Early adversity and trauma – also known as Adverse Childhood Experiences (ACEs) – have significant health effects that carry forward throughout life. ACEs, which include childhood abuse, neglect and household dysfunction, can disrupt the growing bodies and brains of children, leading to a higher risk of disease, disability, risky health behaviours and social problems later in life.
During my clinical training I have found myself wondering: how might the health issues of patients I have met be influenced by their childhood experiences? I am reminded of the middle-aged woman, sitting in the waiting room of the emergency department, following her first suicide attempt on a background of a chronic eating disorder. The refugee with a history of cocaine abuse presenting to the emergency psychiatry clinic. And the young man who came to his family doctor in crisis because of a worsening abusive relationship at home.
In my short discussions with each of these patients, I discovered they had all suffered a traumatic event at some point during childhood. These ranged from sexual or physical abuse at the hands of a loved one to living through a civil war in a developing country.
In 1998, the US Centers for Disease Control and Kaiser Permanente published a seminal study that first coined the term ACEs and has since explored the relationship between childhood adversity and health outcomes. Researchers surveyed more than 17,000 adult patients about their medical history and childhood exposure to ACEs. Exposures included physical, sexual and emotional abuse; emotional or physical neglect; as well as domestic violence, parental separation or divorce, and substance abuse, mental illness and incarceration of family members. Nearly two-thirds of respondents had at least one ACE, and one in eight had four or more.
The study found a powerful dose-response relationship between ACEs and health, suggesting that higher ACE scores lead to more disability, morbidity and mortality in adulthood. Having four or more ACEs was associated with a four- to 12-fold increased risk of alcoholism, drug abuse, depression and suicide attempts. ACEs have been linked to the development of cardiovascular disease, diabetes, cancer, chronic lung disease and hepatitis. Researchers hypothesize that ACEs may lead to poor health by disregulating the body’s normal stress responses.
Of course, the relationship between ACEs and poor health outcomes is multifactorial. ACEs make up just one part of a complex puzzle that are the social determinants of health – gender, income, food security and education being a few other examples. Many people with multiple ACEs thrive in adulthood. It is possible that ACEs could be balanced out by protective factors like caring adults outside the household, a supportive school environment or recreational programs.
So what can healthcare providers do? The jury is out on the value of systematic screening for ACEs in routine clinical encounters. More studies are needed to assess whether screening actually leads to better health outcomes down the road. In 2000, the Canadian Task Force on Preventive Health Care recommended against screening to identify those at risk of experiencing or committing child maltreatment. Although the US Preventive Services Task Force has not made recommendations on screening for ACEs specifically, it has concluded that current evidence is inadequate to evaluate the benefits versus harms of primary care interventions to prevent child maltreatment in asymptomatic children.
Despite this, physicians and other healthcare providers should still remain alert for signs and symptoms of child maltreatment, and other indications of childhood adversity and chronic stress. With a better understanding of ACEs, we can more readily determine key risk factors and address social challenges that may lead to poor health in patients known to have experienced trauma.
Healthcare providers can educate patients and caregivers of young patients about the basics of ACEs. Knowing how adversity affects health later in life may encourage some people with traumatic pasts to come forward to seek help. Physicians can identify those who might benefit from treatments like cognitive behavioral therapy or trauma-specific therapies like Eye Movement Desensitization and Reprocessing. When needed, patients can also be referred to support services and community benefits like home visits for new or expecting mothers; parental education for pregnant teenagers; income support programs for parents; and intimate partner violence prevention programs.
Discussing past traumas is not easy. When a patient discloses this information, they must trust that their physician will hear their story and extend a helping hand. A strong therapeutic relationship can lessen the risk that patients will feel abandoned.
We owe it to patients to push back against the shame and secrecy surrounding ACEs to expose their profound effects on health and wellbeing. Building an awareness of the powerful effects of ACEs, and developing evidence-based methods to prevent childhood adversity and treat its effects should be our next steps forward.
*An draft version of this story was erroneously published on March 29
at 7 a.m. It was replaced with the correct version at noon.*