Question: Do you know your ACE score?

Updated: Mar 28, 2018


Childhood adversity has a profound impact on health, even into adulthood.  Though this has been known since it was initially established by the large-scale Adverse Childhood Experiences (ACEs) study in 1998 [1], it was recently popularized by Oprah on the March 11, 2018, episode of 60 minutes (watch here).  The original study by Feletti, et al, identified risk for ischemic heart disease, cancer, stroke, respiratory pathologies, hepatitis, and skeletal fractures in individuals with elevated ACE scores. Basically, your ACE score is as valuble of information as your blood pressure in health risk information for you and your doctor. That’s why clinics around the country including those founded by those leading the way in ACEs awareness like Dr. Nadine Burke Harris, and Dr. Bruce Perry (Center for Youth Wellness, Saint A's), and even out backyard Harriet Lane Clinic and others (read here), are calculating scores as the new “vital sign”.  ACE scores are calculated based on seven categories including psychological abuse, physical abuse, sexual abuse, substance abuse by a household member, mental illness in a household member, mother treated violently and criminal behavior in a household member.  Since, many additional studies have identified a relationship between ACEs and specific adult health outcomes including cancer diagnoses[2, 3], sleep disturbance[4, 5], adverse pregnancy outcomes[6], migraine[7], and a variety of cognitive and mental health conditions[8, 9].  Further, numerous studies have also deconstructed the ACE score to assess how aspects of the childhood experience may individually be related to adult health and disease outcomes.  For example, child abuse alone has been linked to obesity[10] and chronic pain[11].


ACE scores are calculated based on seven categories including psychological abuse, physical abuse, sexual abuse, substance abuse by a household member, mental illness in a household member, mother treated violently and criminal behavior in a household member.

Though these seven initial ACEs have been linked with significant disease outcome, other childhood experiences not fully assessed by the ACE score, such as socioeconomic status and social isolation, have also been associated with cardiovascular disease[17], diabetes type II[18], and risk factors for these and other diseases in adulthood[19].  Specifically, social isolation, was identified by one study as contributing to inflammation independent of risk factors of adversity and other adversity types[20]. Importantly, the original ACE study recognizes that self-rated health is a significant predictor of mortality[1, 21] and should be included in such analyses.


In an effort to understand the possible underlying mechanisms of these associations, many studies have identified a relationship between adverse experiences in childhood and biological dysfunction such as inflammation, metabolic disturbances, and HPA axis abnormalities[12].  Childhood adversity seems to yield dysfunction across multiple physiologic systems, effecting the stress burden known as “allostatic load”[13].  There is even evidence that childhood adversity can have an impact on cellular aging[14] and epigenetic modifications to the genome[15, 16]. Full disclosure of self interest here and stay tuned as I dig into this in my own future work. In the meantime, if you want to learn more I recommend following the blog ACEs Too High (Here).


So you might ask, now that I know my ACE score may influence my disease risk as much as my blood pressure, what can I do about it? The answer, or resilience, according to experts in the field, popularized by Oprah, starts with “relationships”. Though few studies have aimed to address how the risk can be moderated, those that have suggest that certain conditions and characteristics, including resilience[22, 23], mindfulness[24] and parental warmth[25], may moderate the association between childhood adversity and poor health, or disease risk factors, in adulthood. Each of these is an example of relationships. If one has a strong relationship with self and others, they are well on their way to building resilience against the ACEs they have experienced. Importantly, building healthy habits such as eating well, getting good sleep, and avoiding smoking and substance use can be just as significant in the battle against ACEs risk.


The answer, or resilience, to ACEs starts with RELATIONSHIPS...Importantly, building healthy habits such as eating well, getting good sleep, and avoiding smoking and substance use can be just as significant in the battle against ACEs risk.

Though these relationships exist, research is still needed to understand their underlying mechanisms. A review article written by Danese and McEwen, calls for future research in stating, “…because of the fragmentation in the data so far, future studies should aim to directly test mediation hypotheses by measuring childhood adversities, biomarkers, and clinical outcomes in the same individuals”[13]. 


Despite the many questions in the field of ACEs that are yet to be answered, as a doctor I can tell you that it is just as important to know your ACE score as it is to know your blood pressure. Simply recognizing your own ACEs and understanding their associated health risks will take you one step closer to health. While research is underway, you can work on measuring your blood pressure, and building your personal resilience through lifestyle improvement and healthy relationships! So I ask you, do you know your ACE score?


References

1.         Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS: Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998, 14:245-258.

2.         Brown DW, Anda RF, Felitti VJ, Edwards VJ, Malarcher AM, Croft JB, Giles WH: Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study. BMC Public Health 2010, 10:20.

3.         Brown MJ, Thacker LR, Cohen SA: Association between adverse childhood experiences and diagnosis of cancer. PLoS One 2013, 8:e65524.

4.         Bader K, Schafer V, Schenkel M, Nissen L, Kuhl HC, Schwander J: Increased nocturnal activity associated with adverse childhood experiences in patients with primary insomnia. J Nerv Ment Dis 2007, 195:588-595.

5.         Chapman DP, Liu Y, Presley-Cantrell LR, Edwards VJ, Wheaton AG, Perry GS, Croft JB: Adverse childhood experiences and frequent insufficient sleep in 5 U.S. States, 2009: a retrospective cohort study. BMC Public Health 2013, 13:3.

6.         Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS: The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics 2004, 113:320-327.

7.         Tietjen GE, Khubchandani J, Herial NA, Shah K: Adverse childhood experiences are associated with migraine and vascular biomarkers. Headache 2012, 52:920-929.

8.         Poletti S, Colombo C, Benedetti F: Adverse childhood experiences worsen cognitive distortion during adult bipolar depression. Compr Psychiatry 2014.

9.         Schussler-Fiorenza Rose SM, Xie D, Stineman M: Adverse childhood experiences and disability in U.S. adults. PM R 2014, 6:670-680.

10.       Bentley T, Widom CS: A 30-year follow-up of the effects of child abuse and neglect on obesity in adulthood. Obesity (Silver Spring) 2009, 17:1900-1905.

11.       Walsh CA, Jamieson E, Macmillan H, Boyle M: Child abuse and chronic pain in a community survey of women. J Interpers Violence 2007, 22:1536-1554.

12.       Ehlert U: Enduring psychobiological effects of childhood adversity. Psychoneuroendocrinology2013, 38:1850-1857.

13.       Danese A, McEwen BS: Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiol Behav 2012, 106:29-39.

14.       Tyrka AR, Price LH, Kao HT, Porton B, Marsella SA, Carpenter LL: Childhood maltreatment and telomere shortening: preliminary support for an effect of early stress on cellular aging. Biol Psychiatry 2010, 67:531-534.

15.       Labonte B, Suderman M, Maussion G, Navaro L, Yerko V, Mahar I, Bureau A, Mechawar N, Szyf M, Meaney MJ, Turecki G: Genome-wide epigenetic regulation by early-life trauma. Arch Gen Psychiatry 2012, 69:722-731.

16.       Yang BZ, Zhang H, Ge W, Weder N, Douglas-Palumberi H, Perepletchikova F, Gelernter J, Kaufman J: Child abuse and epigenetic mechanisms of disease risk. Am J Prev Med 2013, 44:101-107.

17.       Merkin SS, Karlamangla A, Roux AV, Shrager S, Seeman TE: Life course socioeconomic status and longitudinal accumulation of allostatic load in adulthood: multi-ethnic study of atherosclerosis.Am J Public Health 2014, 104:e48-55.

18.       Stringhini S, Batty GD, Bovet P, Shipley MJ, Marmot MG, Kumari M, Tabak AG, Kivimaki M: Association of lifecourse socioeconomic status with chronic inflammation and type 2 diabetes risk: the Whitehall II prospective cohort study. PLoS Med 2013, 10:e1001479.

19.       Danese A, Moffitt TE, Harrington H, Milne BJ, Polanczyk G, Pariante CM, Poulton R, Caspi A: Adverse childhood experiences and adult risk factors for age-related disease: depression, inflammation, and clustering of metabolic risk markers. Arch Pediatr Adolesc Med 2009, 163:1135-1143.

20.       Lacey RE, Kumari M, Bartley M: Social isolation in childhood and adult inflammation: Evidence from the National Child Development Study. Psychoneuroendocrinology 2014, 50C:85-94.

21.       Idler EL, Angel RJ: Self-rated health and mortality in the NHANES-I Epidemiologic Follow-up Study. Am J Public Health 1990, 80:446-452.

22.       Logan-Greene P, Green S, Nurius PS, Longhi D: Distinct contributions of adverse childhood experiences and resilience resources: a cohort analysis of adult physical and mental health. Soc Work Health Care 2014, 53:776-797.

23.       Chen E, Miller GE: "Shift-and-Persist" Strategies: Why Being Low in Socioeconomic Status isn't Always Bad for Health. Perspect Psychol Sci 2012, 7:135-158.

24.       Whitaker RC, Dearth-Wesley T, Gooze RA, Becker BD, Gallagher KC, McEwen BS: Adverse childhood experiences, dispositional mindfulness, and adult health. Prev Med 2014, 67:147-153.

25.       Carroll JE, Gruenewald TL, Taylor SE, Janicki-Deverts D, Matthews KA, Seeman TE: Childhood abuse, parental warmth, and adult multisystem biological risk in the Coronary Artery Risk Development in Young Adults study. Proc Natl Acad Sci U S A 2013, 110:17149-17153.