Review of the 1998 ACE study

Title

Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study

Authors

Vincent J. Felitti, MD, FACP, Robert F. Anda, MD, MS, Dale Nordenberg, MD, David F. Williamson, MS, PhD, Alison M. Spitz, MS, MPH, Valerie Edwards, BA, Mary P. Koss, PhD, James S. Marks, MD, MPH

Published

1998

What they did

Sent a survey to 13494 adults who are a part of an HMO (Kaiser Permanente’s San Diego Health Appraisal Clinic- free for members of the Kaiser Health Plan) about whether they had been exposed to psychological, physical or sexual abuse and household dysfunction in the form of substance abuse, mental illness, violence towards maternal figure or criminal behaviour. The number of adverse childhood experiences (ACE) were then compared to measures of adult risk behaviour (smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, drug abuse, injected drug abuse, a high lifetime number of sexual partners(50+) and a history of sexually transmitted disease), self-reported health status and disease (ischaemic heart disease, cancer, stroke, chronic bronchitis, or emphysema, diabetes, hepatitis, or jaundice and any skeletal fractures)

What they found

9508 responded (70.5%)

52.1% exposed to atleast one ACE

The prevalence of smoking, severe obesity, physical inactivity, depressed mood and suicide attempts increased as the number of ACE increased

The prevalence of alcoholism, illicit drugs, injection of illicit drugs, >50 intercourse partners and history of STI increased as the number of ACE increased

A dose response relationship (the more ACE the more likely the following were to be reported) between the number of ACE and the following disease conditions: ischemic heart disease, cancer, chronic bronchitis or emphysema, history of hepatitis or jaundice, skeletal fractures and poor self-rated health

NO statistically significant relationship with stroke or diabetes

Questions raised

The subjects were part of a health plan in San Diego and they were 79.4% white and 43% had graduated college. Can their life experience be expanded to Americans broadly? To other countries?

Fewer ACE were reported among older, white or Asian persons and college graduates – unclear where this was a difference in reporting or actual exposure

The results were based on what people remembered and reported – are there other variables that impact on what people are more likely to remember or report

What it means

Being exposed to ACE does NOT lock someone into a life of health risk behaviours and disease

This study does not demonstrate causality, it does not show that adverse childhood experiences CAUSE particular outcomes, it demonstrates an association. A relationship.

These things are somehow linked, whether it is a direct link or there are other variables that link them together is unclear based on this study alone.

However, from the perspective of working with adults with both physical and mental health distress it is clear that management of the patient as a whole person is beneficial. Rather than reprimanding someone for smoking, it is important to take into account the emotional benefit they get from smoking.

This is a space I enjoy working in as a general practitioner with a focus on mental health as I am able to manage the patient as a whole from both the biological and the psychological perspective

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If you want to talk with a mental health GP to further explore your own exposure to adverse childhood experiences and how they may be impacting on your current mental and physical health, book an appointment here