If you haven’t heard of ACEs (Adverse Childhood Experiences) you might reasonably think having a few Aces up your sleeve is a good thing. Unfortunately not. In child development and life course approach medicine, ACEs are not desirable. They don’t help you win and they definitely don’t increase your chances of a dramatic Hollywood style card drop, winnings scoop, skip out the casino fairy-tale ending.
In the 1980s, Dr Vincent Felitti accidently discovered the power of ACEs when running an obesity clinic with a high dropout rate – patients would successfully lose large amounts of weight, and then suddenly put it back on. A conversation with a patient about the rapid re-gain of weight bought up the issue of childhood sexual abuse.(1) Although discussed for years as a cause of mental health problems in psychology and sociology circles, the link between traumatic experiences, health behaviours and subsequent physical health outcomes had not been much explored.
Further patients disclosed difficult childhood experiences at the clinic once he started asking, but the world of physicians couldn’t believe that these really did have an impact on outcomes (rather than just being a source of “pathetic” excuses). Instead Dr Felitti found support from a CDC (Centre of Disease Control) employee who helped and supported his hospitals running of a large study into the impact of childhood experiences and adult health outcomes in 1998.
What they found was extraordinary (2). Over 9000 adults who attended the hospital for routine health screening responded to a postal survey. Across 7 categories (3 abuse types and other disruptive factors in childhood) those who had a higher number of ACEs had worse physical and mental health outcomes, with over 50% of all participants experiencing one ACE and 6.2% experiencing traumas across 4 categories. (Your ACE score is the number of categories of ACEs you cross, not the number of events that you have).
As the number of ACEs increased, so did the risk factors for disease (smoking, obesity etc) and chronic disease conditions themselves (depression, ischaemic heart disease).
Experiencing 4+ ACEs resulted in 4-12x increase in alcoholism, smoking, suicide attempts and a statistically significant increase in ischaemic heart disease, cancer, lung disease etc. What really attracted attention was that these were people from middle class backgrounds. Poverty as a factor in health is the stuff of Dickens, but the impact of life experiences beyond this had not been well considered. And being completely frank – knowing that poverty discrimination is an issue in medicine – these could not be explained away under that umbrella.
How is it having such an impact?
I take you back to our first 1000 days piece. It’s not just in the early days that outside factors impact on neurological development. Remember the brain is significantly restructuring itself until about 25 years old. The pathways for dopamine (reward), the prefrontal cortex (self control), the amygdala (emotional response) are all continuing to develop. When the body senses stress, it activates fight or flight. The more a pathway is used, the more concrete its connections, and the easier it is to use next time:
- a stronger response to dopamine (to reduce your stress – the body does not like stress),
- a down regulation of the prefrontal cortex (your body doesn’t want you to think your way out of a dangerous situation – it wants you to leave it)
- an upregulation of the amygdala (you need to have fast reactions to fight or flight)
It’s therefore not as simple as bad times = bad behaviour. Again, it’s really easy to be reductive here and assume that an unhappy childhood means that of course you are more likely to drink or smoke or be depressed because your blocking out unhappy memories.
What’s really happening is more complicated than that. Your brain has programmed itself to protect you from harm (stress), and that would be great if all stress was a bad thing. But think about all the times stress leads to a positive outcome. Exams allow you to progress in your education (whether you agree with them or not). Debate about complex issues raises emotions, but leads to growth and better understanding. Telling someone you love and care for them – allowing yourself to love and care for them – there are difficult, nerve wracking, scary parts to that too.
When that is the case lots of things are just harder. That means even therapies like cognitive behavioural therapy, mindfulness and twelve step programmes are harder too. You have bigger hurdles to jump over.
And that is toxic stress.
What are the categories of ACE?
Since the original 1998 study, where 7 categories were used, the number currently explored is ten. They are all experiences or events that lead to increased personal and household stress, which as we know impacts on physical and psychological development. There is much debate about what should be included, and excluded. What can be influenced and what cannot. Despite all the discussions about childhood poverty being a major influence on outcomes – it doesn’t make it into the ACEs list. ACEs still exists as it’s a framework that has an evidence base and makes sense to people, but it’s not without its faults.
So again, what can we actually do?
We don’t currently, as far as I can tell, routinely screen for ACEs in the UK and it is often considered more of a public health issue, rather than a personal health issue.
Yet again, one of the reasons for writing these pieces is to increase awareness and use the frameworks around us to increase knowledge of factors relevant to health outcomes. Whilst Public Health Scotland have an excellent website, and excellent explanatory video on the impact of childhood experiences ,we need to start thinking about how to get our knowledge to influence our practice.
Public health Scotland notes it’s not appropriate to do large surveys of people in clinic and label their ACEs number. And I would agree. Of note, Dr Felitti’s team found that changing practice to asking, listening and acknowledging the impact of childhood experience led to an 11% decrease in ED visits, and 35% decrease in outpatient visits. This was without any directed treatment or labelling.
What is vitally important is that an increased population risk of worse outcomes isn’t translated into a finger pointing assumption about what will happen to a particular young person. Some of the videos and explanations of this on the internet just increase the stigma and ignore all the positive factors in peoples lives, and the complexities of when, where and how events happen which also influences the impact they have.
None of the 10 ACEs are a usual part of social disclosure, they are a source of shame and so often result in silence unless specifically asked about. That requires individualised, sensitive and supportive approach of difficult subjects by someone who cares, and whilst they may not have all the answers, is willing to listen and provide the signposting a family may need. We are also more aware of how experiences at vital times of brain development may influence behaviour, and labels that are inappropriate – this is where trauma informed care comes in. A balance needs to be struck between labelling families unhelpfully, or increasing stigma, and providing people with the holistic care that will make a tangible difference to their lives.
It can be awkward to know what to do if something isn’t clearly a safeguarding issue. But that’s why we don’t work alone, and we ourselves need to be open with colleagues about how to approach these and discuss individual cases. Perhaps think of it as no different from the confusing medical case (it might actually be an explanation for the confusing medical case). Some ideas for approach to wider social issues coming up in interactions are here
Coming pieces on Protective Factors and Trauma Informed Care can help add to our better understanding and care & I hope contribute to the discussion and make sure the kids stay at the centre in real supportive, individualise care – rather than using ACEs as a tick box exercise to discriminate further which is the counter argument for using the framework.
So please, contact me @lizziewortley or the team @paediatricfoam and let’s spread the message, and continue the conversations.
The links here contain a number of videos – not to override the importance of published journal articles, but to allow an accessible format of presenting information.
Read more about our social paediatrics pieces here, in our first one