It's dramatic enough to learn that 66 percent of a large, representative sample of a middle-class, predominantly white, educated population with good health insurance has suffered maltreatment and/or family dysfunction as children. But it's positively astounding to see laid out, again and again, the profound relationship between childhood adversity and so many of the mental, physical, and social disorders plaguing our society. As of fall 2009—15 years since the ACE project began—60-plus different peer-reviewed studies had been published, with about 10 more in the works, not to mention probably scores of other non-ACE-related studies, demonstrating connections between childhood adversity and adult health.
Intuitively, it seems obvious that childhood adversity increases the risk for mental and emotional problems in adult life—and so it proves. People with higher ACE scores (let's call them "Acers") suffer disproportionately from chronic depression and suicidality. A person with an ACE score of 4, for example, is 4.6 times likelier to be depressed than a person with a score of 0; a male child with an ACE score of 6 is 46 times as likely to use intravenous drugs in adulthood than one who scores 0. Acers suffer more from anxiety, panic reactions, poor anger control, sleep disturbances, dissociation, hallucinations, alcoholism, drug addiction, and somatization. ACE-related research demonstrates that childhood trauma and neglect are strongly associated with personality disorders, particularly borderline personality disorder. Again, ACE studies, as well as other research, indicate that the greater the number of traumatic stressors, the higher the risk for psychiatric illnesses.
What wasn't—and still isn't—so intuitive is that ACE scores have a vast and profound influence in the development of biomedical conditions, even half a century after the childhood events occurred. Childhood adversity radically increases the risk for physical illnesses and disabilities, including heart and lung disease, autoimmune disease, liver disease, cancer (48 percent greater chance), diabetes, sexually transmitted infections, HIV, hepatitis, and chronic pain. It's shocking to learn, though it probably shouldn't be, that ACEers with a score of 6 or more die, on average, two decades earlier than those with a score of 0.
Part of the reason that Acers develop so many biomedical disorders is that, as these studies repeatedly confirm, maltreated children are much likelier to become hooked on the self-soothing habits—smoking, drinking, overeating, promiscuous sex, drug abuse—that are known risk factors for most illnesses. Compared with male children with an ACE score of 0, for example, those with a score of 6 are 2.5 times as likely to smoke and 46 times as likely to use drugs, while those with a score of 4 carry 5 times the risk of becoming an alcoholic and 12 times the risk for suicide attempts. As Felitti and Anda point out, this all makes perfect sense—long-term addictions temporarily "fix" problems like anxiety, fear, anger, depression, low self-esteem, loneliness, and despair, although at sky-high risk to health and longevity.
Particularly compelling is that high ACE scores are correlated with diseases, including cancer, coronary artery disease, and chronic obstructive pulmonary disease, even controlling for or without conventional risk factors like smoking, air pollution, or high cholesterol. In other words, diseases that were once considered exclusively hard-core structural, biomedical conditions arising in adulthood may have unsuspected origins many decades earlier in physiological stress reactions arising from childhood abuse and trauma—as Felitti says, "a very big concept."
As a result of the ACE study, childhood adversity and its lifetime effects on health and well-being are often cited as America's most important public health issue. You would think, therefore, that this research, generating a virtual cottage industry of studies over the past 15 years, must have revolutionized the American medical system and the way physicians approach patients. You would, of course, be wrong. Felitti, as you might expect, receives numerous invitations to speak at professional medical meetings with audiences of hundreds. As the presenter, he clearly sees the faces of his listeners and their reactions to what he's saying. Predictably, he notes, 8 or 10 minutes into his presentation, these upturned faces collectively express "a level of anguish that exceeds anything attributable to what you'd expect from a purely empathic response." Several will leave the room in fits of spastic bronchial coughing, he adds. Felitti believes this is at least partly due to personal ghosts in their own lives: maybe pungent memories of their own childhood difficulties being awakened.
Overall, Felitti finds a lot of intellectual interest in what he's saying, but minimal real engagement. In fact, it isn't easy to imagine, under the present system, an internist or gastroenterologist or cardiologist, seeing perhaps 20 to 30 patients a day—most absolute strangers—pausing during a brief, standardized interview and casually saying, "I notice from the questionnaire you filled out that you were molested by your father for seven years starting when you were 6—um, do you want to tell me something about that?" Felitti finds doctors' automatic, defensive response to the suggestion that they explore childhood stressors quite understandable, since they're unprepared to dive into such turbulent waters. He often hears reactions like, "We can't do that, open Pandora's box. I only have twenty minutes, not three hours,' or, 'Patients would be furious if you asked questions like that,' or 'If I'd wanted to be a shrink, I'd have been one.'"