Adverse Childhood Experiences
One of the things I have enjoyed the most about doing my blog posts is the research and personal education involved. I have years of experience under my belt, and while there is a great deal that I know about a lot of things, I have no shame accepting that there is even more out there that I don’t know. I am eager to keep learning.
Last week I went to the 2020 UCSF Chancellor’s Health Policy Lecture. The speaker was the brilliant and inspirational Doctor Nadine Burke Harris. Dr. Burke Harris was a pediatrician in San Francisco’s Bayview-Hunters Point neighborhood. She is currently the very first surgeon general for the state of California.
The topic of the lecture was Adverse Childhood Experiences, known as ACEs. This is a subject that she is clearly passionate about. The American Academy of Pediatrics is now asserting that ACEs are the single greatest unaddressed public health threat facing our nation today. That is quite the statement!
This isn’t new groundbreaking information. In fact, the data has been there for over 30 years, which makes it even more frustrating that it was not on my radar. Why isn’t there more general awareness?
The more I learned, the more intrigued I became. The findings are clear. Adverse Childhood Experiences (ACEs) experienced during childhood can have lifelong health implications. It makes so much sense!
Often western medicine focuses on treating symptoms. It is not surprising that out of 3 trillion dollars spent on healthcare only 5% of that money is spent on preventive medicine.
I will borrow a metaphor from Dr. Burke Harris. If people are drinking from a well and many of them are getting sick, it is all too common for many doctors to treat the diarrhea rather than checking to see if the water is contaminated.
Fortunately, there are doctors who make an effort to get to the root of problems. In 1985, Dr. Vincent Felitti was frustrated that patients in his San Diego obesity clinic, after initial success, were failing to keep the weight off. When he took a closer look, he was astonished to find that more than half of the clients who kept regaining their weight had some history of sexual abuse.
He realized that it couldn’t be a coincidence. Ultimately, he linked up with another doctor Robert Anda. Dr. Anda had been studying how depression and feelings of hopelessness affected coronary heart disease. They decided to collaborate on a much larger study and the findings were significant.
The ACEs study looked at the following risk factors:
Since the original study, questions about other obvious stressors, such as loss of a parent, food scarcity, homelessness, disability, exposure to gun violence, and discrimination, have been added to the screening tools. However, the issues bullet-listed above were the ones that were tested and scored. They found that, as suspected, there was a link between childhood trauma and onset of chronic disease through the lifespan. What they weren’t expecting was how common of an issue this was.
While it may come as no surprise that poverty is associated with higher scores, it turns out that very few of us got a free pass. This initial large study was done through Kaiser and the participants were mostly college educated, middle to upper class:
This relates to so many of us. You may be one of the more fortunate with a low score, but unless you live a remarkably isolated life, someone you know is impacted.
There is a dose response relationship between ACE scores and health outcomes. This simply boils down to the higher the risk, the more an effect there is likely to be. A person with an ACE score of:
A high ACE score can be a predictor of high blood pressure, smoking, teen pregnancy, and suicide. The list goes on and on. This actually may be one of the biggest health discoveries we have ever seen! There seems to be a fairly strong relationship between cause and effect.
The connection between these childhood stressful experiences and subsequent issues like depression, substance abuse, suicide and other social issues seemed fairly obvious. The reason for the connection to physical ailments such as cancer, heart disease, and immunity issues was a bit more baffling to me until I heard Dr. Burke Harris speak. Then the clouds lifted and it made total sense. DUH.
In her analogy, if you see a bear in the woods, you would have a full on “fight or flight” stress response. Your body is doing what it needs to escape. You also have an immune response to help you recover in case you are injured. This is just what your body needs to help you survive this emergency. But, if the bear comes home from the bar into your house every night, this frequent response is going to have serious implications. That frequent stress response is impacting the body and quite literally getting “under the skin”.
I did a blog post several years ago about how your stress level can add up silently before it overflows:
Of course, not all stress is the same. Positive stress stems from adverse experiences that are short-lived. We learn how to cope and adapt. For a child, examples might be the first day at school, falling off of a bike, or even having to share a toy when they would rather not. For some infants, it can be something as simple as exposure to a stranger. This type of stress might cause an increase in heart rate and changes in hormone levels. With the support of a caring adult, children can learn how to manage and overcome positive stress. This type of stress is considered normal adaptive stress and coping with it is an important part of the developmental process. Kids learn to ‘go with the flow’. They learn to get back on the bike and learn how to ride. They learn to get along with others. Babies learn that some people other than mommy or daddy are safe.
Tolerable stress refers to more intense experiences that are hopefully short-lived. This could be an earthquake, death of a loved one, or family disruptions such as separation or divorce. The initial impact packs a wallop, and then eases somewhat.
Here is the important thing to note. If the child has support from a caring adult, this stress remains tolerable. Kids can learn how to adapt thereby building resilience.
Let me put this in a context that many can relate to. Think of your child as a bank account. Stress is a debit, nurturing is a deposit. The positive stress that I mentioned previously could be like using your credit card and paying it off in full every month. This actually gives you a good credit score. If you use the card for a much larger purchase, you may begin to have a negative balance if you don’t have enough to pay it off right away. This is tolerable if you are able to make regular payments. It becomes a real problem when you can’t keep up and are now accruing more and more interest. It is easy to slide deeper and deeper into debt.
If you are filling up the “account” with positive nurturing behaviors, hopefully your child can “afford” the occasional larger expenses because you have helped them have a robust savings account filled with positive past experiences that can be used to inform current and future expenses.
Without “funds in the account” constant stress is no longer tolerable and can become maladaptive and is referred to as toxic stress. This toxic stress can result in direct and measurable physical impact by altering healthy brain development and causing multi-system effects. It can lead to disruptions in the ways that the neurological, endocrine, and immune systems operate. This then can affect other systems throughout the body as well. MRIs show that actual changes are taking place in the brains of kids who experience early adversity.
Science is telling us that ACEs are risk factors that have real implications for our children’s health...the mind may forget but the body remembers. You might not even recognize that there is an issue. Some research revealed that many children who develop emotional and behavioral problems don’t begin showing symptoms until the 4th grade.
Bear with me as I bring in another analogy. Think about lead poisoning. Generations ago we didn’t realize that exposure to lead in our environment was a problem. In fact, most of our homes were covered in lead paint. Eventually, we learned that exposure to lead levels had dramatic implications. The higher the exposure the more of a problem. Some folks live in homes with flagrant peeling old paint and we knew we needed to take action. Others might be getting exposure from a sneakier source such as soil, a brightly colored painted toy, lead pipes, even the varnish on a bathtub. We wouldn’t know until we tested. Now, it is standard for every child to be screened for lead.
This post is simply an attempt to build awareness about an important issue. Every child should be screened for ACEs.
There are easy ways to do this (think audit) and more and more ways to make changes and make real differences for people (think deposit). Those will be addressed in a future post.
What is your score?????
I want to thank Dr. Michelle Stephens, PhD, PNP for her valuable input on this post!
If you are interested in what I have been up to lately aside from blogging and classes
check out oath.health/waitlist