Making the Case: “The Adverse Childhood Experiences Study: Child Abuse and Public Health” by Dr. Robert Anda

The Adverse Childhood Experiences (ACE) Study assesses the effects of child abuse and related adverse childhood experiences as a public health problem and the results clearly show “Why Prevention Matters.”

The study is an ongoing collaboration between the Centers for Disease Control (CDC) and Kaiser Permanente. Begun in 1994, the study includes 17,337 adults enrolled in the Kaiser HMO in San Diego, CA. Fully two-thirds of the study participants reported at least one adverse childhood experience such as abuse or neglect, with most reporting more than one. By bringing understanding of the childhood origins of myriad health and social problems across the lifespan, this study shows that prevention of ACEs, such as abuse and neglect, can have enormous impact on the health of our society.

The ACE Pyramid: A New Framework for Prevention

During the 1980s and early 1990s information about risk factors for disease had become widely known. However, risk factors such as smoking, alcohol abuse, and obesity for common diseases are not randomly distributed in the population. The ACE Study was designed to answer the question: “If risk factors for disease, disability, and early mortality are not randomly distributed, what early life influences precede the adoption or development of them?” The ACE Pyramid (See Figure 1) depicts this conceptual framework. By taking a whole life perspective the ACE Study began to progressively uncover how childhood stressors (ACEs) affect health and social well-being throughout the lifespan.

ACEs are Common

The Study measured a variety of ACEs and many health and social problems. This approach is the essence of public health investigations of factors that affect the health of a society. The first finding is that ACEs are common, even in a middle class HMO population! The 10 categories of ACEs and the prevalence of persons exposed to them during their first 18 years of life are shown in the first column of Insert 1.

ACEs are Highly Interrelated—An Important Insight for Prevention

Most people with one ACE also have others. Insert 1 also shows the percent of people who have other ACEs by category of experience. As a result, a new perspective for prevention of these experiences has evolved. Namely, organizations have traditionally been aligned to address single types of ACEs. Now, it is clear that organizations would benefit from a common goal that coordinates efforts to prevent a variety of ACEs.

The ACE Score—Adding up the Impact

The ACE Score takes interrelatedness of ACEs into account to show how they add up to exert their effects. The number of categories of ACEs is added up for each person to produce the ACE Score (range: 0-10). An ACE Score of 0 means that none of the categories were reported, while an ACE Score of 5 means that the person reported 5 categories of ACEs.

The prevalence of ACE Scores in the study population is as follows:

• 0 ACEs=33%
• 1 ACE=26%
• 2 ACEs=16%
• 3 ACEs=10%
• 4 or more ACEs=15%

The ACE Score Shows the Cumulative Biologic Effects of Childhood Stressors

The ACE Score captures the cumulative negative impact on social, emotional and cognitive development, and other impairments in the function of brain and body systems. These impairments are the biologic pathways to health risks, disability, disease, and early mortality. The short- and long-term outcomes of these childhood exposures include many health and social problems. As the number of adverse childhood experiences increases, the risk of developing significant health problems increases in a strong and graded fashion; this is called a “doseresponse” reaction. More ACEs equals more risk for negative outcomes!

For example, because smoking is a leading cause of preventable health problems, it is important to understand the graded relationship of ACEs to early smoking initiation, current smoking as an adult, and chronic obstructive pulmonary disease — a long term consequence of smoking. (See Figure 2)

The health and social problems associated with the ACE Score read like a “Who’s Who” of major public health priorities in the United States. Insert 2 shows a partial listing of health and social problems that have been documented to have a graded relationship to the ACE Score.

Conclusion—Reducing ACEs Will Greatly Improve Public Health

The ACE Study findings suggest that adverse childhood experiences are major risk factors for the leading causes of illness, disability and death as well as poor quality of life in the United States. Progress in preventing and recovering from the nation’s worst health and social problems will benefit from the understanding that many of these problems arise as a consequence of adverse childhood experiences. There are more than 50 peer-reviewed publications from the ACE Study. A complete listing of the findings is available by subject from the CDC. A video discussion of the ACE Study is also available.