But a trauma-informed approach is most successful when an organization or community builds policies and practices based on a foundation of ACEs science.

Resources:

All Resources

 

(repost: Austin Attachment and Counseling Center: https://www.austinattach.com/)

The Link Between Adverse Childhood Experiences and Later-Life Health

When Nadine Burke Harris began her career as a pediatrician, she considered trauma and adversity as two things to be handled outside of the doctor’s office. “I viewed these things as I was trained to view them — either as a social problem or as a mental health problem,” she said in a TEDMED Talk about adverse childhood experiences. External link  In both instances, she would refer the patient to social or mental health services.

 

After finishing her residency, Burke Harris worked for a new health clinic in a severely underserved neighborhood. She noticed a disturbing trend in the number of children who had experienced extreme trauma, and she couldn’t shake the feeling that there was a connection between their health and their environment. “It felt like something else was going on,” she said.

 

In 1997, the Centers for Disease Control and Prevention (CDC) and Kaiser-Permanente released a study examining the prevalence of adverse childhood experiences (ACEs) and how they affect physical health, External link  confirming what Burke Harris had expected: Experiences of early adversity were linked to poorer health outcomes among adults. The study sparked countless initiatives to help prevent ACEs before they happen and build resilience among children who are at risk for adverse experiences.

 

Prevention is a step toward addressing this issue; however, there are still adults with ACEs who are currently experiencing the repercussions of early trauma, including mental health issues and chronic disease.

How Do Adverse Childhood Experiences Affect Health in Adults?

Adverse childhood experience (ACE), a term coined in that 1997 study, is now universally recognized in the public health sphere. It is used to describe all types of abuse, neglect, and other potentially traumatic experiences that occur to people under 18.

According to the CDC’s resource page for ACEs, External link  childhood trauma has been linked to risky health behaviors such as smoking and substance use, chronic health conditions ranging from cancer to diabetes, and early death. Individuals with ACEs are also more likely to have what the study refers to as “low life potential,” meaning they have lower high school graduation rates and academic achievement and experience more lost time from work as adults.

 

The scientific reason why individuals with ACEs are at higher risk for these issues can in part be attributed to the way early experiences of adversity affect brain and body development.

 

“It affects areas like the nucleus accumbens, the pleasure and reward center of the brain that is implicated in substance dependence,” Burke Harris said. “It inhibits the prefrontal cortex, which is necessary for impulse control and executive function, a critical area for learning. And on MRI scans, we see measurable differences in the amygdala, the brain's fear response center.”

These changes in brain chemistry can make an individual more likely to engage in high-risk behaviors External link  such as the use of tobacco and alcohol, which are associated with physical health risks like cancer and cardiovascular disease. But even when people with ACEs abstain from high-risk behavior, the effects ACEs have on brain development can still cause physiological changes that result in a decline in health.

 

One example is the toxic stress that comes with experiences of childhood trauma that in turn produce poor health outcomes. External link  The constant presence of chemicals such as adrenaline and cortisol heightens blood pressure, weakening the heart and circulatory system. These hormones also raise glucose levels, which can lead to type 2 diabetes and increase cholesterol. Constant stress can cause the adrenal glands to give out, eventually producing immune system issues. As a result, individuals with ACEs are more likely to experience a host of chronic illnesses in adulthood.

 

Health Conditions Associated with ACEs

Autoimmune disease: Among patients with lupus, 63 percent reported having one or more ACE, and nearly 20 percent had four or more ACEs.1

 

Cardiovascular disease: Research has shown a strong association between exposure to ACEs and cardiometabolic outcomes, including heart disease, hypertension, and obesity.2

Chronic obstructive pulmonary disease (COPD): In a study on ACEs among individuals with COPD, after controlling for smoking and other risk contributors, the risk for COPD increased as the number of ACEs increased, suggesting that ACEs were an independent risk factor.3

 

Diabetes: ACEs exposure increases the risk of type 2 diabetes by 32 percent compared to patients with no ACEs.4

Cancer: ACEs strongly predict behaviors that increase the risk of adult cancer.5

Depression: Having at least one ACE is associated with almost three times the odds of depressive symptoms among individuals reporting poor perceived social support.6

Substance use: According to a 2018 study, adults who experienced household abuse were 30 percent more likely to binge drink alcohol than the general population.7

 

Who Is Affected by Adverse Childhood Experiences?

No one is immune to ACEs. The original CDC and Kaiser-Permanente study examining the prevalence of ACEs and how they affect physical health showed participants across different backgrounds had experienced traumatic events in their youth. However, a 2018 study on the prevalence of ACEs External link  found that certain minority groups were more likely to have them than the general population. Based on the data, race and socioeconomic status were among the factors in determining the likelihood of having at least one ACE. The average number of ACEs among black, Hispanic, and multiracial individuals were 1.69, 1.8, and 2.52 respectively, compared to an average ACE score of 1.52 among white participants. Individuals with a household income of less than $15,000 had an average of 2.16 ACEs, a number that steadily decreases as household income increases.

ace-demographics.jpg

A 2018 study examined prevalence of ACEs in adults across multiple backgrounds. Researchers found that certain minority groups were more likely to be exposed to certain ACE categories. Black, Hispanic, and multiracial individuals were more likely to experience parental separation or divorce and the incarceration of a family member than white individuals. Multiracial populations and those with a yearly household income of less than $15,000 had more exposure to all ACE categories than other groups across the board. Go to tabular data at the bottom of this post about the prevalence of adverse childhood experiences by race and household income.

 

Overcoming the Physical Health Risks Associated with Childhood Trauma

Preventive care to mitigate the chances of children having ACEs is a critical step in combating this public health issue. However, steps still need to be taken to provide care for adults who have already experienced trauma. Integrating screenings for ACEs into clinical services is one way to identify risks for conditions associated with traumatic events. This information can be used to provide better care for these individuals.

 

What Is an ACE Score?

A person’s ACE score­ can be determined using a screening survey that was a part of the original study conducted by the CDC and Kaiser-Permanente. It comprises 10 questions that can be asked to determine this score. For each “yes” answer, one point is added to the individual’s score.

  1. 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?

  2. 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?

  3. Did an adult or person at least five 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?

  4. 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?

  5. 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?

  6. Were your parents ever separated or divorced?

  7. 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?

  8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

  9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

  10. Did a household member go to prison?

 

One way these screenings can be incorporated for risk assessment is through primary care, according to a report on the health effects of ACEs in The Journal for Nurse Practitioners. External link 

 

From the article: “Although there is no doubt that it is easier to treat the presenting symptoms rather than addressing the root cause, empowering patients to see the connections of their whole lives may well enable deep healing.”

 

This is particularly important for populations experiencing health disparities as a result of factors such as race or income level. In addition to primary care, screening individuals seeking specialized care has proven to be useful for addressing health risks associated with ACEs. For example, a study on using ACE screening for substance use recovery patients External link showed that all of the participants had experienced at least one ACE — and 82.8 percent reported six or more ACEs. This information was then used to identify additional interventions needed for patient success.

When equipped with this information, health care providers, counselors, social workers, and other professionals working with adults who have experienced ACEs can provide better treatment at two different phases:

 

Public Health Resources for Adults with ACEs

 

Sources:

1. DeQuattro, K., Trupin, L., Li, J., Katz, P. P., Murphy, L. B., Yelin, E. H., … Yazdany, J. (2019). Relationships between adverse childhood experiences and health status in systemic lupus erythematosus. Arthritis Care and Research. Accessed on August 13, 2019. doi:10.1002/acr.23878 Return to anchor link

 

2. Suglia, S. F., Koenen, K. C., Boynton-Jarrett, R., Chan, P. S., Clark, C. J., Danese, A., … Zachariah, J. P. (2018). Childhood and adolescent adversity and cardiometabolic outcomes: A scientific statement from the American Heart Association. Circulation, 137(5), 137:e15–137:e28. Accessed August 13, 2019. doi:10.1161/CIR.0000000000000536 Return to anchor link

 

3. Cunningham, T. J., Ford, E. S., Croft J. B., Merrick M. T., Rolle I. V., Giles W. H. (2014). Sex-specific relationships between adverse childhood experiences and chronic obstructive pulmonary disease in five states. International Journal of Chronic Obstructive Pulmonary Disease, 2014(9), 1033–1043. Accessed August 13, 2019. doi:10.2147/COPD.S68226 Return to anchor link

 

4. Huffhines, L., Noser, A., & Patton, S.R. (2016). The link between adverse childhood Experiences and Diabetes,” Current Diabetes Reports, 16(6), 54. Accessed August 13, 2019.  doi:10.1007/s11892-016-0740-8 Return to anchor link

 

5. Ports, K. A., Holman, D. M., Guinn, A. S., Pampati, S., Dyer, K. E., Merrick, M. T., … Metzler, M. (2019). Adverse childhood experiences and the presence of cancer risk factors in adulthood: A scoping review of the literature from 2005 to 2015. Journal of Pediatric Nursing, 44, 81–96. Accessed August 13, 2019. doi:10.1016/j.pedn.2018.10.009 Return to anchor link

 

6. Cheong, E. V, Sinnott, C., Dahly, D., & Kearney, P. M. (2017). Adverse childhood experiences (ACEs) and later-life depression: Perceived social support as a potential protective factor. BMJ Open, 7(9), 7:e013228. Accessed August 13, 2019. doi:10.1136/bmjopen-2016-013228 Return to anchor link

 

7. Loudermilk, E., Loudermilk, K., Obenauer, J., & Quinn, M. A. (2018). Impact of adverse childhood experiences (ACEs) on adult alcohol consumption behaviors. Child Abuse & Neglect, 86, 368–374. Accessed August 13, 2019. doi:10.1016/j.chiabu.2018.08.006 Return to anchor link

The following section contains tabular data from the graphic in this post.

 

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Citation for this content: The MPH online program from Baylor University's Robbins College of Health and Human Sciences

Original post: Austin Attachment and Counseling Center