SPONSORED: It’s no secret that Alaska struggles with high rates of sexual assault and abuse, neglect, and other crimes against children. Alaska consistently has one of the five highest child abuse rates in the country, according to the Child Welfare League of America. The state Office of Children’s Services told Alaska Dispatch News this summer that in 2017 it has averaged more than 50 reports of abuse and neglect per day.
What's less well known is that these kinds of traumatic experiences, along with other stressors such as turbulent home dynamics and being exposed to substance abuse, leave behind much more than emotional scars. In fact, abuse, neglect and other "adverse childhood experiences," or ACEs as they are known, are directly correlated with dramatically increased risk later in life of diseases ranging from migraines and autoimmune disorders to heart disease, lung disease and cancer.
"There's been a lot of research to try to answer that question," said Dr. Cathy Baldwin-Johnson, medical director of Alaska CARES, a collaboration of community services led by Providence Health & Services Alaska. Alaska CARES is part of a network of children's advocacy centers providing care to children who have experienced physical and sexual abuse.
What is undeniable from two decades of scientific research: There is a strong, clear connection between childhood trauma and increased risk of serious and even life-threatening disease in adulthood.
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A groundbreaking study
While there are any number of different childhood experiences that could be considered "adverse," in the social services world the term ACE functions as shorthand for specific types of experiences covered in a 1998 study authored by physicians from the Centers for Disease Control and the California-based HMO Kaiser Permanente. Their research had its genesis in questions raised by Dr. Vincent Felitti, head of Kaiser Permanente's Department of Preventive Medicine, as he was trying to figure out why patients were struggling in a weight loss program he supervised. He soon discovered a common thread linking many of these patients: childhood sexual abuse.
Felitti partnered with CDC epidemiologist Dr. Robert Anda, who had an interest in public health and experiential risk factors. From 1995 to 1997 they conducted a mega-study -- a survey of 17,000 Kaiser Permanente enrollees -- asking yes-or-no questions about childhood experiences that focused on physical and emotional abuse and neglect and household dysfunction.
The survey yielded an "ACE score" between zero and 10 for each participant. Then they cross-referenced each subject's score with his or her health data.
"They had access to their hospitalizations, their outpatient visits, their ER visits, their prescriptions," Baldwin-Johnson said. And the results were surprising and consistent: The higher the ACE score, the more likely a person was to suffer adverse health impacts. "There was this very clear curve that was identical for everything they looked at ... Hepatitis, chronic liver disease, osteoporosis-related fractures -- it was just incredible, the kind of correlations that they found." Over the past two decades, the findings have been replicated in more than 1,500 peer-reviewed studies.
On one hand, Baldwin-Johnson said, it's not that surprising that adverse childhood experiences have an impact on brain development at key times in a child's life.
"So people adopt high-risk health behaviors" as they get older, she said. "They drink, they smoke, they use drugs, they sit in front of the TV instead of exercising ... they get sick and die younger."
What was unexpected about the original ACE study, she said, is the rate of adverse health effects among adults who didn't engage in risky behaviors. The group participating in the study was largely comprised of middle aged, Caucasian, educated San Diego-area residents. They had health insurance and access to good medical care. Some ran marathons. Some didn't drink.
"You would think this would be a relatively low-risk population," Baldwin-Johnson said. It didn't seem to matter. Regardless of a participant's other risk factors (or lack thereof), a high ACE score translated to a significantly higher likelihood of disease and health problems. In fact, she said, the researchers found that ACE score was a better predictor of heart disease than all of the other circumstances and behaviors that are generally considered risk factors.
"Some of it has to do with impact on brain development and the areas of the brain that are impacted, but some of it has to do with the impact of how genes are expressed," Baldwin-Johnson said.
Childhood trauma doesn't necessarily change a person's genes, she said, but it may change how certain genes are expressed or "turn them on or off."
ACEs and impact on treatment of adults
Baldwin-Johnson first became aware of the ACE study when she heard Felitti speak at a child abuse conference. At the time a physician in private practice, she said she was profoundly impacted by what she learned, and it changed the way she practiced medicine.
"I had this whole shift in my paradigm and how I looked at my patients with chronic disease," she said. Asking patients about childhood experiences helped her better address the underlying risk factors contributing to their poor health. "When I was able to have those conversations with my patients, I was able to help shift their thinking." Instead of blaming themselves for not being able to manage their behaviors or "make themselves better," her patients understood that what they had experienced years earlier could be affecting their health in adulthood, and it helped make them more amenable to things like seeking mental health treatment to address their childhood traumas.
"It's a whole different way of approaching people. Blaming people for being victims or blaming them for their poor choices isn't going to help them get better," Baldwin-Johnson said. When she began treating patients with an acknowledgement of childhood trauma, "they were really able to make significant, life-altering changes that improved their health."
As part of the original ACE study, researchers created what is known as the "ACE Pyramid" to illustrate how childhood trauma, which forms the base of the pyramid, leads to disease and death at the peak.
"We have to get to the bottom of the pyramid before we get to the top," Baldwin-Johnson said. "The top is just the symptom of things that happened a long time ago."
When she began asking patients about their childhood traumas, she added, it sometimes exposed old secrets that her patients had been carrying for decades.
"Some of my patients had never told anybody," she said. "Or I was the second person, because they told somebody when they were five and they weren't believed, so they never told anybody again."
Early intervention makes a difference
Here's another hard truth exposed by research into ACEs: A child who has experienced at least one bad thing is likely to have experienced more than one. Two-thirds of participants in the original ACE study had a score of at least 1; of those, 87 percent had a score higher than 1. And children with adverse experiences are statistically likely to grow up into adults who experience more trauma.
"People that had bad things happen when they were children were also more likely to experience bad things as an adult," said Baldwin-Johnson, citing domestic violence and sexual assault as just two examples. "The bad things didn't end in adulthood."
That's just part of the reason early intervention -- and prevention -- can be critical to protecting young people from further trauma.
"The more bad things that happen to kids, then the higher their risk is going to be for their adult health," Baldwin-Johnson said.
Programs like Alaska CARES provide children who have experienced abuse with an outlet to begin recovery.
"We give kids a safe place to be able to tell what it is that's happening in their life -- just to let them have a voice," Baldwin-Johnson said. "There are people that are going to listen to what they say. There's a lot of power in that." The program also provides outpatient mental health therapy for children and may also provide referrals to services for their parents, many of whom have their own history of trauma.
Young people who are experiencing abuse should talk to a teacher, doctor school nurse, coach, or police officer, all of whom are mandated reporters of child abuse, Baldwin-Johnson said. And any adult who is approached by a child who says they are being abused should make a report to the state Office of Children's Services.
"Kids are very egocentric," Baldwin-Johnson said. "The world revolves around them ... but they also think things are their fault."
In fact, she added, some children have been explicitly told that their adverse experiences are their fault. That's one more reason why it's important to "reframe those experiences" and help them begin to heal.
The cost of ACEs
In Alaska, the state Department of Health and Social Services is now gathering some data on ACEs through its Behavioral Risk Factor Surveillance System survey. The data that is already available will be unsurprising to anyone familiar with Alaska's high rates of interpersonal violence: Sixty-five percent of Alaskans surveyed in 2015 reported an ACE score of 1 or more.
Beyond individual health concerns, there's an economic impact to adverse childhood experiences, both to those who have lived through them and to states like Alaska.
"People with a high ACE score are less likely to graduate from high school, less likely to go to college," Baldwin-Johnson said. "They're more likely to earn less."
And since they're more likely to have poor health, some of those costs end up carried by government programs.
"(Researchers) estimate that over 40 percent of our state's adult Medicaid enrollment is linked to ACEs," Baldwin-Johnson said, adding that there's a very real financial incentive for the state to find ways to reduce the long-term health problems connected to adverse childhood experiences. "If we are investing in children and families, starting even prenatally and certainly when kids are young, it's going to pay off. The payoff won't be tomorrow -- the payoff is going to be for our kids and our kids' kids."
While early intervention can make a significant difference in mitigating the damage done by adverse childhood experiences, just because a person didn't get help as a child doesn't mean it's too late.
If you have a high ACE score, Baldwin-Johnson recommends talking to your primary care physician -- "going to them and saying 'look, now I understand that when these bad things happened to me when I was a child that they could have an impact on my adult health and I'd like to go ahead and try to get some help for this now.'" Your doctor can help direct you to resources, such as a therapist trained specifically to deal with trauma.
"I don't want people to be discouraged and think that they're doomed because they have a high ACE score," Baldwin-Johnson said. "It's a risk factor like a lot of other risk factors. It's not a death sentence."
Providence Alaska Foundation, Alaska CARES and Alaska Children's Trust present a special screening of "Resilience," a documentary about new research into the effects of childhood trauma and stress caused by abuse and neglect, at Bear Tooth Theatre on Monday, Nov. 6 at 5:30 p.m. A panel discussion will follow the screening. Tickets, $4-$22, are available in advance at beartooththeatre.net.
This article was produced by the Marketing Services department of Alaska Dispatch News in collaboration with Alaska CARES. The ADN newsroom was not involved in its production.