Adverse Childhood Experiences As Disease and Shared Social Responsibility

By Lance Chilton

A friend of mine, Jim Duffee, recently wrote in an American Academy of Pediatrics statement on child poverty, “Stakeholders along the political spectrum can agree that a shared social responsibility is to support healthy and thriving families.” I told him I hoped that is true.

Let’s assume that it is; then all of us would like to limit children’s exposures to Adverse Childhood Experiences, ACEs.  ACEs as a concept date to the late 1990s, when a San Diego pediatrician, Vincent Felitti, led a project to look at what happened in later life with 17,000 kids exposed or not exposed to severe problems in childhood, specifically child abuse (physical, emotional or sexual), parental incarceration or substance abuse or domestic violence or divorce or mental health disorders.  Others have since added effects of poverty or war to the list.  

Felitti’s study has been referred to thousands of times – following children into adulthood, the study found that the higher the number of ACEs that a child had experienced, the higher was the likelihood that the child would suffer lately from mental disorders, from substance abuse, from incarceration, from suicide.  This might have been expected: mental stress as a child begets emotional problems when the child grows up.  But what was less expected was that the same ACE score predicted physical ailments as well: diabetes, heart disease, cancer, chronic lung disease, and early death.  And the results were what physicians call “dose-related;” that is, the larger the number of adverse experiences, the more likely were all of these consequences.

Many physicians caring for children screen for ACEs and attempt to find ways to undo some of the harm done by them.  Screening for ACEs suffered by the parents of their patients may help to avoid the “sins of our fathers being laid on the child,” as Shakespeare put it.  If, for example, a new father or mother has been abused by their parents, it is important that they learn – through counseling in a doctor’s office or elsewhere or through a good home visitor – that there are other more effective means of parenting.

You will note that many ACEs are strongly related to poverty, which is strikingly prevalent in the US as compared with many other developed countries.  More than 1 in 7 children in the US live in families below the poverty level.  While physicians must intervene in individual cases to minimize the bad effects of ACEs in their families, all of us should be working to reduce the causes of those ACEs, especially poverty, by supporting ways to raise family incomes.  President Biden’s American Family Plan would cut child poverty in half if he can get it past the Republicans in the Senate, who falsely claim that direct payments to families with children “reduce the incentive to work.”

Adverse childhood experiences may be the most important public health problem that no one has heard about.  Approaches to ending the devastation of ACEs should take place at the individual level, the local, state, and federal levels.  There is no simple immunization for this “disease.”