Adverse Childhood Experiences (ACEs) and Addiction

0:00:15 William Moyers
Hello and welcome to Let's Talk, a series of podcasts produced by the Hazelden Betty Ford Foundation on the issues that matter to us, the issues that we know matter to you, too. Substance use prevention, research, treatment for addiction and recovery management, as well as education and advocacy. I'm your host, William Moyers, and today we're joined by clinician, psychiatrist, and Medial Director Dr. Stephen Delisi. Welcome, Stephen.

0:00:43 Dr. Stephen Delisi
Thank you, William. Pleasure to be here.

0:00:45 William Moyers
And today our topic is Capital A, Capital C, Capital E, small "s". The acronym for ACEs which means Adverse Childhood Experiences. And it has a profound impact on mental health and especially on addiction in adults. Dr. Delisi, what is ACEs?

0:01:03 Dr. Stephen Delisi
ACEs, as you said, it stands for Adverse Childhood Experiences. These are experiences that individuals go through prior to the age of 18. And a seminal study started in the mid-1990s in partnership between the Centers of Disease Control and Kaiser Permanente looked at over 17,000 individuals. And across ten different adverse childhood experiences and then followed them out for years to determine how those childhood experiences affected them in adulthood in their general medical health, mental health, and with addiction.

0:01:42 William Moyers
Childhood experiences—what kind of childhood experiences?

0:01:44 Dr. Stephen Delisi
Yeah so there's ten.

0:01:45 William Moyers
Okay.

0:01:47 Dr. Stephen Delisi
There's a questionnaire that practitioners can use to screen for the adverse childhood experiences. They include things like sexual, physical and emotional abuse. Parental separation and divorce. Witnessing intimate partner violence in the home. Household substance abuse. Mental illness in the household. Incarceration in the household. And then emotional or physical neglect. Those are the ten that are measured.

0:02:17 William Moyers
And when they're measured, you get a score?

0:02:18 Dr. Stephen Delisi
You do. For each of those that you're positive, it's 1 point.

0:02:22 William Moyers
And what happens with that total? 

0:02:24 Dr. Stephen Delisi
Yeah, so what they have gone on to show and this study is ongoing. As of—as of this year. What they've shown is that as you have more and more in a dose response relationship. So the more you have, the more your risk of major chronic illnesses across heart disease, cancer, lung disease, depression, suicide and addiction increases exponentially.

0:02:52 William Moyers
And that's relevant to what we do at Hazelden Betty Ford because?

0:02:55 Dr. Stephen Delisi
Very much so. That is the work that needs to be done around trauma informed care. Recognizing it, acknowledging that many of the individuals who come to us for our treatment and put their trust in us have experienced these early childhood traumas that we are going to need to address and understand as part of their care.

0:03:17 William Moyers
So people who have scored—

0:03:19 Dr. Stephen Delisi
Yes.

0:03:19 William Moyers
Through the—through ACEs, how do you equate that impact those childhood experiences have had on their use of legal or illegal substances: alcohol, cocaine, opiates?

0:03:31 Dr. Stephen Delisi
Yeah. So—so first, as you get to four or more of those Adverse Childhood Experiences, and this is not uncommon—more than two-thirds of the population has at least 1 ACEs. At least 1.

0:03:43 William Moyers
Two-thirds has at least 1?

0:03:44 Dr. Stephen Delisi
Two-thirds has at least 1.

0:03:46 William Moyers
Okay.

0:03:47 Dr. Stephen Delisi
And twelve and a half—1 in 8 Americans has four or more Adverse Childhood Experiences. And at that level, your risk of an alcohol use disorder is two to four times the general population. And sevenfold increases in risk of illicit drug, four and half times the risk of depression, and twelve times risk of suicide. How does that happen? There are now ongoing studies looking at how adverse childhood experiences change the way that our genes and our DNA are read resulting in different transcription of the building blocks of our body. And we have now good data to show that adverse childhood experiences can lead to reduced or delayed development of the prefrontal cortex. An incredibly important part of the brain for controlling our addiction centers and our emotions. Changes in the nucleus accumbens and the amygdala, these limbic regions that we know are implicated in addiction and major psychiatric illnesses. So, in a very real sense, these experiences in childhood change the way our genes are read and the way our brains are developed.

0:05:00 William Moyers
So let's talk a little bit about prevention—

0:05:02 Dr. Stephen Delisi
Yes.

0:05:03 William Moyers
As it relates to that context. If we know a child or young—young teenager has had a series of these impactful experiences—

0:05:12 Dr. Stephen Delisi
Yes.

0:05:14 William Moyers
What can the professional or what can the parent, what can the teacher do, to perhaps move that child through life's experiences without developing a dependency on substances, for example?

0:05:28 Dr. Stephen Delisi
Wonderful question. And I—I think I'll start by saying that these again are common experiences and having an ACEs score that's over zero does not mean—

0:05:38 William Moyers
Right.

0:05:39 Dr. Stephen Delisi
—That you are going to have one of these illnesses. Your risk though is—is elevated. So identifying it early and then looking for ways in which we can build resilience within these kids is critically important. How do we support the children both in the home and in the school? How do we support the parents, especially young parents, to follow more positive parenting so that perhaps some of the adverse childhood experiences like abuse don't even happen. There are evidence-based prevention strategies—

0:06:09 William Moyers
Mmm-hmm.

0:06:10 Dr. Stephen Delisi
That can be embedded into the schools like building assets, reducing risk. Which really help to create cohorts of kids—

0:06:19 William Moyers
Mmm.

0:06:19 Dr. Stephen Delisi
Interacting and supporting each other. But then also, real meaningful relationships with adults. And that is absolutely preventative.

0:06:28 William Moyers
But of course despite our best efforts we know that people are still gonna be vulnerable or susceptible and some are gonna develop for example a dependency—

0:06:35 Dr. Stephen Delisi
Yes.

0:06:36 William Moyers
On substances or develop a mental illness. How and you—you referred to this briefly, we have another podcast actually on trauma informed care—

0:06:44 Dr. Stephen Delisi
Yes.

0:06:45 William Moyers
And treatment, but—but just for the benefit of our viewers and listeners now, how do you apply an ACEs score—

0:06:52 Dr. Stephen Delisi
Mmm-hmm.

0:06:53 William Moyers
To the treatment of somebody who needs help.

0:06:57 Dr. Stephen Delisi
First, get your ACEs score. That's really important.

0:07:00 William Moyers
Huh.

0:07:01 Dr. Stephen Delisi
And then based upon that, determine what level of intervention is going to be needed. And this is—this is not abstract. There was a recent study that was just published this year, 2019, that looked at individuals in rural Tennessee. Being treated for an opioid use disorder with MAT, Medicated-assisted Treatment.

0:07:26 William Moyers
Mmm-hmm.

0:07:27 Dr. Stephen Delisi
They found that for every 1 point on the ACEs score, the risk of a relapse increased by 17 percent. But, good news, and to your point, for each appointment that the person went to that was trauma-informed, there was a two percent reduction in that risk. So you can see how the cumulative effect of staying in treatment and focused on those traumas can reduce the risk of relapse.

0:07:56 William Moyers
I'm impressed and frankly just a little bit alarmed by the fact that external events that occur in a young person's life can be internalized to the extent that they can effect, actually change, the brain.

0:08:09 Dr. Stephen Delisi
Very much so.

0:08:10 William Moyers
Can you talk a little bit more about that?

0:08:11 Dr. Stephen Delisi
I—I can. So, we—we always talk about genetics. The heritability risk.

0:08:16 William Moyers
Right.

0:08:16 Dr. Stephen Delisi
Of addiction and mental health illnesses. But there's also a field of study called epigenetics. And epigenetics looks at how does our environment, our life experiences, affect how those genes are read. And we now know that there are differences. So, you may be genetically predisposed in one direction, but based on life experiences, those genes are read differently. So now there's a different risk.

0:08:47 William Moyers
Hmm. I can promise you that people who are listening or viewing this podcast today are gonna wanna go out and get there ACEs score—

0:08:53 Dr. Stephen Delisi
Yes.

0:08:53 William Moyers
How does somebody go about that process?

0:08:56 Dr. Stephen Delisi
You know, honestly in—in today's world, the all you need to do is get to your computer and google Adverse Childhood Experiences. There's actually an online electronic form of the ACEs questionnaire that you can fill out and get your score.

0:09:13 William Moyers
Then what do you do with it?

0:09:14 Dr. Stephen Delisi
Then I would again really encourage you to go and talk to your medical provider or mental health provider or addiction counselor. Sit down with them and talk about those early life experiences and begin to focus on what are the ways you're gonna build your resiliency.

0:09:33 William Moyers
Should a parent get online and answer those questions on behalf of one of their children?

0:09:41 Dr. Stephen Delisi
I think that the answer to that is yes. In—in fact, the former President of the American Academy of Pediatrics, Dr. Block, he has said that Adverse Childhood Experiences represent the single greatest unaddressed public health crisis facing our nation today.

0:10:02 William Moyers
Hmm.

0:10:02 Dr. Stephen Delisi
So that parent going and looking at that, and then going to their—the pediatrician and talking about that can have a significant impact down in downstream into adulthood.

0:10:15 William Moyers
And what responsibility then does the pediatrician or the general practitioner have in—if a parent or patient brings their ACEs score? Hey, Dr. Delisi, look at my score here!

0:10:22 Dr. Stephen Delisi
Yes. Yes.

0:10:24 William Moyers
I've got 8 of the 12 on the—on the list! And I hand that to you—what are you gonna do with that?

0:10:31 Dr. Stephen Delisi
Yeah, well my hope would be that that pediatrician would recognize that as a screening for serious potential risk to chronic illness. And take it very seriously as a medical intervention. Pediatricians have the ability to make referrals to mental health professionals to connect that child and the parents to evidence-based treatment to help with those early childhood traumas.

0:11:02 William Moyers
And when we see an ACE score for example at Hazelden Betty Ford what do we—how do we use that to—to better guide our one-on-one treatment with the patient?

0:11:14 Dr. Stephen Delisi
In—in—in two fashions. One is it gives us some indication as to the risk of relapse because more, in higher ACEs score, the more the risk of relapse that we saw from that recent study.

0:11:27 William Moyers
Mmm-hmm.

0:11:28 Dr. Stephen Delisi
So, we wanna know that. We wanna have an idea of who's at greater risk of relapse that we need to create a relapse prevention plan that addresses, again, those specific needs—

0:11:39 William Moyers
I see. Mmm-hmm.

0:11:40 Dr. Stephen Delisi
And those specific experiences. We've also really incorporated within our system of care a trauma-informed approach that helps to keep people engaged and informed. Throughout their course of treatment.

0:11:56 William Moyers
Dr. Stephen Delisi, thank you for bringing your expertise and your passion to our viewers and our listeners today. Medical Director at Hazelden Betty Ford, a Psychiatrist, the Medical Director of our Professional Education Solutions division at Hazelden Betty Ford, Dr. Stephen Delisi.

0:12:13 Dr. Stephen Delisi
Thank you very much, William. It was a pleasure.

0:12:15 William Moyers
I'm your host, William Moyers, and on behalf of Lisa Stangl and all of us at Hazelden Betty Ford, we thank you for joining us for another podcast, Let's Talk. Make sure you join us again.