We live in historic times. A worldwide pandemic is surging in the United States, with millions infected and the world’s highest death rate. Many of our hospitals are overwhelmed. Schools have been closed for months. Businesses are struggling, and unemployment is at record levels. The murder of George Floyd unleashed an outpouring of grief and rage over police brutality and structural racism.
It is ironic that this age of adversity emerged at the same time that efforts to assess and address childhood adversity are gaining momentum. The effects of adverse childhood experiences (ACEs) have been well known for decades, but only recently have efforts at universal screening been initiated in primary care offices around the country. The multiple crises we face have made this work more pressing than ever. And
While there has long been awareness, especially among pediatricians, of the social determinants of health, it was only 1995 when Robert F. Anda, MD, and Vincent J. Felitti, MD, set about studying over 13,000 adult patients at Kaiser Permanente to understand the relationship between childhood trauma and chronic health problems in adulthood. In 1998 they published the results of this landmark study, establishing that childhood trauma was common and that it predicted chronic diseases and psychosocial problems in adulthood1.
They detailed 10 specific ACEs, and a patient’s ACE score was determined by how many of these experiences they had before they turned 18 years: neglect (emotional or physical), abuse (emotional, physical or sexual), and household dysfunction (parental divorce, incarceration of a parent, domestic violence, parental mental illness, or parental substance abuse). They found that more than half of adults studied had a score of at least 1, and 6% had scores of 4 or more. Those adults with an ACE score of 4 or more are twice as likely to be obese, twice as likely to smoke, and seven times as likely to abuse alcohol as the rest of the population. They are 4 times as likely to have emphysema, 5 times as likely to have depression, and 12 times as likely to attempt suicide. They have higher rates of heart disease, autoimmune disorders, and cancer. Those with ACE scores of 6 or more have their life expectancy shortened by an average of 20 years.
The value of knowing about these risk factors would seem self-evident; it would inform a patient’s health care from screening for cancer or heart disease, referral for mild depressive symptoms, and counseling about alcohol consumption. But this research did not lead to the establishment of routine screening for childhood adversity in primary care practices. There are multiple reasons for this, including growing pressure on physician time and discomfort with starting conversations about potentially traumatic material. But perhaps the greatest obstacle has been uncertainty about what to offer patients who screened in. What is the treatment for a high ACE score?
Even without treatments, we have learned much about childhood adversity since Dr. Anda and Dr. Felitti published their landmark study. Other more chronic adverse childhood experiences also contribute to adult health risk, such as poverty, homelessness, discrimination, community violence, parental chronic illness, or disability or placement in foster care. Having a high ACE score does not only affect health in adulthood. Children with an ACE score of 4 are 2 times as likely to have asthma2,3 and allergies3, 2 times as likely to be obese4, 3 times as likely to have headaches3 and dental problems5,6, 4 times as likely to have depression7,8, 5 times as likely to have ADHD8,9, 7 times as likely to have high rates of school absenteeism3 and aggression10, and over 30 times as likely to have learning or behavioral problems at school4. There is a growing body of knowledge about how chronic, severe stress in childhood affects can lead to pathological alterations in neuroendocrine and immune function. But this has not led to any concrete treatments that may be preventive or reparative.
Movement toward expanding screening nonetheless has accelerated. In California, Nadine Burke-Harris, MD, a pediatrician who studied ACEs and children’s health was named the state’s first Surgeon General in 2019 and spearheaded an effort to make screening for ACEs easier. Starting in 2020, MediCal will pay for annual screenings, and the state is offering training and resources on how to screen and what to do with the information to help patients and families.
The coronavirus pandemic has only highlighted the risks of childhood adversity. The burden of infection and mortality has been borne disproportionately by people of color and those with multiple chronic medical conditions (obesity, cardiovascular disease, diabetes, etc.). While viruses do not discriminate, they are more likely to infect those with higher risk of exposure and to kill those who are physiologically vulnerable.
And the pandemic increases the risk for adversity for today’s children and families. When children cannot attend school, financially vulnerable parents may have to choose between supervising them or feeding them. Families who suddenly are all in a small apartment together without school or other outside supports may be at higher risk for domestic violence and child abuse. Unemployment and financial uncertainty will increase the rates of substance abuse and depression amongst parents. And the serious illness or death of a parent will be a more common event for children in the year ahead. One of these risk factors may increase the likelihood of others.
Beyond the obvious need for substantial policy changes focused on housing, education, and health care,And resilience can build on itself, as children face subsequent challenges with the support of caring connected adults.
The critical first step is asking. Then listen calmly and supportively, normalizing for parents and children how common these experiences are. Explain how they affect health and well-being. Explain that adversity and its consequences are not their fault. Then educate them about what is in their control: the skills they can practice to buffer against the consequences of adversity and build resilience. They sound simple, but still require effort and work. And the pandemic has created some difficulty (social distancing) and opportunity (more family time, fewer school demands).