What Are Adverse Childhood Experiences (ACE)?
ACEs are adverse experiences that occur during childhood (before 17 years of age) which affect long-term health. These adverse experiences may be emotional, physical, sexual or related to household dysfunction.
In this post, I will share a patient’s story and address the following :
- The Adverse Childhood Experiences (ACE) Study
- How are chronic diseases related to Adverse Childhood Experiences?
- Are there any tests to evaluate the impact of your ACE score?
- What can you do if you have a high ACE score?
A Patient’s Story:
A few years ago Sunita (not her real name) a 32-year-old woman consulted me for hypothyroidism, anxiety and depression. She was on Thyroid medications (T4) and her blood tests were in the “normal range”. Despite this, she felt very anxious and her doctor had suggested that she should consult a Psychiatrist and start anti-anxiety medications. As often happens, she wasn’t keen on starting these medications. Her research for other solutions led her to my practice.
In Sunita’s words,
“I feel awful that despite taking resonably good care of my health, I feel anxious and depressed. My thyroid tests are within normal range on medications , but I don’t feel well!
I am the youngest of three sisters. My parents probably wanted a son. All my life I felt that I had to prove myself to my father. I am the smartest of the three sisters in terms of academic achievement, but my good grades in school and college were never celebrated. Added to that, my complexion is darker compared to my two older sisters. I was never physically or sexually abused, but all my life I was made to feel inadequate. I am single and love being so, but my family does’nt understand that. They are after me to get married!
A few months before Sunita reached out to my clinic, I came across a book called Childhood Disrupted: How Your Biography Becomes Your Biology And How You Can Heal. The author is Donna Jackson Nakazawa, ((Ref)) who is a science journalist and has the autoimmune condition Guillain-Barre Syndrome. Her book led me to read up about ACE. Subsequently, I added the ACE Score to my intake questionnaire.
Sunita had an ACE Score of 4.
” This is the first time that any doctor asked me to do my ACE Score. And what an insight! For the first time in my life I feel encouraged to know that there is an explanation for my health challenges and it is not my personal short-coming!”
What Is The ACE Score?
The ACE Score is an evaluation of the different types of neglect and physical, emotional and sexual abuse and other markers of a difficult early life. The score is based on a landmark research paper, called The Adverse Childhood Experiences (ACE) Study.
ACE Study:
In 1998 a paper ((Ref)) was published in the American Journal of Preventive Medicine, called The Adverse Childhood Experiences (ACE) Study. This was one of the first of several research papers to follow, which showed how traumatic experiences in the early years of life have long-lasting effects on mental and physical health in adults.
The origin of the ACE Study is very interesting. Dr. Vincent Felitti, who was the chief of Preventive Medicine at Kaiser Permanente (a healthcare provider in the USA) was concerned about the high drop-out rate in his obesity clinic. People dropped out in spite of losing weight. He delved deep into patient data and found out that people did not gain weight gradually. When they gained weight, it happened abruptly and then stabilized. Then they’d regain most of the weight after initial weight loss and the weight would stabilize again.
Further enquires from the obesity clinic drop-outs revealed that most of them had been sexually abused. Thus began Dr. Felitti’s quest to understand the health impact of adverse childhood experiences. He wondered whether in some people obesity was an unconscious defence that persisted as a result of adverse childhood experiences. As often happens when you bring forth a new idea many people do not believe you! When he presented his initial 200 + patient data at a conference, many colleagues were skeptical of his findings.
At the suggestion of a colleague that he should validate his findings on a larger scale, Dr. Felitti collaborated with Dr. Robert Anda, an epidemiologist. The result of the collaboration is the ACE Study.
What Did The ACE Study Look At?
The authors of the study sent questionnaires to about 9000 people asking them about different categories of adverse childhood experiences. The adverse experiences included in the questionnaire related to:
- Psychological abuse
- Physical or sexual abuse
- Violence against mother
- Living with household members who were substance abusers
- Mental illness or suicidal family member
- Family member in prison.
What Did They Find?
- People who had a high ACE score (4 or more) had increased health risks for many diseases. (The diseases are listed in the infographic below).
- More than half of the people surveyed had an ACE score of at least 1.
- Higher the ACE score higher was the risk for multiple diseases.
ACE and Autoimmune Conditions:
In the infographic above you can see that several autoimmune conditions are related to having a high ACE score. This paper ((Ref)) from 2009 reported that people with autoimmune diseases and high ACE scores had a higher risk for hospitalization. The five most common autoimmune diseases identified in this study were: Type 1 Diabetes, Rheumatoid Arthritis, Autoimmune Thrombocytopenia Purpura (ITP), Idiopathic Pulmonary Fibrosis and Systemic Lupus Erythematosus.
How Are ACEs Related to Disease? Possible Mechanisms:
- Stress, allostatic load
- Inflammation
- Change in gene expression. DNA Methylation.
Stress, Allostatic Load:
Early life stress and stress in the pregnant mother have a huge impact on the developing brain. This also decides how you respond to any challenge in adult life, be it physical, psychological or emotional. Early life stress changes brain connections and the response to stress chemicals like cortisol, adrenaline(epinephrine), noradrenaline (norepinephrine. Stress can also hamper nerve cell growth and development in the child. ((Ref))
Allostasis and Allostatic Load:
Allostasis refers to a living organism’s normal ability to guard itself against challenges and stressors, both physical and mental. ((Ref))
Allostatic load: It is the cumulative impact of physical, mental and emotional strain on you, where you lose your metabolic flexibility and raise your risk for chronic disease. ((Ref))
The high allostatic load may start with adverse childhood experiences, thereby contributing to chronic disease. ((Ref))
Inflammation:
Markers of chronic inflammation like C-Reactive Protein and Fibrinogen were found to be higher in adults who had high ACE scores. ((Ref)) ((Ref)) ((Ref))
A recent paper in the journal JAMA Pediatrics ((Ref)) looked at inflammation markers in young people exposed to adverse experiences in childhood. They found that levels of a marker of chronic inflammation called soluble urokinase plasminogen activator receptor (suPAR) were elevated in those who were exposed to higher childhood adversities. (suPAR may be a better inflammation marker in some people, but it is probably not available outside research settings).
Change in gene expression: DNA Methylation.
You know that your genes do not decide your destiny. What do I mean by that? Let us say that both your parents have Type 2 Diabetes. This means you have probably inherited the genes for diabetes from your parents. However, just because you have the genes doesn’t mean that you will develop diabetes. Whether you develop diabetes or not will be decided by your lifestyle—-food, sleep, exercise, stress management and more. These factors are epigenetic influences.
Epigenetics: In plain words, epigenetics is the switching on or switching off of your genes. Every cell in your body has the same genes. So how do the cells in the eyes know that they shouldn’t grow hair there? That is epigenetics at play!
DNA Methylation: This is one of the epigenetic processes, where a methyl group is added to a DNA molecule. This addition of a methyl group changes gene expression (the switching on-or-off of genes) without changing the sequence of genes.
One study looked at methylation changes and risk for depression in children who had experienced adversities during childhood. They found differences in DNA methylation and higher depression risk in genes involved with stress response, brain plasticity and brain circuits. ((Ref))
Are there any tests to evaluate the impact of your ACE score?
There are no specific tests to detect ACE, however, there are several measures of allostatic load ((Ref))which can be used as surrogate markers. What are these markers?
- Blood Glucose levels
- Glycated Hemoglobin (HbA1C)
- Waist: hip ratio
- Inflammation markers like CRP, fibrinogen, IL-6, suPAR
- Cortisol in saliva
- Blood Pressure
- Cholesterol Abnormalities
- Serum DHEAS
- Urinary Adrenaline, Noradrenaline.
International ACE Score
The original ACE Study included 10 types of childhood trauma that were most commonly reported by the study population. However, there are additional factors that are equally relevant. The World Health Organization has an expanded questionnaire ((Ref)) which includes several other types of childhood trauma.
Some of the types of trauma included in the Expanded Questionnaire are:
- Death of parents or guardian
- Homelessness
- Being bullied
- Experiencing violence from police, soldiers, militia or gangs
- Did you witness any violence, like seeing somebody being beaten or shot?
- Did you choose your husband or wife? If you did not choose your spouse, did you consent to the marriage?
What can you do if you have a high ACE score?
Having a high ACE score does not mean that your future is bleak. The ACE Score is meant as a guideline. There are several factors that can help you in overcoming your problem….the resiliency factors as opposed to vulnerability.
A paper ((Ref)) looked at ACE scores and resilience in centenarians and seniors from Loma Linda in California. Loma Linda is one of the 5 regions in the world considered to be a part of the Blue Zones.
The Blue Zones are regions in the world identified as places where people live healthier and longer, many of them are centenarians living active lives! Besides Loma Linda, Sardinia in Italy, Nicoya in Costa Rica, Okinawa in Japan and Ikaria in Greece are included in the Blue Zones.
Seven centenarians and 18 seniors (>65 years old) were interviewed in this study. Many of them had experienced hardships like poverty, family dysfunction and community violence in their lives. However, the interviews were focussed on lifestyle factors that made them resilient. What were these factors?
Resiliency Factors:
What else can you do?
Mindfulness:
On a web-based survey, the authors looked at ACE scores, dispositional mindfulness and reported depression, severe headache, lower back pain, obesity, high blood pressure, diabetes or prediabetes and asthma and health-related quality of life, in a group of people. ((Ref))
Dispositional mindfulness is the awareness that results from purposefully paying non-judgemental attention to thoughts, feelings and sensations in the present moment. (Dr. Jon Kabat Zinn)
You can predict where this is going. Those with high ACE scores had worse health. Those people with higher dispositional mindfulness did better despite having high ACE scores. (Mindfulness was measured using the Cognitive and Affective Mindfulness Scale. )
Expressive Writing:
Psychologist Dr. James Pennebaker is considered the father of Expressive Writing. One of his undergraduate students had suggested the survey question “Prior to the age of 17, did you experience a traumatic sexual experience?” As Dr. Pennebaker says, “The responses to that question changed my career. ” ((Ref)) ((Ref))
Expressive Writing Method:
Write for a minimum of 15 minutes a day for at least 3 or 4 consecutive days. Do not bother with grammar and punctuation. You do not need to read your own writing or even let anyone else read it. (The details of the method are here)
Expressive Writing and Childhood Sexual Abuse
In one study, women who had experienced childhood sexual abuse were asked to write weekly for 30 minutes for 5 weeks. They were followed up for 6 months. All of them worked with a qualified psychologist. ((Ref)). (This method is different from Dr. Pennebaker’s but effective nonetheless).
What did they write about? The women in this study were provided with structured writing prompts each week. This included prompts to write about how their sexual abuse may have affected their beliefs about themselves, sexual partners, or sexuality in general.
Result: Expressive writing was effective in reducing symptoms of depression, Post-Traumatic Stress Disorder (PTSD) and sexual dysfunction in women who had experienced sexual abuse.
Summary:
- Adverse Childhood Experiences affect life-long health.
- Having a high ACE score is not a life sentence. It is a guideline, perhaps an explanation for why you have multiple health challenges despite having healthy habits.
- Your resiliency decides your health. Many resiliency factors are under your control. Being in nature, having meaningful relationships, sleep, movement, listening to music, practicing mindfulness, eating good food, expressive writing are some of the strategies that you can use.
Relevant article: IBS
