ACEs is not a game

The year was 1985. The physician was Dr. Vincent Felitti, chair of Preventive Medicine at Kaiser Permanente San Diego. He had started an obesity clinic five years before to help patients with obesity successfully lose weight. Some had only 30 pounds to lose, although most were between 100- and 600 pounds overweight.

But in 1985, he faced the crushing fact that one-half of the people enrolling dropped out each year. But it was not due to a lack of success since they were all losing weight. Patients described him as trustworthy. They spoke of him with reverence. He didn’t appear to be the reason patients weren’t staying.

He had to figure out why these patients didn’t continue after showing success.


He began by reviewing all their medical records, which further confused him. These patients had all been born with average weights. They also did not slowly gain weight but appeared to do it suddenly, then plateau off. If they tried to lose weight, they would succeed only to regain it back again quickly.

He then did face-to-face interviews with about 10% of the dropouts, using a standard questionnaire looking at weights at different times in their lives. One of the questions did ask them when they first became sexually active. But by mistake, while interviewing one woman, he asked what she weighed when she first had sex. She replied 40 pounds. Dr. Felitti was confused, so he asked her again. Again, she said 40 pounds, then broke down crying that she was 4 at the time and her father molested her.

Dr. Felitti decided to modify the question for future patients to see if it had been a fluke or if there was a connection. A large number of the patients also told of histories of rape or incest. Not wanting to be biased, he asked other physicians in the department to interview the rest of the dropouts, making sure to ask this question. Again, incest or rape was a frequent finding.

This connection was never reported or discussed in the medical literature before. But there was a growing belief that childhood trauma led to adult addiction.

He decided to report his findings at the American Association for the Study of Obesity conference in 1990. Many attendees shot down his conclusions. They blamed the patients and saw the reports as excuses for their obesity.

But a physician from the CDC, Dr. David Williamson, was interested in Dr. Felitti’s findings. He encouraged Dr. Felitti to expand his research beyond the obesity clinic to the Kaiser Permanente general population. This study expansion would not be that hard because of Kaiser’s Preventive Medicine department, which saw 55,000 patients yearly for comprehensive medical evaluations. Dr. Felitti went to the CDC at Dr. Williamson’s invitation so that they and Dr. Robert Anda could discuss how to set this up and evaluate the findings.

In 1998, they published their findings in the American Journal of Preventive Medicine. They developed a questionnaire on adverse childhood experiences (ACEs) which covered these three areas:

  • Abuse
    • Physical
    • Sexual
    • Verbal
  • Neglect
    • Physical
    • Emotional
  • Family Dysfunction
    • Mental illness
    • Alcoholism or substance abuse
    • Maternal domestic abuse
    • Family member in jail
    • Loss of parent through divorce or abandonment

They found that two-thirds of the general population (17,000) had experienced one or more ACEs. Of those, 87% had experienced two or more, and 12.6% (one in eight) had experienced four or more ACE events. The higher the ACE score, the more those people went on to have significantly higher rates of chronic health and mental health problems and issues with relationships and employment.

What is essential to understand is that these were primarily white, middle-class people. Their average age when filling out the questionnaire was 57 years old, meaning they were born in the late 1920s to early 1930s. They didn’t have these problems because their mothers worked outside the home, leaving them at childcare or stuck in front of TVs. In fact, there were no TVs when they were growing up, only radios. These patients were in the generation lauded as the last great generation, a time we all talked about returning to.

This information still took a while to reach professionals working with children and families. In 2012, the American Academy of Pediatrics issued a policy statement entitled, The Lifelong Effects of Early Childhood Adversity and Toxic Stress, which introduced the concept of ACEs to pediatricians. It was a call to action for them to find and provide help for these children and families.

There are now numerous organizations working to bring this information to professionals working with children and families so that they can help change the long-term outcomes which Dr. Felitti and his colleagues have uncovered. They have their work cut. It will require reframing how we see these families and approach them to provide help.


In future articles, I will discuss these stress factors and the role of positive factors in helping children develop resilience in day-to-day handling activities, despite being exposed to these toxic experiences.

If you are interested in an in-depth look at three factors of children and adolescents that can create positive or negative futures, check out my program, Developing a Calm Classroom