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This site is for student nurses or nurses starting out. Letters to a Young Nurse are blog posts written like letters to help you find your way and make your journey as a nurse less difficult. 


Adverse Childhood Experiences

Updated: Sep 30, 2023

Does being exposed repeatedly to traumatic events or situation in childhood impact adult health? Research for many years has shown that if a child is physically abused, they may go on to either abuse others or are in a relationship where they are abused, or both. But what about bullying, yelling, poverty, lack of healthy food? Do these cause chronic health issues in adults?

Two significant studies say Yes! In 1998 Dr. Vince Felitti at Kaiser and Dr. Bob Anda from the CDC asked 17, 500 adults about their history of exposure to ACES. Adverse Childhood ACES = physical, emotional, sexual abuse, physical or emotional neglect, parental mental illness, parental substance use, incarceration, parental separation, divorce or domestic violence. For the study every yes = 1 point. Then Felitti and Anda correlated the ACE scores against health outcomes over time by using data from adult medical records. The results showed that ACES are not only extremely common but that there is a significantly related dose-response between ACES and chronic diseases in adulthood.

The higher the ACE score the worse the health outcomes in adults. For an ACE score of 4 or more, adults had 2 1/2 times the risk of getting COPD and Hepatitis, there was a 4 1/2 times risk of Depression and there was a 12 times risk of Suicide. An ACE score of 7 or more leads to triple the lifetime risk of lung cancer and 3 1/2 times the risk of heart disease which is the number 1 killer of adults in the United States.

When the study first came out, there was skepticism about the relationship between ACES and the chronic conditions in adulthood. So, researchers looked at the science. Through PET scans and other devices there is proven evidence of the damage done to parts of the brain during repeated exposure to adverse events. The nucleus accumbens which is the pleasure and reward center and regulates substance dependence is affected adversely. The brain's fear response in the amygdala is damaged during trauma. But the most critical finding is that when the stress response is continually activated it becomes maladaptive and ineffective. Without an adaptive response the body becomes vulnerable to chronic conditions and diseases.

One of the other criticisms of the original ACE's study is that of the 17,500 participants, 70% were Caucasian and 70% were college educated. And the original study did not look at other adverse factors like bullying and living in foster care.

In 2012 a task force made up of physicians, community leaders, nurses, psychiatrists, mental health professionals and others surveyed 1,784 inner city adults in the Philadelphia Expanded ACEs Survey.

"In Philadelphia, where roughly a quarter of residents live in poverty, researchers found that almost seven in ten adults had experienced one ACE and two in five had experienced four or more. The community-level indicators included witnessing violence, living in foster care, bullying, experiencing racism or discrimination, and feeling unsafe in your neighborhood. Researchers found that almost 40 percent of Philadelphians had experienced four or more of these expanded, community-level ACEs."

The results from this study are heartbreaking:

33% had been exposed to emotional abuse

35% had experienced physical abuse

35% had a family member with substance use problems

24% lived in a household with a member who was mentally ill

12.9% lived with a family member who was or who had been incarcerated

83.2% in the Philadelphia study compared to 69.9% in the original study had at least 1 ACEs.

The most distressing result from the survey was that kids with higher ACES scores were at an increased risk of being involved in human trafficking.

The science is clear. Early adversity dramatically affects health across a lifetime.

Dr. Robert Block sums it up perfectly when he said,

"ACEs are the single greatest unaddressed public health threat facing our nation today."

Does being exposed repeatedly to traumatic events in childhood impact adult health? YES!

Does bullying, poverty, racism, growing up in foster care impact health as an adult? YES!?

Do these cause chronic health issues in adults? YES!

If ACEs have been shown to be significantly relevant to children, why is there not more awareness about it? The reason is that most chronic diseases and conditions build slowly over time. A connection is not made to the trauma that happened in childhood. According to research by Karr-Morse & Wiley (2012), diagnoses are disconnected from their early developmental roots. Yet there is so much that can be done to reduce the accumulative effects of childhood trauma if we would only ask patients with chronic diseases about trauma in their lives. If we did more to prevent childhood trauma, rather than treating the symptoms there would be less strain on an already overburdened healthcare system.

These 2 studies have gone a long way in changing healthcare from treating symptoms to a push towards preventing diseases and conditions.

But it is not only children in inner cities who are experiencing chronic conditions in adulthood. Wallace (2023) in her book, Never Enough: When Achievement Culture Becomes Toxic - And What We Can Do About It, reports that research is showing that events that the general public sees as positive are showing negative effects. A 2018 study done by the Robert Wood Johnson Foundation named the top four environmental conditions negatively impacting adolescent wellness were poverty, trauma, discrimination, and “excessive pressure to excel. A 2019 study done by scientists at the National Academies of Sciences, Engineering, and Medicine found that kids in high achieving schools are having similar chronic conditions in adulthood. These are kids who come from parents in the top 20% income brackets. Wallace (2023) did a survey with adults aged 18-30 and asked them what they wished their parents had known about them while growing up. 70% felt that their parents were happier when they got good grades and felt pressured to do so. "The “pressure” our kids are feeling is that they feel their worth is contingent on their achievement." (Wallace, 2023) This is being manifested as chronic conditions in adulthood just as significantly as those int lower socioeconomic income brackets.

For more information about how ACEs, watch this excellent video from Dr. Nadine Burke Harris

What can you do today in the lives of children to prevent chronic conditions in adulthood?

Health Federation of Philadelphia. (2012). Philadelphia ACE Survey | ACES Philadelphia.

Karr-Morse, R., & Wiley, M. S. (2012). Scared sick: the role of childhood trauma in adult disease. Basic Books.

Wallace, J. (2023, August 30). Why Achievement Culture Has Become So Toxic. Greater Good.

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