In looking at the impact of childhood trauma, you can’t get much clearer than this: In 2017, ACEs among Tennessee adults led to an estimated $5.2 billion in direct medical costs and lost productivity from employees missing work.

That’s just one year, according to the new report, “The Economic Cost of ACEs in Tennessee," released on Feb. 1, 2019 by The Sycamore Institute in Nashville, Tenn. And to provide some perspective, $5.2 billion is one-seventh of the state’s annual budget. This $5.2 billion doesn’t even include other consequences of childhood adversity, such as the cost of jails and prisons (most of those incarcerated have high ACE scores), juvenile detention facilities, law enforcement and courts. 

The report’s short — just 10 pages, and five of those are references and methodology. The report tells most of the story through its graphics, included in this post. In addition to the $5.2 billion annual cost —something that should stop every employer in her tracks — the report’s other main points are:

• Adverse childhood experiences (ACEs) can increase a person’s risk of health, social, and economic problems throughout life.
  
  
• ACEs are associated with risky health behaviors and poorer health outcomes even after accounting for other factors.
  
  
• Over half of adult Tennesseans reported at least one ACE between 2014 and 2017, and about 17% had experienced 4 or more.

“I assumed that the effects of ACEs were going to be expensive,” says Dr. Courtnee Melton, a policy analyst at The Sycamore Institute who learned about ACEs science when she interviewed for her position 28 months ago. “I’d read a report that was done for Alaska that helped inform our work, so I wasn’t

shocked.” Alaska took a slightly different slice of the economic costs of ACEs and found that the state spends $777 million a year just on obesity, arthritis, binge drinking, diabetes, smoking and Medicaid. (Alaska has a population of 730,000; Tennessee has 6.7 million people.)

ACEs comes from the groundbreaking CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study), which links 10 types of adverse childhood experiences (ACEs) to adult onset of chronic disease, mental illness, violence or being a victim of violence. ACEs include experiencing physical, sexual or emotional abuse; living with a family member who abuses alcohol, or drugs or is mentally ill; experiencing divorce, and having a family member who is incarcerated. (ACEs science 101)

The study of 17,000 mostly white, college-educated Kaiser patients, all with jobs and great health care, showed that two-thirds experienced at least one ACE. Health and economic problems can become dire after a person accumulates three or four ACEs. A person with an ACE score of 4 doubles the risk of heart disease and cancer, is seven times more likely to be addicted to alcohol, and 12 times more likely to attempt suicide. Subsequent ACE studies have included groups of color and expanded the types of ACEs. Examples of additional types of ACEs include questions about being bullied, experiencing community violence and racism, living in a war zone, having a family member deported and being involved in the foster care system. (Got Your ACE Score?)

The reason why people smoke, overeat, abuse alcohol or other drugs or engage in other unhealthy behavior is that the toxic stress from ACEs leads them to seek relief in ways to cope with the stress. This toxic stress damages our brains when we're young, which can lead to coping behaviors and ill health when we're adults. We can pass this toxic stress on to our children, just as it has been passed on to us. The good news, as the report indicates, is that our brains are plastic and our bodies want to heal: Given a safe place and support to recover, we will.

Melton began working on the report one year ago. “We have other papers that we’ve baked an ACEs lens into,” says Laura Berlind, who became executive director of The Sycamore Institute when it was founded in 2015. “I learned about ACEs when I was executive director of a drug treatment program. I was blown away. It transformed the way we were doing our work. It became a high priority for me to work ACEs science into policy.”

A recent example of that is their report, The Opioid Epidemic in Tennessee: 2018 Update on New Policy Actions. Included in the new policies adopted by the Tennessee General Assembly and the administration of former Governor Bill Haslam were a focus on education, data, neonatal abstinence syndrome, and adverse childhood experiences (ACEs).

Since an institute report in 2017 about the economic costs of chronic disease “opened a lot of doors in the business community,” says Brian Straessle, the institute’s communications director, he hopes this report will do the same.

“This report is a first in a series that we’re going to do in 2019,” says Berlind. “We’ll be doing a deeper dive on the data that is available.” One area to investigate is the impact of other types of ACEs.

The Philadelphia ACE Study, for example, looked at five other ACEs. According to the study:

“Philadelphia's demographic makeup looks significantly different than the original study, in which the majority of participants were white, college-educated, and middle-income. In Philadelphia, where roughly a quarter of residents live in poverty, researchers found that almost seven in ten adults had experienced one ACE and two in five had experienced four or more.

“The community-level indicators included witnessing violence, living in foster care, bullying, experiencing racism or discrimination, and feeling unsafe in your neighborhood. Researchers found that almost 40 percent of Philadelphians had experienced four or more of these expanded, community-level ACEs.”

Tennessee has made enormous strides in awareness and integration of ACEs science. Local ACEs initiatives have sprouted across the state, including in Memphis, Nashville, Chattanooga and northeast Tennessee. The success of a Memphis parenting initiative — Universal Parenting Places — that grew out of the ACE Awareness Foundation, drew the interest of high-level state officials and helped inspire a state initiative, “Building Strong Brains Tennessee.” The Governor, First Lady, and Supreme Court Chief Justice joined other top officials, lawmakers, mayors, doctors, business executives and educators for a state ACEs Summit in 2015. This meeting launched a campaign to change the culture of childhood trauma and make Tennessee the first U.S. state to aspire to change public policy to become trauma-informed.

Building Strong Brains Tennessee focuses on brain science and communication science. The state provides seed funding for community innovations in multiple sectors and created a Public Sector Steering Group to involve child-serving agencies. Tennessee has done two Behavioral Risk Factor Surveillance Surveys and issued the report “ACEs in TN: Fact NOT Fate” in 2015.

It’s only been a few days since the report on the economics of ACEs was published, but emails have been flying into the institute staff’s email — from the State Administrator Office of the Courts, the East Tennessee State University School of Public Health, and the Children’s Hospital Alliance of Tennessee, among others — with kudos and requests for presentations about the report’s findings and implications.

“We want people to be using the information in their work,” says Berlind. “We want them to be thinking about ACEs policy solutions. Many folks have been learning about this for a long time; it’s not a surprise to them. But one thing we talk a lot about here is resisting the silver bullet approach.

“We want people to talk about more than education,” she continues, pointing out that all of the state’s problems have ACEs science as a foundation, and they are all related. “ACEs science is giving people a clear language and lens to solve the intractable problems around the state.”