Thoughts on Trauma & Resilience: The ACE Study

In my 35 years of working with survivors of childhood trauma, I have been struck both by the long-term impact of maltreatment and family dysfunction on the life of a child and by the resilience displayed by many individuals dealing with this experience. While it is generally assumed that the effects of childhood trauma are primarily psychological, that assumption was radically overturned by the results of the Adverse Childhood Experiences (ACE) survey (Felitti, Anda et al., 1998). The ACE project is an ongoing collaborative study between the CDC and Kaiser Permanente of 17,337 adults in San Diego, California. Participants were asked about their history of physical, sexual, and emotional abuse, physical and emotional neglect, exposure to domestic violence, having family members who abused alcohol or drugs or who had mental illness, and their experience of relational stress stemming from separation, divorce or parental incarceration. Since the onset of that first study, there have been multiple replications in other large samples of the general population as well as specific populations.

More than 80 published studies (so far) have established that the most common kinds of trauma experienced by children have a cumulative dose-response effect that leads to a wide variety of physical and mental health outcomes. These include chronic health outcomes such as ischemic heart disease, stroke, asthma, COPD, diabetes, gastrointestinal difficulties, cancer, migraines and other frequent headaches, skeletal fractures, liver disease, and infertility. While many of these diseases are partially mediated by health risk behaviors such as drinking, disordered eating, smoking, obesity and risky sexual behaviors, much of the effect on health outcomes appears to be independent of these risky behaviors. Mental health outcomes include depression, PTSD, loneliness, and suicidality. However, ACEs are also predictive of mental illnesses typically thought of as organically based such as schizophrenia, bipolar disorders and the symptoms of auditory and visual hallucinations. Even adult longevity and telomere length appear to be associated with the number of ACEs in one’s history (Kiecolt-Glaser et al., 2011), with individuals with six or more ACEs dying nearly 20 years earlier than those without (Brown, Anda et al., 2009).

At the same time, some people seem able to transcend the burden of childhood adversity. What we know about these resilient individuals gives us a roadmap for what to focus on in psychotherapy. Of particular importance are assets such as emotion regulation (which can be learned), meaning making (understanding the impact of one’s history) and interpersonal support. Individual psychotherapy can strengthen these forms of resilience, thereby not only relieving distress but also impacting a person’s physical health.

In conclusion, the healthcare costs associated with ACEs are substantial as are other economic societal harms including impaired work performance, teenage pregnancy, and most importantly, the human costs stemming from these early traumas. These costs argue not only for primary prevention but also for interventions explicitly designed to address the needs of individuals who have experienced various forms of trauma. The connection between ACEs and health outcomes also argues for a routine assessment of a history of trauma in patients seeking healthcare. While healthcare providers are understandably reluctant to broach this sensitive topic, research suggests that open and honest questions about a patient’s trauma history actually reduce his/her sense of shame, are not generally resisted, facilitate the doctor-patient alliance, and provide the physician with clearly relevant information for understanding and treating symptoms and underlying causes. The physician’s assessment of these historical events can thus de-stigmatize them and identify when follow-up interventions are necessary.

Brown, D. W., Anda, R. F. et al. (2009). Adverse childhood experiences and the risk of premature mortality. American Journal of Preventive Medicine, 37, 389-396.

Felitti, V. J., Anda, R. F. et al. (1998). Relationship of childhood abuse and household dysfunction to many leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245-258.

Kiecolt-Glaser, J. K., Gouin, J-P., et al. (2011). Childhood adversity heightens the impact of later-life caregiving stress on telomere length and inflammation. Psychosomatic Medicine, 73, 16-22.