Clinicians and researcher alike, suggest that human development progresses within a “normal range” in the average expected environment. The average expected environment for a child from conception is: a well-nourished mother, who herself was well cared for as a child, prepared for her pregnancy, and supported by her partner. The average expected environment permits the fetus to grow peaceful and protected for the full prenatal period. For the infant and the child, the average expected environment includes responsive caregivers who attach, attend, and attune to the child’s emotional, physical, and social needs (Bowlby, 1932; Cicchetti & Valentino, 2006). Any perturbation in the average expected environment is expected to impede development (Cicchetti & Valentino, 2006).
What then of the child who is born into the average unexpected environment? Whose mother is a victim of historical racial trauma (Trent, Dooley, & Douge, 2019)? Whose parents are abusing substances (Kuppens, Moore, Gross, Lowthian, & Siddaway, 2019)? Who experience profound poverty, community, and interpersonal violence (Ehrensaft et al., 2003; Felitti et. al 1998; Finkelhor, Shattuck, Turner, & Hamby, 2015)? What of the children who were neglected or otherwise suffered from physical, emotional, and sexual abuse (Dube & Felitti, 2003)? What happens when the household dysfunction of childhood becomes the biopsychosocial framework that guides growth and development (Larkin, Felitti, & Anda, 2014)?
There is a growing body of strong evidence that Adverse Childhood Experiences (ACEs) (which occur when the average expected environment fails) have a long lasting impact across the lifespan (Choi, Dinitto, Marti, & Choi, 2017; Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss, Marks, et al., 1998). Of emergent interest to public health and policy personnel, is the intersection of ACEs and the abuse of alcohol, tobacco, and other drugs (ATOD) (AAP, 2014; Afifi, Henriksen, Candidate, Asmundson, & Sareen, 2012; Derefinko et al., 2019; Dube & Felitti, 2003).
Adverse childhood experiences (ACEs)
Many people know someone who has poor mental or physical health (AAP, 2014). The traditional praxis of health care professionals is to point to individual lifestyle practices and high-risk health behaviors as a source of poor mental and physical health (AAP, 2014). The American Academy of Pediatrics (AAP) in their 2014 white paper on Adverse Childhood Experiences and the Lifelong Consequences of Trauma, rightly points out that for years medical practitioners have been asking, “What’s wrong with you,” when they should have been asking, “What happened to you?
In a massive population study of white, middle class, Americans, the research team at Kaiser Permanente posed the ground breaking question, “What happened to you?”(Felitti et al., 1998). Queries to over 17,000 people were posed with a view to elucidate information on child abuse (physical, emotional, sexual), neglect (emotional, physical), interpersonal violence, parental incarceration, as well as household substance abuse and mental illness (Felitti et al., 1998). ACE scoring was simple, where one “yes” answer to any of the aforementioned questions, provided an ACE score of 1, with a maximum possible scoring of 10.
A strong dose response relationship between poor adult health behaviors, health outcomes, and cumulative childhood adversity was observed (Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss, & Marks, 1998b). Meanwhile, the pervasive and pernicious nature of ACEs cannot be overstated, contributing to the poor health outcomes of over 60% of white, middle class adults surveyed (Anda et al., 2006; Felitti et al., 1998).). Prevalence rates of substance abuse exposure in the home was the highest of all possible ACE categories, at 25.6% (Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss, Marks, et al., 1998).
Now with excess of eighty studies, ACE research was further advanced by a group of researchers in Philadelphia to included “Expanded ACEs – childhood stressors common amongst urban economically distressed communities” (Wade et al., 2016, p. 2). A smaller sample size of just under 1,800 people were surveyed by direct dial methodology (Wade et al., 2016). The expanded ACE questions were formulated to elucidate information on neighborhood safety, racism, bullying, foster care, and poverty (Wade et al., 2016). Expanded ACE scores were found to be associated with poorer mental health outcomes and risk taking behavior, but not with physical health (Wade et al., 2016). Unsurprisingly, a higher odds ratio for substance use was associated with expanded ACE’s (Wade et al., 2016).
ACE research was born out of obesity and adversity. At the 2019 Academy on Violence and Abuse Global Summit in St. Paul Minnesota, Dr. Felitti shared the story of a woman in 1985, a nurse’s aide on the night shift, who entered the weight loss program at Kaiser Permanente, weighing 408lbs. This patient asked if the medical team could help her with her problem of intractable obesity. Felitti (2019) communicated that as medical professionals, their first mistake was accepting the patient’s diagnosis of “the problem,” which she, and they concurred was obesity — it was not. He went on to share that the woman successfully reduced her weight from 408 to 132lbs in 51 weeks, where she remained for several weeks (Felitti, 2019). Felitti then reported that this same patient (Patti) regained 37lbs within one three week period, which he “had not conceived as being physiologically possible” (Felitti, 2019).
Upon investigation, Dr. Felitti discovered that the patient was eating excessively during an active sleep cycle in response to a sexual inuendo/invitation that an older, male, married colleague made at work (Felitti, 2019). Further investigation revealed that Patti had a “lengthy incest relationship with her grandfather” commencing at age eleven (Felitti, 2019). Patti regained all of the weight lost, faster than she had lost it, and subsequently dropped out of the Kaiser Permanente weight loss program and remained unreachable by medical staff (Felitti, 2019). Patti resurfaced after a twelve year hiatus, to enter a focus group with a view to inform the team at Kaiser Permanente why they had “failed” to help these morbidly obese patients (Felitti, 2019).
Felitti also reported that Patti’s low-income family has raised in excess of $20,000 to pay for her bariatric surgery (Felitti, 2019). Post surgically, at an undiscernible loss of 93lbs, Patti became intractably suicidal, was admitted to five mental health institutions, and endured three courses of electric convulsive therapy (Felitti, 2019). At the eighteen-month mark, Felitti interviewed Patti with a view to discover what had happened. Pattie shared that “the weight was coming off faster than I (she) could handle it and that her “wall was crumbling” (Felitti, 2019). What Felitti and his team “perceived to be the problem (obesity) she perceived to be the solution to problems that we (they) knew nothing about.” Patti’s weight was a functional response to dysfunctional and adverse childhood experiences (Felitti, 2019).
This unexpected pattern of weight loss sabotage, led to the “discovery that overeating and obesity were often being used unconsciously as protective solutions to unrecognized problems dating back to childhood” (Felitti, 2003, p.2). The lead researcher goes on to say that, “Counterintuitively, obesity provided hidden benefits: it often was sexually, physically, or emotionally protective ” (Felitti, 2003, p.2). It appears that dysfunction born in childhood adversity performs a functional biopsychosocial service in adulthood (Felitti, 2003).
Obesity to substance abuse.
Health care providers at Kaiser Permanente report that many of the obese patients were previously users of alcohol, tobacco, and other drugs (ATOD) (Felitti, 2003). Felitti (2003) refuses a siloed medical model of substance abuse by aptly point out that only a small amount of people exposed to illicit substances become substance addicted (Felitti, 2003; Inaba & Cohen, 2011). Use and abuse of ATOD increases “in a graded relationship, dose-response manner that closely parallels the intensity of adverse life experiences during childhood” (Felitti, 2003). Felitti (2003) further submits that these findings strongly suggest that “the basic causes of addiction(s) lie within us and the way we treat each other.” Overwhelming evidence suggests that ACEs are the leading social determinant of health (Anda et al., 2006; Felitti, 2003; Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss, & Marks, 1998b)
Substance use, abuse, and dependence
Substance use, abuse, and dependence is one of North America’s most intractable issues as well as one of the “most common outcomes from ACEs” (Letendre & Reed, 2010, p.1). Furthermore, an ACE score of 4 or more is associated with a 4-12 fold increased risk to abuse ATOD (Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss, & Marks, 1998b). Any equitable explanation of etiology would be remiss if it does not account for ACES.
Alcohol use disorder (AUD).
A strong graded relationship exists between ACEs and AUD with a more than 500% increase in self-reported alcoholism for those with a score of 4 or more (Strine et al., 2012). Evidence also suggests that men have higher prevalence rates for AUD than women and that whites are more likely than all other races to abuse alcohol (Letendre & Reed, 2010; Strine et al., 2012). Higher education level was correlated with higher self-report of alcohol use, while each one point increase on the ACE score was associated with a 34% increase in the risk of AUD (Letendre & Reed, 2010; Strine et al., 2012). Religion proved to be a compensatory mechanism for the development of AUD with a 10% reduction in AUD reported by those to whom faith was personal plumb line (Letendre & Reed, 2010).
Tobacco use disorder (TUD).
A strong graded relationship between TUD and ACEs has been observed, with a 250% increased risk of a child who incurred an ACE score of >6, becoming a smoker (Anda et al., 1999; Felitti, 2003). This evidence alone suggests that TUD becomes a functional, psychoactive coping mechanism in the face of household dysfunction (Anda et al., 1999; Carmondy, 1992; Felitti, 2003). Given the intractable nature of TUD, public health proponents and policy makers would be prudent to incorporate ACE prevention and mitigation into smoking prevention and cessation programs (Carmondy, 1992; Felitti, 2003). ACE researchers make a strong case for “the conversion of emotional stressors into an organic disease, through the intermediary mechanism of an emotionally beneficial (although medically unsafe) behavior” (Felitti, 2003, p.6)
“A strong graded relationship between Tobacco Use Disorder (TUD) and ACEs has been observed, with a 250% increased risk of a child who incurred an ACE score of >6, becoming a smoker (Anda et al., 1999; Felitti, 2003).
Popular injectable drugs such as heroin and methamphetamine effectively sharing pharmacologic properties with amphetamine, used as an antidepressant in the 1930’s (Felitti, 2003; Inaba & Cohen, 2011). A child with an ACE score of six or more has a staggering 4600% higher risk of using injectable drugs than the same child with an ACE score of zero (Felitti, 2003; Felitti, et al., 1998). 78% of injectable drug use by women, and 67% of both genders is correlated to ACEs (Dube & Felitti, 2003; Felitti, 2003).
Between 1993 and 2003, the US saw a two-fold increase in the use of prescription drugs (Anda, Brown, Felitti, Dube, & Giles, 2008). At 11% of overall health expenditures, topping $180 billion in annual costs, prescription drug use etiology is worth exploring (Anda et al., 2008). In 1960, $2.7 per capita was spent on prescription drugs, inflating to $263.3 in 2014, a nearly 10,000% increase in expenditure (Centers for Medicare & Medicaid Services, 2014). As often is the case, fiscal cost exacts a human cost. Turning to ACE research, once again a strong graded relationship is seen between prescription drug use and ACEs (Anda et al., 2008; Derefinko et al., 2019).
Evidence suggests that in older and younger subjects there is a 1.7-2 fold increase risk of being prescribed multiple prescription medications, respectively (Anda et al., 2008). ACE researchers posit that childhood stressors are known to produce changes in the developing brain that affect emotions, behaviour, and cognition which in turn can impair health and quality of life via numerous pathways. These traumatic pathophysiological insults may be “silent” until much later in life, leading clinicians to prescribe medications to treat symptoms and illnesses without knowledge of their potential origins in the disruptive effects of ACEs on neurodevelopment (Anda et al., 2008, p. 8).
Opioid use disorder (OUD).
Opioid use is a growing public health crisis with the number over overdoses quadrupling in the last decade (NSDUH, 2014). As with ATOD, OUD also experiences a strong graded relationship with ACEs (Dube & Felitti, 2003). Recent research in OUDs have discovered that an inverse relationship between age of onset and ACE score exists (Stein et al., 2017). Women reported significantly higher ACE scores than their male OUD counterparts (Stein et al., 2017). Female opioid users have higher ACEs overall and also report a four-fold higher incidence rates of sexual abuse than their male peers (Felitti, et al., 2017). Finally and tragically, the OUD population experiences ACEs of 4 or more at a rate of over 50% (Stein et al., 2017), compared to the 15.5% of the general population (Dube & Felitti, 2003). Additionally, with every increase in ACE score, a 17% increase in relapse risk was noted (Derefinko et al., 2019).
Actions for prevention & implications for policy
ATOD abuse is one of the many intractable human problems that appears to be resistant to efforts of eradication. By demonstrating strong graded relationships between ACE scores and the use of ATOD, this robust association must move policy makers and public health professionals towards action. Community and clinical screening for ACEs with trauma informed care options should become standard practice to stakeholders and service providers alike (Stein et al., 2017).
Felitti posits, and ample ACE evidence suggests, that chronic, unrelieved stress causes intractable health issues such as obesity, mental illness, and ATOD dependence (Felitti, 2003). Affecting over 60% of the population with one ACE or more, adverse childhood experiences are “remarkably common” even among middle class professionals (Anda et al., 2008). Public policy MUST center around early and prolonged efforts towards prevention of adversity in childhood. Providers and policy makers alike must work together to ensure that each child can grow and develop within the average expected environment (Cicchetti & Valentino, 2006). Where adversity is intractable and the environment unexpected, positive childhood experiences show a strong dose response relationship increasing resilience, reducing the use of ATOD, while improving public health outcomes (Bethell, Jones, Gombojav, Linkenbach, & Sege, 2019).
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