Why ACEs should have changed everything in medical education
and why trauma recovery is root-cause prevention
One of the most important scientific research papers came out the same year that I graduated from medical school. And because it hasn’t been emphasized enough in continuing medical education, I didn’t learn about it until 15 years afterwards.
The adverse childhood experiences (ACE ) study took place through a massive medical insurance system in California. Dr. Vincent Felitti was an internal medicine specialist at a weight loss clinic. He was finding that some of his patients would have an excellent recovery, but then would regain the weight. When he was interacting with one of his patients, he inadvertently asked about their first age of sexual activity, and she answered three. He was stunned. He started asking more of his patients whether they had encountered childhood abuse, specifically sexual abuse, and it was exceedingly prevalent.
He partnered with Kaiser Permanente to create a large survey that went out to more than 10,000 people. The responses were astonishing, and really should have changed everything about what we learn in medicine. For the 10 ACE questions that they asked, which certainly are not the only forms of abuse that happened to children, there was an exponential increase in every physical and mental health illness that they studied. Exponential means that there was a steep rise, so if they had one adverse event in childhood, that would increase the risk, but if they had six, then it would increase the risk far more, and if they had nine or 10, then it would literally shorten their lifespan dramatically.
image from CDC website
The 10 elements that they studied are quite common, sadly. Within the study of population, only a third of people hadn’t encountered at least one of them. It helped them understand just how prevalent childhood abuse is in our communities and its impact. But they did miss a number of possible experiences, such as racism and bullying. Parental separation was mentioned, but not explicitly death of a parent, which is quite a different experience. But in fact, the ACE questionnaire was never intended to be a screening tool, as it is commonly used now. It was a public health measure for a particular study. Dr. Nadine Burke-Harris, in her book The Deepest Well, describes how she has expanded the survey in her clinical practice. Her work has been so groundbreaking that she was even the first surgeon general of California, hoping to implement this for all pediatric care. She prescribes a lot of early childhood intervention, parent education, and community building as solutions.
What this means is that every single subspecialist should be screening for a past history of trauma, and referring to appropriate resources - as the foundational risk factor for every condition that we treat. We need accessible, inclusive, and effective trauma therapy available to all people. And we need to have more conversations about trauma and post-traumatic growth.
Learn the basics about trauma and how you can recover through my book The Modern Trauma Toolkit.
Disclaimer: much has come out lately from the Decoder interview with Substack CEO Chris Best and his stance on amplifying racist rhetoric. I want to publically denounce this position as it harms communities placed at risk. I don’t care who funded your last seed round.