The results of the Adverse Childhood Experiences study demonstrate alarming news: that children exposed to abuse are more prone to obesity, heart disease, cancer, depression, and other chronic health problems as adults.

by Valerie R. Gregg

In a bright exam room painted in primary colors, with a carton of toys close at hand, Nancy Fajman draws pictures with her patients. First she sketches an outline of a little girl. She fills in the eyes, nose, and mouth and eventually moves on to the genitals and breasts. They talk about each body part and its function, and then Fajman draws a larger figure standing next to the first.

"This one little girl - a bright little chatterbox of a 3-year-old - very matter-of-factly called her vagina a 'Pocahontas,'" laughed Fajman, an Emory pediatrician and medical director of the Child Protection Program at Egleston Children's Hospital. "She was so cute."

Then, the cute scenario took an uncomfortable and disturbing turn. Using the pictures, the child showed Fajman exactly how her teenaged cousin had tried to molest her.

Fajman confronts such heartbreaking scenarios every day. Children often leave her office and go back to horribly chaotic and traumatic home lives. But she takes comfort in providing them a safe place to confront their private torments and helping them realize that their bodies and souls are still their own.

She also may be helping her patients live longer, healthier lives.

A recent study conducted in part at Emory showed that children who are abused or grow up in dysfunctional households are more prone to obesity, heart disease, cancer, depression, and other chronic health problems as adults. Of about 20,000 middle-class, middle-aged San Diego residents studied, more than half reported suffering childhood abuse or growing up in dysfunctional households. Further, the more risk factors they experienced in childhood, the more likely they were to develop common but life-threatening diseases.

Emory, Kaiser Permanente, the University of Arizona, and the Centers for Disease Control and Prevention (CDC) conducted the Adverse Childhood Experiences (ACE) study, with findings published in the May 1998 issue of the American Journal of Preventive Medicine. Questions in written surveys asked participants about childhood exposure to seven areas of abuse or severe family dysfunction. Researchers then compared the responses with adulthood disease and the unhealthy behaviors that can cause them.

The results were startling. Those who experienced four or more types of adverse childhood experiences - specifically being a victim of physical, sexual, or emotional abuse, witnessing their mothers being abused, or having family members who were substance abusers, mentally ill, or imprisoned - suffered significantly more chronic disease. They were 60% more likely to have diabetes, twice as likely to suffer cancer or heart disease, and nearly 2.5 times as likely to have had a stroke. Researchers then measured ten categories of disease risk factors, including smoking, obesity, physical inactivity, depression, suicide attempts, alcoholism, drug abuse, more than 50 sexual partners during a lifetime, and a history of sexually transmitted diseases.

Emory pediatrician Dale Nordenberg, a principal investigator for the study, says the work has dramatically changed his outlook.

"I now see child abuse as years of life lost," he says. "That's a very big change. These data contribute to mounting evidence that child abuse may cause victims to adopt unhealthy behaviors as coping mechanisms - things like smoking, sexual promiscuity, and drug and alcohol abuse that cost the health care system millions of dollars and have an immeasurable human cost. It's important for the legal system, health care systems, health care providers, managed care organizations, and public health agencies to understand this."

Estimates that 20% to 30% of girls and 15% to 20% of boys are sexually abused before they reach adulthood cry out for action, says Nordenberg. "That's a lot of boys and girls. How many diseases affect that many children? Not even measles or mumps, at least in the United States. We should be screening abuse victims for years for evidence of high-risk health behaviors that are common coping strategies for victims of adverse childhood experiences and that also are associated with chronic disease."

Victims hide abuse for years in most cases, under a mask of shame and fear. But its effects never really go away. That's what Kaiser internist Vince Felitti found in his treatment of morbidly obese women. During the early 1980s, when he noticed that one patient after another told him tales of childhood abuse, he started keeping count. The CDC and Emory soon became interested in his work, and researchers there envisioned the ACE study.

Convincing middle-aged people to talk to their doctors about childhood trauma is difficult enough, says Fajman. Getting physicians and mainstream social service agencies to confront the problem early on is another matter completely.

"Most pediatricians are not trained to do routine genital exams," she says. "They don't routinely ask parents and children the right questions about these issues. We must make genital exams part of routine checkups. Physicians should be able to direct parents to the resources they need to support their families. Physicians should also be willing to testify for the child in court. The whole issue makes many people - including doctors - extremely squeamish."

Nordenberg hopes data from ACE and other studies like it will help bring child abuse and other family issues to the forefront of pediatric practice.

Felitti says that internal medicine physicians should ask questions about child abuse right along with questions about allergies to medication. "It is that important," he says. "Physicians need to realize that a lot of the chronic disease they see could have psychosocial roots. Just treating the physical disease won't solve the problem. They need to ask the right questions, become better listeners, and help their patients get the resources and counseling they need."

Emory pediatrician Jean Wright, medical director of Egleston Children's Hospital, often sees the short-term results of abuse in her area of expertise: intensive care.

"But by then it's too late," she says. "Once a child has been hit, it's like Humpty Dumpty - you can never truly put that child's life back together. Pediatricians need to identify families at risk before they explode." Wright would like to see parental surveys integrated into all well-child appointments so that pediatricians could direct unstable parents to classes in parenting or anger management.

"As a society, we've told children it's OK to tell," says Wright. "But society is still uncomfortable dealing with the result. It's too complicated and shameful and messy. I can't think of another disease that affects one-third of the population. If one-third of the population had something like Ebola virus, and you sat down with the Surgeon General and public health agencies and talked about health care dollars spent, they'd lobby Congress for money to stamp it out. But because child abuse carries such a social and sexual stigma, that's not happening. More studies like ACE can expose this hidden problem, which has such deep roots in our society."

Under Lock and Key

Emory pediatrician Nancy Fajman, medical director of the Child Protection Program at Egleston Children's Hospital, uses a colposcope for noninvasive examinations when she suspects a child has been sexually abused.

They're an unusual group - a lanky black kid in baggy pants, a white boy wearing Birkenstocks and a preppy haircut, and a stocky, athletic adolescent with five-o'clock shadow and hoop earrings.

And they've got an unconventional message. At a recent rehearsal for a teen theater group called EN-ACTE, they were stuck on the chlamydia scene.

"Let's put them in a locker room - maybe playing poker or something," suggested one of the actors. "Guys don't just stand around a water fountain and talk about this stuff. They gotta be doing something."

So they sat down on imaginary locker room benches, dealt imaginary cards, and ribbed their friend about his new girlfriend. They laughed nervously when he told them he caught chlamydia from unprotected sex with her. "How do you know what it is? Man, you better have a doctor look at it or it might fall off. . . . Didn't you and her talk about using protection beforehand?"

EN-ACTE (Achieving Change Through Theater in Education) is an Emory-sponsored program using teen actors who perform for local school and teen groups to educate them about HIV, unplanned pregnancy, sexually transmitted diseases, gender issues, peer pressure, and communication. The youth actors are important to its success by identifying issues, creating the content, and communicating the show to peers, according to Nordenberg, who is the principal investigator and health director of the program.

"Many of the high-risk health behaviors that EN-ACTE deals with are the same behaviors associated with adverse childhood experiences," he says. "It's a shotgun intervention for general audiences to educate them about the consequences of risky behavior and to direct them to resources that can help."

Says EN-ACTE director Ken Hornbeck: "We want to get our audience talking. People are frightened by issues like these - teen pregnancy, AIDS, sexually transmitted diseases - but the consequences for not talking about them are so costly. It's almost like a crusade for us. We have to speak the truth."

In the future, Nordenberg would like to see further study on both the long- and short-term health effects of childhood abuse. He is especially interested in how abuse affects the childbearing decisions of victims and the health of their children, treatment and compliance patterns among abused children, and the development of improved screening tools to identify children and families at risk. Continuing its work, the ongoing ACE study has recently examined the association between adverse childhood experiences and unwanted pregnancy in adulthood, sexually transmitted disease risk, patterns of teen sexual activity, and other risk behaviors.

"The ACE study has shown us that the effects of child abuse stretch from birth to grave," he says. "From pediatrics to geriatrics, adverse childhood experiences have serious effects on health. I'm hoping that these data will encourage public health agencies, health care systems, and managed care companies to direct more resources to address the environmental issues at the root of so many health problems."

Fajman wants to know how some abuse victims avoided unhealthy coping mechanisms. She is convinced that physicians who listen to and empathize with their patients can help.

"We need to know that as physicians, our reassurance has great power," she says. "When that 3-year-old girl was finished with her exam, she ran out to the waiting room and jumped into her mother's arms yelling, 'Mommy, Mommy, the doctor said my Pocahontas is OK! We can go home now!' I'd like to think I made a difference for her."

Valerie Gregg is a freelancer writer in Atlanta.

Speaking the Truth

In his spare time, Emory pediatrician Dale Nordenberg (foreground), a principal investigator of the ACE study, teaches Aikido, a martial art stressing conflict resolution that is used to help youth and adults learn techniques to deal with violence and aggression.


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