NPR Article
March 02, 2015 3:02 PM ET
 |
| Maria Fabrizio for NPR |
In the
1980s, Dr. Vincent Felitti, now
director of the California Institute of Preventive Medicine in San Diego,
discovered something potentially revolutionary about the ripple effects of
child sexual abuse. He discovered it while trying to solve a very different
health problem: helping severely obese people lose weight.
I
remember thinking, 'Well, my God, this is the second incest case I've seen in
23 years of practice.' And so I started routinely inquiring about childhood
sexual abuse. And I was really floored. - Dr. Vincent Felitti, co-developer of
the Adverse Childhood Experiences Study Felitti, a specialist in preventive
medicine, was trying out a new liquid diet treatment among patients at a Kaiser
Permanente clinic. And it worked really well. The severely obese patients who
stuck to it lost as much as 300 pounds in a year.
"Oh
yeah, this was really quite extraordinary," recalls Felitti. But then,
some of the patients who'd lost the most weight quit the treatment and gained
back all the weight — faster than they'd lost it. Felitti couldn't figure out
why. So he started asking questions. First, one person told him she'd been
sexually abused as a kid. Then another. "You know, I remember thinking,
'Well, my God, this is the second incest case I've seen in [then] 23 years of
practice,' " Felitti says. "And so I started routinely inquiring
about childhood sexual abuse, and I was really floored."
More
than half of the 300 or so patients said yes, they too had been abused. Felitti
wondered if he'd discovered one of the keys to some cases of obesity and all
the health problems that go along with it.
That
possibility made him very curious: What if having a bad childhood could affect
health in other ways?
The idea
that childhood abuse and neglect could affect adult health was a revelation to
Felitti. But a poll
released Monday (from NPR, the Robert Wood Johnson Foundation and the Harvard
T.H. Chan School of Public Health) finds that the public widely believes this
to be the case today.
How to
Measure the Troubles of Childhood
As he
continued to explore the idea in the 1990s, Felitti got together with an
epidemiologist named Dr. Rob Anda,
who at the time was on staff at the Centers for Disease Control and Prevention.
They came up with a set of questions to trace, in a larger group, how tough
childhood experiences might affect adult health.
They
called their work the study of Adverse Childhood Experiences, or ACE.
First
developed in the 1990s, the 10 questions of the Adverse Childhood Experiences
test are designed to take a rough measure of a difficult childhood.
The
17,000 or so patients in this study were mostly middle-aged white people,
upper- and middle-class, from San Diego. Felitti and Anda asked them to think
back to their childhoods and list how many of 10 different types of adverse
childhood experiences they'd had, including sexual, physical or emotional
abuse; neglect; loss of a parent due to death, divorce or incarceration; mental
illness in a parent; and drug or alcohol abuse by a parent.
The
researchers wanted to get a sense of how being exposed to these different
categories of adverse experience early in life might affect long-term health.
So, on Felitti and Anda's score sheet, having undergone any one of those
different categories of trauma or neglect before age 18 would add one point to
a person's ACE score. Whether someone had been sexually abused one time, or
dozens of times, the experience would count as one point in their study. Being
habitually abused, and losing a parent to death, would add up to an ACE score
of 2.
Even
though Felitti and Anda were just getting a rough measure of the severity of
the patients' experiences, when Anda's team at the CDC crunched the numbers, he
was shocked.
One in
10 of the patients surveyed had grown up with domestic violence. Two in 10 had
been sexually abused. Three in 10 had been physically abused.
"I
thought that people would flock to this information, and be knocking on our
doors, saying, 'Tell us more. We want to use it.' And the initial reaction was
really — silence."
- Dr.
Rob Anda, epidemiologist and co-developer of the ACE study
"Just
the sheer scale of the suffering — it was really disturbing to me," Anda
remembers. "I actually ... I remember being in my study and I wept."
And then
came the part where he found out what happened to all those people when they
grew up: "very dramatic increases in pretty much every one of the major
public health problems that we'd included in the study," he says.
Cancer,
addiction, diabetes and stroke (just to name a few) occurred more often among
people with high ACE scores. Now, not everyone who'd had a rough childhood
developed a serious illness, of course. But, according to the findings,
adults who had four or more "yeses" to the ACE questions were, in
general, twice as likely to have heart disease, compared to people whose ACE
score was zero. Women with five or more "yeses" were at least four
times as likely to have depression as those with no ACE points.
When
ACEs Are Very High
Carol
Redding, one of Felitti's patients, answered yes to every single ACE question,
and she ended up with an ACE score of 10. Ten out of 10. Today Redding lives in
a tidy, peaceful house outside San Diego. The walls of her home office are
lined with degrees and certificates — at age 58, she's working on a Ph.D. From
the outside, she's a success. "An association doesn't necessarily mean
that one thing causes the other thing."- Sarah Floud, epidemiologist,
Oxford University. But inside — in her body as well as her mind, Redding says —
she has been battling all her life. She was diagnosed with post-traumatic
stress disorder, as a result of those childhood experiences. "I had the
flashbacks," she says, "the depression, the anxiety — Oh, my lord!
Anxiety, like ... if it were a tangible thing living in the house with me, I'd
need another room just to house that." In childhood, she was diagnosed
with high blood pressure. In adulthood, she had a thyroid condition and has
survived three different types of cancer: leukemia, breast cancer and lymphoma.
Learning
about the ACE study and her own results made Redding wonder if all of that —
maybe even the cancer — might be partly connected to her troubled childhood.
After so many years, all of a sudden, "all those very confused, very
scattered puzzle pieces of my life just locked together in one big, amazingly
clear picture," she says.
This
revelation meant so much to Redding that she started a newsletter about the ACE
study and later worked for the CDC, publicizing the study's results. And she
did all that because one big question kept nagging at her: Why didn't more
people know about this research?
Medical
Community Initially Skeptical
Anda
says that when he and Felitti first published their results in the late 1990s,
the response from the medical community was frustrating. "I thought that
people would flock to this information," Anda says, "and be knocking
on our doors, saying, 'Tell us more. We want to use it.' And the initial
reaction was really — silence." In fact, it took a long time to even get
the study published. A number of top medical journals rejected the article,
Anda says, "because there was intense skepticism."
Sarah Floud, an
epidemiologist at Oxford University in England, says she understands that
skepticism and thinks it may still be warranted. "An association doesn't
necessarily mean that one thing causes the other thing," says Floud. She
thinks doctors and patients should take care not to over-interpret an ACE score
— it's not a crystal ball that predicts health or illness. Rather, Floud says,
this rough indicator of a difficult childhood is just one risk factor in the
mix with lots of others, such as your genes, your diet, whether you drink
heavily or smoke, for example — factors known to be strongly related to some
illnesses, like heart disease, diabetes and cancer.
So if
you're otherwise healthy, not a smoker or a drinker, and not obese, can
childhood trauma alone increase the likelihood of diseases like cancer and
heart disease?
"I
don't think there's quite so much evidence for that," Floud says.
"But that's not to say that it might not be true. It's just that ... that
seems to be harder to prove." Now, 15 years after the ACE study came out,
some scientists are trying to connect the dots — to get a clearer picture of
what exactly adverse childhood experiences do
to the body and why the study results came out the way they did. "Well,
you've reshaped the biology of the child," says Megan Gunnar,
a developmental psychologist at the University of Minnesota who, for more than
30 years, has been studying the ways children respond
to stressful experiences. "This is how nature protects us,"
Gunnar adds. We all become adapted to living in "the kinds of environments
we're born into."
And if
you have scary, traumatic experiences when you're small, Gunnar says, your
stress response system may, in some cases, be programmed to overreact,
influencing the way your mind and body work together. Research in animals and
people suggests that the part of the mind that scientists call "executive
function" — thought, judgment, self-control — seems to be most affected,
she says.
"Over
time, especially when you're young, experiences of neglect and abuse and stress
impair those circuits," Gunnar says. "You're less able to tell
yourself not to eat the ice cream, or smoke the cigarette, or have that
additional drink. You're less capable of regulating your own behavior. And that
seems to be terribly important for linking early experiences with later health
outcomes." This growing body of research indicates that, right now, the
health of millions of children is being shaped by abuse and neglect. As they
grow up, these children will be more likely than other children to use
behaviors like smoking, drinking and overeating to cope with stress. Preventing
childhood trauma in the first place, Felitti, Anda and their proponents now
believe, is one of the biggest opportunities to prevent disease — and save
billions in health care costs. It's an opportunity, they say that American
medicine and the health care industry still seem to be missing.
This
story is part of the NPR series, What
Shapes Health? The
series explores social and environmental factors that affect health throughout
life. It is inspired, in part, by findings in a poll
released Monday by NPR, the Robert Wood Johnson Foundation and the
Harvard T.H. Chan School of Public Health.
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