Adverse childhood experiences increase the risk of poor long-term health

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Clinicians can play a role in reducing the impact of ACEs

Adverse childhood experiences (ACEs) trigger pathophysiologic responses that exert real physical and psychological harm. Thus, clinicians can and should address them as part of good medical care, Christopher M. Jones, PharmD, Melissa T. Merrick, PhD, and Debra E. Houry, MD, MPH, said in a JAMA commentary.

“A large and growing body of research indicates that the underlying mechanism by which ACEs are associated with health outcomes is through the development of toxic stress, a chronic activation of the stress response system. Toxic stress results in dysregulation of the limbic-hypothalamic-pituitary-adrenal axis, elevating levels of catecholamines (“fight or flight” response), cortisol, and proinflammatory cytokines, leading to cascading effects on the nervous, endocrine, and immune systems. These changes can affect attention and other executive functioning, impulsive behavior, brain reward systems, decision-making, and response to stress throughout the life span,” they said.

While societies and communities at large must work together to reduce ACE exposure, clinicians also have a role. Research indicates that many don’t routinely ask questions about these issues, in a large part because they lack training in how and when to screen.

“Incorporating components of primary ACEs prevention into everyday clinical practice may be achievable through talking with parents and caregivers about creating safe, stable, nurturing environments and protective relationships, and reinforcing positive parenting techniques and coping skills at routine clinical visits,” the editorialists said. “In addition, clinicians can refer parents to parenting skills classes or refer higher-risk parents to home visitation programs such as Healthy Families America and Nurse-Family Partnership. Home visitation programs have demonstrated significant reductions in rates of child abuse and neglect and have improved substance use, violence, and parenting outcomes.”

Clinicians also may have a role to play in mitigating the harms of ACEs, by incorporating trauma-informed care and services into their daily practice.

“Important elements of trauma-informed care include understanding how trauma affects health, routinely screening for ACEs and trauma, using culturally responsive assessments, promoting resilience and protective factors, addressing trauma-related somatic and mental health issues, and ensuring appropriate linkage to services and supports for identified issues,” the editorialists concluded.

Dr. Jones is associate director in the Office of Strategy and Innovation in the CDC Injury Center. Dr. Merrick is president and CEO of Prevent Childhood Abuse America, Chicago. Dr. Houry is director of the National Center for Injury Prevention and Control at the CDC, Atlanta. They discussed the MMWR analysis in a commentary (JAMA. 2019 Nov 5. doi: 10.1001/jama.2019.18499). They had no relevant financial disclosures.



Reducing childhood exposure to adverse events such as violence, abuse, and parental jail time could reap immense improvements in long-term health and societal outcomes, according to a new report by the Centers for Disease Control and Prevention.

A young boy appears to be frightened zdravinjo/Thinkstock

“Our analysis suggests that preventing or reducing these adverse childhood experiences [ACEs] could potentially reduce the annual number of coronary heart disease cases by up to 13%,” said Ann Schuchat, MD, the CDC’s principal deputy director. “If we apply this analysis to other national disease estimates, preventing ACEs could prevent 1.9 million cases of heart disease, 2.5 million cases of overweight or obesity, 21 million cases of depression, and 1.5 million high-school incompletions.”

The analysis, conducted by Melissa T. Merrick, PhD, and colleagues at the National Center for Injury Prevention and Control at the CDC, Atlanta, is based on data acquired from more than 144,000 adults in 27 states.

It’s the first time the CDC has waded into this territory, Dr. Schuchat said during a press briefing. But a hard look into the data is long overdue. ACEs have been linked to at least 5 of the top 10 leading causes of death in the United States: heart disease, cancer, respiratory disease, diabetes, and suicide.

“It’s been proven that exposure to abuse, violence, and familial substance abuse and mental health problems can lead to health and social problems during the entire lifespan. Multiple exposures can produce toxic stress and chronic activation of the stress response system,” Dr. Schuchat continued. “Our report found that more than half of adults have experienced at least one type of ACE, and one in six adults has been exposed to four or more. The effects add up – the more types of ACE encountered, the higher the risk for negative outcomes that limit their entire lives.”

Dr. Merrick, a behavioral scientist with the CDC, and her team reviewed data collected from the Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey of noninstitutionalized adults administered every year within each state. During the 2015-2017 data collection years, 27 states included questions about ACEs. The experiences included childhood exposure to three types of abuse (physical, emotional, and sexual) and five types of household challenges (household member substance misuse, incarceration, mental illness, parental divorce, or witnessing intimate partner violence) before age 18 years.

In all, 61% of respondents reported experiencing at least one of the events; 16% reported experiencing four or more. Women, Native Americans, Native Alaskans, and blacks were more likely to have these experiences than were men and whites.

A multivariate regression analysis found that adults with the highest level of ACE exposure had significantly elevated risks of several chronic health issues and social challenges, compared with nonexposed subjects. These included increased risk of overweight or obesity (adjusted odds ratio, 1.2), chronic obstructive pulmonary disease (aOR, 2.8), depression (aOR 5.3), smoking (aOR 3.1), heavy drinking (aOR 1.8), and underemployment (aOR 1.7), compared with adults reporting no ACEs.

Reducing ACE exposures could in turn reduce many of these challenges, especially among people with the highest number of exposures. Among this group, preventing all ACE exposure could cut overweight and obesity by up to 1.7%, chronic obstructive pulmonary disease by up to 27%, depression by up to 44%, smoking by up to 33%, and heavy drinking by 24%. Preventing ACE exposure also could reduce lack of health insurance by 4% and unemployment by 15%, the researchers said.

The good news, Dr. Merrick and associates said, is that ACE exposure can be at least partially offset by positive interactions with adults and in social and community settings.

“Prevention of adverse childhood experiences is possible with state and community efforts to build resilient families and communities, provide parental support to develop positive parenting and coping skills, and increase access to, and use of, comprehensive health services,” they said.

The CDC recommends a comprehensive approach to preventing ACEs and mitigating their impact. The data-driven suggestions include:

  • Promoting family economic health, including tax credits and family-focused work policy.
  • Endorsing programs to mitigate violence and adversity, including public education programs that support parents.
  • Promoting early childhood development with high-quality child care and preschool programs.
  • Recommending stress reduction skills for parents and young people, and programs that teach safe dating and healthy relationship skills.
  • Supporting youth development by connecting youth to adult mentors and after-school programs.
  • Encouraging clinicians to identify and address ACE exposure with screening, referral, and support.

“This is important for reducing the consequences of adverse childhood experiences and for helping to protect the next generation of children from exposure to violence and other adverse experiences, such as witnessing substance misuse in their household,” Dr. Merrick and associates said.

The researchers had no relevant financial disclosures.

SOURCE: Merrick M et al. MMWR. 2019 Nov 5. doi: 10.15585/mmwr.mm6844e1.

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