ACEs
The ACE Study &
The Philadelphia Expanded Ace Survey
The MACE Foundation has an intentional focus and unwavering commitment to address the disparities in health and health equity for Black, Brown and Indigenous women in the United States through the lens of maternal adverse childhood experiences and their deleterious impact on the preconceptual, pregnancy, childbirth and postpartum periods.
The ACE Study has guided public health policy for more than 25 years in the U.S., and the Philadelphia ACE Project Survey has broadened the public health understanding of the additional stressful impact of community-based adversities and intergenerational trauma on minority populations. ACEs and the expanded ACE survey are some of the most scientific means for assessing social determinants of maternal health and risks of childhood neurodevelopmental disruption. Research has affirmed that Black, Brown and Indigenous populations suffer the highest negative impacts of these life experiences which are mediated by toxic serum cortisol levels, ultimately affecting the body, mind and spirit.
No longer should health care teams blithely attribute the term “stressed out” as an excuse for discounting the many concerning medical symptoms reported by their Black and Indigenous patients.
The goals of the MACE Foundation are to promote resilience against toxic stress in the pre-conceptual and pregnancy periods with resultant improved health of Black, Brown and Indigenous mothers and infants and to educate health care systems regarding toxic stress as a significant factor contributing to poorer health and diminished maternal survival.
The ACE Study
The Adverse Childhood Experiences Study was a survey conducted by Dr. Vincent Felitti and Dr. Robert Anda in conjunction with the Centers for Disease Control and Prevention and Kaiser Permanente from 1995-1997. The study population was a non-representative sample in that it included more than 17,000 participants all of whom were insured. The racial representation was 74.8% White, 4.6% Black, 11.2% Hispanic and 7.2% Asian. The education level of the participants was 39.3% College Graduate or Higher, 35.9% Some College, 17.6% High School Graduate and 7.2% Not High School Graduate.
The participants were asked to respond “Yes” or” No” to experiencing 10 specific childhood adversities. Participants were followed for 15 years after the initial survey, and medical diagnoses were documented showing significant correlations between the number of adversities and the social and educational impact as well as the severity of chronic medical problems. The 10 “Yes/No” ACE questions reflected three categories of adversities: abuse, neglect and household dysfunction. The abuse related questions included physical abuse, emotional abuse and sexual abuse. The neglect questions included physical neglect and emotional neglect.
The remaining five questions, reflecting household dysfunction, queried about the occurrence of parental mental illness, incarceration of a relative, intimate partner violence affecting the mother in the household, substance misuse and divorce. Each “Yes” response yielded a score of one with the maximum score of 10. Higher ACE scores resulted in poorer health outcomes and four or more ACEs were significantly more problematic.
According to the research, ACEs reflected a lasting impact in numerous areas to include injuries (e.g. traumatic brain injury, fractures and/or burns); mental health (e.g. depression, anxiety and suicide); maternal health (e.g. unintended pregnancy, pregnancy complications and fetal death); infectious disease problems (e.g. HIV and STDs); chronic diseases (cancer, diabetes, cardiovascular disease and obesity); high risk behaviors (alcohol and/or drug misuse, or unsafe sex); and decreased opportunities (education, employment and income). The study also found that adults who had experienced four or more categories of ACEs, compared to those who had experienced none, had increased risk for negative health behaviors including a 1.4 to 1.6-fold increase in physical inactivity and severe obesity; 2- to 4-fold increase in smoking, poor self-rated health, multiple sexual partners (i.e., ≥50 sexual intercourse partners), and sexually transmitted disease; and 4-to 12-fold increased risk for alcoholism, drug misuse, depression and suicide attempt.
The Philadelphia Expanded ACE Survey
Researcher Dr. Peter Cronholm and others recognized that the original ACE study relied on data collected from white, middle- and upper-middle-class participants and focused on experiences in the home. The Philadelphia Urban ACE Study was designed and administered in 2012 and 2013 to understand the impact of community-level adversities. The study was administered in conjunction with the Public Health Management Corporation’s Household Health Survey and surveyed 1,784 adult participants in Philadelphia, Pennsylvania using the original ACE study questions and five additional community-level stressors. The study used a more socioeconomically and racially diverse urban population ages 18 and older with racial representation of 44.1% White, 42.5% Black, 3.5% Latino, 3.6% Asian, and 3.8% Biracial. The educational levels were 35.7% College Graduate, 22.7% Some College, 31.4% High School Graduate, and 10.3% < High School.
The participants were asked to respond “Yes” or” No” to experiencing the 10 specific childhood adversities originally studied in the Kaiser ACE study with some differences in the wording. In addition to the standard ACE indicators, the survey asked questions to measure stresses associated with growing up in an urban community. In addition, qualitative focus groups were conducted by an ACE Task Force with urban youth to identify common causes of stress in the community as well as a study of racism and discrimination in children. The primary urban themes that were selected were experiencing racism, witnessing violence and living in unsafe neighborhoods. The urban questions were taken from the California Health Interview Survey Adult Questionnaire; the Adverse Childhood Experiences International Questionnaire; the National Survey on Children’s Exposure to Violence; and the CDC Family Health History and Health Appraisal Questionnaire and revised by the ACE Task Force.
Incorporating these additional resources, the Philadelphia Expanded ACE Survey with Urban ACE Indicators resulted in two additional questions which included a bullying question (bullied by a peer or classmate) and a question regarding foster care (ever in foster care).
The findings of the Philadelphia Expanded ACE Survey questions revealed that ACEs were common among Philadelphia residents and that on most measures, the rate of ACEs in Philadelphia is higher compared to the rates found in the original Kaiser study. Only two types of abuse and neglect were lower in the Philadelphia study population: sexual abuse (16.2% Philadelphia vs. 20.7% Kaiser) and emotional neglect (7.7% Philadelphia vs. 9.9% Kaiser).
Indicators of household dysfunction by race in the Philadelphia Expanded ACE Survey, as compared to the Kaiser study, revealed elevated scores in all areas except the category of having a mentally ill household member. It is pertinent to note that the survey revealed that the household dysfunction indicator, cited as “household member in prison,” was 6.9% White vs. 15.9% Black.
The Urban ACE indicators reflected 40.5% witnessed violence; 34.5% felt discrimination; 27.3% had adverse neighborhood experiences; 7.9% were bullied; and 2.5% lived in foster care. Males experienced these adversities more than females in every category.
In summary, the results of the Philadelphia Expanded ACE Survey revealed demographics that looked significantly different than the original ACE Study, in which the majority of participants were white, college-educated and middle-income. In Philadelphia, where an estimated 25% of the residents live in poverty, researchers found that almost seven in 10 adults had experienced one ACE and two in five had experienced four or more.