Journ Child Adol Trauma (2017) 10:205–206
DOI 10.1007/s40653-017-0189-1
Future Applications of the Adverse Childhood
Experiences Research
Vincent J. Felitti 1
Published online: 7 September 2017
# Springer International Publishing AG 2017
Abstract The Adverse Childhood Experiences (ACE) Study
demonstrated a link between early trauma and various aspects
of adult health. Despite the proven benefits of exploring and
integrating ACEs in clinical practice, the medical community
has been slow to incorporate them. This prevents us from truly
understanding and addressing public health issues such as
smoking, obesity, and drug abuse. In recent years, however,
adult primary care medicine is slowly moving away from a
biomedical approach and adopting a biopsychosocial perspec-
tive. This is essential for the development of appropriate treat-
ment and prevention programs.
Keywords Trauma . Public health . Biopsychosocial . Child
The focus of this issue of the Journal of Child and Adolescent
Trauma is the Adverse Childhood Experiences (ACE) Study, a
major retrospective and 20-year prospective medical research
project of the CDC and Kaiser Permanente involving 17, 337
middle-aged, middle class adults, matching their current bio-
medical and mental health, social function, and life span
against 10 categories of adverse childhood experience during
infancy, childhood, or adolescence. Should you need to learn
more about the Study and its findings, you can readily do so on
the Internet and YouTube by searching BACE Study.^
The prevalence of adverse childhood experiences (ACEs)
was found to be so common, once they were routinely sought
in clinical practice, and their powerful, dose-related relation-
ship to various damaging outcomes so strong, that one can
* Vincent J. Felitti
VJFMDSDCA@mac.com
1
Kaiser Permanente Medical Care Program, Clinical Professor of
Medicine, University of California, San Diego, CA, USA
only wonder why the relationship of life experiences in the
developmental years to adult functionality, disease, and life
span was not recognized long ago. On reflection, certain
topics like childhood sexual abuse and abuse by parents are
generally treated as unspeakable topics, thus effectively
blocking our ability to understand certain difficult and intrac-
table public health problems. Such opprobrium comfortably
keeps us from seeing a Public Health Paradox wherein many
of our most intractable public health problems are, from the
standpoint of the individual involved, also unconsciously
attempted solutions to problems of which we remain unaware
because we cannot comfortably inquire about them. Thus, we
remain unaware of the protective benefits of obesity for those
sexually abused as children, and hence the significant threat
frequently posed by later weight loss. Or the fact that the
dangerous street drug, crystal meth, is methamphetamine,
one of the first effective prescription antidepressants intro-
duced for use in the United States in the 1940s. Or that inhaled
nicotine has almost immediate psychoactive benefits in addi-
tion to its major long-term risks. These generally unstated
benefits are of course the reason people smoke.
Although the ACE Study resulted from exploration of our
unexpectedly counterintuitive clinical findings in a major
medical setting, the medical arena has been slow in integrating
its findings. Unawareness of the findings of the Study, or
resistance to using them in medical practice has been obvious
for years. Fortunately, the articles herein provide encouraging
evidence of a spreading awareness and utilization of the ACE
findings, internationally as well as in a wide variety of other
settings like school systems, universities, state Legislatures,
judicial settings, police, prison systems, and social work.
Hopefully, they may also indicate the beginning of a late start
in medical practice.
As you will discover, many new points of interest are being
raised in these articles. For instance, the realization that it takes
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years for certain biomedical outcomes to develop and manifest
themselves. And that there are undoubtedly additional out-
comes yet to be discovered. Practical questions are explored
about how best to obtain this information about traumatic
experiences in childhood. Thus, in Pediatrics, risk may some-
times best be inferred from the ACE Score of parents rather
than from very young children who either cannot communi-
cate adequately or who haven’t lived long enough to have
experienced their upcoming adversities. R. J. Gillespie and
A. T. Folger, in their article in this issue, describe their imag-
inative comparison of two versions of an ACE screening ques-
tionnaire used with the parents of infants at their four-month
visit. One version collected total ACE Score, the other collect-
ed the individually identified categories. They then asked the
parents how they thought their own ACEs affect their parent-
ing. They report that this process has been easily accepted and
brief enough to cause no loss in productivity.
In adult medicine, we found that using an inert mechanism
like a well-devised medical history questionnaire to obtain this
sensitive information initially from patients has been very
Journ Child Adol Trauma (2017) 10:205–206
helpful. What is learned is then followed up in the exam room
by the simple question, BI see on the Questionnaire that….
Can you tell me how that has affected you later in your life?^
And one simply listens, but also implicitly Accepts. This was
found to take 3–5 min and, in a very large Kaiser cohort of
130,000 members undergoing comprehensive medical evalu-
ation, led to a 35% reduction in their doctor office visits and an
11% reduction in their ER visits over the next year. This dra-
matic finding has attracted the current interest of 20 state
Legislatures because of its implications for their Medicaid
budgets. And ultimately, because of the difficulty of dealing
with these problems after the fact, and their huge though gen-
erally unrecognized prevalence, the important question is
raised of how one might prevent them in the first place
through primary prevention.
The articles in this issue are evidence of an internationally
widespread, initially small-scale approach, that is developing
to move primary care medicine from a biomedical to a
biopsychosocial approach. If so, that could be one of the major
medical advances of our time.