S1E2: How ACEs Work
How do our childhood experiences turn into chronic disease as we progress through our lives? This episode dives into the layers that are behind many of our common chronic and debilitating illnesses. We're exploring a pyramid from the CDC that visualizes the progression of our experiences and how they can contribute to an early death.
Resources
In this episode we discuss The ACE Pyramid from the CDC.
Transcript
Athalie: Welcome to the second episode of season one, where we are exploring Adverse Childhood Experiences, or ACEs for short. In episode one we gave an overview of ACEs and the research behind them. If you haven't already heard that episode, now might be a good time to pause and go listen to it.
As a quick recap, ACEs are a set of 10 adverse experiences that someone can experience as a child. Things such as physical abuse and imprisonment of a family member. There are strong correlations between these experiences and significant health issues later in life.
Today I'm here again with my friend Joseph. We're going to dive a little bit deeper into some of the things that we talked about in Episode One.
One of the issues that you brought up in Episode One was how your doctor had never brought these things up to you when you had appointments with them or interactions with healthcare providers of various sorts. We talked about that briefly, but I wanted to go back and dig into that a little bit more.
There's several different approaches to healthcare. And a lot of Western medicine is very focused on identifying people that are sick, treating their sickness, focusing on a cure, and then you move on to the next sick person. But I think we know intuitively, one, there's a lot of problems that don't have cures. And two, there's usually a lot more things happening than a single illness, at any one time.
And so in the nursing profession, Florence Nightingale, who's considered our founding mother of nursing realized this pretty early on. And she started a focus in nursing on preventing diseases, which grew into a public health mindset. Digging deeper beyond what's happening to any individual, and looking at what's happening to a family, what's happening to a community, what's happening to a large population of people and finding the common things that might be causing problems.
Sometimes this is called an upstream approach because, it's based off of the idea that you can keep fishing someone out of the water who's drowning, or you can go upstream and figure out how these people are getting in the water in the first place. So when we look at these adverse childhood experiences, in the context of going upstream and looking at what's happening, there's a lot of layers that happen before we have a sick person who's showing up with diabetes or, a substance use problem in front of a healthcare provider in our system.
The CDC has a graphic, which shows this very succinctly. It's a pyramid shaped diagram. And at the point of the pyramid is "early death". Immediately below that is "disease and disability" and really obvious social problems. Where your doctor and many doctors are sitting is trying to prevent people that are in the "disease, disability, and social problems" setting from having an "early death". And so that work is focused very much at the point of the pyramid at the top. And that's very worthy work. Obviously we want people who are sick, disabled, who are struggling with these things to get help.
But a prevention and public health approach says, ask more questions and figure out what's happening underneath this. And how can we prevent people from even getting to this point? We'll, put a copy of this diagram in the show notes so it's easy to see. It's also easy to find on the CDC website.
So starting at the bottom, we have things like historical trauma. This is stuff like your ancestors have experienced war. There's racism. There's been a lot of studies done with people that are survivors of the Holocaust and changes that happened in their biology and their DNA as a result of their experiences. These studies have looked through their experiences, how these things manifested in their lives. But also generations later, their descendants are still expressing a lot of these same issues and same changes in the DNA.
So that's kind of far, far in our past, then there's the local conditions or the context around us. This would be like the family you were born into, what your race is, and the resources in the community around you. All of these things happen outside of individual people. They're not things that we are personally experiencing. This is the situation we're born into.
All of these lead to the time you're born and what your childhood experiences are.
These are the positive and negative things that we discussed and that are asked about in the ACE screening tool. Those adverse childhood experiences lead to disrupted neurodevelopment and changes in the brain, especially for things that happen or are experienced at a very young age, zero to 18 months. And some things have been studied also in the zero to five-year-old age range.
This is changing how your brain and your body are going to perceive and react to the world around you for the rest of your life. This is also the time where really positive experiences and having a very safe childhood, provide a lot of protection to you for later in life.
I think that's an important thing to keep in mind: the hope comes from the fact that the same way that these negative experiences can affect you, you can, at any point start working towards positive experiences and those things will also stay with you as well.
So the disrupted neurodevelopment often leads to things like learning disabilities, emotional impairments, social problems as people are getting older. Then the adoption of high risk behaviors, which in the context of like a substance use problem, seems very obvious. It's like, someone tried out using drugs or they started smoking.
But this is also things like how you interact with food, exercise, what your relationships look like. How you interact with other people around you and how you expect to be treated, which in turn relates to people being victims or perpetrators of domestic violence.
And then after you've gone through all of those layers, we have the disease, disability and the social problems.
Then all of these things combined lead to the statistically likely early death that was talked about in a lot of the original ACE study. That's kind of a deeper dive back into the other layers of this. This is something that I think we need to really supplement our understanding of sickness and disease.
Joseph: Thanks for that. That was pretty detailed. I totally have a better understanding of how all this plays out. But what stood out for me also is the fact that, like I talked about my experience with my healthcare provider.
Yeah. The tendency is to think that they know something and didn't tell me about it. But from what you said, they may not even be equipped in all cases to dive deep into some of these things, right? Because like you said, a lot of this stuff is covered under the public health umbrella.
So they have basically a different mandate. We just want to get you a better and they move to the next thing. Underscoring that with the fact that medicine is also a business. And so some things are optimized also to produce profit, but looking at this image, it's disheartening actually because where the medical professionals, as we know them (talking about doctors and physicians), where they come in is the second to last layer of the pyramid. The one after that is early death.
So it's like they're coming in really late in the process and there's five or six layers where the problems actually started and got worse over time. So I'm showing up to my medical professional too little too late if I don't have conversations like this. If I don't begin to really ask the right questions and begin to seek appropriate help to begin to reverse some of those things.
I think something you said that was super helpful to me also is the fact that this experiences happened at a time when someone was young. But they can be reversed, maybe not a hundred percent, but to the point where someone can lead a better quality life. Thinking about chronic illnesses, I feel when the medical professionals come in already set in chronic problems. I'll speak for myself with addictions. I had a lot of problems with alcohol. And the thing that gave me the most relief was actually going back and really looking at my mental health and doing all these other things. It really hits close to home for me, you know? I'm really appreciative of, the conversation we're having right now. So thank you for that.
Athalie: I think a lot of people that know about this stuff don't want to dig into it. Because it becomes immediately obvious that a lot more has to change than our healthcare system. Right? So we need to be going back to how we structure our communities. We need to look at things like racism. We need to look at what our supports are for, single parents to support their children. We need to look at the education we provide and the experiences that kids are having in that system. This could also help provide a supportive environment for people that have already started down this pathway and have some developmental and cognitive impairments.
These are often the "problem kids" at school who are causing problems and a lot of resources, get pushed at them (relative to what education has to offer in terms of funding). But a lot of those things that we're doing, they aren't changing the outcome.
Anytime you're talking about a whole societal rethink of how we do everything, people are like, well, that's, that's like a lot, maybe we'll just go back to diagnosing diabetes. We don't want to look at our prison system and our racism, and the fact that we reward our web designers better than our school teachers.
We don't want to look at all those things cause those solutions to that seem really difficult.
Joseph: You're right. It's a lot of work and it's going to involve a lot of stakeholders. But as you were speaking, something came to me. We're talking about adverse childhood experiences. In society right now, there's a lot of help given to expecting mothers, right? They're told what to do to carry their baby and how to have a safe delivery. They want to bring down child mortality and things like that.
I would think that with information available, there should be also an arm educating expectant parents. Saying, "look, these are also some of the things that you should be aware of. These are some of the things that can happen if the kid is exposed to this environment". Not just, "we want you to have a safe delivery". Yes.
We understand that you can have a safe delivery and still have the right education to protect the kid when they actually do show up. I feel like those two, at that point can go hand in hand because I don't know that any parent, knowing some of the effects that a child can go through would do that intentionally. I still have faith in humanity. I don't know that any parent will look at their kid and say, "I want this for you sometime in your future".
And so I don't know if what existing works like that. Where expecting parents are shown some of this information and basically trying to teach them how to parent better, is what I'm saying without saying it like that. I guess. So I don't know if you can shed some light on that.
Athalie: I don't know all the systems that could potentially do that, but a couple of places that I have seen that are, for instance, in the foster care system. When child protective services gets involved, it's usually because there's some threat or danger to the child. Either abuse or neglect and part of what the parents have to do to prove themselves, or to demonstrate that they are capable of caring for their kids is go through a lot of parenting support stuff.
But then this comes back to the same problem that we talked about with medicine. That we're waiting until a family is an utter crisis before we give them assistance. That's the hardest time to address parenting. Once you've been parenting your kid for years, and you're in a rut and the kid is already experiencing things and you're still dealing with your own situation.
So I think some of those resources are available, but we're not broadly using them in a preventative way. It's more of a reaction to something that has already happened. And after the fact at that point, things are already moving into the next generation and being carried on.
Joseph: So in the work you're doing, is that something that you can advise on basically taking that caught Monday to parenting and moving the timeline up?
Athalie: I think there's a lot of different ways that could happen. The setting that I work in as a primary care provider, I care for people at all ages. So part of this is things that, we, as medical providers can do a better job asking questions about things and identifying people that are at risk.
You can ask about the risk to the person who's currently a child now, but often those experiences also happened to their parents. And so unless their parents are also doing the work to do their own healing, things get passed on through their parenting. Through the way they're able to show up for their kids.
So I think part of it is asking those questions and then helping find resources like family therapy. As a whole, that is not nearly as available as it should be. Mental health help is very hard to get funding for. Even states that have pretty comprehensive Medicaid state funded insurance programs often have very limited options for mental health services.
Another thing is through the schools. There are systems that provide preschool education and support. And a lot of that is building skills, in the children from a young age, as a supplement to parenting. But that's not comprehensive support to parents. I think there there's several avenues that could be made better that already exist.
A lot of it is figuring out where you can get money. It's very time consuming because people don't change overnight. They need often months or years of coaching and having support. Can we get it through funding for school systems? I think any of these places could do a good job. It's just where you can get the support.
Joseph: I think it's also an issue of priority and people seeing the information for what it is. It's an investment that's going to pay off. I believe it will. Yeah. But, I think this conversation can only move forward if we start having the kind of conversation, we're having right now.
I have something I want to ask you and see if you have some insight into it. One of the experiences from the questionnaire for ACE is divorce. So separation of the parents. Now I understand the other factors of physical harm and things like that. And I understand clearly how those can be mitigated. But when it comes to divorce, we know the numbers, right? it's pretty high up there. You can't really do a whole lot about that because you can't make people be together in a marriage or whatever union that is. What is your thought on that?
Athalie: My guess is that the reason that they found separation of parents to be one of the common experiences, is that it's a kind of proxy for dysfunction between the parents. If that culminates in divorce then that's like a measurable thing that you can point to. But I don't know that it's healthier for your child to stay together if your relationship is super dysfunctional.
In fact, there's a lot of research in the realm of domestic violence that shows that witnessing a parent be physically abused, even if you are not, has a lot of the same psychological effects as if the abuse was being directed at you. And so, I don't think the divorce is as cut and dry as what either, if it happened that's bad, if it didn't happen that's good. Because I think sometimes there is actually an increase in safety that comes with your parents separating. However, the fact that they needed to separate often is pointing to there being a toxic thing at some point.
I also think that there's kind of this expectation in our society that if you are separated, you can't be on amicable terms. And so anytime we see examples of this with celebrities or, I can think of specifically of an author that I follow. When she and her husband got divorced, but she was still posting pictures of them having family dinner together. Everybody was like, "What's going on?" And she's like, "We love our kids and being divorced it doesn't mean we can never see each other." She is now married to a woman and he, I think has a partner as well. They separated because that's what was best for them. I'm sure that was not an easy process, but they've been able to work through that in a way that has allowed them to continue to be a family in some ways. And I think that there are definitely worse ways to get divorced.
Joseph: Yeah, I didn't think about it that way. I just was looking at it from the point where we protect the kid at all costs. But I don't know that anyone can get in between that. Like you said, the divorce a lot of times points to something.
I have another question. From your experience as a medical professional, what is the communication like between the medical professionals that we encounter at the second to the last stage, the stage before early death, which is disease, disability, and, social problems and the public health side of things. Because, from where I'm standing, it doesn't seem like there's a lot of information sharing between these two groups of people, even though they both have the same end goal to get people healthy and things like that. What is your take on that?
Athalie: I think there is an increasing amount of overlap and I think we're coming to a place where the way we do healthcare, especially in the US, but in most of the Western world is just not sustainable. The amount of money that we're spending. It's very expensive to wait until someone is very sick to treat them. The vast majority of healthcare money gets spent in the last very short period of someone's life. In that time where they're in the hospital, possibly in the ICU, we're trying to keep them alive once they're very sick. Compared to the amount of money that that could be spent trying to prevent us from ever getting to that point.
And so I think as economists and politicians are looking at that, they're starting to be more of a realization that like, Hmm. Maybe it actually would be more cost-effective if we tried to shift this money that we're already spending upstream. It's one of the things with this current Supreme court justice nominee, this debate about how we, spend money on health care and whether or not the new justice that's replacing Ruth Bader Ginsburg is going to uphold "Obamacare" the Affordable Care Act.
It's definitely not a perfect piece of legislation, but one of the things that it does do is put a lot of emphasis on and funding to preventative things. It required health insurance businesses that were just waiting, hoping they didn't have to pay, that maybe you would be insured with a different company by the time you got really sick and they wouldn't have to deal with the fallout of your illness. The Affordable Care Act is trying to distribute that more equally. So I do think that's, changing. There's a lot more people that I'm encountering that are trained in both areas medical doctors who also have public health degrees are working in public health fields. They're trying to help those two systems work together.
And that's really where my passion lies. Because, I think we need both of these things. Obviously we want to keep intervening to prevent people from dying. but we also need to make some investments, so that 50 years from now, we don't have the highest yet rates of heart disease, diabetes, depression and anxiety, and these other major killers that we have in the Western world.
Joseph: so for someone like me, I've made certain life changes, right? Because I read some statistics and things like emphysema and high blood pressure - those, are things that I could make a couple life changes so I don't overexpose myself to those things. If I came to you today and I understand you're not my therapist or anything like that. Just talking to you as a friend, what is the one thing that you can point me to now that I can start to do to move me along on this journey? Where until I'm in a situation where I have the resources to begin to talk to a licensed therapist, what's something I can begin to do until I get to that point.
Athalie: I'm not sure what exact actions you were talking about that you would avoid, but I'm guessing they are smoking, the food you eat, whether you exercise, these things are linked with a lot of disease. Also stress levels ,which is a more nebulous thing. That's a little bit harder to pin down and measure. I believe one of the starting points for, any of these behaviors that we would say are unhealthy, is understanding why you do them in the first place.
Oftentimes we don't know, right? Because it's become so second nature to us to just eat this when I feel this way. Or "I'm stressed" so I'm going to go out and smoke a cigarette. And so the first step in changing that behavior is figuring out why you're doing it in the first place. Sometimes that will point to something that would be really obvious. Sometimes it will take a lot of time sitting with yourself and thinking through that. But the real change doesn't come from, just telling yourself not to do something.
It comes from understanding why you're doing it in the first place. That lets you think about other ways you could meet that need in a less harmful way. Or ways to meet that need that would reduce your risk.
Joseph: That's actually really helpful. Well, thank you.
Athalie: Thanks for being here.
Joseph: Thanks for having me.
Song Credits
Many thanks to these artists for licensing their music under Creative Commons. Tracks featured in this episode, in order of first appearance, are:
I dunno by grapes (c) copyright 2008 Licensed under a Creative Commons Attribution (3.0) license. http://dig.ccmixter.org/files/grapes/16626 Ft: J Lang, Morusque
reCreation by airtone (c) copyright 2019 Licensed under a Creative Commons Attribution (3.0) license. http://dig.ccmixter.org/files/airtone/59721
Silence Await by Analog By Nature (c) copyright 2008 Licensed under a Creative Commons Attribution (3.0) license. http://dig.ccmixter.org/files/cdk/17432 Ft: oldDog
