July 2019, Volume XXXIII, No 4

cover story One

Adverse childhood experiences

Trauma in youth affects long-term health

met “Donna” several years ago when I was practicing as a therapist. She was coming to see me because she was struggling with life and was getting tired of being unable to live a quality lifestyle. Talking with her, I found out that Donna was married, was not able to work due to some chronic health issues, had a bout with cancer, and was not able to function in her daily living activities. Whenever she smelled a hot smell, she would have a panic attack. As I learned more about her, I found out that she had a close call with death and was recovering from drug and alcohol use. She had a tumor residing in her abdomen that could not be removed due to its proximity to vital organs. As she continued to tell me her story over many sessions, I learned that she had been involved in a fire where a family member died, and she barely escaped. She eventually revealed that she had been abused by her father, but felt that she justly deserved it.

I had just completed two classes on trauma and adverse childhood experiences (ACEs). I started to make some connections. Was it possible that the trauma she had suffered as a child was affecting her now? Could her past trauma relate to her current health, mental well-being, and substance use? Research shows that it could, and that Donna is not alone.

Early research

ACEs were first studied in 1997 by Kaiser Permanente and two scientists from the Centers for Disease Control and Prevention (CDC). They studied over 17,000 individuals who were mostly middle-aged, white, and college educated. They found that people who had experienced some form of adverse childhood experience—which could include abuse, neglect, living with a parent that had mental illness, domestic violence that occurred between their parents, or parents who were not together—had a significantly higher chance of suffering from chronic health issues, mental illness, and substance use when they grew older.

Further research has shown that babies become hard-wired by their experiences and that each area of the brain is sensitive to toxic stress during different times of development. ACEs can even affect gene expression, according to a study by the National Scientific Council on the Developing Child, which stated that “environmental influences can actually affect whether and how genes are expressed… . [E]arly experiences can determine how genes are turned on and off and even whether some are expressed at all.”

This can happen any time there is continued or frequent exposure to toxic stress or trauma: parents engaging in intense arguments, a mom that is suffering from mental illness and struggling with daily living activities, or a parent that suffers from substance use. Parents and families that live in poverty, have a parent in prison, or have a mom that does not engage in nurturing activities with their baby, can cause physical changes in the young brain that contribute to learning disabilities when the child enters school, along with physical and mental health issues as the child grows into adulthood.

ACEs and long-term health

Researchers at Kaiser Permanente, the CDC, and other institutions developed the ACE Pyramid (https://bit.ly/2J4k8xv), which presents potential consequences of childhood exposure to ACEs: social, emotional, and cognitive impairment; adoption of health-risk behaviors; disease, disability, and social problems; and early death. Clinicians often assess each of ten ACEs—five personal, and five related to behaviors of other family members—and assign one “point” for each.

ACEs were first studied in1997 by Kaiser Permanente.

Someone who has experienced two or more ACEs has a 390% greater chance of Chronic Obstructive Pulmonary Disease (COPD), 1,220% greater chance of suicide, and 490% greater chance of depression. ACE scores have been correlated with cancer (190%), heart disease (220%), obesity (180%), diabetes (160%), stroke (240%), depression (460%), and fetal demise (180%). Someone who has experienced six or more ACEs has a significant chance of shortening their life span by 20 years.

In addition, families that have experienced trauma or toxic stress can suffer from intergenerational trauma or epigenetics. Their DNA is modified by their response to traumatic events. A study in the Netherlands, focusing on children born during harsh winters in the 1940s, showed that they were at an increased risk for diabetes and heart disease, possibly due to the famine and conditions during that time. Animal studies have shown that when electric shock was administered in the presence of strong odors—in one case, that of cherry blossoms—subsequent generations also displayed trauma when faced with the same smell. Some have suggested that similar intergenerational, epigenetic trauma could appear in humans, particularly among Native Americans, people of color, and others at high risk of experiencing ACEs. More research is needed in this area.

Uncovering ACEs

Identifying ACEs in someone’s life is sometimes difficult. The person may have created adaptations that disguise the true issues. Assessing all your patients could uncover the underlying issue for individuals that continue to lack resolution of their problems. It is also helpful to identify social determinants that may contribute to or fuel the health condition. The main theme of recognizing ACEs is to look at the whole person, including their life outside of your office. It is only by putting the pieces together that we can solve the puzzle.

Multiple ACE questionnaires are available to help practitioners identify individuals that may have ACEs. Some question the advantage of this approach, arguing that people will not be honest in answering questions that might implicate themselves—e.g., “Do I physically or emotionally abuse my child?” The Center for Youth Wellness ACE questionnaire addresses this by allowing the patient to identify the ACEs, but revealing only the number of ACEs to the provider.

The ACE questionnaire does not address social determinants of health, so finding a way to identify those through assessment is helpful in completing the big picture. The American Academy of Pediatrics has been outspoken in weaving adverse childhood experiences into pediatric practices, and has offered multiple courses on identifying and treating trauma and ACEs.

The ACE questionnaire that is used throughout CentraCare’s behavioral health programs, both inpatient and outpatient, and at our Clara’s House facility (which provides day treatment for children), is the Center for Youth Wellness quiz. We have had conversations about starting to implement this in our Pediatric Clinic as well. We have also placed a social worker and Legal Aid lawyer in the clinic to identify and help those that are facing social determinates that affect their health and that of their family. We have placed a parent educator in our Pediatric Clinic to identify resources for parents. The clinic has become a “No Hit Zone,” a program that identifies alternative methods of disciplining children.

Coping with ACEs

The good news is that our brains can be rewired at any time during our lives. The most important factor for developing resiliency in a child is to have a loving, nurturing, supportive adult who displays the traits of predictability, compassion, and availability in the child’s life. A supportive adult can include teachers, librarians, grandparents, neighbors, coaches, and mentors.

Identifying ACEs in someone’s life is sometimes difficult.

The brain can also be re-wired by therapy that is specific to treating trauma. The benefits of talk therapy have been debated in this context, as it seems that most trauma lies in the area of the brain that is not reached by talk therapy. There is scientific data that shows that trauma is also fragmented throughout the body, if it cannot be released after the event(s). Therapies such as EMDR (Eye Movement Desensitization and Reprocessing) or trauma-focused play may be helpful. It also suggests that healing body practices may be beneficial. So as adverse experiences create deficiencies in building a child’s brain, positive experiences create a brain wired for resiliency.

The definition of resiliency can vary and is ambiguous. Some define it as the ability to rebound from adverse events. Most of the time when we hear the word resiliency, we think about deep breathing, meditation, yoga, and mindfulness. But that is only the beginning of resiliency. True resiliency is diving down into the person’s depth and confronting the negative thoughts, events, and beliefs that they have hung onto throughout their lives. Once they have changed the messages that the brain is giving them, they will have created new paths. The older the adult gets, the longer it takes to change the hard-wired paths in their brain, but science is telling us that they can do it at any age.

ACEs do not just include individual events that are adverse; they also include community events such as poverty, violence, lack of education or economic ability, lack of food access, and structures that propagate the systems that give birth to the above. Some of the highest ACE scores are found in individuals that are homeless, LBGTQ, foster kids, and incarcerated individuals.

Summing up

There is hope for those who have experienced a toxic or traumatic childhood. There is nothing to be ashamed about. It does not define who we are, but is an important piece of us that can cause chronic physical illness later in life. ACEs have been recognized as having an impact on the health of our population in general, and in the 5% of the population that uses 80% of our health care resources at the end of life.

But we also need to be aware of the “other” picture of our patients that occurs outside of the clinic. Social determinants play a significant role in what happens to our patients. Studies have shown that clinical care only impacts 10% of an individual’s health and that 80–90% of their health comes from their social determinants.

Resiliency is an important factor in changing the outcome of a child’s life, both physically and mentally. Teaching parents how to nurture and interact with their child is probably one of the most important pieces of changing the trajectory of that child’s life.

Further information about trauma and ACEs can be found at www.FeelingGoodMN.org.

Pam Beckering, MS, LPCC, is Trauma Informed Care Program Manager at CentraCare Health Foundation.


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© Minnesota Physician Publishing · All Rights Reserved. 2019


cover story One