Adverse Childhood Experiences: A Public Health Crisis That is Treatable and Preventable

On Thursday, July 11, 2019, Congressman Elijah Cummings of Baltimore, Maryland chaired the first ever hearing of the House Committee on Oversight and Reform on childhood trauma in the United States.  The event, entitled Identifying, Preventing, and Treating Childhood Trauma: A Pervasive Public Health Issue that Needs Greater Federal Attention, featured trauma survivors, public health experts, and government officials and was live streamed from Washington, D.C. and recorded.

In his opening address, Representative Cummings described childhood trauma in the United States as a public health epidemic that costs taxpayers billions of dollars every year.  He cited a conservative estimate from the Centers for Disease Control and Prevention (CDC) that attributed an annual cost of $428 billion to adverse outcomes related to toxic stress and childhood adversity, such as substance use disorder and suicide, both of which have dramatically increased in the U.S in recent decades (House Committee on Oversight and Reform, 2019).

A recurring topic throughout the hearing was the adverse childhood experiences or ACEs study, published in 1998, situated in the broader context of the science of childhood trauma and adversity. What began as the unexpected outcome of a weight loss program for obesity, has become a core component of the science of trauma and resiliency the United States and abroad. The Committee has published the following takeaways from the hearing on their website:

• Childhood trauma is a pervasive public health issue with long term negative health effects that cost the United States billions of dollars.

• We need a comprehensive federal approach that recognizes the severe impact of childhood trauma and prioritizes prevention and treatment.

• Some states and localities are implementing promising programs to help prevent and treat childhood trauma that can inform federal solutions – but they face resource constraints that limit their ability to do so. (House Committee for Oversight and Reform, 2019).

Origins of the Adverse Childhood Experiences (ACEs) Study

In the 1990s, researchers were surprised to find that some of the most successful participants of a weight loss program (in terms of overall weigh loss) were leaving the program at an alarming rate.  Eventually, the investigators uncovered a connection between a history of sexual abuse and weight gain in one participant.   Upon further investigation, they found that 55 percent of adults in the program acknowledged a history of “contact childhood sexual abuse.”  Individuals would self soothe by eating. As they put on weight, they found that it reduced their level of sexual attraction to others and acted as a perceived protective factor from future abuse, an unconscious solution to hidden problems.  Although all participants had articulated a desire to lose weight in joining the program, weight loss became threatening to those who had suffered abuse.  The investigators decided to explore some of the root causes of negative physical and behavioral health outcomes and opened a Pandora’s Box. Dr. Vincent Felitti recounts the experience in a 2019 interview.

Led by Doctors Vincent Fellitti and Robert Anda, the Adverse Childhood Experience Study, or ACEs, was a collaboration between the CDC and Kaiser Permanente. Felitti and Anda developed an inventory of seven adverse childhood experiences that were later expanded to address the additional category of neglect.

The original seven categories of adverse childhood experiences studied included:

• Psychological abuse
• Physical abuse
• Sexual abuse
• Violence against mother
• Living with householdmembers who were substance abusers
• Living with householdmembers who were mentally ill or suicidal
• Living with householdmembers who had ever been incarcerated.

The number of categories of adverse childhood experiences was compared to measures of adult risk behavior, health status, and disease, using logistic regression to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (Felitti et al., 1998).  Between 1995 and 1997, in two waves, over 17,000 members of Kaiser Permanente’s Health Maintenance Organization in San Diego, California, completed confidential surveys regarding their childhood experiences and current health status and behaviors (CDC, 2019).  The researchers published the results of their findings in American Journal of Preventive Medicine in 1998 in an article entitled Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study.

Investigators found that adverse childhood experiences were common in a population that was predominantly white, educated, and had the advantage of comprehensive health insurance. Future research would show that ACEs are exacerbated by poverty and that ACE scores are higher among vulnerable populations, such as incarcerated individuals, youth and adults experiencing homelessness, or victims of sex trafficking (House Committee on Oversight and Reform, 2019; Hughes et al.).

Results showed a significant dose response effect between an individual’s ACE score and adverse health outcomes.  As an individual’s ACE score increased, so did the magnitude of poor health outcomes.  It was eventually determined that individuals with a high ACE scores had their life expectancy reduced by up to 20 years.

Response from the Centers for Disease Control and Prevention (CDC)

At the congressional hearing on July 11, hearing, witness Debra Houry, MD, MPH spoke on behalf of the CDC and cited adverse childhood experiences as a major source of trauma:

“the estimated U.S. population economic burden of child maltreatment, major contributors to childhood trauma and ACEs, based on 2015 data was $428 billion, but this number may underestimate the total cost of ACEs because it is focused solely on child maltreatment. This estimate accounts for

• increased health care costs,
• public spending for child protective services and special education,
• increased criminal justice spending,
• as well as reduced quality of life for survivors and
• life lost for fatal victims,” (Houry, 2019).

Furthermore, the estimated lifetime costs for survivors of child maltreatment was $830,928 per case, and for fatal cases was $16.6 million per case (Houry, 2019).”

Houry and other expert witnesses cited the decades of research demonstrating that adverse childhood experiences and their corollaries are preventable and treatable.  Evidence-based strategies are available to address ACEs and foster healthy individuals and communities.  Houry and the CDC recommend the following strategies:

• The use of data to inform prevention and action;
• A change the context in which children are being raised through:
  • norms change,
  • programs that are supportive of children and families,
  • policies that are supportive of children and families, and
• Raised awareness and commitment to promote safe, stable, nurturing relationships and environments for all children and their families (Houry, 2019).

Where to Begin?

The congressional hearing on July 11, 2019 was one step towards addressing yet another public health crisis in our midst.  The assertion that ACEs and other childhood trauma are treatable and preventable remains consistent throughout the testimony and in the scientific literature.

One important recommendation from the congressional hearing is that parents with ACEs get the support they need before their children start school.  Parents need the cognitive, emotional and social skills to engage in the types of positive relationships that will be protective for their offspring.  Community involvement and buy-in was also emphasized, because it truly takes a village to raise emotionally healthy children. The Self-Healing Communities model was cited by on expert witness, Dr. Christina Bethell, Director, Child and Adolescent Health Measurement Initiative of the Johns Hopkins Bloomberg School of Public Health, as an evidence-based road map for engaging communities in ACES prevention, intervention, and healing in response to the challenge of limited resources and insufficient infrastructure. The Self-Healing Community Model used in Washington is one that used the development of strong networks that promoted much greater collaboration across sectors. Local leadership was empowered and nurtured to use a “whole systems” concept rather than just “their part” of a system. Data was used to decide how and where to focus efforts and to evaluate what was working. Visible changes helped to instill a real sense of hope in communities that had given up on the prospect of a better world for their children (Robert Wood Johnson Foundation, 2018)

ACES Screening and Brief Intervention for Adults

In August of 2018, the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) and the Collaborative Family Healthcare Association (CFHA) co-sponsored a webinar entitled Real World Strategies: Assessing for ACEs and brief interventions in an integrated care environment, where they presented the latest research and the recommendations to date for ACEs screening of adults in integrated or primary care settings. The learning objectives were to: 1) Review the relevance of adverse childhood experiences in integrated care settings, 2) Learn best practices for brief assessment and intervention related to adverse childhood experiences relevant to integrated care settings, and 3) Understand keys to implementation of screening and intervention for adverse childhood experiences, including leadership buy-in and culture change.

The speakers, Linda Ligenza, LCSW, Clinical Services Director for the National Council for Behavioral Heath, Dennis Pusch, PhD, a Clinical Psychologist from the University of Calgary, and Keith S.  Dobson, PhD, Professor of Clinical Psychology at the University of Calgary, argue that while the adverse childhood experiences intervention research is still in its infancy, we now know enough to move the conversation forward to the point where  “providers and patients on the ground can benefit, namely, what can be done to help reduce the impact of ACEs.”

The webinar conversation was initiated by sharing the results of a Canadian study, the EmbrACE Research Program.  The purpose of the project was to identify and treat adults with multiple ACEs in primary care settings using the following four phase implementation:

Phase 1: Develop and validate an ACEs measure

Phase 2: Large scale replication of the first ACEs study that included a search for moderators and modifiers of adverse childhood experiences.

Phase 3: Develop and test an intervention for people with high ACE scores in primary care

Phase 4: Test the intervention in an RCT

EmbrACE used the following indicators for adverse childhood experiences in their research:

Abuse

• Emotional: recurrent threats, humiliation (11% of sample population)
• Physical: beating, not spanking (28%)
• Contact sexual abuse (28% women; 16% men)

Neglect

• Physical (10%)
• Emotional (15%)
• Household Dysfunction
• Mother treated violently (13%)
• Household member was drug or alcohol abuser (27%)
• Household member was imprisoned (6%)
• Household member with chronic mental illness (17%)
• Not raised by both biological parents (23%)

The EmbrACE Results confirmed that ACEs are a significant predictor of chronic disease, depression, addictions. Something must be done about the long-term effects of ACEs and their associated costs. Researchers cited the key takeaways from the work as follows:

• The research helps to establish emotion dysregulation and interpersonal problems as mechanisms by which ACEs may be associated with anxiety and depression, and resilience as a buffer of these associations.
• All of these variables have been shown to be modifiable treatment targets.
• Treatment initiatives for ACE-related depression should address emotion dysregulation, interpersonal problems, and resilience as treatment targets.

For further research the EmbrACE team is conducting analyses with other physical health conditions as criteria.

Based in part upon the research shared by the Calgary contingent, the United States has devised its own three-year initiative that was launched in 2017 with the goal of creating and piloting a process for integrating trauma-informed approaches into primary care. The pilot, Trauma-Informed Primary Care: Fostering Resilience and Recovery project, is being developed and piloted by the National Council with support by Kaiser Permanente, and will offer primary care practices “field-informed methods, tools and resources to advance understanding and address the impact of trauma.”

What can be done now?

An important tenet of the EmbrACE program is that screening alone isn’t enough.  The following possible approaches were highlighted in the embrace presentation:

1) Primary prevention (stop ACEs from happening)

• Home visits for families with newborns
• Parenting training programs; family wellness
• Social justice; reducing incarceration rates
• Social development; economic opportunity

2) Secondary prevention (early help for people with ACEs)

• Screen People at risk
• Offer treatment to increase resilience and reduce risk

3) Tertiary prevention (treat the final condition that emerges)

• Chronic disease support groups
• Mental illness and substance abuse treatment

What can Behavioral Health Practitioners on the ground do in the interim, while research continues to be conducted and neuroscience is advanced? To quote Dr. Bethell,

… most importantly healing is prevention.  We are at a point in this “syndemic,” meaning it has escalated to the point that even if you don’t have ACEs, you are impacted … healing has to lead the process of prevention.

We must continue to provide rigorously evaluated, robust, evidence-based prevention and intervention programing, treatment, and recovery services across the lifespan and across the continuum of care.   Programming. Public and behavioral health practitioners can strive to become trauma informed by pursuing continuing education in topics such as ACEs, the neurobiology of trauma, and trauma informed care (TIC).  Professionals in the field can advocate for the continued support of scientific research and/or participate in that research to advance the field.

References

Bethell, C. D., Solloway, M. R., Guinosso, S., Hassink, S., Srivastav, A., Ford, D., & Simpson, L. A. (2017). Prioritizing possibilities for child and family health: An agenda to address adverse childhood experiences and foster the social and emotional roots of well-being in pediatrics. Academic Pediatrics, 17(7), S36-S50. doi:10.1016/j.acap.2017.06.002

Bethell, C. D., Solloway, M. R., Guinosso, S., Hassink, S., Srivastav, A., Ford, D., & Simpson, L. A. (2017). 2017 Summary Report of the Child and Adolescent Health Measurement Initiative.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.

Burke Harris, N. (2019). The Deepest Well: Healing the Long-Term Effects of Childhood Adversity. Courtney, K. & Cappello, D. (2018) Anna Age Eight: The data-driven prevention of childhood trauma and maltreatment.

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. doi:10.1016/S0749-3797(98)00017-8

Felitti, V. (2019, July 19). [Televised interview with Dr. Brian Altman]. https://vimeo.com/349164603/b152fa1e61

Finkelhor, D. (2018). Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse & Neglect, 85, 174-179. doi:10.1016/j.chiabu.2017.07.016

Glowa, P., Olson, A., & Johnson, D. (2016). Screening for adverse childhood experiences in a family medicine setting: A feasibility study. Journal of the American Board of Family Medicine, 29(3), 303-307. doi:10.3122/jabfm.2016.03.150310

HRSA- SAMHSA Center for Integrated Health Solutions (CIHS) and the Collaborative Family Healthcare Association (CFHA). (2018). Real World Strategies: Assessing for ACEs and brief interventions in an integrated care environment

Houry, D. (2019). Written Testimony House Committee on Oversight & Reform. July 11th, 2019. Statement of Debra Houry, M.D., MPH Director, National Center for Injury Prevention and Control Centers for Disease Control and Prevention Department of Health and Human Services.

House Committee on Oversight and Reform: Identifying, Preventing, and Treating Childhood Trauma: A Pervasive Public Health Issue that Needs Greater Federal Attention, 116th Cong.  (2019).

Hughes, K., Bellis, M., Hardcastle, K., Sethi, D., Butchart, A., Mikton, C., . . . Dunne, M. (2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. Lancet Public Health, 2(8), E356- E366.

LeTendre, M. L., & Reed, M. B. (2017). The effect of adverse childhood experience on clinical diagnosis of a substance use disorder: Results of a nationally representative study. Substance use & Misuse, 52(6), 689-697. doi:10.1080/10826084.2016.1253746

Porter, L., Martin, K., & Anda, R. (2016) Self-Healing Communities A Transformational Process Model for Improving Intergenerational Health. Robert Wood Johnson Foundation.

Pournaghash-Tehrani, S. S., Zamanian, H., & Amini-Tehrani, M. (2019). The impact of relational adverse childhood experiences on suicide outcomes during early and young adulthood. Journal of Interpersonal Violence, 886260519852160-886260519852160. doi:10.1177/0886260519852160

Reid, J. A., Baglivio, M. T., Piquero, A. R., Greenwald, M. A., & Epps, N. (2018). No youth left behind to human trafficking: Exploring profiles of risk. The American Journal of Orthopsychiatry, doi:10.1037/ort0000362

SAMHSA-HRSA Center for Integrated Health Solutions (producer). 2018. Real World Strategies: Assessing for ACEs and brief interventions in an integrated care environment [webinar]. Retrieved from: https://integration.samhsa.gov/Assessing_for_ACEs_and_brief_interventions_in_an_integrated_care_environment_slides_final_2.pdf

Additional ACEs Resources and Links Can be found in the CASAT OnDemand Resources and Downloads section.

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