Department of Family and Community Medicine, Office of Community Engagement and Neighborhood Health Partnerships, University of Illinois Hospital and Health Sciences System, Chicago, Ill; Center for the Collaborative Study of Trauma, Health Equity, and Neurobiology, an educational program of the Hektoen Institute of Medicine, Chicago, Ill. ajstille@uic.edu
The author reported no potential conflict of interest relevant to this article.
The first paper about the landmark Adverse Childhood Experiences (ACE) Study, published 20 years ago, is 1 of more than 90 on this topic.3 This study explored the relationship of physical, emotional, and social health in adulthood and self-reported childhood adversity, and comprised 10 categories of abuse, neglect, and household distress between birth and 18 years of age. One of the largest epidemiological studies of its kind, the ACE Study surveyed more than 17,000 mostly white, middle-aged, educated, and insured participants. Study researchers developed an “ACE Score”—the total number of ACEs faced by a person before her (his) 18th birthday—and found that 64% of respondents endorsed 1 or more ACEs; 27% reported 3 or more ACEs; and 5% experienced 6 or more.
The ACE Study revealed a dose–response relationship between ACEs and more than 40 health-compromising behaviors, negative health conditions, and poor social outcomes. Examples include cardiac, autoimmune disease, obesity, intravenous drug abuse, depression and anxiety, adolescent pregnancy, and worker absenteeism. Tragically, an ACE score of ≥6 conferred a significant risk for premature death.1
ACE data have been collected in diverse populations in 32 states and many countries through the Behavioral Risk Factor Surveillance Survey conducted by the Centers for Disease Control and Prevention3; the Child & Adolescent Health Measurement Initiative’s National Survey of Children’s Health6; and The World Health Organization’s ACE International Questionnaire7—underscoring the pervasiveness of childhood adversity. Evaluation of ACEs in special populations, such as people experiencing homelessness,8 incarcerated youth,9 people struggling with addiction,10 and even health care workers,11 uncovers notably higher rates of ACEs in these populations than in the general population.
Is childhood adversity a true cause of bad outcomes?
Or is the relationship between the 2 entities merely an association? To help answer this question, researchers evaluated the ACE Study using Bradford Hill criteria—9 epidemiological principles employed to infer causation. Their findings strongly support the hypothesis that not only are ACEs associated with myriad negative outcomes, they are their root cause12 and therefore a powerful determinant of our most pressing and expensive health and social problems.Nevertheless, strategies to prevent and address childhood adversity, which are critical to meeting national health goals of successful prevention and treatment of myriad conditions, are absent from the paradigm and practice of most physicians.
Childhood adversity is at the root of our most pressing physical, psychological, and social health problems.
The body of research about the health impact of additional adverse experiences is growing to include community violence, poverty, longstanding discrimination,2 and other experiences that we describe as social determinants of health. Furthermore, social determinants of health, or adverse community experiences, appear to maintain a dose–response relationship with health and social outcomes.2 ,13 Along with adverse collective historical experiences (historical trauma),14 these community experiences are forcing further re-examination of existing paradigms of health.
Continue to: The biological pathway from experience to illness
