Link between early trauma, bad health

What society does to its children, its children will do to society.

- Cicero, 106 B.C.E.

A radical change in the underlying beliefs of what causes and accelerates adult diseases and childhood health is underway. It's a paradigm shift - a transformation in the practice of pediatrics.

On a recent Friday, I had a full panel of patients. A jumpy 7-year-old with ADHD. A 12-year-old weighing more than 150 pounds. A teenager with a flat affect.

It was a typical day for a pediatrician, except that this diverse group most likely has one unifying factor that predisposes them to their health issues: ACEs.

Just as germ theory shifted our understanding of infectious disease in the late 19th century, ACEs are changing how we look at early traumatic experiences - and early disease and death.

ACE stands for adverse childhood experiences. A brief, and recent, history:

In 1995, researchers asked more than 17,000 middle-upper class adults in San Diego sensitive questions about their childhood exposure to events such as abuse (emotional and physical) and household dysfunction (domestic violence, substance abuse, mental illness, separation and divorce, incarceration). Each adverse experience equaled one ACE point, with a maximum of 10. Then things got interesting.

First, the prevalence of ACEs was high; more than two-thirds of respondents had at least one; more than 20 percent had three or more. (In Philadelphia, the most impoverished large city for children in America, 37 percent of residents have at least four ACEs, according to a study by the Institute for Safe Families released at a national ACEs summit here last month.)

Second, and even more fascinating, the original study and many that followed found the higher the ACE score based on childhood, the more likely you are to have diseases as an adult. These include the most common causes of death and disability: heart disease, stroke, suicide, HIV, diabetes.

One ACE is associated with a 20 percent greater risk of heart disease compared to no ACEs; four ACEs, 70 percent greater; more than six ACEs, 330 percent higher risk. A person with six or more ACEs is likely to die 20 years earlier than someone with none.

Why does this happen?

The more traumatized a child is, the more likely he or she is to adopt health-risk behaviors like smoking and overeating. That explains some of it, but not all.

So what is the cause?

Inflammation.

Evolution has made us survivors. If we see a bear, our "fight or flight" mechanism goes into action and our bodies respond by secreting substances that make our hearts race faster, get more blood flow to our muscles and rev up the brain, which helps us focus on the here and now.

The bear passes and our bodies quickly recover. But if that bear comes home several nights a week in the form of a parent with alcohol on his breath and rage in his eyes, the child's body has no time to recover.

The resulting toxic stress affects the glandular system, raising children's risk of diabetes and obesity. Chronic stress taxes immune systems, so higher ACE scores lead to more infections, asthma, and autoimmune diseases such as lupus. Chronic stress can even affect how genes are turned on and off, passing down life's stressors to future generations.

The health effects of ACEs have been teased out in dozens of studies (posted at www.cdc.gov/ace). Newer research has linked ACEs to social effects such as divorce, sexual dissatisfaction, unemployment, housing instability, and homelessness. In pediatrics, we see more: developmental delays, bed wetting, school failure, poor impulse control.

For medical professionals, the ACE research has transformed our big questions from "what's wrong with an individual" to "what happened to them." We know we must take a dual generational approach - healing the trauma in the parent while trying to prevent more in the child.

We have a long way to go. An article in May's JAMA Pediatrics reported that 60 percent of U.S. children were exposed to some form of violence in the last year.

We must acknowledge that ACEs are all around us and take a more trauma-informed approach to care. The Philadelphia nonprofit Institute for Safe Families (www.instituteforsafefamilies.org) is the driving force here. And we can learn from clinics such as Drexel's 11th Street Family Health Services, where practitioners prescribe reflexology, yoga, Zumba, and mindfulness training, along with antibiotics and insulin.

As I prepare for my next day of patients, the ACEs research makes me more attuned to the complexities of health, more aware of the toxic effects of stress on families I serve, more conscious of the path we must take. I have become more awake as a pediatrician.