Adverse Childhood Experiences and their Relationship to Adult Well-being, Disease, and Death :

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Alannah Johnston
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Kaiser Permanente and the Centers for Disease Control ECHO Parenting Forum

1 Adverse Childhood Experiences and their Relationship to Adult Well-being, Disease, and Death : Turning gold into lead A collaborative effort between Kaiser Permanente and the Centers for Disease Control ECHO Parenting Forum CalEndow, LA March 19, 2013 Robert F. Anda, M.D. Vincent J. Felitti, M.D.

2 Origins of the ACE Study 51 weeks later lbs What is the core diagnosis here? Which photo depicts the problem?

3 Summary of the ACE Study The ACE Study is a retrospective and prospective analysis in 17,337 middle-class adults of the effects of ten categories of adverse life experiences in childhood. The very existence of these experiences was found to be quite unexpectedly high, though unrecognized because they are lost in time and protected by shame, by secrecy, and by social taboos against routinely exploring certain realms of human experience. Their effect a half century later is powerfully and proportionately related to the number of categories of adverse life experiences in childhood, and thereby is a major determinant of well-being, health risks, mental illness, occupational performance, social malfunction, biomedical disease, and premature death.

4 ACE Study Design Survey Wave 1 71% response (9,508/13,454) n=13,000 71% response All medical evaluations abstracted Survey Wave II n=13,000 vs. Present Health Status 17,337 adults & Mortality National Death Index Morbidity Hospital Discharges Doctor Office Visits Emergency Room Visits Pharmacy Costs All medical evaluations abstracted

5 Empirically Selected Categories of Adverse Childhood Experiences Prevalence (%) Abuse, by Category Psychological (by parents) 11% Physical (by parents) 28% Sexual (anyone, but typically family) 22% Major Neglect, by Category Emotional 15% Physical 10% Household Dysfunction, by Category Alcoholism or drug use in home 27% Loss of biological parent <18 23% Depression or mental illness in home 17% Mother treated violently 13% Imprisoned household member 5%

Adverse Childhood Experiences Score Number of categories (not events) is summed ACE Score Prevalence 0 33% 1 25% 2 15% 3 10% 4 6% 5 or more 11%* Two out of three adults experienced at least one

6 Adverse Childhood Experiences Score Number of categories (not events) is summed ACE Score Prevalence 0 33% 1 25% 2 15% 3 10% 4 6% 5 or more 11%* Two out of three adults experienced at least one category of ACE. If any one ACE is present, there is an 87% chance at least one other category of ACE is present, and a 50% chance of three or more. Women are 50% more likely than men to have an ACE Score >5.

7 Smoking to Self-Medicate Is he describing dysfunctional behavior, or is it functional in realms of which we know nothing?

8 Health Risks Adverse Childhood Experiences vs. >1 ppd Smoking as an Adult % P<.001

9 Social function Childhood Experiences vs. Adult Alcoholism

10 Health Risks ACE Score vs. Intravenous Drug Use p<0.001

11 Well-being Childhood Experiences Underlie Chronic Depression

12 Death Childhood Experiences Underlie Later Suicide

13 Costs Childhood Experiences Underlie Later Prescription of Antidepressants approximately 50 years later Prescription rate per 100 person-years) or more ACE Score

14 Social malfunction: ACE Score and Indicators Impaired of Worker Performance 25 ACE Score or more Absenteeism ( > 2 days/month) Serious Financial Problems Serious Problems Performing job

15 Biomedical disease ACEs Increase Likelihood of Heart Disease* Emotional abuse 1.7x Physical abuse 1.5x Sexual abuse 1.4x Domestic violence 1.4x Mental illness 1.4x Substance abuse 1.3x Household criminal 1.7x Emotional neglect 1.3x Physical neglect 1.4x * After correction for age, race, education, and conventional risk factors like smoking and diabetes. Circulation, Sept. 2004

16 Newly Recognized Biomedical Relationships

17 Well-being Childhood Experiences Underlie Rape

18 Disease ACE Score and Hallucinations Ever Hallucinated* (%) Abused Alcohol or Drugs ACE Score *Adjusted for age, sex, race, and education.

Turning Research into Practice a beginning Set up properly, and in high volume, comprehensive medical evaluation affordably can be provided to all patients at the outset of ongoing medical care.

20 Turning Research into Practice a beginning Set up properly, and in high volume, comprehensive medical evaluation affordably can be provided to all patients at the outset of ongoing medical care. Comprehensive biomedical evaluation provides a net 11% reduction in DOVs in the subsequent year. Comprehensive biopsychosocial evaluation, which incorporates ACE Study findings, provides a 35% reduction in DOVs in the subsequent year compared to the prior year. (125,000 patient sample) Imagine the possibilities!

21 Further Information Medline PubMed (Felitti or Anda as author name) AVAHealth.org (Detailed DVD)

Adverse Childhood Experiences and their Relationship to Adult Well-being and Disease :

Adverse Childhood Experiences and their Relationship to Adult Well-being and Disease : Turning gold into lead A collaborative effort between Kaiser Permanente and the Centers for Disease Control Loma Linda