Our Study of Adverse Childhood Experiences (ACE) & Mental Health – the urgent need for public health intervention in India has been published this year in the Journal of Preventive Medicine & Hygiene.  The ACE framework forms the basis of our work, in the area of training, coaching and even further research.

For a full paper review, please click the link below or you can listen to the video summary and/or read the abstract after the video:

The PubMed link to the entire paper is available HERE.

Key highlights:

If an individual goes through some of the experiences captured (Figure 1 below), there are several long term negative health and wellbeing experiences.  Figure 2 highlights some of these outcomes, which include increased risk of mental health challenges (such as high level of anxiety, depression, poor sleep quality, obesity and so on), physical health challenges etc resulting in poor quality of life and in many cases reduced life expectancy.

ACE (Adverse Childhood Experiences) study

Figure 1 – Adverse Childhood Experiences categories and elements

ACE implications

Figure 2 – Consequences of adverse childhood experiences (ACE)

The following video covers highlights by all the authors.

The abstract is reproduced below for easy reference:

Abstract:

Global evidence has demonstrated that Adverse Childhood Experiences (ACEs) up to age 18 significantly increase the risk of mental and physical health for an adult. The research linking ACE with health and well-being has confirmed a dose-response relationship between the number of ACEs experienced and the extent of the impact on wellbeing. The source of ACE is the family, community, and the immediate environment, and it causes long-term risk for mental health with the potential to carry it over beyond the present generation. The findings are consistent across the developed and developing countries, and the evidence highlights the need for new elements beyond the 10 ACE elements in the pathbreaking original study. India needs urgent intervention on ACE prevention and management with 0.4 billion children and adolescents, with one out of seven Indians with mental health issues. Firstly, this commentary reviews global research and summarizes the limited evidence available in India on ACE elements’ impact on mental health. And, secondly, it proposes a multi-pronged approach to identify, manage and prevent the mental health implications of ACE in India to preempt a significant public health challenge.

Keywords: Adverse Childhood Experiences (ACE), Post Traumatic Stress Disorder (PTSD), Physical abuse, Sexual abuse, Neglect, Mental health, Inner child
Adverse Childhood Experiences, India, study

The Text of the video (by Gunjan Y Trivedi, Nishitha Pillai, Riri G Trivedi) on Adverse Childhood Experiences and mental health (India)

My name is Gunjan Trivedi and let me begin by sharing what led to the research that reviewed the impact of Adverse Childhood Experiences (ACE) in India. We have worked for many years now with people who have a completely functional life but have many mental and emotional challenges.

And as we dealt with these issues of anxiety, depression, phobia, lack of confidence, et cetera, et cetera, we started to look for the contributors. These risk factors would increase the chances of having mental health disorders. And as we searched, we realized that about 30 years ago, there was a study done by Dr Feletti at Kaiser Permanente that defined how the experiences that a child goes through from the age of 3 to 18 have a profound impact on long-term mental health. We started integrating some of those ideas and measurements as we realized this. And not to our surprise, we realized that this is something consistently seen in the individuals we worked with. As we started analyzing the study and similar studies worldwide, we also found the answers that matched the original study’s conclusions. We began to measure it consistently with several hundred people’s data when that happened. We were sure that this was the case that led to searching the evidence in India for adverse childhood experiences. And we found there are only limited studies that compared the impact of multiple such incidents on the mental and emotional health of the person. India has zero. 4 billion adolescents and children, and research says that one out of every seven Indians has been diagnosed or is potentially suffering from mental health issues. These numbers are enormous, and unfortunately, there are very, very few studies in India related to ACE. These numbers are also provided. So post Covid-19, we would believe that the numbers would be even worse. Hence, ACE prevention and management is a serious health care concern for India and the Indian public health sector. Therefore, we decided to form a team and look into this.

Let me introduce the team that worked on this project. Nishitha Pillai is a bright psychology graduate, and she’s pursuing her Master’s in Forensic psychology. She joined us in the summer of 2020 for this research. Her primary focus areas were looking for evidence in specific elements in India and understanding. Are there additional questions compared to the original 10 ACE questions and the evidence behind it to expand the survey and include conditions relevant in India while using the globally relevant templates? Finally, Ririi Trivedi is a regression therapist, and she’s pursuing research in adverse childhood experiences. She’s worked with many childhood trauma cases and brings in the practical aspect of the implications of such situations on adults.

With this, three of us formed a team and started the study. When we began the study, we asked ourselves several questions. First are their experiences beyond the core ten questions Dr Felitti asked in the Kaiser Permanent study. Second, are the outcomes that the original research found consistent across developing and developed countries? Do they carry on from generation to generation as a behavioural trait? Third, not many studies compare the impact of multiple such experiences on India. So the question we asked was, are there specific elements studied in India and what did they discover? Fourth, what is India’s current challenge in mental health, and if that is not addressed, what are the country’s long-term implications? Fifth, how can we identify, manage and ideally prevent the implications of ACES? Six, can we leverage the existing policy framework? Is it working? What could it be? What could we do to integrate some new ideas into it and our recommendations? So the original had ten questions, and they broadly were divided into categories of household challenges, abuse and neglect. In household challenges, mostly there were questions related to domestic violence or substance abuse by a parent in abuse; of course, it covered the areas of physical abuse, emotional abuse, sexual abuse, and neglect. These were the original ten questions. The original ACE research and a lot of other research on ACE in developed and developing countries indicated that the impact of adverse childhood experiences is multifold. The impact was observed not just on mental health but also on physical health and high-risk behaviours. It was also linked to criminal behaviours and addictions. It was found that time does not heal these ACE traumas and that the prevalence of ACE and its impact was found across developed and developing countries. It was also found that the impact is across generations. It does not stop at one generation,

but it continues generation after generation. Eventually, the further studies added a few more questions to this original questionnaire in the areas that were not covered earlier: peer victimization, that is, bullying or parental separation, parents who are constantly fighting with each other and community violence. So the original ten questions and the additional five questions total of 15 questions formed the core of our ACE question.

Nishitha Pillai:

Hello, my name is, and I’m Nishitha Pillai. I’m currently pursuing my Masters in forensic psychology. I have also done my bachelor’s in psychology. So today, I’m going to talk about ACE’s or adverse childhood experiences and the work done in India. So talking about India, there has been not much research done on adverse childhood experiences or integration of all the elements of ACE to understand the impact on mental health. And wellbeing, there was this once. A study was conducted in India in Carolina in 2019, where there was a 91% prevalence among youth having at least one adverse childhood experience. And among that as well, there were 50% of youth had more than three adverse childhood experiences. The study was actually very similar to the global findings and it also showed a very high prevalence or risk of developing major depression in later adulthood the study actually showed a very significant finding but as I said before there was not much studies or research done in this area so hence we decided to take up this topic and to understand the work done on each individual ACE element and also its impact on mental health and wellbeing so as that’s adverse childhood experiences majorly includes physical abuse, childhood sexual abuse, emotional abuse, neglect, household substance abuse so Firstly I’ll talk about physical abuse so physical abuse a lot of the searches are actually showed a very high prevalence of it among children especially the age between five to twelve years not only these studies have also indicated that this is the very first kind of or the very common kind of trauma or child experiences which actually leads to suicidal ideation later in the adulthood so the next is childhood sexual abuse so studies have actually reviewed that childhood sexual abuse not only impairs mood but the person has temperamental issues, finds it difficult to adjust socially, finds it difficult to actually maintain relations with their parents, have a lot of insecurities and it actually leads to a lot of anxiety disorders prevalence of this is actually it ranges from 4% to 55% in both the genders and sadly here the thing is that childhood sexual abuse does not occur solely but it actually occurs with the other forms of age in the same child so the next is emotional abuse so a lot of researches have been done on emotional abuse but the major one was conducted in several colleges across different Indian States where it was found that out of 936 participants five out of ten were mocked for their physical appearance, four out of ten were like call idiots and even three out of ten were faulted for the things which was not even their mistake when I talk about its impact on mental health it has shown a very significant role especially the people who are emotionally abused they meet the criteria for oppositional defiant behavior, major depression, dysthymia not only this it leads to a lot of mental health challenges later in the adulthood also so the next is neglect so there was a study which was conducted in Gujarat where it indicated that three out of ten children actually have experienced neglect and in this area especially we could see that there’s a gender discrimination which is found in studies conducted by the Ministry of Women and Child Development in 2007 where it indicated that girl child were getting very less food compared to their brothers. So when I talk about its impact on mental health again, it plays a significant role in generalized anxiety disorder, bipolar disorder dysthymia, and sometimes eating problems. Lastly, I would like to talk about household substance abuse again. This also plays a preeminent role in generalized anxiety disorder dystonia. Also, it exhibits a trend for major depression, so now, other than these areas, many researchers have covered areas beyond the major ten ACE questionnaire, which includes areas like bullying, PTSD (Post Traumatic Stress Disorder), and  Complex PTSD. Here is post-traumatic stress disorder and community violence in other areas like a specific phobia. And researchers have also supported this, that these areas have a huge impact on our mental health in the later stages. A study also showed that people experiencing specific phobia, social phobia, have experienced childhood Maltreatment. Even disorders like generalized anxiety disorder PTSD have been linked to childhood maltreatment. So lastly, overall, if I have to talk about the evidence that we see from these researchers, we see that adverse childhood experiences have a huge impact on our mental health and wellbeing, not only that childhood maltreatment of the ACE includes the areas which I mentioned before, but also the areas like bullying, PTSD, and community violence because it has a huge impact on our mental health. So there was this urgent need to see if the person has experienced multiple adverse valued experiences and see what sort of problems they are facing right now or in adulthood. So I decided to work on this topic and work with this team.

ACE prevention can happen in three areas. The primary prevention is, of course, through awareness so that the children do not go through these adverse childhood experiences at all. So this primary prevention would be focused on parents and educators and increasing awareness. The secondary impact aims to reduce or minimize the impact on the individual and the family. The tertiary prevention treats and reduces the long term prevention. There are several recommendations covered in the research paper. Let’s go through them through the visual that is being shown now. The outer layer covers elements that need to be integrated, starting with the policy and legal framework, the social framework, the integration of mental health professionals, public health professionals, parents and caregivers, and the primary health clinic. By integrating all of this and creating a framework that incorporates education, research and awareness leading to action, we could focus on prevention. The prevention must focus not only on occurrence but also on addressing the short-term and long-term impact of adverse childhood experiences. So, as you can see, the core idea is around preventing the occurrence and, if it has happened, dealing with the short term impact and preventing further damage. And if it’s a long term impact, we need to prevent further implications beyond what has happened. And it must cover the key roles, the key policy interventions, et cetera, et cetera, et cetera. Adverse childhood experiences have a strong impact on the mental and physical health and the behavioural health of individuals. It also highlights the need to expedite this research to speed up this research and the awareness about this to prevent the burden on public health and address this huge mental health issue that we could be facing in the coming years.