How do you turn a newborn baby with all its promise and infinite capacities into a thirty-year-old homeless drunk? As with so many great discoveries,
internist Vincent Felitti came across the answer to this question accidentally.
In 1985 Felitti was chief of Kaiser Permanente’s Department of Preventive Medicine in San Diego, which at the time was the largest medical screening program in the world. He was also running an obesity clinic that used a technique called “supplemented absolute fasting” to bring about dramatic weight loss without surgery. One day a twenty-eight-year- old nurse’s aide showed up in his office. Felitti accepted her claim that obesity was her principal problem and enrolled her in the program. Over the next fifty-one weeks her weight dropped from 408 pounds to 132 pounds.
However, when Felitti next saw her a few months later, she had regained more weight than he thought was biologically possible in such a short time. What had happened? It turned out that her newly svelte body had attracted a male coworker, who started to flirt with her and then
suggested sex. She went home and began to eat. She stuffed herself during the day and ate while sleepwalking at night. When Felitti probed this
extreme reaction, she revealed a lengthy incest history with her grandfather.
This was only the second case of incest Felitti had encountered in his twenty-three-year medical practice, and yet about ten days later he heard a similar story. As he and his team started to inquire more closely, they were shocked to discover that most of their morbidly obese patients had been sexually abused as children. They also uncovered a host of other family problems.
In 1990 Felitti went to Atlanta to present data from the team’s first 286 patient interviews at a meeting of the North American Association for the Study of Obesity. He was stunned by the harsh response of some experts:
Why did he believe such patients? Didn’t he realize they would fabricate any explanation for their failed lives? However, an epidemiologist from the Centers for Disease Control and Prevention (CDC) encouraged Felitti to start a much larger study, drawing on a general population, and invited him to meet with a small group of researchers at the CDC. The result was the monumental investigation of Adverse Childhood Experiences (now know at the ACE study), a collaboration between the CDC and Kaiser Permanente, with Robert Anda, MD, and Vincent Felitti, MD, as co–principal
investigators.
More than fifty thousand Kaiser patients came through the Department of Preventive Medicine annually for a comprehensive evaluation, filling out an extensive medical questionnaire in the process. Felitti and Anda spent more than a year developing ten new questions14 covering carefully defined categories of adverse childhood experiences, including physical and sexual abuse, physical and emotional neglect, and family dysfunction, such as having had parents who were divorced, mentally ill, addicted, or in prison.
They then asked 25,000 consecutive patients if they would be willing to provide information about childhood events; 17,421 said yes. Their
responses were then compared with the detailed medical records that Kaiser kept on all patients.
The ACE study revealed that traumatic life experiences during
childhood and adolescence are far more common than expected. The study respondents were mostly white, middle class, middle aged, well educated, and financially secure enough to have good medical insurance, and yet only one-third of the respondents reported no adverse childhood experiences.
One out of ten individuals responded yes to the question “Did a parent or other adult in the household often or very often swear at you, insult you, or put you down?”
More than a quarter responded yes to the questions “Did one of your parents often or very often push, grab, slap, or throw something at you?” and “Did one of your parents often or very often hit you so hard that you had marks or were injured?” In other words, more than a quarter of the U.S. population is likely to have been repeatedly physically abused as a child.
To the questions “Did an adult or person at least 5 years older ever have you touch their body in a sexual way?” and “Did an adult or person at least 5 years older ever attempt oral, anal, or vaginal intercourse with you?” 28 percent of women and 16 percent of men responded affirmatively.
One in eight people responded positively to the questions: “As a child, did you witness your mother sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her?” “As a child, did you witness your mother sometimes,
often, or very often kicked, bitten, hit with a fist, or hit with something hard?”15
Each yes answer was scored as one point, leading to a possible ACE score ranging from zero to ten. For example, a person who experienced frequent verbal abuse, who had an alcoholic mother, and whose parents divorced would have an ACE score of three. Of the two-thirds of
respondents who reported an adverse experience, 87 percent scored two or more. One in six of all respondents had an ACE score of four or higher.
In short, Felitti and his team had found that adverse experiences are interrelated, even though they’re usually studied separately. People
typically don’t grow up in a household where one brother is in prison but everything else is fine. They don’t live in families where their mother is regularly beaten but life is otherwise hunky-dory. Incidents of abuse are never stand-alone events. And for each additional adverse experience reported, the toll in later damage increases.
Felitti and his team found that the effects of childhood trauma first become evident in school. More than half of those with ACE scores of four or higher reported having learning or behavioral problems, compared with 3 percent of those with a score of zero. As the children matured, they didn’t
“outgrow” the effects of their early experiences. As Felitti notes,
“Traumatic experiences are often lost in time and concealed by shame, secrecy, and social taboo,” but the study revealed that the impact of trauma pervaded these patients’ adult lives. For example, high ACE scores turned out to correlate with higher workplace absenteeism, financial problems, and lower lifetime income.
When it came to personal suffering, the results were devastating. As the ACE score rises, chronic depression in adulthood also rises dramatically.
For those with an ACE score of four or more, its prevalence is 66 percent in women and 35 percent in men, compared with an overall rate of 12 percent in those with an ACE score of zero. The likelihood of being on
antidepressant medication or prescription painkillers also rose proportionally. As Felitti has pointed out, we may be treating today experiences that happened fifty years ago—at ever-increasing cost.
Antidepressant drugs and painkillers constitute a significant portion of our
rapidly rising national health-care expenditures.16 (Ironically, research has shown that depressed patients without prior histories of abuse or neglect tend to respond much better to antidepressants than patients with those backgrounds.17)
Self-acknowledged suicide attempts rise exponentially with ACE scores. From a score of zero to a score of six there is about a 5,000 percent increased likelihood of suicide attempts. The more isolated and unprotected a person feels, the more death will feel like the only escape. When the
media report an environmental link to a 30 percent increase in the risk of some cancer, it is headline news, yet these far more dramatic figures are overlooked.
As part of their initial medical evaluation, study participants were
asked, “Have you ever considered yourself to be an alcoholic?” People with an ACE score of four were seven times more likely to be alcoholic than adults with a score of zero. Injection drug use increased exponentially: For those with an ACE score of six or more, the likelihood of IV drug use was 4,600 percent greater than in those with a score of zero.
Women in the study were asked about rape during adulthood. At an ACE score of zero, the prevalence of rape was 5 percent; at a score of four or more it was 33 percent. Why are abused or neglected girls so much more likely to be raped later in life? The answers to this question have
implications far beyond rape. For example, numerous studies have shown that girls who witness domestic violence while growing up are at much higher risk of ending up in violent relationships themselves, while for boys who witness domestic violence, the risk that they will abuse their own partners rises sevenfold.18 More than 12 percent of study participants had seen their mothers being battered.
The list of high-risk behaviors predicted by the ACE score included smoking, obesity, unintended pregnancies, multiple sexual partners, and sexually transmitted diseases. Finally, the toll of major health problems was striking: Those with an ACE score of six or above had a 15 percent or
greater chance than those with an ACE score of zero of currently suffering from any of the ten leading causes of death in the United States, including chronic obstructive pulmonary disease (COPD), ischemic heart disease, and liver disease. They were twice as likely to suffer from cancer and four times
as likely to have emphysema. The ongoing stress on the body keeps taking its toll.