CDC: Too Many Adverse Childhood Events

Adverse childhood events (ACEs), such as emotional abuse, domestic violence, or incarceration, were commonly reported by U.S. adults, and these events were associated with the later development of many of the country’s leading causes of death, according to CDC survey data.

Of 144,017 individuals who completed a phone survey, those who reported at least four ACEs (15.6%) had a higher risk for all measured conditions, including coronary heart disease (CHD, adjusted odds ratio 1.8, 95% CI 1.3-2.1), obesity (aOR 1.2, 95% CI 1.1-1.3), and chronic obstructive pulmonary disease (aOR 2.8, 95% CI 2.5-3.1), reported James Mercy, PhD, of the CDC National Center for Injury Prevention and Control in Atlanta, and colleagues.

Those with four or more ACEs were also more likely to report depression (aOR 5.3, 95% CI 4.9–5.7) and socioeconomic hardships, such as unemployment (aOR 1.7, 95% CI 1.5–2.0), compared with people who did not report ACEs, they wrote in a new Vital Signs publication in the CDC’s Morbidity and Mortality Weekly Report.

“One of the really important issues is that when these cases occur in the absence of adult support, their impact can be even greater,” Mercy said in a conference call with the media. “It really gets to the issue of prevention and the need to support safe, stable, and nurturing relationships for all children.”

Using national disease estimates from 2017, researchers estimated that preventing ACEs would have potentially resulted in up to 1.9 million avoided cases of CHD and 21 million cases of avoided depression, said Anne Schuchat, MD, CDC principal deputy director, during the conference call.

“Behind their impact on health, ACEs also negatively affect life opportunities like completing high school or future employment,” Schuchat said. “For example, using the same 2017 national estimates, preventing ACEs could have kept up to 1.5 million students from dropping out of school.”

While ACEs are strongly associated with many negative outcomes, there are evidence-based interventions that can mitigate these outcomes, Schuchat said. These include mentoring and enrichment programs, or interventions such as the Safe Environment for Every Kid (SEEK) program, which has been shown to reduce child maltreatment.

“Children’s positive experiences, relationships, or other protective factors and interventions, can strengthen resilience and reduce behavioral health consequences even after ACEs have occurred,” she said.

Physicians have an important role to play in screening and addressing ACEs, but many do not routinely ask about such events, primarily due to a lack of training or clinical time constraints, wrote Christopher Jones, PharmD, DrPH, MPH, also of the CDC National Center for Injury Prevention and Control, and colleagues, including Melissa T. Merrick, PhD, one of the Vital Signs report authors.

“Clinicians should realize that some patients who have experienced ACEs may not be achieving optimal outcomes for their health conditions due to the physiological and psychological effects of toxic stress,” they wrote in an accompanying JAMA Viewpoint. They added that incorporating trauma-informed care may help attenuate the effects of ACEs.

The Vital Signs report included 2015-2017 data from the Behavioral Risk Factor Surveillance System, a 25-state telephone survey including questions about physical, emotional, and sexual abuse, as well as household substance misuse, incarceration, mental illness, divorce, or domestic violence, collectively referred to as ACEs.

Of the 144,017 respondents, 60.9% reported experiencing at least one such ACE. Although the prevalence of ACEs was similar between sexes, women were more likely to have four or more ACEs than men (17.1% vs 13.9%) as were black, American Indian/Alaska Native, and those who responded “Other” to the race/ethnicity question compared with white individuals (17.7%, 28.3%, and 28% vs 15%). Lastly, ACEs were also more common among younger versus older adults.

“The higher risk among the younger groups could be due to differences across cohorts in risk, willingness to disclose, or ability to recall adverse childhood experiences,” Mercy and colleagues wrote. “Increased mortality among those with higher adverse childhood experiences could also contribute to this pattern.”

If ACEs were prevented, the authors estimated the number of adults with heart disease would be reduced by 12.6%, the number with depression by 44.1%, and the number who were overweight or obese by 2%. By preventing ACEs, the number of people unemployed could be reduced by 15%; smoking and heavy drinking could also be reduced by 33% and 24%, respectively, across the population, they added.

The data in this report were self-reported and due to its cross-sectional nature, a causal link cannot be assumed, the authors noted. The findings also come from half of the states in the U.S. which limits their generalizability. Also, the authors did not control for factors contributing to ACE prevalence and certain outcomes, such as socioeconomic status.

Schuchat said the CDC is still building an evidence base regarding programs to prevent ACEs from occurring, but that they recently released a report that provides six strategies for parents, communities, and providers to prevent them.

“The bottom line is this: adverse experiences in childhood produce toxic stress that can impact people all their lives,” Schuchat said. “But adverse childhood experiences are potentially preventable.”