While gravely concerned about Washington County’s alarming health status commented on in the Oct. 6 BDN editorial “Washington County’s Health,” we are glad to see this problem gain increased attention. While the measures of ill health become clearer as populations age, both our work and national research show that the problems leading to poor health, followed by early and premature death, start during the infant and early childhood years much more frequently than is usually realized or acknowledged.
Critical research by Dr. Vincent Felitti at Kaiser Permanente’s medical insurance HMO in San Diego has found important correlations between early exposure to trauma and adverse experiences with later ill health. The research is referred to as Adverse Childhood Experiences, or ACEs, has been confirmed with further research by the national Centers for Disease Control led by Dr. Robert Anda.
Dr. Felitti, an internist, not a psychiatrist or mental health expert, gained his insights on ACEs through an obesity study at Kaiser Permanente. Too many patients who began losing significant weight regained it — an all too frequent result. Follow-up with detailed life interviews revealed that childhood sexual assault or other trauma was remarkably common and, if present, came before the onset of the obesity.
These findings led to further research in several categories, including childhood abuse and household dysfunction, recurrent physical abuse, recurrent severe emotional abuse, contact sexual abuse, growing up in a household where someone was in prison, where the mother was treated violently, with an alcoholic or drug user, where someone was chronically depressed, mentally ill or suicidal, or where at least one biological parent was lost to the patient during childhood regardless of the cause were considered an adverse childhood experience. One point is given for each of these factors that occur to obtain a their ACE score.
The research led to measuring the adverse childhood experiences effects on the health of a larger group of Kaiser-Permanente patients whose average age was 57. Unlike many in Washington County, this California population was middle class; able to afford a good quality, prepaid health insurance program.
Anda and Felitti’s research found that ACEs are 1) vastly more common than previously recognized or acknowledged and 2) have a powerful impact on adult health a half-century later in patient’s lives.
Slightly more than half of the studied middle-class population experienced one or more adverse childhood experiences. One quarter had one or two ACEs; one in 16 had four. With a score of one ACE there is an 80 percent likelihood of exposure to another ACE. The ACEs do not occur in isolation. A child does not grow up with an alcoholic parent or with domestic violence in an otherwise supportive, well-functioning household.
We, as a society are shielded by societal taboos from seeking this kind of information; although the Kaiser-Permanente practice now uses a simple questionnaire to gather ACE information on its patients and the doctors follow up with a simple question, “How did that (the ACE condition) affect your later life?” Doctors, as concerned about asking personal, intimate questions as any of us, have found their patients remarkably responsive to this question which is generally not seen as judgmental or intrusive.
The implications for Washington County are huge. High ACE scores strongly correlate with Washington County’s health status cited in Maine’s CDC Health Status Report, which was the impetus for the BDN’s editorial. Conditions such as stroke, diabetes, obesity, cancers, substance abuse, depression, suicide and others correlate with childhood experiences of trauma and adverse life experiences. As Dr. Dora Mills pointed out, the economic disadvantages in Washington County increase the stresses and strains on family, resulting in our increasingly disturbing statistics on health status.
Turning the situation around will require the best from all of us. Within Washington County our medical providers, social service agencies, protective service workers and others need to become familiar with this research; learn to gather ACE data in medical offices and in our intake procedures; place an emphasis on families of infants and young children; on the infants, toddlers and preschoolers themselves. We need to embrace prevention and early interventions as a means of improving health outcomes.
At the state level we need our agencies of government to understand the ACE research, to promote its understanding and practice in Washington County and elsewhere, despite our inclination to avoid these hard topics that relate to trauma, violence and substance abuse. Whether we want to face it or not, adult behaviors have a profound effect on our young children. If these behaviors are commonly negative, then the outcomes for our children will too often be negative.
What the ACE research teaches us is that not only do negative experiences hurt children, they create health responses that are deadly in later adulthood. We cannot afford this. We are losing lives.
Marjorie Withers and Jane Weil are the lead staff of the Community Caring Collaborative in Washington County. The CCC recently received a federal grant for Project LAUNCH, or Linking Actions for Unmet Needs in Children’s Health.