HDG #030: Childhood ACES: the overlooked SDOH
Read time: 10 minutes
During a recent road trip, I went on a TED Talk binge (did you know there was an app for that?).
One of the first Talks my husband and I listened to was from Dr. Nadine Burke Harris called “How childhood trauma affects health across a lifetime,” where she shared some rather sobering facts about something many of us in this field either know of or maybe know a little about, but I’ll admit was eye-opening.
That topic was Adverse Childhood Experiences (ACEs), specifically the lasting impact of them. ACEs are traumatic events or situations that a child experiences before the age of 18 and that have profound implications not just for immediate health, but also for long-term outcomes, including generational poverty, trauma, and mental health issues.
Today we will dig a little deeper into just how much impact ACEs have on a person’s health and wellbeing as a reminder that these can affect anyone, and are a major determinant of health that are easy to overlook or forget, despite the fact that based on the study:
67% of the population had at least one ACE, indicating some level of prevalence
12.6% (1 in 8) had four or more ACEs, some indication of magnitude and co-occurrence
There is a dose-response relationship between ACEs and health outcomes: the higher the ACE score, the worse the health outcomes.
What are the 10 ACEs?
The term "Adverse Childhood Experiences" was initially defined in a landmark study by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente. They identified ten specific ACEs, categorized into three groups: abuse, neglect, and household challenges. Those 10 ACEs are:
Physical Abuse: Any physical injury inflicted on a child that is not accidental, such as hitting, beating, or shaking.
Emotional Abuse: Verbal and emotional mistreatment, such as constant criticism, belittling, shaming, or verbal humiliation.
Sexual Abuse: Any sexual act with a child, including fondling, rape, incest, or exposing a child to adult sexual activity or pornography.
Physical Neglect: Failure to meet a child's basic physical needs, including lack of food, shelter, safety, and appropriate supervision.
Emotional Neglect: Failure to meet a child's basic emotional and psychological needs, such as love, belonging, and assurance of safety.
Parental Separation or Divorce: The absence or departure of a biological parent, often leading to emotional distress and changes in family structure.
Substance Abuse in the Household: A household member’s addiction to or abuse of substances like alcohol or drugs.
Mental Illness in the Household: Living with a family member who has significant mental health issues, such as depression, anxiety, or schizophrenia.
Household Member Treated Violently: Witnessing domestic violence, particularly violence against the mother or a primary female caregiver.
Incarcerated Household Member: Having a family member who has been in jail or prison.
The ACE scoring mechanism is from 0-10, with 1 point for every question answered as a “yes.” You can view/take the assessment with specific verbiage on MDCalc, here.
One thing the Talk also made me realize is that my score is not zero, despite growing up in a fairly reliable home.
The Tangible Health Impact
The psychological effects of ACEs are both profound and far-reaching, influencing a person's mental health, behavior, and relationships well into adulthood, the science of which Dr. Burke Harris goes into in her talk.
The gist is that research consistently shows that these experiences can physically alter a child's developing brain and body. The persistent stress from ACEs can lead to tangible changes in brain development, affecting areas responsible for emotion regulation and decision-making. The impacts may also include:
Altered Brain Development:
ACEs can disrupt the normal development of the brain, particularly in areas responsible for emotion regulation and stress response. This can lead to increased anxiety, difficulty in controlling emotions, and heightened stress reactions to everyday challenges.
Impact on Mental Health:
Children with a history of ACEs are at a higher risk for developing mental health disorders such as depression, anxiety, and post-traumatic stress disorder (PTSD). These conditions often stem from the chronic stress and emotional turmoil experienced during critical developmental stages.
Behavioral Consequences:
ACEs can lead to risky behaviors in adolescence and adulthood, such as substance abuse, eating disorders, and self-harm. These behaviors are often coping mechanisms for unresolved trauma and emotional pain.
Impaired Social Skills and Relationships:
The emotional turmoil caused by ACEs can impair a child's ability to develop healthy social skills. This can result in difficulties forming and maintaining relationships, leading to feelings of isolation and difficulty in personal and professional relationships later in life.
Cognitive Effects:
Children exposed to ACEs may experience cognitive impacts, such as difficulties with attention, memory, and problem-solving. This can affect academic performance and career progression, limiting opportunities and perpetuating cycles of hardship.
This can manifest in adulthood as challenges in relationships, employment, and overall life satisfaction. And as Dr. Burke Harris cited, individuals with a high number of ACEs are at an increased risk for various health issues later in life, including chronic diseases, mental illness, and substance abuse. Specifically:
A person with an ACE score of four or more has 2.5 times the risk of chronic obstructive pulmonary disease and hepatitis compared to someone with an ACE score of zero. The risk of depression increases 4.5 times [for these individuals, and the risk of suicidality increases 12 times.
An ACE score of seven or more triples the lifetime risk of lung cancer and leads to 3.5 times the risk of ischemic heart disease.
. . .
Actionable Idea of the Week:
Consider how your organization regards screening for and addressing elements like these, and how you might use your internal data, health data utilities, and/or public data to identify and support individuals at risk due to ACEs. On a broader scale, think about how you might create or advocate for programs that offer mental health support, community resources for families in crisis, and educational initiatives to raise awareness about the impact of ACEs.
Here are some starter resources that I found very useful for this article:
American Academy of Pediatric’s Recommendations for healthcare provider interventions and parental recommendations to decrease the risk of violence and harm to children during periods of crisis (such as COVID)
ACEs as a SDOH: JAMA article
ACEs score calculator by MDCalc
And of course, the TED Talk that sparked this article, which I highly recommend watching even if you’ve already read this article twice:
. . .
By proactively addressing these issues, we can play our part in helping to recognize the cycle of trauma and long-term health outcomes. In our roles as healthcare providers, policymakers, advocates, or even data analysts, we have a part to play in this. By shining a light on the profound impact of ACEs and actively working towards solutions, we're not just improving individual lives; we're nurturing healthier, more resilient communities.
See you next week,
-Stefany
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