April 10, 2009
Adverse childhood experiences (ACE’s) can be defined as harmful or unfavorable conditions or events that act in contrast to what’s best and needed for a child’s healthy development. Common forms of adverse childhood experiences include abuse, neglect, and household dysfunction. For decades it’s been argued whether childhood conditioning or the genetic characteristics and predispositions we are born with have a greater impact on the people we become in adulthood. While it might be common sense to argue that genetics play a strong role research supports both sides of this argument. Further research into this matter has expanded the scope for what childhood conditioning has the capacity to affect, showing that not only do childhood experiences impact the adults whom children become but that they also strongly impact their future physical well-being, even many decades into their adulthoods. Two main pieces of evidence support this argument. By first exploring the physically damaging neurobiological changes that have been consistently found among adults who’ve had significant exposure to adverse childhood experiences it will be illustrated that “just getting over” childhood wounds may have less to do with will power and more to do with physical dynamics that lay beyond one’s immediate control. Secondly, by examining the data collected from on very important study the connection between a child’s level of exposure to adverse experiences and their increased likelihood for nicotine addiction, alcoholism, and drug use in adulthood is exhibited. It will be shown that these public health problems may be symptoms of a deeper problem that could be better solved through the prevention of child abuse and neglect, in turn decreasing the numerous health problems and diseases that are associated with smoking, excessive drinking, and drug use. In the end one thing is clear. As a society we cannot afford not to protect our nation’s children.
Through changes in brain structure and hormonal abnormalities found in adult survivors of childhood abuse and neglect exhibit consistent alterations in their neurobiological responses to stress. In reference to the changes found in brain structure Bruce McEwen PhD, Professor and Head of the Laboratory of Neuroendocrinology at Rockefeller University states, “The brain pays a very important price as a result of trauma.” (Bremner, 1997). McEwen, along with scores of other researchers around the world have published research all pointing to the negative impact that trauma has on the developing brain. For example, in one study performed by J. Douglas Bremner M.D. of the Yale University School of Medicine and colleagues adult survivors of abuse showed a 12 % reduction in the size of the left hippocampus in comparison to the volume of adults who had experienced no abuse in childhood(Bremner).
The hippocampus is a portion of our brains responsible for the production of cortisol, otherwise known as the stress hormone, which we produce to regulate our body’s response to perceived threats. It’s important to note that high levels of cortisol are also often associated with decreased hippocampal volume such as that found in Bremner’s study. Taking this association into consideration, it’s not surprising then that early and sustained adverse experiences lead to hormonal abnormalities, especially in cortisol levels. One example of such cortisol level abnormalities was found by Frank W. Putnam, chief of developmental traumotology at the National Institute of Health. After following the stress responses of 77 sexually abused girls for more than a decade he found that that they released significantly higher levels of cortisol when a stress response was induced when compared to a control group of non-abused girls. Dr. Putnam explains, “As we followed all of the abused girls over time, they went from being hypercortisolemic – putting out to much cortisol – to being hypocortisolemic – putting out too little cortisol”(Center for Advancement of Health).
Both the resulting increased and decreased stress cortisol output found in adult survivors of childhood abuse and neglect strongly impacts their physical wellbeing. Unfortunately for the girls in Putnam’s study and for many exposed to high levels of stress during childhood, both too much and too little cortisol negatively affects the body’s health over time. Higher and more prolonged levels of cortisol such as those noted thus far have been shown to have negative effects such as lowered immunity and inflammatory responses in the body, slowed healing, and other health consequences(Ebrecht, Hextall and Kirtley). In the case of having too much cortisol Dr. Esther M. Sternberg at NIH’s National Institute of Mental Health explains, “If you’re pumping out too much cortisol and your immune cells are bathed in high levels of stress hormones, they’re going to be tuned down”(National Institute of Health). In the reverse situation it’s been found that a lack of cortisol is likewise associated with an increased vulnerability for auto-immune disorders, inflammation, chronic pain syndromes, allergies, and Asthma(Helm, Ehlert and Hanker). Therefore the physical health of an individual can be greatly impacted if their childhoods were marked by excessive stress, evident cases of abuse and neglect. In reference to these numerous health problems Dr. Robert Anda at the Centers for Disease Control and Prevention points out, “Adverse childhood experiences substantially increase the number of prescriptions and classes of drugs used for as long as 7 to 8 decades after their occurrence. The increases in prescription drug use were largely mediated by documented Adverse childhood experience-related health and social problems” (Anda, 2008).
Aside from these changes in brain structure and hormone output there is a second important finding to take into account. The connection between increased exposure to childhood adverse experiences and increased likelihood for nicotine addiction, alcoholism, and drug use in adulthood illustrates plausibility that childhood exposure, in itself, is the source of origin for substance abuse and addiction. The bulk of the research supporting this position has been gathered from a study that took place from 1995 to 1997. Seventeen thousand members of a U.S. Health Maintenance Organization (HMO) participated and the findings systematically disproved the common notion that time heals all wounds. Prior to examining the data from the Adverse Childhood Experiences Study, also known as the ACE study, it is first necessary to understand the scoring method used in measuring each participant’s exposure to childhood adverse experiences.
Nine categories of ACE’s were divided into two main areas of experience which were then used to access each patient’s level of exposure. The first area examined was the history of personal abuse which included recurrent physical abuse, emotional abuse, contact sexual abuse, and neglect. The second area, household dysfunction, was divided into five categories: where an alcoholic or drug user was present in the home; where a household member was in prison; where someone was chronically depressed, mentally ill, or suicidal; where the mother was treated violently; and where the parents were separated, divorced, or in some way lost to the patient during childhood (Felitti, 2002). For every category of exposure patients had a point added to their ACE score resulting in a maximum score of 9 if exposed to all categories of adverse childhood experience and a minimum score of 0 for those that were exposed to none.
The prevalence of cigarette smoking found among participants with high ACE scores is astounding. Though, as will be shown, the likelihood for alcoholism and drug abuse is even more greatly impacted by exposure to adverse childhood experiences. For a participant who was exposed to 6 categories of childhood adverse experiences, in comparison with participates exposed to none, there was a 250% increase in the likelihood of their being a current smoker(Anda, Croft and Felitti). To illustrate the significance of smoking Vincent Felitti, founder of the ACE Study notes, “A participant exposed to 4 categories of adverse childhood experience was 390% more likely to have chronic obstructive pulmonary disease compared to those with no exposure”(Felitti).
Secondly, the level of alcoholism commonly found among participants with high ACE scores was even more pervasive than that of cigarette addiction. Through regression analysis, using participant questionnaires, it was determined that each of the eight individual ACEs are associated with an increase in the risk for alcohol abuse in adulthood. For a participant who was exposed to 6 categories of childhood adverse experience, in comparison with a participant exposed to none, there is a 500% increase in adult alcoholism. Furthermore, compared to persons with no ACEs, the risk of heavy drinking, self-reported alcoholism, and marrying an alcoholic were increased two-fold to four-fold by the presence of multiple ACEs(Dube, Anda and Felitti). It’s important to note that this two-fold to four-fold increase was found regardless of parental alcoholism, indicating that this increase has more to do with childhood trauma than any genetic predisposition.
Thirdly, even more so than addiction to cigarettes and alcoholism, the initiation of drug use, drug use problems and drug addiction was greatly increased through exposure to childhood adverse experiences. As a result of ACE’s the attributable risk for each of these three illicit drug use problems was increased by 67% for an adult over 19 years of age(Dube, Felitti and Dong). Compared to participants with 0 ACEs, participants with 5 or more ACEs were 7- to 10-fold more likely to report illicit drug use problems and addiction to illicit drugs. For a male participant exposed to 6 categories in comparison to those exposed to none there was a 46-fold increase (4600%) in the likelihood of them becoming an injection drug user sometime later in life (Felitti, 2003). In reference to this increase in injection drug use Dr. Vincent J. Felitti asks:
Because no one shoots heroin to get endocarditis or AIDS, might heroin then be used for relief of profound anguish dating back to childhood experiences? Is drug abuse self-destructive, or is it a desperate attempt at self-healing, albeit at a significant future risk? This point is important because primary prevention is far more difficult than anticipated--possibly because incomplete understanding of the benefits of so-called health risk behaviors causes these behaviors to be viewed as irrational acts that have only negative consequences. (Felitti, 2003)
In conclusion, the effects of adverse childhood experiences transcend the more commonly perceived causes for the physical illnesses and diseases that we as a society fight to cure. Through combined research illustrating the bio-neurological alternations caused by early and prolonged adverse experiences and the epidemic of alcoholism, drug abuse, and addiction found in adults with high ACE scores, it’s clear that we cannot afford to continue to sweep child abuse and neglect under the rug. Recognition of the reduction in the quality of life associated with child maltreatment is paramount in order to evaluate the programs that have been put in place to prevent child abuse and neglect from an economic standpoint. Programs are needed that better address the underlying motivations of patients who continue to smoke despite health problems caused by smoking. Reducing society’s problems with drug and alcohol problems means bringing serious attention to these common types of damaging childhood experiences. Heightened awareness will not only reduce the occurrence of adult substance abuse problems but it will also reduce the higher health care costs they so often predict. Lastly, intervention is essential for children who’ve been victims of abuse and neglect. Not only in order to treat their symptoms but also to help them in building coping skills that will offset the problems with drug abuse and poor physical health that may otherwise await them.
Anda, Robert F. "Adverse Childhood Experiences and Prescription Drug Use in Cohort
Study of Adult HMO Patients." BMC Public Health (2008): 198.
Anda, Robert F., et al. "Adverse Childhood Experiences and Smoking During Adolescence
and Adulthood." JAMA (1999): 1646-1651.
Bremner, John Douglas. "Magnetic Resonance Imaging Based Measurement of
Hippocampal Value in Postraumatic Stress Disorder Related to Childhood Physical
and Sexual Abuse - A Preliminary Report." Biological Psychiatry (1997): 23-32.
Center for Advancement of Health. "Abused Stress Response." March 1999. Facts of Life:
Issue Briefings for Health Reporters. 3 March 2009
Centers for Disease Control and Prevention. Adverse Childhood Experiences Study. 1
April 2009 <http://www.cdc.gov/nccdphp/ACE/>.
Dube, Shanta R., et al. "Adverse childhood experiences and personal alcohol abuse as an
adult." Addictive Behaviors (2002): 713-725.
Ebrecht, Marcel, et al. "Perceived stress and cortisol levels predict speed of wound
healing in healthy male adults." Psychoneuroendocrinology (2004): 798-809.
Felitti, Vincent J. "Childhood Abuse, Neglect, and Household Dysfunction and the Risk of
Illicit Drug Use: The Adverse Childhood Experiences Study." Pediatrics (2003): 564-572.
Felitti, Vincent J. "Drug Use: The Adverse Childhood Experiences Study." Pediatrics
Felitti, Vincent J. "The Relation Between Adverse Chilhood Experiences and Adult Health:
Turning Gold Into Lead." 2002. The Permanente Journal. 3 March 2009
Fink, George. Encyclopedia of Stress: A-D. San Diego, CA: Academic Press, 2000.
Helm, Christine, et al. "Abuse-Related Posttraumatic Stress Disorder and Alternations of
the Hypothalamic-Pituitary-Adrenal Axis in Women With Chronic Pelvic Pain."
Journal of Biobehavioral Medicine (1998): 309-318.
National Institute of Health. "Stressed Out?: Stress Affects Both the Body and Mind."
January 2007. NIH News on Health. 4th March 2009