Adverse Childhood Experiences: Early Trauma and Adult Mortality

Professionals working in clinical medicine and general healthcare have known about the long-term effects of early trauma on the development of chronic disease in adulthood for over twenty years. Until recently, however, most of these professionals worked in mental health, and understood early trauma in terms of its impact on psychological issues – mood and anxiety disorders in particular. These professionals established the trauma-informed approach to care that gains momentum with every new publication offering evidence on the clear connection between childhood trauma and adult mental health disorders.

As the evidence mounted, beginning with the publication of the seminal ACE Study in 1998, researchers began to understand the impact of ACEs extends far beyond the psychological and emotional: it includes a range of chronic physiological disorders, as well. Which makes sense, as the evidence which drove the original ACE study was the prevalence of obesity in adult populations in a specific location in Southern California.

Doctors at Kaiser Permanente’s Department of Preventive Medicine wanted to understand why so many people in their obesity/weight loss program dropped out despite initial success in the program. To get to the root of the problem, they enhanced their screening process, adding more detailed questions about patient history. Then, by accident, one of the physicians – Dr. Vincent Fellitti – learned something that changed everything.

Dr. Fellitti was interviewing a female adult, and instead of asking, “How old were you when you were first sexually active?” he asked, “How much did you weigh when you were first sexually active?”

“Forty pounds,” she replied.

It took a moment, and a follow-up question or two, before he realized what the woman was saying was that she’d been sexually abused by her father, beginning when she was four years old.

The Study That Transformed How We See Trauma

Dr. Fellitti then asked his colleagues at Kaiser to pose similar questions while collecting information on patient medical history. When they realized that childhood trauma was a common element in a disproportionate number of their obesity patients, they were perplexed. They knew this subject merited further examination, and wanted to explore the connection between childhood trauma and not only obesity, but other chronic health conditions.

A series of informal conversations led to official meetings with other influential figures in the field of preventive medicine, which, in turn, led to the original ACE study, conducted in collaboration with Dr. Robert Anda of the Centers for Disease Control (CDC) in Atlanta. They knew that the small sample size of about one hundred patients upon which Dr. Fellitti and his colleagues at Kaiser formed their initial hypothesis – childhood trauma may be causally related to adult pathology – was too small to convince the medical community about the validity of their findings. Therefore, they embarked on a two-year study that included over seventeen thousand participants.

That sample size, they believed, would be large enough to support their initial instincts – if the data confirmed those instincts, that is.

The Results

As it turned out, the results confirmed their instincts, and more.

They found that early trauma was directly linked to the onset of chronic disease during adulthood. They also found that childhood trauma was related to:

Additional analysis of their data revealed that 87% of the people in their study had experienced two or more types of early trauma. This taught them that childhood trauma rarely occurred in isolation, and the higher the number of traumatic experiences each individual experienced, the greater their risk of physical, mental, and social problems during adulthood.

In response to this data, they coined the term Adverse Childhood Experiences (ACEs) and developed a scale that they believed could be used as a scoring system. Their goal was for the scale to allow health professionals to classify the frequency and types of ACEs for each individual, thereby enabling them to determine both the root of their patient’s current pathologies and identify their vulnerability to future physiological, physical, and emotional pathologies.

Between 1998 and 2014, this research group published over 50 papers on the long-term consequences of early trauma on adult health. Taken together, these studies show that when individuals accrue four or more ACEs, they’re at increased risk of developing problems in the following areas:

  1. Disrupted Neurodevelopment
  2. Social, cognitive, and emotional impairment
  3. Risky behavior
  4. Disease, disability, and social productivity

These discoveries have led to slow-moving but comprehensive revolution in the way we view healthcare. If revolution is too strong a word, think of it as a complete re-evaluation of treatment practices, beginning with pediatrics and spreading all the way to typical primary care. Then, this year, the CDC published a new study that may speed up that revolution – and will most certainly enhance our re-evaluation.

The New ACE Report

This report clearly establishes the connection between ACEs, mental illness, and chronic disease. This new report, however, leaves no doubt as to the damage ACEs cause individuals: the data include two key points that, until now, have not been spelled out this clearly. The first point is the overall effect of ACEs on long-term health and longevity. The second is an estimated percentage of reduction of chronic disease that could be achieved if ACEs were prevented.

First, we’ll look at the health and longevity question. Researchers found that exposure to ACEs is directly related to five of the top ten leading causes of mortality in the U.S.:

Now we’ll look at those reduction estimates. Researchers projected that if ACEs were prevented, the results would mean nationwide reductions of:

  • 12.6% for coronary heart disease
  • 44.1% for depression
  • 1.7% for obesity and overweight

Due to study constraints, researchers were unable to calculate precise potential reductions in other ACE-related areas such as high school completion, incarceration, alcohol and drug use/abuse, and adult employment. However, it does not strain logic to recognize that the prevention of ACEs could lead to substantial reduction in nationwide prevalence of all of these negative ACE outcomes.

The Role of Clinicians

This new CDC report forecasts an expanded role for mental health clinicians and primary care providers in the ongoing effort to prevent ACEs in our youth. A companion report, Identifying and Preventing Adverse Childhood Experiences: Implications for Clinical Practice, published by the Journal of the American Medical Association (JAMA) the same day as the CDC report, elucidates the critical role clinicians can play in addressing the phenomenon of ACEs in the future. It revolves around the concept of trauma-informed care:

“In addition to primary prevention of ACEs, clinicians and health systems are likely important in reducing health harms associated with prior exposure to ACEs by incorporating trauma-informed care and services into clinical practice settings. Important elements of trauma-informed care include understanding how trauma affects health, routinely screening for ACEs and trauma, using culturally responsive assessments, promoting resilience and protective factors, addressing trauma-related somatic and mental health issues, and ensuring appropriate linkage to services and supports for identified issues.”

We can see the opportunities for population-scale reform in these recommendations from JAMA. When we infuse a trauma-informed perspective into our existing standards and best practices for care, we stand to substantially improve the mental and physical health of millions of our citizens who live with the consequences of ACEs every day. That’s not all. When we look at the mortality data, we can see that working to prevent ACEs and treat their consequences transcends categories of mental health, physical disability, or chronic disease: the data indicate it will increase longevity at the population level – and that’s a very good thing.