“Look at This!”

“Look at this! They finally proved what we told them twenty years ago!” wrote psychiatrist Charles Whitfield, MD, ten years ago across the top of a just published research report. The article was reporting on lifetime health and mental health consequences of the chronic emotional stress that lurks in homes with parental addiction, and related adverse childhood experiences that create havoc and repeated trauma.  

It was the beginning of a slow and often reluctant awakening to a major ten-year study with a cohort of seventeen thousand primarily middle class adults who had health care insurance with Kaiser Permanente. The original purpose of the study, which has generated over one hundred articles in peer-reviewed journals to date, was to identify potential new strategies to prevent, or to address earlier and more effectively, the chronic diseases among the burgeoning older population that were increasingly absorbing higher and higher percentages of the country’s health care resources. 

The unexpected results that began to surface in interviews with research clients was a pattern of adverse childhood experiences creating traumatic events and/or chronic emotional stress from early childhood that could be identified as precursors to such chronic diseases as heart disease, strokes, diabetes, cancer, and obesity, as well as depression and other mental health disorders.  Certain adverse experiences during the critical years of early childhood brain development began to be noticeable, including alcoholism or other drug addiction in the family, seeing your mother get hit, having a parent in prison or a parent suffering with mental illness, and being physically or sexually abused as a child. From that growing awareness at the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente, the cosponsors of this landmark research, came the study’s name: The Adverse Childhood Experiences (ACE) study.

What Dr. Whitfield, one of NACoA’s founders, was saying to us at NACoA was that the conditions in addicted families—and the often deleterious impact on children in those families—was obvious to the twenty-two NACoA founders who gathered in 1982 and again in early 1983 to share their individual work and what they had learned about children of alcoholics in their lives and their practices. At these gatherings, they determined that the silence that trapped these children—one in four from all socioeconomic and educational backgrounds—had to be broken. They realized they needed to work collaboratively to break the silence, and they created NACoA to be a voice for the children. 

Now, over thirty-three years later, there is an awakening of the impact of chronic emotional trauma on developing children, and a growing sense that this is proving too costly to our medical system, mental health system, school systems, and court systems, over and above the human cost to impacted children and families. As a result of this awareness, we now have a federal Health and Human Services Department (HHS) that has a growing focus on making all programs and most professional training trauma-informed as well as evidence-based. 

“The ACE study provides population-based clinical evidence that unrecognized adverse childhood experiences are a major, if not the major, determinant of who turns to psychoactive materials and becomes addicted,” noted Vincent Felitti, MD, the Kaiser Permanente ACE study coprincipal investigator (2004). As this becomes better understood by program designers, addiction treatment and prevention program directors, school systems, and those who fund them, we could imagine a world where all responsible adults would argue for child- and family-focused preventive interventions across our systems, including juvenile justice. Furthermore, in the next generation we could reap an historical drop in health care and mental health care costs among adolescent and adult populations, and an emotionally stable life for the one in four children who still suffer in silence in addicted families. 

The ACE study researchers identified the most frequent adverse childhood experiences and developed an “ACE Score” to identify the most at-risk populations of children to whom public policy could direct more effective prevention and intervention strategies. They recognized that most ACEs did not exist in isolation in families. “Growing up with alcohol-abusing parents is strongly related to the risk of experiencing other categories of ACEs,” stated Robert Anda, MD, a heart disease prevention researcher with CDC and coprincipal investigator of the ACE Study with Dr. Felitti (2010). The study has proven what we knew clinically and environmentally twenty years earlier.

Today, as a result of the ACE study findings, childhood trauma is now called the nation’s number one public health problem. The relationship is difficult to miss between the NIAAA conclusions and the findings of the ACE study. The evidence continues to mount that compels the critical imperative for childhood to be a time of nurturing supportive environments and of developing healthy attachments to loving and supportive adults. Conversely, evidence mounts simultaneously that we must, as a matter of public policy and clinical practice, do all possible to ameliorate or halt the damage from chronic emotional stress in early childhood, with its lifetime of adverse consequences and shortened life span. 

According to Rosemary Tisch, MA, and researcher Rivka Greenburg, PhD, there is ample evidence that prevention programs which target the whole family can delay initiation of substance use, create healthier parent/child relationships and whole family healing that improves youth resistance to peer pressure to use alcohol, reduces affiliation with antisocial peers and levels of problem behaviors (2015; UNODC, 2009). Family programs are found to be second only to in-home family support and nearly fifteen times more effective than programs working with youth only. In addition, the effect of family skills training programs is sustained over time (Cheng et al., 2007).  

Family treatment courts (FTC) have offered successful treatment approaches for child abuse, neglect, family violence, and addiction “probably due to their focus on family-centered services,” said Ms. Tisch (2015).  Reviews of FTCs show that “manualized, structured, evidence-based family treatments” are an essential component (Marlowe & Carey, 2012). 

Family-centered services are critical for healing, yet few evidence-based family-focused programs exist; fewer still focus on addiction. NACoA is attempting to change that. With its updated and enhanced Children’s Program Kit to be rereleased this year, and its widely spreading and evidence-based whole family recovery program curriculum Celebrating Families!, NACoA is working to put the most effective evidence-based tools in the hands of those in prevention and treatment services. These professionals are in a position to offer program services that are proven trauma-informed and age-appropriate preventive interventions to counteract the impact of ACEs on so many of America’s children. As ACE study research findings are published, there is a constant reminder of the need for enhanced, resilience-promoting interventions and program services. That family-centered treatment offers a solution to the intergenerational cycle of substance use and related consequences by helping families reduce substance use and improve child health and safety is clear to all who look (Werner, Young, Dennis, & Amatetti, 2007). 

The ACE study has been a trigger for a critical awakening—the first step in the development and implementation of effective programs that can foster resilience and a balanced life for all those hurt by its findings. For all of us, it is a powerful challenge from Drs. Anda and Felitti to remember that we already know what to do in each of our systems. We need to get busy and do it for our nation’s children and for our nation’s mental and physical health.  

Anda, R. (2010). The health and social impact of growing up with alcohol abuse and related adverse childhood experiences: The human and economic costs of the status quo. Retrieved from http://www.nacoa.org/pdfs/Anda%20NACoA%20Review_web.pdf

Cheng, S., Kondo, N., Aoki, Y., Kitamura, Y., Takeda, Y., & Yamagata, Z. (2007). The effectiveness of early intervention and the factors related to child behavioral problems at age two: A randomized controlled trial. Early Human Development, 83(10), 683–91.

Felitti, V. J. (2004). The origins of addiction: Evidence from the adverse childhood experiences study. Retrieved from http://www.nijc.org/pdfs/Subject%20Matter%20Articles/Drugs%20and%20Alc/ACE%20Study%20-%20OriginsofAddiction.pdf 

Grant, B. F. (2000). Estimates of US children exposed to alcohol abuse and dependence in the family. American Journal of Public Health, 90(1), 112–5. 

Marlowe, D. B., and Carey, S. M. (2012). Research update on family drug courts. Retrieved from http://www.nadcp.org/sites/default/files/nadcp/Reseach%20Update%20on%20Family%20Drug%20Courts%20-%20NADCP.pdf

Tisch, R., & Greenberg, R. (2015). Addressing adverse childhood experiences (ACEs) through family-focused services for families dealing with substance use disorders. Retrieved from http://www.acesconnection.com/blog/addressing-adverse-childhood-experiences-aces-through-family-focused-services-for-families-dealing-with-substance-use-disorders-by-rosemary-tisch-ma-and-rivka-greenburg-ph-d?reply=419293293307247851

United Nations Office of Drugs and Crime (UNODC). (2009). Guide to implementing family skills training programmes for drug abuse prevention. Retrieved from https://www.unodc.org/documents/prevention/family-guidelines-E.pdf 

Werner, D., Young, N. K., Dennis, K., & Amatetti, S. (2007). Family-centered treatment for women with substance use disorders – History, key elements and challenges. Retrieved from http://www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf