12 Myths of the Science of ACEs

The two biggest myths about ACEs science are: 

MYTH #1 — That it’s just about the 10 ACEs in the ACE Study— the CDC-Kaiser Permanente Adverse Childhood Experiences Study. It’s about sooooo much more than that.

MYTH #2 — And that it’s just about ACEs…adverse childhood experiences.

These two myths are intertwined. The ACE Study issued the first of its 70+ publications in 1998, and for many people it was the lightning bolt, the grand “aha” moment, the unexpected doorway into a blazing new understanding of the link between childhood adversity and the adult onset of chronic disease, mental illness, violence and being a victim of violence, among many other surprising consequences. Most people don’t realize that the original ACE questionnaires had more than 100 questions, and explored many aspects of a person’s family history. To make things easier to grasp, one of the people working with Drs. Robert Anda and Vincent Felitti, the co-principal investigators, came up with the suggestion for a shortened version, and the 10 ACEs and the ACE score were born. By the way, Anda and Felitti recognized that there were many other ACEs than those they chose to look at — including racism, bullying, a father being abused, and community violence — but they settled on those ten because they were identified as common in a pilot study of about 300 people; several of the adverse experiences — such as sexual abuse and physical abuse — had been individually well studied.

Since the original ACE Study was done, there have been many other surveys and studies, and many of those have expanded the types of ACEs. Based on the other parts of ACEs science, we now know that any experience that results in toxic stress can be regarded as an ACE. So, we put together this infographic to show the three realms of ACEs:

1. Family
2. Community
3. Climate crises
   
   

This infographic expands the types of experiences in the original ACE Study and combines them with the “Pair of ACEs” described by Wendy Ellis, director of Building Community Resilience Collaborative and Networks, and adverse experiences from climate crises, which are sure to increase over the next several decades. The truth of the matter is that the experiences listed in the three areas in the infographic can all cause harm to children’s brains and bodies. How they recover — or cope — depends on the supports provided them after the experience.

There’s no doubt that the ACE Study is an easy door to go through to begin to explore the mind-bending, world-changing knowledge of ACEs science, but there was so much more going on before, during and after the ACE Study was first published. The story of that evolution is for another time. For this post, it’s important to grok that around 2012, give or take a couple of years, among leaders of the ACEs movement, ACEs science jelled into what it is today — an interlocking matrix of five areas of complementary research:

• The ACE Study and subsequent ACE surveys that show how many people experience ACEs, at what levels, and the consequences (epidemiology).
• How toxic stress from ACEs damages children’s developing brains (neurobiology or brain science).
• How toxic stress from ACEs affects our short- and long-term health.
• How we pass ACEs from generation to generation through our genes (epigenetics).
• And how resilience research shows that our brains are plastic and our bodies can heal through implementing protective factors and resilience-building practices based on ACEs science.

The other 10 myths:

MYTH #3 — The ACE Study findings are just about figuring out your ACE score. It’s more complicated. And eye-opening.

1. ACEs are surprisingly common — 64% of the 17,000 in the ACE Study had one of the 10 ACEs; 12 percent had four or more. 
2. There’s an unmistakable link between ACEs and adult onset of chronic disease, mental illness, violence, being a victim of violence, and so much more, including more broken bones (from thrill sports). 
3. The more types of childhood adversity, the direr the consequences. An ACE score of 4 increases the risk of alcoholism by 700%, attempted suicide by 1,200%; it doubles heart disease and lung cancer rates. 
4. ACEs contribute to most of our health problems, including chronic disease, financial and social health issues.
5. One type of ACE is no more damaging than another. An ACE score of 4 that includes divorce, physical abuse, a family member depressed or in prison has the same statistical outcome as four other types of ACEs. This is why focusing on preventing just one type of trauma (stopping sexual abuse) and/or coping mechanism (stopping smoking) won’t ever eliminate that trauma or coping mechanism.
   
   

MYTH #4 — If you have ACEs, you’re doomed. If you have no ACEs, you’re fine. The brain is plastic. The body wants to heal. No matter who has ACEs — kids or adults — it’s not too late to heal. Understanding ACEs science is the first step, because that leads to understanding that you weren’t born bad, you had no control over your childhood, the way you coped was appropriate because you weren’t given healthy alternatives, and you can heal. Recent research shows that if you have protective factors in your childhood along with ACEs, you do much better than people who have ACEs and no protective factors. And here’s something interesting: if you have no or low ACEs, that doesn’t mean life is a bed of roses. Without protective factors, you do worse than someone with ACEs and protective factors. Those protective factors are crucial to health and well-being.   

MYTH #5 — Screening should be done everywhere. Not necessarily. When you want to know the burden of ACEs and the promise of protective factors in a community, a school, an organization — and it’s extremely useful to know what the ACEs burden is, as well as the level of protective factors — an anonymous ACE and resilience survey is enough.  But in healthcare an individual's score is useful for treating and following patients. In both circumstances an ACE questionnaire should never be done without explaining ACEs science. Some people don’t think ACEs screening should become common, and often say, “What if insurance companies start screening for ACEs to determine insurance rates?” Well, we’re hoping to build enough of a movement so that insurance companies would have to look at the ACEs in their own organization first, before using it in a nefarious manner.

MYTH #6 — Physical and sexual abuse are the worst ACEs. The brain can’t distinguish between different types of ACEs — once the experience goes into the brain, it’s toxic stress. The ACE Study showed that it doesn’t matter what the types of ACEs are. An ACE score of 4 that includes divorce, physical abuse, an incarcerated family member and a depressed family member has the same statistical outcome as an ACE score of 4 that includes living with an alcoholic, verbal abuse, emotional neglect and physical neglect. “We studied a whole range of outcomes — emotional, social, financial, biomedical, etc. If someone had an ACE score of 2 or 4 or 7, it didn’t matter how you made the ACE score up. It didn’t matter.That was unexpected and a surprise,” says Felitti.

MYTH #7 —You don’t need to learn about ACEs science if you’re becoming trauma-informed. We know organizations that skipped over the ACE Study, included a little bit of brain science, and went right to implementing a trauma-informed approach. But that approach is not going to get an organization to be as successful as it could be if it integrated ACEs science.

MYTH #8 —You can’t ask someone about ACEs because you’ll traumatize them. When the ACE Study was going through the design and approval process, the institutional review board that decided if the study could be done turned it down at first because they thought that people would have what is known in layperson’s terms a “nervous breakdown” if they were asked the questions. To receive approval for the study, a person on the research staff was required to wear a pager 24-7 for the dozens, perhaps hundreds of people the review board thought would be needing emergency care. Not one person called this hotline. However, although anyone can do the 10-question ACE survey online — it’s in lots of places (e.g., NPR, here) — it’s NOT a good idea to introduce ACEs science in a staff meeting by requiring everyone to take the survey first. The trauma-informed approach is to educate people about ACEs science, make time for questions and discussion, then do the survey anonymously. And always have someone there available to talk with people who have their lives suddenly altered by the knowledge and want to talk about how it’s affecting them. It happens. Some therapists have been reluctant to ask their patients about ACEs. But what better place to address ACEs than with a therapist?

MYTH #9 — For physicians to start asking about ACEs, they need to have a therapist on staff. When Felitti realized the power of the ACE survey, he integrated it into the Health Appraisal Center at Kaiser Permanente in San Diego. Over the next few years, more than 440,000 patients who came through the center took the survey. He didn’t have a therapist on staff. For a while, a therapist had a temporary office in his clinic, and the nurse-practitioners called on him when necessary. It turns out that just the act of listening and acknowledging can make a difference — in the only study that’s been done on this, of 125,000 people who went through his center, there was a 35% drop in doctor visits and an 11% in visits to emergency rooms.

Felitti wrote:

It turned out that asking, listening, and accepting are a powerful form of doing that appears to provide great relief to patients. A common interchange was for the examiner to remark, "I see on the questionnaire that ...... (your father killed himself / you were raped / you were frequently beaten as a kid). Can you tell me how that has affected you later in your life?"

It took patients only a minute or two to describe how their childhood trauma affected them later in life. Their responses were to the point and usually helpful to understand what might be done. 

MYTH #10 — There’s no difference in being trauma-informed or ACEs-science informed. Being ACEs-science informed is the bedrock, the foundation of becoming trauma-informed. You need both. ACEs science is the WHAT and WHY. Trauma-informed is the HOW. If we do only the how, becoming trauma-informed risks becoming a fad, especially if implementing trauma-informed practices without ACEs science shows only slight improvement.

MYTH #11 — Since ACEs only happen during childhood, we only have to focus all our resources on kids and we’ll solve our problems. Research shows that parents pass their ACEs on to kids, so you have to involve parents. If parents address their ACEs, learn about ACEs science, and get help, they get healthier, and, as a result, their kids get healthier. What causes ACEs? Toxic stress. And since toxic stress appears in the community and the environment, parents won’t get as healthy as their kids need them to be until the organizations and systems they work for and interact with, the communities they live in, and the nations they’re part of stop traumatizing already traumatized people, and start healing. The early ACEs science pioneers have shown that we can solve our most intractable problems, but we won’t solve our most intractable problems unless all organizations, systems in all sectors, all communities and nations integrate trauma-informed practices based on ACEs science.

MYTH #12 — We need to address ACEs only in poor people of color who live in urban areas, because they’re the demographic with the highest burden of ACEs. This just further exacerbates the them-us culture we’re all living in now, and is remarkably short-sighted. ACEs are everywhere, in all demographics. And people with ACEs in power — which in the United States are mostly white men who come from middle-class and upper middle-class backgrounds — can and do act out their ACEs by abusing people individually and by the policies that they create, either in the organizations they lead or the positions they hold in public service. You can find many examples of leaders in the business, faith-based, healthcare, entertainment, political and other arenas who have done so, and are doing so, due to their own ACEs. So it's just as important to educate kids and their parents in Palo Alto High School in Palo Alto, CA., about ACEs science as it is kids and their parents in McClymonds High School in Oakland, CA.

ACEs are everywhere, but, generally speaking the people with the least burden of ACEs are those who have the most power, because they have the most resources. Those with the greatest burden of ACEs are those with the least power and the fewest resources, no matter what country you're talking about. Traditionally, the people in power create a social structure that keeps those without the power as powerless as possible by instituting racism, sexism, classism, etc.

The promise of ACEs science is that we humans finally understand that these "isms" harm everyone — the powerful and the powerless — and that it's better for everyone to institutionalize sharing. Yeah, I know — much easier said than done. But now we have — and are accumulating more — scientific evidence, and, just like the increasing evidence for climate disruption, that genie won't be put back in the bottle.