In my book Renewed: Finding Your Inner Happy in an Overwhelmed World I talked about the Adverse Childhood Experiences Study (ACE), which shows a scientific link between many types of childhood adversities and the adult onset of physical and mental health disorders. I just finished reading Donna Jackson Nakazawa’s book Childhood Disrupted where she takes a deep dive into the ACE Study. Her book is incredibly well researched and easy to understand. But first for some backstory on the ACE Study . . .
This article does a good job of describing the history of ACE Study:
The ACE Study – probably the most important public health study you never heard of – had its origins in an obesity clinic on a quiet street in San Diego.
It was 1985, and Dr. Vincent Felitti was mystified. The physician, chief of Kaiser Permanente’s revolutionary Department of Preventive Medicine in San Diego, CA, couldn’t figure out why, each year for the last five years, more than half of the people in his obesity clinic dropped out. Although people who wanted to shed as little as 30 pounds could participate, the clinic was designed for people who were 100 to 600 pounds overweight.
But the 50-percent dropout rate in the obesity clinic that Felitti started in 1980 was driving him crazy. A cursory review of all the dropouts’ records astonished him — they’d all been losing weight when they left the program, not gaining. That made no sense whatsoever. Why would people who were 300 pounds overweight lose 100 pounds, and then drop out when they were on a roll?
The mystery turned into a 25-year quest involving researchers from the Centers for Disease Control and Prevention and more than 17,000 members of Kaiser Permanente’s San Diego care program. It would reveal that adverse experiences in childhood were very common, even in the white middle-class, and that these experiences are linked to every major chronic illness and social problem that the United States grapples with – and spends billions of dollars on.
But in 1985, all that Felitti knew was that the obesity clinic had a serious problem. He decided to dig deep into the dropouts’ medical records. This revealed a couple of surprises: All the dropouts had been born at a normal weight. They didn’t gain weight slowly over several years.
“I had assumed that people who were 400, 500, 600 pounds would be getting heavier and heavier year after year. In 2,000 people, I did not see it once,” says Felitti. When they gained weight, it was abrupt and then they stabilized. If they lost weight, they regained all of it or more over a very short time.
But this knowledge brought him no closer to solving the mystery. So, he decided to do face-to-face interviews with a couple hundred of the dropouts. He used a standard set of questions for everyone. For weeks, nothing unusual came of the inquiries. No revelations. No clues.
The turning point in Felitti’s quest came by accident. The physician was running through yet another series of questions with yet another obesity program patient: How much did you weigh when you were born? How much did you weigh when you started first grade? How much did you weigh when you entered high school? How old were you when you became sexually active? How old were you when you married?
“I misspoke,” he recalls, probably out of discomfort in asking about when she became sexually active – although physicians are given plenty of training in examining body parts without hesitation, they’re given little support in talking about what patients do with some of those body parts. “Instead of asking, “How old were you when you were first sexually active,” I asked, “How much did you weigh when you were first sexually active?’ The patient, a woman, answered, ‘Forty pounds.’”
He didn’t understand what he was hearing. He misspoke the question again. She gave the same answer, burst into tears and added, “It was when I was four years old, with my father.”
He suddenly realized what he had asked.
“I remembered thinking, ‘This is only the second incest case I’ve had in 23 years of practice’,” Felitti recalls. “I didn’t know what to do with the information. About 10 days later, I ran into the same thing. It was very disturbing. Every other person was providing information about childhood sexual abuse. I thought, ‘This can’t be true. People would know if that were true. Someone would have told me in medical school.’ ”
Worried that he was injecting some unconscious bias into the questioning, he asked five of his colleagues to interview the next 100 patients in the weight program. “They turned up the same things,” he says.
Of the 286 people whom Felitti and his colleagues interviewed, most had been sexually abused as children. As startling as this was, it turned out to be less significant than another piece of the puzzle that dropped into place during an interview with a woman who had been raped when she was 23 years old. In the year after the attack, she told Felitti that she’d gained 105 pounds.
“As she was thanking me for asking the question,” says Felitti, “she looks down at the carpet, and mutters, ‘Overweight is overlooked, and that’s the way I need to be.’”
During that encounter, a realization struck Felitti. It’s a significant detail that many physicians, psychologists, public health experts and policymakers haven’t yet grasped: The obese people that Felitti was interviewing were 100, 200, 300, 400 overweight, but they didn’t see their weight as a problem. To them, eating was a fix, a solution. (There’s a reason an IV drug user calls a dose a “fix”.)
One way it was a solution is that it made them feel better. Eating soothed their anxiety, fear, anger or depression – it worked like alcohol or tobacco or methamphetamines. Not eating increased their anxiety, depression, and fear to levels that were intolerable.
The other way it helped was that, for many people, just being obese solved a problem. In the case of the woman who’d been raped, she felt as if she were invisible to men. In the case of a man who’d been beaten up when he was a skinny kid, being fat kept him safe, because when he gained a lot of weight, nobody bothered him. In the case of another woman — whose father told her while he was raping her when she was 7 years old that the only reason he wasn’t doing the same to her 9-year-old sister was because she was fat — being obese protected her. Losing weight increased their anxiety, depression, and fear to levels that were intolerable.
For some people, both motivations were in play.
Kaiser Permanente in San Diego was a perfect place to do a mega-study. More than 50,000 members came through the department each year, for a comprehensive medical evaluation. Every person who came through the Department of Preventive Medicine filled out a detailed biopsychosocial (biomedical, psychological, social) medical questionnaire prior to undergoing a complete physical examination and extensive laboratory tests. It would be easy to add another set of questions. In two waves, Felitti and Anda asked 26,000 people who came through the department “if they would be interested in helping us understand how childhood events might affect adult health,” says Felitti. Of those, 17,421 agreed.
Before they added the new trauma-oriented questions, Anda spent a year pouring through the research literature to learn about childhood trauma, and focused on the eight major types that patients had mentioned so often in Felitti’s original study and whose individual consequences had been studied by other researchers. These eight included three types of abuse — sexual, verbal and physical. And five types of family dysfunction — a parent who’s mentally ill or alcoholic, a mother who’s a domestic violence victim, a family member who’s been incarcerated, a loss of a parent through divorce or abandonment. He later added emotional and physical neglect, for a total of 10 types of adverse childhood experiences, or ACEs.
There are 10 categories that make up the ACE Study:
- Physical abuse
- Sexual abuse
- Emotional abuse
- Physical neglect
- Emotional neglect
- Mother treated violently
- Household substance abuse
- Household mental illness
- Parental separation or divorce
- Incarcerated household member
It takes about one or two minutes to take the ACE assessment. You might be surprised at your own results.
Results from the ACE Study are staggering. Here are just a few:
- About two-thirds of individuals reported at least one adverse childhood experience
- 87% of individuals who reported one ACE reported at least one additional ACE.
- The number of ACEs was strongly associated with adulthood high-risk health behaviors such as smoking, alcohol and drug abuse, promiscuity, and severe obesity, and correlated with ill-health including depression, heart disease, cancer, chronic lung disease and shortened lifespan.
- Compared to an ACE score of zero, having four adverse childhood experiences was associated with a seven-fold increase in alcoholism, a doubling of risk of being diagnosed with cancer, and a four-fold increase in emphasyma.
- An ACE score above six was associated with a 30-fold increase in attempted suicide and a shortened lifespan of 20 years!
Nakazawa says, “This is not to say ACE is the only thing that leads to disease.”
She uses a simple metaphor, imagine the immune system as being something like a barrel. If you encounter too many environmental toxins from chemicals, a poor processed-food diet, viruses, infections, and chronic or acute stressors in adulthood, your barrel will slowly fill. At some point, there may be one certain exposure, that last drop that causes the barrel to spill over and disease to develop. Having faced the chronic unpredictable stressors of Adverse Childhood Experiences is a lot like starting life with your barrel half full. ACEs are not the only factor in determining who will develop disease later in life. But they may make it more likely that one will.
Smashing Point: We are biological responders to our environment.
If you ran into a bear in the woods you would go to into fight, flight, or freeze stress response. But what if the bear is circling your house every day. This is what happens in households with Adverse Childhood Experiences. Every moment a child is on high alert for mom to tell him how fat he is, or for dad to come home drunk and angry. Children want to run towards parents when they are scared, but in these homes they also want to run away. When this happens, a child’s brain gets caught in fight, flight or freeze reaction. The brain begins to make changes to the genes that will manage how he responds to stress for life. The body’s stress response leads to higher rates of inflammation and disease. This biological expression is invisible and long-term, and usually appears many years after the fact.
Nakazawa’s book is about what happens to the the developing brain when it experiences chronic, unpredictable stress.
But the last part of book is about hope! The brain, which is so changeable in childhood, remains malleable throughout life. Today researchers around the world have discovered a range of powerful ways to reverse the damage that Adverse Childhood Experiences do to both brain and body. No matter how old you are, or how old your children may be, there are scientifically supported and relatively simple steps that you can take to reboot the brain, create new pathways that promote healing, and come back to who it is you were meant to be.
If you’ve suffered childhood trauma you can go on a healing journey. Every patient’s journey is different; different patients require different things (Cognitive Behavioral Therapy, EMDR, Mindfulness training, etc). People have to try various healing strategies because we don’t know which one will help each patient. Ultimately, people need an environment to figure out what is most helpful and that cannot happen unless one finds a safe therapeutic relationship in which it is okay to be seen.