In the past 20 years, doctors and public healthcare professionals have uncovered a clear link between poor adult health and adverse childhood experiences (ACEs). According to the Substance Abuse and Mental Health Services Administration, adverse childhood experiences (ACEs) are “stressful or traumatic events, including abuse and neglect. They may also include household dysfunction such as witnessing domestic violence or growing up with family members who have substance abuse disorders.” ACEs not only lead to early morbidity, but they also have been found to promote participation in maladaptive, “high-risk,” behaviors.
In the United States, adults who have experienced 6 or more ACEs during their childhood are 24.36 times more likely to attempt suicide than a person without ACEs. According to the 2017 article from the International Journal of Child Abuse and Neglect, not only are adults with high ACE scores likely to attempt suicide, but they are also 3.73 times more likely to use illegal drugs, 2.84 times more likely to engage in heavy alcohol use, and 2.73 times more likely to suffer from depression.
Unfortunately, adults who suffer from drug addictions and alcohol abuse are not less likely to have children than their peers. Instead, they become families with adult caregivers who suffer from drug and alcohol addictions. At a certain point, when the substance abuse is unmanageable, law enforcement and Child Protective Services will intervene in the best interest of the child. If the parent is unable to cure their addiction, their child will join nearly 52,000 other youth who are in California’s Foster Care System.
That child, who is now in foster care, has already experienced at least two ACEs of their own: parental incarceration and substance abuse. If we fail to provide mental-health services to the child who is accumulating their own ACEs, they, like their parents, will likely learn maladaptive behaviors, and create a new generation of children affected by ACEs. By understanding ACEs and confronting the generational problem, we can help a generation of youth avoid maladaptive behavior and the pitfalls of ACEs.
Beginning of ACE Research
In 1998, Kaiser Permanente and the Center for Disease Control (CDC) published, “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults.” This landmark study set the foundation for our understanding of ACEs today. The study involved roughly 9,500 adults at Kaiser’s San Diego Health Appraisal Clinic. The participants were sent a questionnaire about adverse childhood experiences, asking about psychological, physical, or sexual abuse, if the participant had witnessed violence against his/her mother, if household members were substance abusers, mentally ill or suicidal, and if a household member was ever imprisoned. The questionnaire then inquired into the participants’ current health and disease status, and it asked the participants whether or not they currently engaged in “high risk” behavior.
The study found that 52% of the participants reported at least 1 ACE, and 25% of the participants reported having more than 2 ACEs. 23.5% of participants indicated that they had an adult in the household who abused alcohol; 25.6% of participants were exposed to substance abuse during childhood. Alarmingly, the Kaiser-CDC study found that individuals who experienced four or more categories of ACEs had a “4 to 12-fold increased health risks for alcoholism, drug use, depression, and suicide attempt; a 2 to 4-fold increase in smoking, poor self-rated health, > 50 sexual intercourse partners, and sexually transmitted disease; and a 1.4 to 1.6-fold increase in physical inactivity and severe obesity.” The study concluded that the behaviors may also be consciously or unconsciously used as coping mechanisms in the wake of ACE based traumas. Along with those increased adult behaviors, the study found that adult participants were more likely to develop “heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.”
The Kaiser-CDC study results were staggering and alarming, giving an insight to the intense connection between childhood experiences and adult health like never before. It served as a call-to-arms for psychologists and healthcare professionals and demonstrated the urgency of further examination into the phenomenon of ACEs. Since its inception in 1998, ACE-based studies have become more prevalent.
What is an ACE score?
An ACE score is the total number of adverse childhood experiences youth experience before the age of 18. While traumatic experiences may not stop at age 18, the reasoning behind the age cutoff is that traumatic experiences will have less of an impact once the youth has reached the technical, legal definition of adulthood.
A person with an idyllic childhood may have an ACE score of 0. Conversely, a youth with a tumultuous upbringing could have an ACE score of 4 or greater.
What do ACE scores mean?
Generally, a higher ACE score indicates a higher likelihood of negative outcomes in adulthood. According to the 1998 Kaiser-CDC study, ACE factors drive high-risk behavior in adulthood and impact overall health. For example, when compared to individuals with an ACE score of 0, a person with 4 or more ACEs has 1.6 times greater chance of developing diabetes, 3.9 times greater chance of developing chronic bronchitis or emphysema, and 2.3 times greater chance of developing hepatitis.
More recently, a 2016 article from the American Journal of Preventative Medicine conducted an in-depth analysis of ACE scores based on the 2010 CDC Behavioral Risk Factor Surveillance System data. The study found that certain ACEs increased odds for certain high-risk behaviors in adulthood. For example, verbal abuse increased the odds that a person would develop binge drinking; victims of sexual abuse were 1.59 times more likely to develop adult obesity; and youth with incarcerated parents were 2.21 more times likely to develop HIV. The study concluded that participants who had 4 or more ACEs had “172% increased odds of comorbid conditions,” like diabetes, coronary heart disease, and depression compared to their peers with no ACEs. The study hypothesized that ACEs are associated with higher odds of criminal and “high-risk” behavior as a “dose-response effect of increasing exposure” of trauma in childhood.
Emerging science has discovered that a child’s brain has physiological changes when exposed to traumatic events, and as a result of these changes, they may have develop maladaptive behavior and have difficulties controlling impulses. Youth with high ACE scores not only develop neurological differences, but recent research has shown that neglected youth experience epigenetic changes that leave them predisposed to develop future health problems. It is hypothesized that these changes are caused by the body’s physiological responses to cope with trauma, but there has been a lack in communication between neurobiologists and social scientists in regard to biological findings and behavioral expression. More troubling, the findings have yet to be implemented to help youth with ACEs receive better treatment. (For more information on individual studies regarding changes in brain development due to childhood trauma, see The Journal of Child Psychology and Psychiatry “Enduring neurobiological effects of childhood abuse and neglect” and The Journal of Mental Health Counseling “Adverse Childhood Experiences, Brain Development, and Mental Health: A Call for Neurocounseiing.”
What are common ACEs?
According to the Kaiser-CDC study, ACEs are divided into three categories: abuse, household challenges, and neglect. Each category is then broken down into further subsections, for a total of 10 original ACEs. (Today, ACEs have grown beyond the 10 original types. Therefore, the data from the Kaiser-CDC may be underinclusive when considering the expanding criteria.)
How are ACEs tested and compiled?
ACE scores are generally tested by healthcare providers or through government health agencies. For the initial Kaiser-CDC study, a three-part questionnaire was given to participants. The initial section inquired about the participant’s general health and asked if any specific conditions existed. The next section asked what high-risk behaviors the participant engaged in. The final section asked the participant about certain events that may have occurred before their 18th birthday; those events were based on the ACE trauma categories of abuse, household challenges, and neglect.
ACE questionnaire testing has experienced difficulties with the reliability of its participants. As the Kaiser-CDC study admitted, many of the ACE scores may be underreported as adults “forget” or repress traumatic experiences from childhood. This is caused by a desire to “rewrite” or suppress a tumultuous childhood. If participants are unable to accept and admit instances of trauma, it makes the process of ACE identification and treatment very difficult. ACE testing has faced criticisms globally as researchers in China have pointed out that ACE research omits developing countries and may be underrepresenting a large group of abused youth. A similar type of omission may have affected the Kaiser-CDC study, as its participants were taken from a population who had private healthcare insurance. It required that the ACE participants be Kaiser Permanente members throughout the entirety of the study. Adults suffering from ACE related trauma who were unable or unwilling to purchase Kaiser healthcare were omitted by the initial study. While there is not a clear link between ACEs and financial stability, there is a link between ACEs and poverty. Individuals in low-income areas are more likely to experience environmental ACEs and have a higher ACE score. Many individuals struggling in a low socio-economic area are not in the financial position to afford private healthcare, like Kaiser Permanente. This may have skewed the Kaiser-CDC initial reporting of the prevalence of ACEs as individuals with detrimental high-risk behavior, who likely have very high ACE scores, were not in the financial position to afford private healthcare and went unreported.
How many people have ACEs?
According to the 2012 Attorney General’s National Task Force on Children Exposed to Violence report, 46 million children in the United States will be exposed to violence, crime, and abuse annually. Of those children who are exposed to situation trauma, 2/3 of those children have an increased probability of developing at least one ACE annually.
In 2013, the California Department of Public Health conducted a telephone survey called the Behavioral Risk Factor Surveillance System. The survey found that 62% of Californians had at least one ACE before age 18. Furthermore, the study found that 16% had an ACE score of 4 or more. The range of reported ACEs also varied depending on ethnicity. The Aleutian, Eskimo, and American Indian participants reported the greatest population percentage of individuals carrying 4 or more ACEs, trailed by African American and Hispanic populations. The ethnicity with the lowest indication of ACE trauma was the Asian/Pacific Islander category: 58% of Asian/Pacific Islander participants reported having 0 ACEs, while only 7% reported having an ACE score of 4 or more.
In 2019, researchers from Ohio State University, the University of Pittsburg, and the University of North Carolina continued researching the link between ACEs and race. They found that African American children were more likely to experience ACEs at a greater rate than White and Latinx children. On the other hand, it found that White youth were more likely to experience parental drug use in comparison to their African American counterparts. Additionally, the study also found that 45% of African American youth had 1 ACE by their first birthday; 43% of white youth experienced their first ACE by age 10. A 2017 study by the Child and Family Policy Center and the Center for the Study of Social Policy explained the link between ACEs and race, noting that environmental factors, like neighborhood violence and criminality of the area, not only have a connection to higher ACE scores but also race. For example, if a child is in a low socio-economic area that is riddled with crime and violence, then they are more likely to have experienced ACEs relating to criminality, abuse, and violent trauma.
Why do ACE scores matter?
ACE scores are an important tool an indicating future challenges in adulthood. By understanding ACE scores, we can address the problems that ACE scores present. According to the 2012 Attorney General’s Task Force study on violence, the predicted cost of violence and abuse to the American healthcare system will be $333 billion to $750 billion annually. Furthermore, there is a great financial burden on the child welfare system, social services, law enforcement, criminal justice, and education systems. While it’s possible to give an accurate figure to the amount of money that trauma related issues cost various systems, it is impossible to accurately measure the amount of money that is lost due to the loss of citizens participating in the economy. ACEs affect everyone regardless of their own ACE score.
Incarceration as an ACE factor
According to Rutgers University’s National Resource Center on Children and Families of the Incarcerated, more than 2.7 million children in the U.S. have a parent who is incarcerated. By age 18, nearly 10 million children have experienced parental incarceration. While these statistics are based on instances of formal incarceration, it does not reflect parents who are temporarily held in custody or removed from the home. For example, parents who are temporarily arrested but then released, do not have charges filed, have charges dropped, or win their case may not figure into the number of “incarcerated” since they are in the court process that will designate their status as free or formally incarcerated. Therefore, it is likely that the actual number of children who have an ACE from parental arrest is much higher than current statistics suggest.
When the groundbreaking Kaiser-CDC study was conducted in 1998, only 3.4% of participants indicated that they had exposure to criminal behavior by an adult in their household. However, adults (those 18+) who participated in the questionnaire likely reached the age of 18 before the “War on Drugs” made a dramatic impact on prison populations. The “War on Drugs” started in 1982. Since its inception, the number of people incarcerated for drug offenses rose from 40,900 people in 1980 to 450,345 people in 2016. Additionally, “mandatory minimums,” which changed sentencing laws, gave those convicted of drug offenses longer prison terms. According to The Sentencing Project, not only are people in jail in unprecedented numbers, but people are sentenced to longer sentences. Sentencing has not only increased for narcotic offenses, but the rates of people sentenced to prison for property and violent crimes have also increased. The increase in arrests, conviction, and longer sentencing created an absentee generation of parents. The children of these parents were now more susceptible to poverty, neglect, and abuse- all ACEs. The Health Resources & Service Administration’s 2016 National Survey of Children’s Health ACE study found that 8.2% of youth had experienced the ACE of parental incarceration and out of that subsection, 90.6% of those children had additional ACE scores.
Children with incarcerated parents are more likely to have higher ACE scores than youth whose parents have not been incarcerated. According to research out of the University of California, Irvine, the 2016 National Survey of Children’s Health ACE study showed that children exposed to parental incarceration were seven times more likely to experience another ACE than their peers not exposed to incarceration. Children with incarcerated parents are more likely to suffer from additional ACEs because many adverse experiences are, by their very nature, criminal experiences that will trigger legal response and intervention. For example, children whose parental guardians are arrested for narcotics or alcohol offenses will also an ACE for alcohol or narcotic use in the home. Alarmingly, the study found that participants with the ACE of parental incarceration were 8 times more likely to experience household member substance abuse problems, 6 times more likely to experience household member abuse, 5 times more likely to experience exposure to violence, and 4 times more likely to experience parental divorce or separation.
Parental Incarceration and Foster Care Youth
While the statistics for parental incarceration are alarmingly high, one group of youth are affected at greater rates than their peers. 40% of children in the foster care system have experienced the ACE of parental incarceration. This means that youth who are in foster care due to parental incarceration are more susceptible to acquire additional ACEs. The Health Resources & Service Administration’s 2016 National Survey of Children’s Health ACE study found that 8.2% of youth had experienced the ACE of parental incarceration and out of that subsection, 90.6% of those children had additional ACE scores.
For example, if a caregiver is arrested for drug possession or driving under the influence, it is highly unlikely that their interaction with law enforcement is the first time they have ever used drugs or alcohol. By the time that an addiction or substance abuse has triggered law enforcement intervention, it has likely become an issue that the caregiver can no longer keep hidden in the home. Unfortunately, in the meantime, the child has been living with their caregiver struggling with an addiction and now have the additional ACE of substance abuse in the home.
The U.S. Department of Health and Human Services releases annual statistics regarding children in the foster care system. The Adoption and Foster Care Analysis and Reporting System (AFCARS) data gives an in-depth breakdown of the number of youth in the foster care system, their ages, and how they entered the system. In 2017, 690,548 children were served by the foster care system. Of these children, 348,517 were removed for circumstances that directly relate to parental incarceration. For example, 20,131 youth were removed due to parental incarceration; 14,684 youth were removed for parental abuse of alcohol; and 96,720 were removed for parental abuse of narcotics. By the time Child Protective Services is called for reasons of parental abuse of alcohol abuse or narcotics, law enforcement has already made contact with the parent and incarceration, to some extent, has occurred. The statistics also include into the number of youth removed for parental neglect: 166,991 children annually.
The ACE of parental incarceration is like a large web that includes many additional ACEs and factors for child removal. Not only are youth with incarcerated parents more likely to 7 times more likely to have additional ACEs (like parental abuse of drugs, alcohol and neglect), but the very process of parental arrest and incarceration is averse to childhood development. It is important to view parental incarceration as the thread that can unravel a host of other adverse experiences. We must use the opportunity of parental incarceration to provide the best services to caregiver and child, to alleviate past trauma and prevent future harm.
Foster Care System and ACE Testing
By the time a child enters the foster care system, they have had an encounter with Child Protective Services (CPS). Traditionally, CPS intervention is commonly associated with physical and sexual abuse of a child. However, that is rarely the case; the majority of children are removed for issues of neglect. When a caregiver is incarcerated, CPS is often called to the home to investigate on the wellbeing of the child, as now the child falls into a de-facto category of neglect, being without an adult to provide care. When CPS is dispatched to investigate a report of child abuse or attend to a child who is left without a caregiver due to the parent’s incarceration, they conduct interviews with the child as part of an intake process. According to Child Protective Services’ 2018 Guide for Caseworkers, the intake process is the agency’s first stage of the CPS process and is one of the critical decision-making points in the child protection system. At intake, the child and caregiver(s) are asked questions by CPS screening agents about their immediate physical and emotional well-being, relationships inside and outside the home, and the alleged mistreatment that triggered CPS intervention. Based on the screening proceeding, if immediate intervention is not needed, the CPS agent will ask more questions in a subsequent intake meeting. Once the agent speaks with the child, caregiver(s), and other residents of the home (including siblings and other cohabitants,) the agent will determine whether ongoing services, through the agency or the community, are necessary to help the parenting capacities of the caregivers to provide for the child’s safety and well-being in the future. At this point, a CPS agent is also supposed to “explain the agency’s role to the children and families and serve as advocates to help them receive the best possible services from the agency and/or community.”
CPS tries to fulfill their role of helping families by identifying familial needs and matching those needs with suitable services to try to ensure their success. CPS identifies familial problems and needs through the intake meeting’s interview process. The CPS Guide for Caseworkers provides examples of information that CPS workers should gather from each source. (Child Protective Services’ 2018 Guide for Caseworkers, pages 69-74). The majority of the questions, reasonably, are focused on the alleged maltreatment and the examples of information are given in topical breakdowns. Only one subtopic recommends the CPS agent ask the caregiver about their “[h]istory as a child (positive and negative memories), educational and employment history, any criminal activity, or history of physical or mental health problems.”
While it’s reasonable that a great deal of the interview questions would focus on the alleged maltreatment, there should be more questions directed at the childhood experiences of youth and caregivers in order for CPS to effectively match them with the best possible services from the agency and/or community. Although there has been a push for a trauma-informed response, with heightened awareness of ACEs and their effects, the 2018 Child Protective Service Guide has the same interview topics for children and caregivers that was provided to CPS caseworkers in the 2003 Child Protective Services Guide for Caseworkers (pages 52-57).
Given the effect of ACEs on maladaptive adult behavior, CPS is missing an opportunity to assess and try to prevent future harm, through the use of ACE tests, when they fail to inquire into about the caregiver’s history. While generalized topics can be useful to point CPS agents in the right direction to gather useful information, it leaves too much discretion to the individual caseworker and increases the chances that useful information, provided by an ACE test, will be omitted. As I will discuss in a later post, implementing the standardized, 10-question ACE test into CPS intake interviews can help CPS match children and parents into better services, helping parents with difficulties keep their children out of foster care and helping youth in foster care gain access to the services they need based on their trauma.
While I’ve discussed the scientific background of ACEs, it is somewhat difficult to contextualize the gravity of ACEs without reading the testimony of someone affected by ACEs. For that reason, my next post will contain the testimony of an individual who experienced adverse childhood experiences in his upbringing and illustrate how traumatic experiences affected his behavior as an adult.