Research Update for Practitioners: The ACE Study
Adverse Childhood Experiences (ACEs) is a term coined by physician-researchers Vincent Felitti and Robert Anda to describe all types of abuse, neglect, and other traumatic childhood experiences. ACEs can be further defined as experiences that result in long-term exposure to severe chronic stress and the absence of a supportive adult. ACEs are experiences that profoundly effect a child’s developing brain that can lead to negative adult behavioral and health outcomes. For example, a young child growing up in a home with a chronic drug abuser will experience adversity due to dysfunctional parent-child interactions set within a chaotic, unpredictable, and/or unresponsive home environment. These early experiences will have an impact on the child’s brain development and could lead to the child having long-term effects on learning, behavior, and health. Numerous researchers have documented lasting effects of toxic stress on brain development.
In a landmark study conducted jointly by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente Health Maintenance Organization (HMO), Felli and Anda studied the link between adverse childhood experiences to adult health and well-being. This study was the first to scientifically link the short and long term effects of ACEs to an increased risk of physical, mental, and behavioral problems in adulthood. Results of the study have generated great interest in how to prevent as well as protect against the impact of ACEs.
What were the results of the ACE Study?
The original ACE study was conducted from 1995-1997 with over 17,000 adult participants in two separate waves of data collection. Participants ranged in age from 19 years old to over 60 years old. The average age of the participants was 57 years old. After a standard physical exam, members of the Kaiser Permanente HMO in San Diego completed confidential surveys regarding their childhood experiences prior to age 18 and current health status and behaviors. The childhood adverse experiences were divided into three categories that included ten adversities:
- Abuse- psychological, physical and sexual abuse
- Neglect- physical and emotional neglect
- Household Dysfunction- parental separation or divorce, violence against mother; and household members who were mentally ill or suicidal, substance abusers, or ever imprisoned
An ACE score was calculated by tallying up the number of experiences encountered by an individual. The ACE score ranged from zero, which means the individual had no exposure to any of the ten adversities prior to age 18, to a score of ten, which means the individual had exposure to all of the ten adversities prior to age 18.
Reports of these experiences were then compared to a number of health risk behaviors and health status, including diseases. The results were sobering. First, it was found that ACEs were common. Only about one third of respondents had no ACEs, while more than half reported at least one, and one-fourth reported two or more categories of childhood adversity exposure. Findings also included that ACEs tended to cluster and were interrelated, that is, 87% of participants with one ACE had an additional ACE.
Another important finding of the ACE study was the “dose-response” relationship between the ACE score and risk of later health and social problems. This means that as ACE scores increased, so did the chances of encountering an ACE attributable problem. Compared to participants who reported no ACEs, those with multiple ACEs were much more likely to experience health risks, including:
- drug abuse
- depression and suicide attempt
- multiple sexual partners and sexually transmitted diseases
- physical inactivity and obesity
More specifically, the ACE study found that individuals with an ACE score of 4 or higher were twice as likely to smoke, seven times as likely to be alcoholics, and six times as likely to have had sex before fifteen years of age. It was also found that men with an ACE score of 6 or higher were forty-six times as likely to have injected drugs than men who had no exposure to ACEs.
A final finding was the association between the number of ACEs an individual had with leading causes of death in the United States, including:
- ischemic heart disease
- chronic lung disease
- skeletal fractures
- liver disease
The research findings suggest that the higher the ACE score of an individual, the higher the individual’s risk of death. It was found that individuals with an ACE score of 4 or higher were twice as likely to have been diagnosed with cancer, twice as likely to have heart disease, and four times as likely to suffer from emphysema or chronic bronchitis. Adults with an ACE score of 4 or higher were twelve times as likely to have attempted suicide than those with an ACE score of 0.
What are community responses to ACEs?
The original ACE study has been widely criticized due to the limitations of the participant pool. First, all of the participants had health insurance. Next, majority of the participants of the original ACE study were from middle to upper socio-economic status with 69% reporting Caucasian as their ethnicity. Last, 74% of the original participants reported having attended college. Subsequent ACE studies have been administered to multiple populations and have revealed similar findings (Philadelphia, Wisconsin, Washington) to the original ACE study.
The results of the original ACEs study and the studies (e.g., Crittenton ACE study, The Philadelphia Urban ACE study) that have followed are being used to create programmatic and policy solutions to address and prevent ACEs at the individual, community, and systems levels. For example, in a report by Peck from the Tennessee Department of Children’s Services, the department has begun a statewide ACEs initiative to make a paradigm shift in thinking about prevention at all levels within the private and public sectors. For more specific examples of community efforts and evidence-based research across the United States of America, refer to ACEs in Action (https://acestoohigh.com/ace-concepts-in-action/ ).
How can Family Life Educators make an impact?
There are many stories throughout history regarding people who have been successful in life despite early adverse experiences. Luthar points out that research has provided insight into resiliency or positive adaptation despite adversity. The resiliency literature discusses three core protective systems that assist an individual in overcoming Adverse Childhood Experiences. These protective systems are interrelated and can be used to guide positive adaptation. Protective systems include a person’s individual capabilities, attachment and belonging with caring and competent people, and a protective community, faith, and cultural processes.
According to Masten, by addressing these three systems, there is the opportunity to prevent or reduce ACEs in future generations, which may lead to a reduction in all ACE-attributable problems. Family Life Educators can advocate within the areas of government agencies, social services, health care providers, insurance companies, private businesses, community organizations and philanthropy, for a paradigm shift to move toward a focus on preventing ACEs, rather than a reactive approach to mitigating ACEs effect on individuals and families. Society is positively impacted when the effects of ACEs are reduced and individuals are raised in thriving families and communities. Globally, the World Health Organization (WHO) has information on ACE policies (http://www.who.int/violence_injury_prevention/policy/en/ ). For specific steps to creating an ACE informed state infrastructure refer to “Essentials for Childhood Framework: Steps to Create Safe, Stable, Nurturing Relationships and Environments for All Children” (http://www.cdc.gov/violenceprevention/childmaltreatment/essentials.html).
The original ACE study has generated numerous studies that reflect similar findings, and the research continues to grow. Additional ACEs research provides strong evidence that early toxic stress causes enduring brain dysfunction that, in turn, affects health and quality of life throughout the lifespan. Data from community prevention programs has equipped advocates with evidence to bring to policy makers to change policies at the local, state, and federal levels. According to the National Conference of State Legislatures (NCSL), in 2017, nearly 40 bills in 18 states were introduced that specifically included ACEs in the text. This is in contrast to the 2016 findings in which only a handful of bills with ACEs in the text were introduced. Hopefully, this is a promising trend in the direction to reduce ACEs and produce thriving families and communities.
Dr. Mary Sciaraffa, CFLE, is an Associate Professor in Child and Family Studies at Eastern Kentucky University. She holds a doctorate degree in Curriculum & Instruction and a Master’s in Human Development & Family Studies. She has presented within a variety of venues with a variety of audiences and has been published in peer-reviewed professional journals, textbooks, and practitioner’s books.
Center for Disease Control and Prevention (CDC). ACE Study. http://www.cdc.gov/violenceprevention/acestudy/ Accessed 1 October 2016.
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M. and Marks, J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245-258.
Luthar, SS. (2006). Resilience in development: A synthesis of research across five decades. In D. Cicchetti & DJ., Cohen (Eds.), Developmental Psychopathology: Risk, Disorder, and Adaptation. (pp. 740- 795). New York: Wiley.
Masten, A. S., Cutuli, J. J., Herbers, J. E., & Reed, M.-G. J. (2009). Resilience in development. In C. R. Snyder & S. J. Lopez (Eds.) Oxford Handbook of Positive Psychology, 2nd ed., (pp. 117 – 131). New York: Oxford University Press.
Peck, C. 2016. “Building strong brains: Tennessee ACEs initiative– an overview” https://tn.gov/assets/entities/dcs/attachments/Building_Strong_Brains,_OVERVIEW__MISSION_6.10.16.pdf
Pizzolongo, P. & Hunter, A. (2011). I am safe and secure: Promoting resilience in young children. Young Children. http://www.naeyc.org/content/i-am-safe-and-secure-promoting-resilience-young-children Accessed 12 September 2016.
Spenrath, M.A., Clarke, M.E. Kutcher, S. (2011). The Science of Brain and Biological Development: Implications for Mental Health Research, Practice and Policy. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 25(2), 130–131.