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 5 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 was facing a crushing fact that each year one half of the people enrolling were dropping out. But it was not due to a lack of success since they were all losing weight. It didn’t appear to be due to him since he was described as trusted and was spoken about with reverence.  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 normal 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 decided to do 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 instead 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 breaking down crying that she was 4 at the time and it was her father who 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 some other physicians in the department to do interviews on the rest of the dropouts, making sure to ask this question. Again, it was found that incest or rape was a frequent finding.

This connection was never reported or discussed in the medical literature before. But there had been a growing belief that addiction was linked to past childhood trauma. He decided to report on his findings at the American Association for the Study of Obesity in 1990. His findings were shot down by many attendees who felt that patients were simply trying to find an excuse for their obesity.

But there was a physician from the CDC, Dr. David Williamson, who 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 would not be that hard because of Kaiser’s Preventive Medicine department which saw 55,000 patients each year 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 had 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 that general population (17,000) had experienced one or more types of ACEs. Of those, 87% had experienced two or more and 12.6% (one in eight) had experienced four of more ACE events. The higher the ACE score, the more those people then went on to have significantly higher rates of chronic health and mental health problems, as well as problems with relationships and employment.

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

It still took awhile for this information 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 out for them, since it will require a reframing of how these families are viewed and approached to provide help.


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

If you are interested in an in-depth look at 3 factors of children and adolescents that can create positive or negative futures, check out my program, Never Assume: Know Children Before Labeling Them.

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