While at a recent brain-storming session about adverse childhood experiences (ACEs), a colleague echoed my mantra—“What is predictable is preventable.” This reality came to me many years ago while training as an injury epidemiologist at a time when injuries were considered accidents that were inevitable or in other words, not preventable. Ground-breaking research by Professors Susan Baker and Stephen Teret at Johns Hopkins and others would change our thinking on both unintentional and intentional injuries. As a result, patterns of predictability led us to realize that these tragedies could be prevented.
The ACE Study and the considerable body of research on early trauma send the same message for suicide [for more information about the ACE Study, go to our first posting]. Early adverse childhood experiences dramatically increase the risk of suicidal behaviors. ACEs have a strong, graded relationship to suicide attempts during childhood/adolescent and adulthood. An ACE score of 7 or more increased the risk of suicide attempts 51-fold among children/adolescents and 30-fold among adults (Dube et al, 2001). In fact, Dube and colleagues commented that their estimates of population attributable fractions for ACEs and suicide are “of an order of magnitude that is rarely observed in epidemiology and public health data.” Nearly two-thirds (64%) of suicide attempts among adults were attributable to ACEs and 80% of suicide attempts during childhood/adolescence were attributed to ACEs. Further, while system responses to family violence continue to place greater emphasis on physical forms of abuse, the strongest predictor of future suicide attempts in ACE research was emotional abuse.
These data beg the question—what does suicide prevention look like in your agency and community? Also, does risk assessment for suicide incorporate questions about ACEs? How can we start early to interrupt the predictable pathway between ACEs and risky behaviors including suicidality? Is the impact of emotional abuse truly recognized and addressed in our system’s response to children living in abusive environments?
I live in a state where our suicide rates are typically double the national rate and there are major disparities in terms of risk. Consequently, there is a lot of discussion around what are the most effective strategies to reach our culturally diverse population. Increasingly, these discussions include the role of ACEs in understanding and preventing suicide. It starts with education for service providers, survivors, and communities. With increased awareness, we can make the case for routine assessment of ACEs as an early intervention and prevention strategy. Around the country, there are efforts to develop educational resources for clients and communities to promote self-understanding about how early trauma can affect health and risk behaviors even decades later. The Institute for Safe Families will expand its “Amazing Brain Series” to include a booklet for adult survivors called “It’s Never Too Late.” While the first four booklets in the series focus on early brain development and implications of trauma for children, “It’s Never Too Late” will help adults to understand the long-term effects of trauma and the capacity of the adult brain to heal. One of our greatest and most critical challenges is conveying this information to a sector of the population that is at especially high risk for suicide due to ACEs--adolescents. How can we create a safe and meaningful dialogue with teens about ACEs when the trauma is so recent or current, the need is so urgent, and yet many of the traditional responses to children at risk may not be effective in reaching this population?
Dube SR, Anda RF, Felitti FJ et al. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the lifespan: Findings from the Adverse Childhood Experiences Study. JAMA, 2001; 286:3089-3095.
Disclosure: Linda Chamberlain trained in injury prevention at Johns Hopkins with Professors Stephen Teret and Susan Baker. She lives in Alaska. Statistics for suicide including comparison to national rates and disparities between non-Native and Native Alaskans can be found at http://www.hss.state.ak.us/suicideprevention/statistics.htm and there is also an online forum about suicide prevention at www.stopsuicidealaska.org .