For the first time, the CDC has analyzed how preventing adverse childhood experiences could benefit public health throughout the United States.
ACEs include a wide range of events, such as personally experiencing physical, sexual or psychological abuse; witnessing violence or substance misuse in the home; and having a parent or sibling incarcerated. Exposure to ACEs can provoke extreme or repetitive toxic stress responses that can cause both immediate and long-term physical and emotional harms.
At least five of the 10 leading causes of death are associated with ACEs, the CDC stated in a Morbidity and Mortality Weekly Report(www.cdc.gov) posted online Nov. 5 as an MMWR Early Release in conjunction with a Vital Signs report(www.cdc.gov) released the same day. Preventing these experiences could potentially reduce or avoid chronic diseases, risky health behaviors and socioeconomic challenges later in life.
"We now know that adverse childhood experiences have a significant impact on an individual's future health," said CDC Director Robert Redfield, M.D., in a news release.(www.cdc.gov) "Preventing traumatic experiences in childhood and initiating key interventions when they do occur will lessen long-term health consequences and benefit the physical and emotional well-being of individuals into adulthood."
Using Behavior Risk Factor Surveillance System data from 25 states that included state-added ACE questions from 2015 through 2017, CDC researchers examined the association between ACEs and 14 negative outcomes.
- At least five of the top 10 leading causes of death are associated with adverse childhood experiences, according to a recent CDC Morbidity and Mortality Weekly Report.
- The agency analyzed data from 25 states that included ACE questions in the Behavior Risk Factor Surveillance System from 2015 through 2017.
- CDC scientists analyzed data from more than 144,000 adults and found that, among other things, ACEs are linked to chronic health problems, mental health, substance misuse and reduced educational and occupational achievement.
Those outcomes were coronary heart disease, stroke, asthma, COPD, cancer (excluding skin cancer), kidney disease, diabetes, depression, overweight or obesity, current smoking, heavy drinking, lack of health insurance, current unemployment, and lack of a high school diploma or equivalent education attainment.
Data collected from more than 144,000 adults via BRFSS telephone surveys revealed that about 61% of adults had at least one ACE, and nearly 16% had four or more ACEs. Younger adults were more likely than their older counterparts to have been exposed to ACEs. Women, American Indian/Alaska Natives and African Americans/blacks were more likely than other population groups to experience four or more ACEs.
In their analysis of the association between exposure to ACEs and the health outcomes examined, the report's authors determined that adults with the greatest exposure to ACEs had higher odds of having chronic health conditions compared with those reporting no ACEs. Adjusted odds ratios for those associations ranged from 1.2 for overweight or obesity to 2.8 for COPD.
According to national estimates based on 2017 BRFSS data, the authors stated, preventing these experiences could have reduced the number of adults who had heart disease by as much as 13%, or about 1.9 million avoided cases. Similarly, the number of adults with overweight or obesity could have been reduced by as much as 2%, or about 2.5 million avoided cases, and the number who had depression could have been reduced by as much as 44%, or some 21 million avoided cases.
The CDC researchers acknowledged a number of limitations of their study, including that data drawn from the 25 participating states might not be generalizable to other states.
In addition, the BRFSS data identified only a limited set of ACEs; did not include any assessment of the severity, frequency or duration of ACEs; and reflected no attempt to contrast the effects of specific types of ACEs.
Furthermore, it was not possible to control for factors that could affect both ACEs and the selected outcomes (e.g., family socioeconomic position during childhood).
"Despite these limitations, the findings from this study can help multiple sectors, including clinicians, researchers, policymakers and the public, appreciate the connections between cumulative exposure to adversity and mental, physical and socioeconomic outcomes," the report noted.
Family Physician's Perspective
Daniel Salahuddin, M.D., M.P.H., of the University of Pittsburgh Medical Center Combined Family Medicine/Psychiatry Residency Program, told AAFP News that it's critical to study and address ACEs because these experiences stay with patients throughout their entire lives and are often normalized, which comes at a significant cost to both these individuals and the communities in which they live.
"Work in this field has consistently shown the impact that ACEs have on negative health outcomes, which in turn result in increased morbidity and mortality," he said. "If ACEs remain unaddressed, we as health care professionals will be doing a tremendous disservice to the patients and communities we serve because we will likely continue missing or being unaware of the underlying causes that are truly driving the outcomes we encounter on a regular basis."
Salahuddin, who participated in the AAFP Foundation's Family Medicine Leads Emerging Leader Institute program this past year, said his project sought to explore the relationship between ACEs and social determinants of health in a family medicine residency clinic in McKeesport, Pa., an urban, underserved community outside of Pittsburgh.
For the project, patients were asked to complete both The EveryONE Project's Social Needs Screening Tool and the Philadelphia ACE Survey,(www.philadelphiaaces.org) which uses the standard ACE questions examining the categories of "abuse," "neglect" and "household dysfunction," but also adds questions to better capture community-level adversity that may more accurately represent experiences in diverse urban environments; these additional ACE indicators ask about neighborhood safety, bullying, foster care, witnessed violence and racial discrimination.
"What we found was that 90% of patients who responded reported an ACE score of at least 1, whereas 51% reported an ACE score of 4 or above, which places them at highest risk for negative health outcomes," Salahuddin said. "We also showed that 51% screened positive for food insecurity. Overall, 83% of participants felt that it was a good idea for our clinic to be asking these questions."
The results of this project helped generate a conversation about what can be done at the clinic and community levels to address both ACEs and social needs, he said.
"The first step in any program design and implementation needs to be receiving community buy-in, so we are in the process of figuring out next steps to disseminate the results of this project throughout the entire clinic, as well as in the community so that we can begin having an honest conversation about ACEs and how we can work in partnership to address this critical issue," Salahuddin said.
Unfortunately, he added, there is not a clear gold standard for addressing ACEs in a clinic setting. Furthermore, clinicians may be apprehensive about screening for ACEs for many reasons, including how to best connect patients who screen positive with the necessary resources.
"Much of what I am interested in doing throughout residency and beyond is to help establish a standard for routinely addressing ACEs and SDoH in an effort to provide more comprehensive care and address the underlying social structures that lead to these problems in the first place," Salahuddin said.
It will be important to continue studying ACEs, he added, while simultaneously working toward developing practical and clinically meaningful interventions that will ultimately improve the health of patients and communities.
"Our entire health care system certainly needs to become more trauma-informed, and this starts with disseminating the information we already have and implementing corresponding programs and practices," said Salahuddin.
"Additionally, as health care professionals, we need to improve our advocacy efforts and partner with community organizations and our health department and lobby our local representatives to make sure that ACEs is an issue that is taken seriously and that it is at the forefront of policy discussions," he concluded.
Related AAFP News Coverage
USPSTF: Research Lacking on Child Maltreatment Interventions
Task Force Unable to Assess Harms, Benefits of Such Interventions