The ACE (Adverse Childhood Experiences) Study and EMDR

Breaking The Adverse Childhood Experiences (ACE)
Poor Health Cycle With EMDR
Carol Forgash, LCSW
EMDR Europe Conference
Milano, Italia


This article is a summary of a plenary presented by Carol Forgash, LCSW at the 2015 EMDR Europe Conference in Milan.

THE ACE report is a groundbreaking public health study co-authored by Dr. Vincent Felitti and Dr. Robert Anda in 1998. It used a ten-question screen on over 17,000 patients at Kaiser Permanente, a large health maintenance organization in San Diego, California.

What are Adverse Childhood Experiences (ACE)? They are events that occur in the home and include household dysfunction, substance abuse, parental separation and divorce or early death of a parent. Also identified as ACE are: mental illness, spousal or partner violence, and criminal behavior resulting in incarceration of a household member.

Child abuse: psychological, physical, sexual, and emotional, physical and educational neglect are also categories of ACE.

The ACE Study resulted in several important conclusions.

  • ACEs are common…nearly two-thirds (64%) of adults have at least one.
  • ACEs don’t occur alone…if you scored one, there’s an 87% chance that you have experienced two or more.
  • There is strong evidence that ACE have been found to contribute to adult onset of chronic disease, such as immune disorders, cancer and heart disease, as well as mental illness and violence.
  • The more ACEs one has, the greater the risk for chronic disease, mental illness, violence.
  • People with an ACE score of four are twice as likely to be smokers and seven times more likely to be alcoholic.
  • Having an ACE score of four increases the risk of emphysema or chronic bronchitis by nearly 400 percent, and suicide by 1200 percent.
  • People with high ACE scores are more likely to have more marriages, more broken bones, more drug prescriptions, more depression, and more autoimmune diseases.
  • People with an ACE score of six or higher are at risk of their lifespan being shortened by 20 years.
  • ACEs are responsible for a big chunk of workplace absenteeism, and for high costs in health care, emergency response, mental health and criminal justice. An important finding from the ACE Study is that childhood adversity contributes to many of our major chronic health, mental health, economic health and social health issues.

The Cornerstone of the ACE Study is the Ace Questionnaire. There are ten questions in the questionnaire which can be asked in both medical and mental health settings.

  • Did a parent or other adult in the household often or very often… swear at you, insult you, put you down, or humiliate you? Or act in a way that made you afraid that you might be physically hurt?
    No___ If Yes, enter 1___
  • Did a parent or other adult in the household often or very often… push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured?
    No___ If Yes, enter 1___
  • Did an adult or person at least five years older than you ever… touch or fondle you or have you touch their body in a sexual way? Or attempt or actually have oral, anal, or vaginal intercourse with you?
    No___ If Yes, enter 1___
  • Did you often or very often feel that … no one in your family loved you or thought you were important or special? Or your family didn’t look out for each other, feel close to each other, or support each other?
    No___ If Yes, enter 1___
  • Did you often or very often feel that … you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
    No___ If Yes, enter 1___
  • Was a biological parent ever lost to you through divorce, abandonment, or other reason?
    No___ If Yes, enter 1___
  • Was your mother or stepmother: often or very often pushed, grabbed, slapped, or had something thrown at her or kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
    No___ If Yes, enter 1___
  • Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
    No___ If Yes, enter 1___
  • Was a household member depressed or mentally ill, or did a household member attempt suicide?
    No___ If Yes, enter 1___
  • Did a household member go to prison?
    No___ If Yes, enter 1___

The sum of the “Yes” answers equals the ACE Score.

Among the consequences of ACE are that maltreated individuals are at greater risk of heightened stress sensitivity and are predisposed to unfavorable courses of illness. These ACE survivors may have elevated inflammation levels which are associated with recurrent depressive episodes and poor medical and psychotherapy treatment responses.

  • As the number of ACEs increase in a child’s life – the risk for the following health problems increases throughout the life cycle: alcoholism and alcohol abuse, illicit drug use, chronic obstructive pulmonary disease, depression, fetal death. Other health-related quality of life issues are also problematic for ACE survivors, such as ischemic heart disease (IHD) and liver disease.
  • ACE are also associated with adult vulnerability to chronic stress-related gastrointestinal, metabolic, cardiovascular immunological illness.
  • Other typical problems encountered by ACE survivors, are respiratory, musculoskeletal, chronic pain, fibromyalgia, chronic fatigue, eating disorders, headaches, irritable bowel syndrome, gynecological problems including pregnancy, and sleep disorders.
  • They frequently overutilize emergency and specialty care and underutilize routine healthcare.
  • Other difficult problems affecting ACE survivors are increased risk for intimate partner violence, multiple sexual partners, sexually transmitted diseases (STDs), suicide attempts, high rates of adolescent pregnancy and early use of cigarettes and other addictive substances.

It is becoming more evident that ACE contributes to what has been called a public health epidemic. It may also be evident that EMDR can contribute to the improvement of physical and mental health in an ACE survivor.

ACE survivors require EMDR trauma-informed therapy to deal with the many problems they endure. Their diagnoses generally include complex post traumatic stress disorder. From the beginning of treatment, one can integrate ACE information and concepts with EMDR therapy.

In history taking from an EMDR perspective, the clinician can utilize the ACE questionnaire and a genogram. Include developmental history, family of origin issues, and attachment issues as part of the history taking. Additionally, explore the client’s health history going back to infancy, the health of the mother during pregnancy and also inquire about the health of family members.

Issues for complex PTSD-high ACE score clients include the following.

  • If untreated, the intrusive and numbing symptoms of chronic PTSD may continue across the lifespan.
  • Untreated PTSD depresses the immune system.
  • PTSD may be a result of ACE, ill health, even iatrogenic events.
  • In addition to PTSD, attachment deficits and dissociative symptoms, survivors often have issues with trust, self-hatred, and abandonment.
  • The ability to be an educated health consumer, to ask questions during medical exams, and ability to follow-up with annual visits and diagnostic testing, may all be compromised. Thus trauma survivors generally have serious difficulties addressing their health problems and accessing adequate health care.
  • Good preventative and ongoing health care may have been minimal or absent – exacerbating existing health problems.
  • Survivors often do not believe they deserve good health, have  shame and guilt issues.
  • They may have issues about authority figures (MDs & dentists).
  • Many aspects of healthcare treatment are triggering.
  • There may be years of avoidance of healthcare treatment, resulting in serious health problems.
  • There is a tremendous opportunity, given the number of possible targets, to develop an individualized treatment plan that will address medical and mental health problems.

Can we hypothesize that since successful EMDR therapy minimizes or eliminates symptoms of PTSD, it could restore the balance in the neurobiological/chemical systems of the body, thus improving health or reducing risk factors of ACE survivors?

The ACEs and other negative core events and beliefs that drive harmful behavior, or avoidance of current problems must be addressed and resolved.

Successful trauma informed EMDR therapists will pay attention to underlying issues, and recognize that past traumas need to be addressed for physical and mental health to improve.