Linking chronic disease to adverse childhood experiences
(Calif.) In another part of his community, Assemblyman Joaquin Arambula is known as Dr. Armabula, and before he decided to run for the Legislature he was an emergency room physician at the Adventist Hospital in Selma.
It is from this perspective that the Fresno Democrat is looking for support for a for a novel wellness program aimed at reducing childhood exposure to adverse experiences as a means of preventing chronic disease later in life.
The concept, known as adverse childhood experiences, or ACE, is driven by a landmark 1998 study by the Centers for Disease Control and Kaiser Permanente that linked events like divorce and family financial hardship as well as more severe experiences like physical and emotional abuse, domestic violence and parental mental illness—to stress-related health illness decades later—such as heart disease, obesity and premature death.
After conducting hearings into ACE earlier this month, Arambula wants to incorporate the success of some bellwether pediatricians who have translated the research into better patient care.
“In the emergency room, we want to address those factors that may worsen issues in health care without being directly related,” he said in an interview. “It became obvious to me that we have to address those things further upstream rather than waiting until they arrive at the ER. We needed to figure out what is happening out in our community.
“And I believe that adverse childhood experiences is that missing piece,” he said.
Just as the ‘whole child’ concept has caused education policy makers to consider the myriad of factors outside the school campus that diminish student performance, health care officials are looking more deeply at the cause of chronic disease.
The Kaiser study focused on the largely unaddressed question of whether health risk and disease in adults could be attributed to exposure to traumatic events in childhood.
Researchers identified seven categories of adverse childhood experiences: psychological, physical, or sexual abuse; violence against a child’s mother; or children living with household members who were substance abusers, mentally ill or suicidal or imprisoned.
Almost 14,000 adults were surveyed and the results of the childhood experiences were then compared to the subject’s current health status.
What they found was a strong relationship between ACE and a large number of chronic conditions including heart disease, cancer, chronic lung disease, skeletal fractures and liver disease.
Further studies indicate that exposure to ACE can not only change the brain development of a child but may cases also change the hormonal and immune systems and in some cases actually alter the DNA of an individual.
Earlier this month, Arambula invited a panel of experts to talk about the ACE and how knowledge of its relationship to disease is being used in the field. He said the first step for the Legislature is to find ways to duplicate those practices on a statewide basis.
“The question is really about how we might scale interventions throughout the state,” he said. “So far, we’ve gotten good response from the members—both sides are asking good questions and I think are interested.”
Among the experts that spoke at a committee hearing earlier this month was Dr. Nadine Burke Harris, a San Francisco-based pediatrician who has spent more than a decade working to reduce ACE and toxic stress among her patients.
Burke Harris, whose recent book—The Deepest Well: Healing the Long-Term Effects of Childhood Adversity—is considered one of the leading resources on the subject, explained how the body reacts to physical threats by equating it to a confrontation in the forest with a wild bear.
Such an encounter, she told the panel, triggers a survival ‘flight-or-fight’ reaction. But there is also an immune response to prepare the body in the event of being wounded.
“This system was designed over millennia to save our lives from a mortal threat,” she said. “The problem is when that bear comes into the home every night and this biological process is activated over and over and over again. And it goes from being adaptive, or life-saving; to maladaptive or health damaging.”
When the original study came out, she said, many doctors were not surprised and attributed ACE’s link to poor outcomes with poor behavioral habits—such as drinking, drug use or smoking. But she said, follow up work has debunked that premise—that even those people with high exposure to ACE who never engaged in risky behavior and otherwise followed a healthy lifestyle, they were still more likely than the mainstream population to have chronic disease.
At her clinic in the Bayview Hunters Point section of San Francisco, in-coming patients fill out a questionnaire and medical staff assign an ACE score by adding up the number of adversities the participant reports.
She told of a patient’s mother who said her daughter’s asthma seemed to get worse whenever her father “punches a hole in the wall.”
Once armed with that information, intervention can be applied. In some cases, intervention could take the form of helping a mother out of an abusive relationship. In other situations, it can include better nutrition, more exercise or even mindfulness training.
Neal Halfon, a professor of pediatrics at the University of California, Los Angeles, who also testified, noted that the impact of ACE felt throughout society. Affluence, he said, is not a buffer.
“We have 40 percent of children with chronic health problems,” he said. “When I started as a pediatrician 35 years ago, the number was closer to 15 percent. More than 20 percent have mental health problems with impairments. And lots of kids have multiple problems and much of this, we believe can be traced back to the roots in ACE.”