Produced by David L Corwin, MD

Review by David L Chadwick, PhD

Summer 2012 - Volume 16 Number 3

When I was asked to review this DVD about the Adverse Childhood Experiences (ACE) Study, I had some reservations. I had been listening to and accepting the concepts outlined by the ACE Study for about 20 years and I thought there wasn't much that could be said about that research that would be new to me. I was wrong, and this new production contains novel observations and thinking about an internationally recognized Kaiser Permanente (KP)-Centers for Disease Control and Prevention (CDC) research project.

p77In this four-hour DVD, Vincent Felitti, MD, gives a historical review; then he, Robert Anda, MD, and Frank Putnam, MD, comment on the effect of the Study on the practice of medicine. There are interviews with Felitti, Anda, and David Williamson, PhD, about the history and implications of this major piece of medical research. Anda points out the good news that State Health Departments across the country are increasingly using the ACE Study to guide program development. The continuing interest and support of the CDC in the ACE Study principles are vital.

Putnam points out that the ACE Study has recently been shown to apply to psychiatric diagnosis. Adverse experiences of childhood affect the incidence of many adult diseases, conditions, and behaviors that are described in the Diagnostic and Statistical Manual.1 He notes that there is accumulating evidence for the benefits of positive childhood experiences, and he encourages development of early intervention programs for infants and children who are maltreated. Increasingly, health officials and other policymakers are paying attention to the ACE Study. Many psychiatrists have been slow to develop an interest in child maltreatment. Putnam's leadership may accelerate this educational process.

Felitti explains the use of detailed patient questionnaires and brief interviews to gather data from thousands of patients about their unspoken childhood experiences. This process was not just accepted by KP members, but many found it helpful and responded with gratitude and a lowered physician-visit rate that lasted for a year. The process produced striking findings of the high prevalence of ACEs and was simple for the staff. Felitti argues that it makes a good model for improved medical practice, but acceptance by physicians has been slow. Felitti recognizes the difficulties of change and cites Eric Hoffer who said, "In a time of drastic change it is the learners who inherit the future. The learned usually find themselves equipped to live in a world that no longer exists."2

Felitti dwells on the frequent encounters with patients whose "problems" are really their solutions, showing how this applies to obesity, smoking, and abuse of "illicit" methamphetamine. He points out that this was the first major prescription antidepressant in the US in 1940, then asks if this observation matters.

Felitti summarizes and proposes a new way to change medical practice to recognize the importance of childhood experiences: providing the public a comprehensive medical history questionnaire to be completed and taken to their physicians, understanding that some will resent the burden imposed by unsolicited medical information of a traumatic nature. He also proposes the public health benefit of media portrayals of good and bad parenting.

nda's interview describes his personal professional pathway, from epidemiology, to chronic disease epidemiology, to behavioral epidemiology, and to the ACE Study after learning of Felitti's early experiences with treating obesity. His descriptions of the intense opposition to the ACE Study at both the CDC and at KP San Diego reminded me of the opposition to revelations of child abuse encountered by Freud and (later) by C Henry Kempe and other early child abuse physicians. He describes the selection of the term "Adverse Childhood Experience." It was not (as I have sometimes suspected) a deliberate avoidance of the term "child abuse" but rather a decision to cast a wider net than the legally defined term "child abuse" would provide. Thus the ACEs include parental divorce or death, which are not "child abuse" but which may be as likely to have an effect on health as the more obviously damaging events of domestic violence, parental substance abuse, mental illness, and criminal behavior.

Early attempts at publication of the ACE Study findings met with rejection until the 1998 article by Felitti et al in the American Journal of Preventive Medicine broke open that door.3 At about the same time, Felitti began to be invited to conferences for child abuse professionals where he preached to the choirs.

Anda predicts a powerful social movement growing out of the work on ACEs and leading rather quickly to improving the childhood experience. This may be overly optimistic in view of our past experience with societal denial of child abuse.

The Williamson interview emphasizes the importance of continuing surveillance for the occurrence of ACEs and notes that 20 states are now attempting this, using CDC-generated definitions. He firmly states that our society is ethically obliged to improve the childhood experience over and above the practical benefit of reducing the health costs generated by ACEs. He advocates the formation of professional alliances that cross disciplines and professional sectors and cautions that the findings of the ACE Study not be oversold because there are still risk factors for disease other than ACEs.

Dr Corwin's new production of the ACE Study DVD needs to be shown to all primary care physicians, all health officers, and to policymakers generally. It is much more than a rehash of old material from the ACE Study. It points to new directions for policy and program development. The ACE Study and its spin-offs are among the most important public health advances in our time. This DVD is an important contribution to improving medical practice.

1.    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition. Arlington, VA: American Psychiatric Association; 2010.
2.    Hoffer E. The ordeal of change. Cutchogue, NY: Buccaneer Books; 1976.
3.    Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998 May;14(4):245-58.


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