Childhood Trauma - The ACE Study
This topic is not one of judgment or discrimination. My aim is to highlight crucial information for healthcare professionals who interact with affected individuals, as well as for those personally impacted by these experiences, to improve patient care and bring more awareness to the subject. With everything going on in the world right now and its impact on mental health care, it feels increasingly important to reinforce the need for practitioners in this space. At RxTeach, we care about preventative medicine and self-care to improve quality of life and enhance lifespan. It's heartbreaking that some individuals face such circumstances so early in life, long before they have the opportunity to care for themselves. These experiences were not their fault, and they didn't choose them, but they now live with imposed repercussions and often require secondary preventative measures as opposed to primary.
Adverse childhood experiences (ACEs) are common traumatic events experienced prior to the age of 18 and are associated with a large array of risk behaviors and consequences, including 9 of 10 leading causes of death. For both healthcare professionals and patients who have experienced childhood trauma, it is important to realize how it may affect multiple aspects of one's life and contribute to perceived barriers to attaining healthcare. This can be pretty tricky when you haven't experienced any traumas, but it is especially important to put forth the effort to listen and do your best to supply a truly patient-centered approach to medicine.
For research purposes, the authors of the ACE study had to define adverse childhood events. They sent out questionnaires to patients with a list of 10 questions from published studies that were broadly categorized by childhood abuse, household dysfunction, and neglect (neglect was added in Wave 2 surveys).
Childhood abuse was further broken down into three categories: psychological abuse, physical abuse, and sexual abuse.
Household dysfunction was further broken down into five categories: substance abuse, mental illness, mother being treated violently, incarceration of household member, and parental separation/divorce.
Neglect was broken down into two categories: physical and emotional neglect.
Between 1995 and 1997, over 17,000 survey responses were attained from patients of a large HMO out of southern California that showed it was common to have at least 1 ACE across all populations, which they separated by age groups, sex, race, and education.
Female/male representation was relatively blanced, though slightly more females were included at 54%.
A large majority of the participants were white at 74.8%.
Roughly 84.9% of participants were aged 40+, and 46.4% were aged 60+.
Approximately 75.2% had some college education, and about 39.3% were college graduates or higher. While this may appear to reflect higher rates of college education, this means that 60.7% of participants did not have a college degree. For a more detailed breakdown of demographics, you can click HERE to view some of the demographic tables under the Data and Statistics section.
The results are presented by sex, and immediately something jumps out. Of the 10 subcategories assessed, 8 were more commonly reported by females. The two specific categories reported more commonly in men were physical abuse and physical neglect. When looking at the total numbers, men were more likely to report having 0, 1, or 2 ACEs, while women were more likely to report 3 or more.
When looking at tallied numbers of ACEs experienced by study participants, they found that 36.1% of participants had zero ACEs. That means nearly 2/3 had at least 1 ACE... If there's one positive takeaway from this, it is that people who have experienced these types of traumas are clearly not alone.
The primary goal of this study was to examine the relationship between adverse childhood experiences and long-term health outcomes. They found that childhood trauma extends well beyond childhood, impacting multiple dimensions of adulthood. This includes difficulties in relationship building, immune system dysregulation, altered brain developmental patterns, unstable job histories, diminished socioeconomic status, and increased rates of "risky" behaviors, including illicit drug use and alcohol misuse. Ultimately, the chronic stress placed on these children often results in complex coping mechanisms and internal barriers further shaping adulthood. It can manifest as disease development and even early mortality. Below are some quick highlights of adjusted odds ratios (AORs) with 1 ACE and 4+ ACEs compared to zero ACEs from a logistic regression analysis:
Coronary Heart disease: 1 ACE = AOR 1.1, CI (1.0-1.3); 4+ ACEs = AOR 1.8, CI (1.6-2.1)
Stroke: 1 ACE = AOR 1.1, CI (1.0-1.3); 4+ ACEs = AOR 2.1, CI (1.7-2.5)
Asthma: 1 ACE = AOR 1.3, CI (1.2-1.4); 4+ ACEs = AOR 2.2, CI (2.0-2.4)
COPD: 1 ACE = AOR 1.3, CI (1.1-1.4); 4+ ACEs = AOR 2.8, CI (2.5-3.1)
Depression: 1 ACE = AOR 1.6, CI (1.5-1.7); 4+ ACEs = AOR 5.3, CI (4.9-5.7)
Current Smoker: 1 ACE = AOR 1.4, CI (1.3-1.6); 4+ ACEs = AOR 3.1, CI (2.8-3.3)
For clarity, this means patients with ACE scores 4+ are ~2 times more likely to have coronary heart disease, stroke, or asthma compared to someone with zero ACEs. They are ~3 times more likely to have COPD and be a current smoker, and they are ~5 times more likely to suffer from depression.
Some of these findings are truly staggering, and I hope it's evident how impactful these childhood traumas can be for an individual. Though the ACE study has confounders and limitations, it provides a crucial foundation for ongoing conversation and future research.
To reiterate an earlier point, these adults were once kids who didn't ask for these experiences. In my opinion, compassion and empathy are essential qualities for healthcare professionals regardless of the patient's background. Individuals with these negative life experiences often have additional barriers to accessing and utilizing healthcare, and it is our responsibility to do what we can to support people, even if it's just offering a listening ear.
Fortunately, there are meaningful steps we can take to combat the impact of ACEs, and everybody, not just healthcare professionals, can play a role. Creating safe and nurturing environments for children is an essential first step. This can happen in your neighborhoods, schools, and after-school programs. The CDC has played a crucial role in the prevention, identification, and response to adverse childhood events at the community, state, and national levels. Another great resource is the ACEs Aware initiative, which helps to promote awareness, perform screening efforts, and offer trauma-informed care. For more information on ACEs Aware, click HERE.
Look forward to seeing an additional article on this topic in the future covering the Philadelphia ACE study!
*Information presented on RxTeach does not represent the opinion of any specific company, organization, or team other than the authors themselves. No patient-provider relationship is created.
References:
https://www.cdc.gov/violenceprevention/aces/about.html
https://www.cdc.gov/aces/about/index.html
https://www.cdc.gov/mmwr/volumes/68/wr/mm6844e1.htm?s_cid=mm6844e1_w#T2_down