Childhood experience and lifelong health

January 9, 2008

—Nina Pierpont, MD, PhD

A doctor friend put me onto some amazing research lately, research with the power to change how we think about a host of the important diseases—obesity, diabetes, and heart disease among them.

The research comes from a big clinic in southern California, together with the federal Centers for Disease Control.  It’s about what happens to people in childhood and how it affects their physical and mental health up to half a century later.

The study started in a weight loss program in San Diego in the mid-1980’s.  People who were successfully losing weight were dropping out of the program.  One of the doctors wondered why, and interviewed several hundred of them about their lives.

Childhood sexual abuse emerged as a remarkably common finding.  When it was present, it always happened before the onset of the obesity.  Stories and comments made by the participants revealed that being overweight often played an important function in their lives which conflicted with the desire to lose weight.  For example, a woman became and remained very overweight after she was sexually assaulted because it made her “overlooked.”  Prison guards felt safer going to work looking “larger than life.”

These people became anxious at lower weights.  They felt unsafe or uncomfortable with the changed expectations people had of them.

Smoking and other addictions have similar puzzling aspects.  Why do people continue to smoke?  We all know what smoking does to us in the long run.  The public campaign to inform people of the hazards of smoking has been very successful, but a certain percentage of people seem immune to its message.

We call this “addiction” and blame it on the substance, or we say it’s biologic and inherited.  However, not everyone exposed even to the most addicting substances becomes addicted.  During the Vietnam War, for example, many American GI’s injected heroin, but after they came back only 5% continued.  Why were the other 95% no longer susceptible?

The study in California involved over 17,000 adults attending a clinic for physicals, who agreed to participate.  They were middle-class, educated, and mostly white.  The average age was 57.  They were asked about their childhood and teenage histories of being abused (physical, sexual, or emotional) and about the households they grew up in (with regard to parents being present, alcoholism/drug use, domestic violence, mental illness, and incarceration).

Twenty-two percent of these middle-class participants were sexually abused as children.  Eleven percent were physically abused in a repeated way and 11% emotionally abused.  Twenty-eight percent grew up in a household with an alcoholic or drug abusing adult, 22% had lost a biological parent (meaning no significant contact), 19% had mental illness in the family, 13% witnessed abuse of their mother, and 4% had a family member in jail.

More than half the people had at least one of these things in their history.  Once there was one, the likelihood of several was high.

The study separated its subjects into groups:  those who had none of these things happen to them, those with experiences in one category, those with two, etc., up to all eight categories.  The study then looked at questions like, “What percentage of people with 0, 1, 2, 3, etc. of these types of childhood experiences now have diabetes?  Now are very overweight?  Now smoke?  Started to smoke early?  Now have emphysema or chronic bronchitis?  Now have coronary artery disease?  Had an early pregnancy?  Have been depressed?  Have attempted suicide?  Are alcoholic?”  And more.  The study has many parts, including an ongoing one which looks at how much people in the different categories use clinical services and hospitals.

Every graph from the study looks the same and is highly significant from the point of view of statistics:  people with “adverse childhood experiences” scores of 0 have little of the health problem in question, people with scores of one have a little more, and so on, up to people with scores of 4 or 6 or more.

This study is powerful, meaning well done in terms of numbers of subjects, who they were and how they were selected, and the organization of the data gathering and analysis.

It’s telling us something radically new:  that preventive medicine is not just about getting people to lower their calorie intake, say, but also about healing the underlying wounds which make them eat too much in the first place.  Preventive medicine is also about healing families and children.

With 22% of a large middle-class adult population having been sexually abused as children or teens, and evidence for lifelong health effects, it’s time for this question to become routine in pediatric care.

For those who would like to read more, see http://www.acestudy.org/ or http://www.cdc.gov/nccdphp/ace/index.htm, or search on VJ Felitti in PubMed.