Section 1: Impact on health and disease

(e)

ba ACE Score
35 OO #1 G2 03 04

30
25
20

Memory impairment (%)

ACE Score
Fig. 8.1. (Continued)

An analysis of population attributable risk (that
portion of a problem in the overall population whose
prevalence can be attributed to specific risk factors)
shows that 54% of current depression and 58% of sui-
cide attempts in women can be attributed to adverse
childhood experiences. Whatever later factors might
trigger suicide, childhood experiences cannot be left
out of the equation. Seeman et al. [8] have described
this general concept of background burden as allo-
static load.

A similar relationship exists between ACE Score
and later hallucinations, shown in Fig. 8.1d. As it
might be suspected that, at ACE Score 7 or higher,
people will likely be using street drugs or alcohol
to modulate their feelings, and that these might be
the cause of hallucinations, the results are corrected
for alcohol and drug use and the same relationship
exists [9].

Clinicians treating somatization or disorders
with no clear medical etiology, as well as those dread-
ing such patients, will find Fig. 8.2 of special interest.
Indeed, this figure exemplifies the observation in the
weight program that what one sees, the presenting
problem, is often only the marker for the real prob-
lem, which lies buried in time, concealed by patient
shame, secrecy and sometimes amnesia - and fre-
quent clinician discomfort. Amnesia, usually consid-
ered a theatrical device of Hollywood movies of the
1940s, is in fact alive and well, although unrecognized,
in everyday medical practice. In the weight program,
12% of the participants were partially or sometimes
totally amnestic for a period of their lives, typically
the few years before weight gain began. In the ACE
Study, there was a distinct relationship of ACE Score
and impaired memory of childhood, and we under-
stand this phenomenon to be reflective of dissociative
responses to emotional trauma (Fig. 8.1e) [10].

455
40
35
30
254
20
154
107 0. ete.
54

Abused (%)

Number of Unexplained Symptoms

Fig.8.2. The relationship between the likelihood of childhood s
ual abuse and the number of unexplained symptoms in adulthoc

All told, it is clear that adverse childhood experi-
ences have a profound, proportionate and long-lasti
effect on emotional state, whether measured by depr:
sion or suicide attempts, by protective unconscio1
devices such as somatization and dissociation, or by
self-help attempts that are misguidedly addressed
solely as long-term health risks - perhaps because we
physicians are less than comfortable acknowledging
the manifest short-term benefits these “health risks”
offer to the patient dealing with hidden trauma.

ks

Health risks

The most common contemporary health risks are
smoking, alcoholism, illicit drug use, obesity and
high-level promiscuity. Although widely understood
to be harmful to health, each is notably difficult to
give up. Conventional logic is not Particularly, ise Hy
in understanding this apparent paradox. A: ppostne
forces are not known to exist commonly in biological
systems, little consideration is given to the possibility
that many long-term health risks might also be person-
ally beneficial in the short term. For instance, American
Indians understood the psychoactive benefits of nico-
tine for centuries with their peace pipe, before its risks
were recognized. We repeatedly hear from patients
of the benefits of these “health risks.” Indeed, rele-
vant insights are even built into our language: “Have
a smoke, relax.” “Sit down and have something to eat.
You'll feel better.” Or, need “a fix,” referring to intra-
venous drug use. Conversely, the common reference
to “drug abuse” serves to conceal the short-term func-
tionality of such behavior. It is perhaps noteworthy
that the demonized street drug crystal meth is the very
compound that was introduced in pure form and reli-
able dosage in 1940 as one of the first prescription anti-
depressants in the USA: methamphetamine.


Chapter 8: Childhood trauma leading to adult healthcare issues

+ Have you ever been a combat soldier?

+ Have you ever lived in a war zone?

+ Have you been physically abused as a child?

¢ Have you been sexually molested as a child or
adolescent?

+ Have you ever been raped?

+ Whoin your family has been murdered?

+ Whoin your family has had a nervous
breakdown?

+ Who in your family has been a suicide?

+ Whoin your family has been alcoholic or a drug
user?

Such questions have been accepted by patients in the
context of a well-devised medical questionnaire that
is filled out at home. Examiners have learned that the
most productive response to a “Yes” answer is, “I see
that you have .... Tell me how that has affected you later
in your life.” While not a simple transition for staff, and
one requiring an organized training effort, the transi-
tion has been effective and with measured benefits. An
independent organization carried out a neural network
analysis — an artificial intelligence approach to math-
ematical modeling and data mining — of the data from
over 100 000 patient evaluations (2 years’ work) using
this new approach: a truly biopsychosocial approach
to comprehensive medical evaluation. Surprisingly, a
35% reduction in doctor office visits was found in the
year subsequent to evaluation, compared with the year
before. Additionally, analysis showed an 11% reduc-
tion in emergency department visits and a 3% reduc-
tion in hospitalizations. This change was dramatically
and unexpectedly different from a much smaller, 700-
patient evaluation carried out 20 years earlier when we
worked in the more usual biomedical mode. That earlier
approach provided a net 11% reduction in doctor office
visits compared to the antecedent year, in spite of a 14%
referral rate. No evaluation was made then of emer-
gency department visits or hospitalization. Finally, we
found that the unexpectedly notable reductions in doc-
tor office visits and emergency department visits totally
disappeared in the second year after comprehensive
evaluation, when there was a reversion to prior base.
line. While the underlying biopsychosocial information
was present in charts with laser-printed clarity, it was
almost never integrated into subsequent medical visits.
Interpreting the basis of this major reduction in doctor
office visits was not within the purview of the ACE Study
design, but the impression of the clinicians initially eval-
uating these patients is that the reduction represents

the benefit of having, through a comprehensive medi-
cal history, the worst secrets of one’s life understood by
another, and still being accepted as.a human being. The
Swiss psychologist Alice Miller describes this as the role
of “the enlightened witness” [26] .

If these first year results are replicable, and we
believe they should be, the implications for primary
medical care are those of a paradigm shift. While
offering tremendous opportunity, paradigm shifts are
resisted. The philosopher Eric Hoffer has discussed this
problem in his book The Ordeal of Change [27]. Jeftrey
Masson, in Assault on Truth [28], describes the enor-
mous social pressures on Freud to recant his interpre-
tation of his findings of traumatic sexual experiences
in childhood as being valid. Louise De Salvo points
out in Virginia Woolf [29] how literary commentators
almost uniformly avoid discussing the themes of incest
in Woolf's work in favor of erudite discussions of her
style and literary techniques.

If the treatment implications of what we have
found in the ACE Study are far reaching, the problems
of integrating this information into clinical practice
are absolutely daunting. Simply put, it is easier for all of
us to deal with the presenting symptom of the moment
than to attempt to understand it in the full context of
the patient, particularly when that full context involves
thematic material of child abuse and household dys-
function that is usually protected by social taboos
against exploring these areas of human experience.
Although the proposed approach demonstrably would
save time and money in the long run, most of us oper-
ate in the short term and respond to valid forces that
are both external and internal.

The very nature of the material in the ACE Study is
suchas to make most of us uncomfortable. Why would
a physician or leader of any major health agency want
to leave the familiarity of traditional biomedical dis-
ease and enter this area of threatening uncertainty for
which none of us have been trained? As physicians,
we typically focus our attention on tertiary conse-
quences, far downstream, while the primary causes
are well protected by time, social convention and
taboo. We have often limited ourselves to the smallest
part of the problem, that part in which we are erudite
and comfortable as mere prescribers of medication
or users of impressive technologies. Consequently,
although the ACE Study and its 50-some publica-
tions have generated significant intellectual interest
in North America and Europe during the past dozen
years, its findings are only beginning to be translated

85



82

Section 1: Impact on health and disease

(Fig. 8.3c) [14] are strongly related in a proportion-
ate manner to the several specific categories of adverse
experiences during childhood. Additionally, poor self-
rated job performance correlated with ACE Score (Fig
8.3d) [15].

The relationship of intravenous drug use with ACE
Score is particularly striking, given that male children
with ACE Score 6 or more have a 46-fold increased
likelihood of later becoming an injection drug user
compared with a male child with an ACE Score 0; this
moves the probability from an arithmetic to an expo-
nential progression. Relationships of this magnitude
are rare in epidemiology. This, coupled with related
information, suggests that the basic cause of addic-
tion is predominantly experience dependent during
childhood and not substance dependent. This chal-
lenge to the usual concept of the cause of addictions

(a)

S
a

ACE Score
BO m10203 24

= ER pe =
asespes

Percent With Health Outcome (%)
Ss

oa

Intercourse by
‘Age 15

Teen Pregnancy Teen Paternity

S

Adjusted Odds Ratio
n

0 1 2 3 24
ACE Score
Fig. 8.4. Sexual behavior. The relationship between ACE Score

and teenage sexual behavior (a) and promiscuity (likelihood of > 50
sexual partners) (b).

has significant implications for medical practice and
for treatment programs|16].

Sexual behavior

Using teenage pregnancy and promiscuity as measures
of sexual behavior, the ACE Score has a proportionate
relationship to these outcomes (Fig. 8.4). So too does mis-
carriage of pregnancy, indicating the complexity of the
relationship of early life psychosocial experience to what
are usually considered purely biomedical outcomes [17] .

Medical disease

Biomedical disease in adults had a significant relation-
ship to adverse life experiences in childhood in the ACE
Study. The implication of this observation that life expe-
rience can transmute into organic disease over time is
a profound change from an earlier era when infectious
diseases such as rheumatic fever or polio, or nutritional
deficiency such as pellagra, would come to mind as
the main medical links between childhood events and

(a)

12
& 10
ro
e 8
3
o6
5
54
=
= 2
0
0 1 2 3 24
ACE Score
(b) 20
18
16

With COPD (%)

0 if 2 3 24
ACE Score

Fig.8.5. Medical disease. The relationship between ACE Score
and prevalence of liver disease (hepatitis/jaundice) (a) and chronic
obstructive pulmonary disease (COPD) (b)


Chapter 8: Childhood trauma leading to adult healthcare issues

(a) (b)
20 18)
18 164
16 144
git 124
£12 ze. |
2 ‘9 104 8
2 10 3
£ 8 § 3)
Bg g |
] <6;
4 | |
2 | 4) ‘
| |
o} - 2 | 0
0 1 2 3 45 26 é
ACE Score ACE Score
(c)
35
= 3
R
25
&
2
fal
8
2 15
= 4
@
g
£05 =
0) -
0) 1 2 3 24
ACE Score
(a)
25>
ACE Score
G0 m1 O2 O3 @4ormore
ZX 205
sf
ro
ic 4
gets
52
Se
s% 10+
£8
3
8
E54
0 =
Absenteeism Serious Serious
(&2 days/month) Financial Job
Problems Problems

Fig. 8.3. Health risks. The relationship between ACE Score and adult smoking (a), adult alcoholism (b), intravenous drug use (c), and indicators

of impaired worker performance (d)

In the ACE Study, there were strong, proportion-
ate relationships between ACE Score and the use of
various psychoactive materials or behaviors. The say-
ing, “It’s hard to get enough of something that almost
works” provides insight. Three common categories of

what are usually termed addictions (the unconscious
compulsive use of psychoactive agents) are illustrated
in this section. Self-acknowledged current smoking
(Fig. 8.3a) [11,12], self-defined alcoholism (Fig. 8.3b)
[3,5,13] and self-acknowledged injection drug use

81


84

Section 1: Impact on health and disease

(a) 12

@ 10
2g
2s
ars
58
ag ©
88 4
en

a oh

0
0 1 2 8 4 35
ACE Score

(b) 35

@ 30
2s
co S 25
58 20
S= 10
a5

25

0
0 1 2 3 4 25
ACE Score

Fig. 8.6. Healthcare costs. Rates of issuing prescriptions for anti-

psychotic drugs (a) and anxiolytic drugs (b).

60 Age Group

Q 19-34
3 50 a
5 35-49
8 a0 050-64
© 30 i >=65
@
S
# 20
=
8
ae | Te
2
of [ten
0 2 4
ACE Score

Fig. 8.7. Older individuals in the ACE Study are more likely to have
low ACE Scores (null hypothesis).

Life expectancy

Given that the ACE Score hasbeen shown to bestrongly
related first to health risks and then to disease, it is rea-
sonable to expect that the relationship will continue
to the major outcome of disease, premature death.
Figure 8.7 shows that the older individuals in the ACE
Study are more likely to have a low ACE Scores (ACE
Score 0) and are substantially less likely to have higher
ACE Scores (ACE Score 2 or 4). One explanation for

this finding is that persons with higher ACE Scores do
indeed die younger; thus older people would tend to
have lower ACE Scores because others in their birth
cohort were less likely to survive to be included in the
study.

Reasonably, this interpretation of selective attrition
could be challenged by hypothesizing that our patients
were progressively so humiliated by exposure of their
increasing ACE Scores that they are subsequently
avoiding necessary medical care. Such an hypothesis
is not supported by the findings. Some years ago we
had on site for 6 months a psychoanalytically trained
psychiatrist who saw selected patients with high ACE
Scores immediately after their comprehensive med-
ical evaluation, rather than after referral to psychiatry.
An anonymous questionnaire, returned by 81% of the
patients he saw, showed that his hour-long interview
was overwhelmingly interpreted by patients as highly
desirable and appreciated. Talking about the worst
secret of one’s life with an experienced person, being
understood and coming away feeling still accepted as
a human being seems to be remarkably important and
beneficial, perhaps not unlike the role of confession in
the Roman Catholic Church, a technique whose per-
sistence over nearly two millennia suggests it has func-
tional benefit for those involved in its use.

At the 14 year mark, an analysis of adult death rates
has been initiated as they may be related to adverse
childhood experiences. Carrying the above approach
further, analysis of findings from the prospective
phase of the study has confirmed the expectation out-
lined above with the discovery that individuals with
ACE Score 6 and higher had a lifespan almost two dec-
ades shorter than seen in those with an ACE Score 0
but otherwise similar characteristics [25]. This finding
supports the hypothesis that decreases in ACE Scores
with age may be explained by the effects of ACEs on
premature mortality.

Implications for healthcare

We have made a limited but instructive attempt to
integrate the ACE Study findings into clinical practice.
At Kaiser Permanente’s high-volume Department
of Preventive Medicine in San Diego, we have used
what we learned to expand radically the nature of our
Review of Systems (ROS) and Past History question-
naire. We have now asked routinely of over 440 000
adult individuals undergoing comprehensive medical
evaluation a number of questions of newly discovered
relevance; the following are a sample:


EDITED BY
Ruth A. Lanius ° Eric Vermetten ° Clare Pain

THE IMPACT of
EARLY LIFE
TRAUMA on

HEALTH AnpD DISEASE

m2 The Hidden
Epidemic



Chapter 8: Childhood trauma leading to adult healthcare issues

1%.

19.

. Anda, R. F., Fleisher, V. L., Felitti, V. J. et al. (2004).

Childhood abuse, household dysfunction, and
indicators of impaired worker performance in
adulthood. Permanente Journal, 8, 30-38.

. Felitti, V.J . (2003). Urspriinge des Suchtverhaltens:

Evidenzen aus einer Studie zu belastenden
Kindheitserfahrungen. Praxis der Kinderpsychologie
und Kinderpsychiatrie, 52, 547-559.

Hillis, S. D., Anda, R. F., Dube, S. R. et al. (2004). The
association between adolescent pregnancy, long-term
psychosocial outcomes, and fetal death. Pediatrics, 113,
320-327.

. Dube, S. R., Felitti, V. J., Dong, M., Giles, W. H. and

‘Anda, R. F . (2003). The impact of adverse childhood
experiences on health problems: Evidence from four
birth cohorts dating back to 1900. Preventive Medicine,
37, 268-277.

Dong, M., Dube, S. R., Felitti, V. J., Giles, W. H. and
Anda, R. F . (2003). Adverse childhood experiences
and self-reported liver disease: New insights into a
causal pathway. Archives of Internal Medicine, 163,
1949-1956.

. Anda, R. F., Brown, D. W., Dube, S. R. et al. (2010).

‘Adverse childhood experiences and chronic obstructive
pulmonary disease in adults. American Journal of
Preventive Medicine, 34, 396-403.

. Dong, M., Giles, W. H., Felitti, V. J. et al. (2004).

Insights into causal pathways for ischemic heart

22.

23:

24,

25.

26.

27.

28.

29.

disease: Adverse Childhood Experiences Study.
Circulation, 110, 1761-1766.

Dube, S., Fairweather, D., Pearson, W. et al. (2009).
Cumulative childhood stress and autoimmune diseases
in adults. Psychosomatic Medicine, 71, 243-250.
Kirkengen, A. L. (2001). Inscribed bodies.

Dordrecht: Kluwer Academic.

Heckman, J., Knudsen, E., Cameron, J. and Shonkoff, J.
(2006). Economic, neurobiological, and behavioral
perspectives on building America’s future workforce.
Proceedings of the National Academy of Sciences USA,
103, 10155-10162.

Brown, D. W., Anda, R. A., Tiemeier, H. et al. (2009).
Adverse childhood experiences and the risk of
premature mortality. American Journal of Preventive
Medicine, 37, 389-396.

Miller, A . (2006). The body never lies. New York:
Norton.

Hoffer, E. (1959). The ordeal of change. New York:
Harper and Row.

Masson, J. M . (1984). Assault on truth. New York:
Farrar, Straus, and Giroux.

DeSalvo, L . (1989). Virginia Woolf: The impact of
childhood sexual abuse on her life and work. Boston,
MA: Beacon Press.

87



86

Section 1: Impact on health and disease

into significant clinical or social action. The reasons
for this are important to consider if this information
is to be converted into meaningful social and medical
opportunity.

Conclusions

The influence of childhood experience, including
often-unrecognized traumatic events, is as powerful
as Freud and his colleagues originally described. These
influences are long lasting, and neuroscientists are now
describing the intermediary mechanisms that develop
as a result of these stressors. Unfortunately, and in
spite of these findings, the biopsychosocial model and
the biomedical model of psychiatry remain at odds
rather than taking advantage of the new discoveries to
reinforce each other.

Many of our most intractable public health prob-
lems are the result of compensatory behaviors such
as smoking, overeating, and alcohol and drug use,
which provide immediate partial relief from the
emotional problems caused by traumatic childhood
experiences. The chronic life stress of these develop-
mental experiences is generally unrecognized and
hence unappreciated as a second etiologic mechanism.
These experiences are lost in time and concealed by
shame, secrecy and social taboo against the explora-
tion of certain topics of human experience.

‘The findings of the ACE Study provide a credible
basis for a new paradigm of medical, public health and
social service practice that would start with compre-
hensive biopsychosocial evaluation of all patients at
the outset of ongoing medical care. We have demon-
strated in our practice that this approach is acceptable
to patients, affordable and beneficial in multiple ways.
‘The potential gain is huge. So too is the likelihood of
clinician and institutional resistance to this change.
Actualizing the benefits of this paradigm shift will
depend on first identifying and resolving the various
bases for resistance to it. In reality, this will require far
more planning than would be needed to introduce a
purely intellectual or technical advance. However, our
experience suggests that it can be done.

References

1. Eliot, T. S. (1943). Four Quartets. New York: Harcourt,
Brace, and World.

2. Breuer, J. and Freud, S. (1893-95). Studies on hysteria.
InJ. Strachey (ed.), The standard edition of the complete
psychological works of Sigmund Freud, Vol. 2. London:
Hogarth Press, 1955.

wo

10.

is

. Felitti, V.J., Anda, R. F., Nordenberg, D. et al. (1998).

The relationship of adult health status to childhood
abuse and household dysfunction. American Journal of
Preventive Medicine, 14, 245-258.

. Dong, M., Anda, R. F,, Felitti, VJ. ef al. (2004). The

interrelatedness of multiple forms of childhood abuse,
neglect, and household dysfunction. Child Abuse &
Neglect, 28, 771-784.

. Anda, R. F., Whitfield, C. L., Felitti, V. J. et al. (2002).

Alcohol-impaired parents and adverse childhood
experiences: The risk of depression and alcoholism
during adulthood. Psychiatric Services, 53,
1001-1009.

. Dube, S. R., Anda, R. F., Felitti, V. J. et al. (2001).

Childhood abuse, household dysfunction and the risk
of attempted suicide throughout the life span: Findings
from the Adverse Childhood Experiences Study.
Journal of the American Medical Association, 286,
3089-3096.

. Anda, R. F., Brown, D. W., Felitti, V. J. et al. (2007).

‘The relationship of adverse childhood experiences
to rates of prescribed psychotropic medications in
adulthood. American Journal of Preventive Medicine,
32, 389-394,

. Seeman, T., McEwen, B., Rowe, J. and Singer, B. (2001).

Allostatic load as a marker of cumulative biological risk.
Proceedings of the National Academy of Sciences USA,
98, 4770-4775,

Whitfield, C. L., Dube, S. R., Felitti, V. J.and Anda, R. F.
(2005). Adverse childhood experiences and subsequent
hallucinations. Child Abuse and Neglect, 29, 797-810.
Anda, R. F., Felitti, V. J., Walker, J. ef al. (2006).

‘The enduring effects of abuse and related adverse
experiences in childhood: A convergence of evidence
from neurobiology and epidemiology. European
Archives of Psychiatry and Clinical Neurosciences, 256,
174-186.

. Anda, R. F., Croft, J. B., Felitti, V. J. et al. (1999).

Adverse childhood experiences and smoking during
adolescence and adulthood. Journal of the American
Medical Association, 282, 1652-1658.

. Edwards, V. J., Anda, R. F., Gu, D., Dube, S. R.and

Felitti, V. J . (2007). Adverse childhood experiences and
smoking persistence in adults with smoking-related
symptoms and illness. Permanente Journal, 11, 5-13.

. Dube, S. R., Miller, J. W., Brown, D. W. et al. (2006).

Adverse childhood experiences and the association with
ever using alcohol and initiating alcohol use during
adolescence. Journal of Adolescent Health, 38, 444.
Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P.
and Giles, W. H. (2003). Childhood abuse, neglect,

and household dysfunction and the risk of illicit

drug use: The adverse childhood experiences study.
Pediatrics, 111, 564-572.


Chapter 8: Childhood trauma leading to adult healthcare issues

adult disease. In spite of this change in our understand-
ing of the etiology of biomedical outcomes, we find no
evidence that there has been a change in the frequency
of overall adverse childhood experiences in various age
cohorts spanning the twentieth century [18] .

Four examples of the links between childhood expe-
rience and adult biomedical disease are the relationship
of ACE Score to liver disease (Fig. 8.5a) [19], chronic
obstructive pulmonary disease (Fig. 8.5b) [20], coro-
nary artery disease [21] and autoimmune disease [22].
Our data for coronary artery disease show the effect of
ACE Score after correcting for, or in the absence of, the
conventional risk factors for coronary disease, such as
hyperlipidemia, smoking, fhe likelihood of heart dis-
ease was increased in all categories of ACE Score:
¢ emotional abuse 1.7x
¢ physical abuse 1.5x
¢ sexual abuse 1.4x
e domestic violence 1.4x
« substance abuse 1.3
¢ mental illness 1.4x
¢ household criminal 1.7x
* emotional neglect 1.3x
e physical neglect 1.4x.

Certain of these relationships of childhood experience
to later biomedical disease might initially be thought to
be straightforward, for instance assuming that chronic
obstructive pulmonary disease and coronary artery dis-
ease are merely the obvious outcomes of cigarette smok-
ing. In this case, one might reasonably assume that the
total relationship of adverse childhood experience to
later biomedical disease lies in the observation that stress-
ful early life experience leads to a coping behavior like
smoking, which becomes the mechanism of biomedical
damage. While this hypothesis is true, it is incomplete;
the actual situation is more complex. For instance, in
our analysis published in Circulation [21], we found that
there was a strong relationship of ACE Score with coro-
nary disease, after correcting for all the conventional risk
factors such as smoking, cholesterol and so on. This illus-
trates that adverse experiences in childhood are related
to adult disease by two basic etiologic mechanisms:
* conventional risk factors that actually are
attempts at self-help through the use of agents
like nicotine, with its documented, multiple
psychoactive benefits, in addition to its now well-
recognized cardiovascular risks
¢ the effects of chronic stress as mediated through
the mechanisms of chronic hypercortisolemia,

pro-inflammatory cytokines and other stress
responses on the developing brain and body
systems, dysregulation of the stress response
and pathophysiological mechanisms yet to be
discovered.

A public health paradox is implicit in these observa-
tions. One sees that certain common public health
problems, while being often also unconscious attem-
pted solutions to major life problems, harken back
to the developmental years. The idea of the problem
being a solution, while understandably disturbing to
many, is certainly in keeping with the fact that oppos-
ing forces routinely coexist in biological systems.
Understanding that it is hard to give up something
that almost works, particularly at the behest of well-
intentioned people who have little understanding of
what has gone on, provides us a new way of under-
standing treatment failure in addiction programs,
where typically the attempted solution rather than the
core problem is being addressed.

Healthcare costs

At the 14 year point in the prospective arm of the ACE
Study, we have only begun to analyze pharmacy data.
Given the average age of the cohort, we are now look-
ing at prescription drug use 50 to 60 years after the
fact. Prescription costs are an increasingly significant
portion of rapidly rising national healthcare expen-
ditures in the USA. The relationship of ACE Score to
antidepressant prescription rates has already been
shown in Fig. 8.1c. Figure 8.6 shows the relationship
of adverse childhood experiences to the decades-later
use of antipsychotic and anxiolytic medications [5].
Analyses of the relationships of ACE Score to doctor
office visits, emergency department visits, hospitaliza-
tion and death are in progress. The economic effect of
the results shown in Fig. 8.2 will be intuitively obvi-
ous to practitioners who have observed that patients
with multiple visits to the doctor commonly do not
have a unifying diagnosis underlying all the medical
attention. Rather, they have a multiplicity of symp-
illness, but not disease. Kirkengen has more fully
ssed the nature, origins and often-unwitting med-
ical creation of this complex phenomenon in her book
Inscribed Bodies [23]. The 2000 Nobelist in Economics,
James Heckman, has grasped the enormity of the eco-
nomic and social consequences of the long-term effects
of adverse childhood experiences and has written per-
ceptively on the subject [24].



Chapter 8: Childhood trauma leading to adult healthcare issues

e household dysfunction
- mother treated violently (13%)

- household member was alcoholic or drug user
(27%)

- household member was imprisoned (6%)

- household member was chronically depressed,
suicidal, mentally ill or in psychiatric hospital
(17%)
- not raised by both biological parents (23%)
« neglect
- physical (10%)
- emotional (15%).
The essence of the ACE Study has been to match retro-
spectively, approximately a half century after the fact,
an individual’s current state of health and well-being
against adverse events in childhood (the ACE Score),
and then to follow the cohort forward to match ACE
Score prospectively against doctor office visits, emer-
gency room visits, hospitalization, pharmacy costs and
death. The study has recently passed the 14 year mark
in the prospective arm.

Findings

This section illustrates with a sampling from the find-
ings in the ACE Study, the long-lasting, strongly pro-
portionate and often profound relationship between
adverse childhood experiences and important categor-
ies of emotional state, health risks, disease burden, sex-
ual behavior, disability, and healthcare costs - decades
later.

Psychiatric disorders

The relationship between ACE Score and self-acknowl-
edged chronic depression is illustrated in Fig. 8.1a [5].
Should one doubt the reliability of self-acknowledged
chronic depression, there isa similar but stronger rela-
tionship between ACE Scoreandlater suicide attempts,
as shown in the exponential progression of Fig. 8.1b
[6]. The p value of all graphic depictions herein is 0.001
or lower.

One continues to see a proportionate relationship
between ACE Score and depression by analysis of pre-
scription rates for antidepressant medications after
a 10-year prospective follow-up, now approximately
50 to 60 years after the ACEs occurred (Fig. 8.1c) (7).
It would appear that depression, often unrecognized
in medical practice, is in fact common and has deep
roots, commonly going back to the developmental
years of life.

Women
70) (Men

Depression (%)
iS
&

0 1 2 3 =4
ACE Score

Ss
yD
&

4+

“ ~ ny
3 a 8

Attempting Suicide (%)

oa

ACE Score

(c) 100
90
80
70

50
40
30
20 °

Prescription rate
Per 100 person-years

ACE Score

(9) 124 abused Alcohol
or Drugs

ONo BYes

ro

Ever Hallucinated* (%)
BD @

ACE Score

Fig.8.1. Psychiatric disorders. The relationship between ACE Score
and chronic depression (a), suicide attempts (b), rates of antidepres-
sant prescriptions approximately 50 years later (c), hallucinations
(tadjusted for age, sex, race and education) (d), and impaired
memory of childhood (e).

79



78

Section 1: Impact on health and disease

‘The findings from the ACE Study provide aremark-
able insight into how we become what we are as indi-
viduals and as a nation. They are important medically,
socially and economically. Indeed, they have given
us reason to reconsider the very structure of medical,
public health and social services practices in America
and other countries.

The Adverse Childhood Experiences
(ACE) Study: outline and setting

‘The ACE Study was carried out in Kaiser Permanente’s
Department of Preventive Medicine in San Diego, in
collaboration with the US Centers for Disease Control
and Prevention (CDC). This particular department
provided an ideal setting for such collaboration
because detailed biomedical, psychological and social
(biopsychosocial) evaluations had been carried out
over many years for the adult Kaiser Health Plan mem-
bers (50 000 a year). The CDC contributed the essential
skill sets for study design and the massive data man-
agement required for meaningful interpretation of
clinical observations.

Kaiser Health Plan patients are middle-class
Americans; all have high-quality health insurance. In
any 4 year period, 81% of adult members in San Diego
choose to come in for comprehensive medical evalu-
ation. A group of 26 000 consecutive adults coming
through the department was asked if they would help
us to understand how childhood events might affect
adult health status. The majority agreed and, after
certain exclusions for incomplete data and duplicate
participation, the ACE Study cohort had over 17 000
individuals. The study was carried out in two waves, to
allow midpoint correction.

The participants were 80% white including
Hispanic, 10% black and 10% Asian; 74% had attended
college; their average age was 57 years. Almost exactly
half were men, half women. This is a solidly middle-
class group from the seventh largest city in the USA; it
is not a group that can be dismissed as atypical, aber-
rant or “not in my practice.” Disturbingly, it is us -
a point not to be overlooked when considering the
problems of translating the ACE Study’s findings into
action.

Eight categories of adverse childhood experiences
(ACEs) were studied in the first wave; two categories
of neglect were added in the second wave. These cat-
egories were selected empirically because of their dis-
covered high prevalence in the weight program. Their
prevalence in a general, middle-class population was

also unexpectedly high. An ACE Score was created
for each individual, a count of the number of categor-
ies of adverse experience that had occurred during
the first 18 years of life. The ACE Score does not tally
incidents within a category. The scoring system is sim-
ple: the occurrence during childhood or adolescence
of any one category of adverse experience is scored as
1 point. There is no further scoring for multiple inci-
dents within a category; thus, an alcoholic and a drug
user within a household score the same as one alco-
holic; multiple sexual molestations by multiple indi-
viduals are totaled as 1 point. If anything, this would
tend to understate our findings. The ACE Score, there-
fore, can range from 0 to 8 or 10, depending on the data
being from wave 1 or wave 2. Specifics of the questions
underlying each category are detailed in the original
article [3].

Only one-third of this middle-class population
had an ACE Score of 0. If any one category was expe-
rienced, there was 87% likelihood that at least one
additional category was present. One in six individuals
had an ACE Score of 4 or more, and one in nine had
an ACE Score of 5 or more. Consequently, every phy-
sician will see several patients with high ACE Scores
each day. Typically, they are the most difficult patients
of the day. Women were 50% more likely than men to
have experienced five or more categories of adverse
childhood experiences. We believe that here is a key to
what in mainstream epidemiology appears as women’s
natural proneness to ill-defined health problems such
as fibromyalgia, chronic fatigue syndrome, obesity,
irritable bowel syndrome and chronic non-malignant
pain syndromes. In the light of these findings, we now
see these as medical constructs, artifacts resulting from
medical blindness to social realities and ignorance of
the impact of gender.

Somewhat surprisingly, the ACE categories turned
out to be approximately equal to each other in impact;
an ACE Score of 4 consists of any four of the categories.
The categories do not occur randomly; the number of
individuals with high ACE Scores is distinctly higher
than if the categories exist independently of each other
[4]. The 10 reference categories experienced dur-
ing childhood or adolescence are as below, with their
prevalence in parentheses:

« abuse

- emotional: recurrent threats, humiliation (11%)

- physical: beating not spanking (28%)

- contact sexual abuse (28% women, 16% men;

22% overall)


> The relationship of adverse childhood

@ experiences to adult medical disease,
psychiatric disorders and sexual
behavior: implications for healthcare

Vincent J. Felitti and Robert F. Anda

In my beginning is my end.
T.S. Eliot, Four Quartets [1]

Introduction

Biomedical researchers increasingly recognize that
childhood events, specifically abuse and emotional
trauma, have profound and enduring effects on the
neuroregulatory systems mediating medical illness as
well as on behavior from childhood into adult life. Our
understanding of the connection between emotional
trauma in childhood and the pathways to pathology
in adulthood is still being formed as neuroscientists
begin to describe the changes that take place on the
molecular level as a result of events that occurred dec-
ades earlier.

The turning point in modern understanding of the
role of trauma in medical and psychiatric pathology is
commonly credited to Freud, who studied patients of
the French neurologist Charcot and attributed their
unusual behavior to histories of trauma rather than to
underlying biomedical pathology [2]. The writings of
Freud and Breuer as well as Janet represented a depart-
ure from the traditional view that mental illness and
unexplained medical disease were the result of divine
retribution or demonic possession, instead revealing
that they were strongly associated with a history of
childhood abuse [2].

The focus of this chapter will be an examination of
the relationship between traumatic stress in childhood
and the leading causes of morbidity, mortality and
disability in the USA: cardiovascular disease, chronic
lung disease, chronic liver disease, depression and
other forms of mental illness, obesity, smoking and
alcohol and drug abuse. To do this, we will draw on our

experience with the Adverse Childhood Experiences
(ACE) Study, a major American epidemiological
study providing retrospective and prospective analysis
in over 17 000 individuals of the effect of traumatic
experiences during the first 18 years of life on adoles-
cent and adult medical and psychiatric disease, sexual
behavior, healthcare costs and life expectancy [3].

The ACE Study is an outgrowth of repeated counter-
intuitive observations made while operating a major
weight loss program that used the technique of sup-
plemented fasting, which allows non-surgical weight
reduction of approximately 300 Ib (135 kg) per year.
Unexpectedly, the weight program had a high dropout
rate, limited almost exclusively to patients successfully
losing weight. Exploring the reasons underlying the high
prevalence of patients inexplicably fleeing their own suc-
cess in the program ultimately led us to recognize that
weightloss is often sexually or physically threatening and
that certain of the more intractable public health prob-
lems such as obesity were also unconscious, or occasion-
ally conscious, compensatory behaviors that were put in
place as solutions to problems dating back to the earliest
years, but hidden by time, by shame, by secrecy and by
social taboos against exploring certain areas of life expe-
rience. It became evident that traumatic life experiences
during childhood and adolescence were far more com-
mon than generally recognized, were complexly inter-
related and were associated decades later in a strong
and proportionate manner with outcomes important to
medical practice, public health, and the social fabric ofa
nation. In the context of everyday medical practice, we
came to recognize that the earliest years of infancy and
childhood are not lost but, like a child’s footprints in wet
cement, are often lifelong.

‘The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic, ed. Ruth A. Lanius, Eric Vermetten and Clare Pain. Published
by Cambridge University Press. Copyright © Cambridge University Press 2010.

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