Salus Health Care Forum July 2, 2025

The ACE study has many limits. It ignored the social context of households that help produce and predict the very adversities they measured, like food and income insecurity. And as a result, they failed to identify potential preventions of childhood adversity. The validity, one of the authors and colleagues in the original article said, primary prevention of adverse childhood experiences has proven difficult and will ultimately require societal changes that improve the quality of family and household environments during childhood. That takes us pretty clearly to sociology and to social policy. The items included in the ACE score, as I noted, are much more likely for economically challenged households or families living in high poverty areas.

The study also failed to recognize positive experiences and protective factors that cushion the effects of adversity to resources in communities and households. The ACE score, the simple rubric that’s been widely misused, especially in California, has been used to promote the view that individual ACE scores have predictive value They do not. They don’t predict an individual’s health. They are epidemiological. It was an epidemiological study that suggested differential rates of health outcomes, depending on the number of ACEs people experienced.

The MacArthur Network, which I referred to earlier, included my brother Bruce and Sir Michael Marmot, who, along with Richard Wilkinson, developed the idea of social determinants of health, really in the same year, 1998, that the ACE study was done. It’s the social determinants of health which provide a more useful framework, both for understanding adult health, child development, and their differentials, which are substantial. Underlying that linkage between social adversities, some of which are in the household, and childhood and adult health and well-being, is the notion of chronic stress or toxic stress that creates wear and tear on the body, and that even small effects accumulated over time affect physiological functions and create, as Arlene Geronimus has said, weathering of the body.

Jeremy

Craig, although you didn’t mention the word allostatic load, your brother had quite a lot to do with that term coming into the public health and healthcare lexicon.

Craig

Regulation, the imbalance that toxic stress creates, can be called allostatic load.

Jeremy

Which is, in many ways, a much broader term than ACEs, as you demonstrated in your discussion. As physicians, we do work a lot in individual risk, and so using epidemiological risk to define risk to an individual is really awkward. So, this has been an interesting challenge. ACE inhibitors, not ACE inhibitors; the ACE scoring has brought an awareness that I think was necessary. And thank you for talking about the biological, the absence of biological markers, although I’m sure someone’s working on those to reference the biochemical changes that actually seem to occur with what you’re framing as allostatic load or toxic stress.