The Impact of Adverse Childhood Experiences Across The Life Course

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1 The Impact of Adverse Childhood Experiences Across The Life Course Robert Anda, MD, MS ACE Study Concepts

2 In the brain, as in the economy, getting it right the first time is ultimately more effective and less costly than trying to fix it later. James Heckman Nobel Laureate Economist National Scientific Council on the Developing Child, Perspectives: The Cradle of Prosperity. (2006).

3 The Walk to Paradise Garden W. Eugene Smith

4 Stress (adrenaline, cortisol) Unpredictable Severe Vulnerability Number of Episodes Chronicity Predictable Moderate Resilience Epigenetics Intrauterine exposures Gene mutations

9 Barriers to Educational Achievement Emerge at a Very Young Age 1200 Cumulative Vocabulary (Words) College Educated Parents Working Class Parents Welfare Parents 16 mos. 24 mos. 36 mos. Child s Age (Months) Source: Hart & Risley (1995)

12 The Adverse Childhood Experiences (ACE) Study Examines the health and social effects of ACEs throughout the lifespan among 17,421 members of the Kaiser Health Plan in San Diego County A Primary Care Setting Educated Middle Class.. Predominantly White

13 ACE Study Design Survey Wave I (N=9,508) Survey Wave II (N=8,667) Mortality Follow-up National Death Index Morbidity N = 17,421 Hospital Discharge Outpatient Visits Emergency room visits Pharmacy Utilization Comprehensive medical Evaluations abstracted

14 Adverse Childhood Experiences Ten Categories Household dysfunction: Substance abuse Parental sep/divorce Mental illness Battered mother Criminal behavior Abuse: Emotional Physical Sexual Neglect: Emotional Physical

15 Adverse Childhood Experiences Are Common Household dysfunction: Substance abuse 27% Parental sep/divorce 23% Mental illness 17% Battered mother 13% Criminal behavior 6% Abuse: Psychological 11% Physical 28% Sexual 21% Neglect: Emotional 15% Physical 10%

16 Adverse Childhood Experiences Rarely Occur in Isolation They come in groups.

17 Prevalence of Childhood Abuse by Frequency of Witnessing Domestic Violence Percent (%) Frequency of witnessing domestic violence Never Once,Twice Sometimes Often Very often 20 0 Emotional Physical Sexual Childhood Abuse

18 ACEs tend to come in groups Additional ACEs (%) >5 If you had: A battered mother

19 Adverse Childhood Experiences Score Biologic Stress Dose ACE Score Prevalence 0 33% 1 26% 2 16% 3 10% 4 or more 16%

20 ACEs, Smoking, and Lung Disease Percent With Health Problem (%) ACE Score or more 0 Early smoking initiation Current smoking COPD

21 ACE Score and HIV Risks Percent With Health Problem (%) ACE Score or more 0 Ever Injected Drugs Had 50 or More Intercourse Partners Ever Had an STD

22 Percent with alcohol related problem The ACE Score Alcohol Use and Abuse ACE Score or more 0 Alcoholic Married an Alcoholic

23 ACEs are a Pathway to Leading Causes of Death

24 The ACE Score and the Prevalence of Liver Disease (Hepatitis/Jaundice) Percent (%) >=4 ACE Score

25 6 5 The ACE Score and the Prevalence of Coronary Heart Disease Percent (%) >=4 ACE Score

26 A Focus on Mental Health

27 The ACE Score and a Lifetime History of Depression Percent depressed (%) Women Men >=4 ACE Score

28 The ACE Score and the Prevalence of Attempted Suicide Percent atempted (%) >=4 ACE Score

29 Cumulative ACEs Increase the Number of Lifetime DSM-IV Diagnoses* 9 8 National Comorbidity Survey Replication Sample N=5692 Number of Lifetime DSM-IV Diagnoses *Putnam, Harris, Putnam unpublished data, 2011 CCAP0 CCAP1 CCAP2 CCAP3 CCAP4 Increasing ACEs

30 Art of: Hieronymous Bosch

31 The Creation of Adam Michelangelo

32 Relationship Between Number of Adverse Childhood Experiences and Adolescent Pregnancy ACE Score

33 Percent of Women Who Ever Had an Unintended Pregnancy by ACE Score Percent or more ACE Score

35 Relationship Between Number of Adverse Childhood Experiences and Fetal Death First or Second Pregnancy ACE Score

36 The Costs of the Status Quo.. Reflect the Costs of Impairing Early Childhood Development

38 Population Average ACEs and High School Sophomores and Seniors

39 Spokane Washington Students with ACEs: Are 2 ½ times more likely to fail a grade Score lower on standardized tests Have language difficulties Are suspended or expelled more Are designated to special education more frequently -Have poorer health Courtesy of Chris Blodgett, PhD Washington State University

40 Costs of the Status Quo Criminal Justice..the prison pipeline

41 ACEs Among Youth on Probation Pierce County, Washington

42 ACE Exposure and Youth Outcomes Tacoma Urban Network History of Alcohol & Drug Use and ACE Score 100% 80% 60% 50% 54% 63% 68% 77% 80% 71% 74% 72% 74% 81% 84% 40% 20% 0% Alcohol Drug

43 ACE Score and Repeated Suspension/Expulsion Youth on Probation, Pierce County, WA History of > 7 expulsions or suspensions since the first grade Prevalence (%) % (n=11) 25.5% (n=69) 35.3% (n=158) 35.7% (n=148) 38.6% (n=124) 39.4% (n=148) 1 aor (95% CI) ACE Score 0.1

44 ACE Score and Poor Academic Performance Youth on Probation, Pierce County, WA Poor academic performance during most recent school term Prevalence (%) % (n=11) 25.0% (n=68) 29.1% (n=132) 28.1% (n=117) 32.3% (n=105) 35.7% (n=135) 1 aor (95% CI) ACE Score 0.1

45 ACE Score and Felony Re-offense Tacoma Urban Network Felony Re-offense Post Probation and ACE Score 40% 30% 20% 10% 16% 12% 10% 18% 16% 25% 11% 20% 19% 25% 23% 31% 0% ACE Score Within One Year Within Two Years

One of Many Public Policy Responses Values Drive Decisions 400 300 200 100 0 Washington State Crime Rate Per 1,000 Males Age 12-39

Department of Social and Health Services Office of the Secretary 46 1000% 750% 500% 250% 0% Annual Populations As a Percent of the

46 One of Many Public Policy Responses Values Drive Decisions Washington State Crime Rate Per 1,000 Males Age Down 16 percent since Murder Rape Robbery Assault Burglary Theft Auto Theft WASHINGTON STATE Department of Social and Health Services Office of the Secretary % 750% 500% 250% 0% Annual Populations As a Percent of the 1925 Population SOURCE: Caseload Forecast Council, June War on Drugs Prison Population State Population JULY 2004

48 States With ACE Studies in 2008 No data Source: Behavioral Risk Factor Surveillance System, CDC.

49 States With ACE Studies in States No data 2009 Source: Behavioral Risk Factor Surveillance System, CDC.

50 States With ACE Studies in States No data Source: Behavioral Risk Factor Surveillance System, CDC.

51 States With ACE Studies in States No data Source: Behavioral Risk Factor Surveillance System, CDC.

52 States With ACE Studies States No data Source: Behavioral Risk Factor Surveillance System, CDC.

53 States With ACE Studies ?? 21 States No data Source: Behavioral Risk Factor Surveillance System, CDC.

55 The paradigm is shifting An the word is getting around

57 ACE Scores of 4 or More Women in the Kaiser Health Plan Vs Young Women Served by Crittendon Percent with ACE Score of 4 or more (%) Kaiser All Young Moms on Moms Mothers Welfare in Juv Just Crittendon Foundation Survey

59 ACEs Effect An Array of Brain Functions Affect Regulation Panic reactions, depression, anxiety, hallucinations Somatic Issues Sleep disturbances, severe obesity, pain Substance Use Smoking, alcoholism, illicit drug use, IV drug use Sexuality Early intercourse, promiscuity, sexual dissatisfaction Memory Amnesia (childhood) Arousal High stress, problems with anger, perpetrating domestic violence

60 Neurobiology and Epidemiology Converge Complex Trauma Trauma Spectrum Disorders and the mean number of a variety of problems 6 Mean Number of Co-occurring Outcomes ACE Score *

61 Adverse Childhood Experiences As a National Health Issue ACEs have a strong influence on: -adolescent health -reproductive health -smoking -obesity -alcohol abuse -illicit drug abuse -sexual behavior -mental health - risk of violence and revictimization -stability of relationships -performance in the workforce

62 Adverse Childhood Experiences As a National Health Issue ACEs increase the risk of: -Early death -Heart disease - Chronic Lung disease -Lung cancer - Liver disease -Autoimmune disease - Suicide - Injuries -HIV and STDs - other risks for leading causes of death

Beham, (Hans) Sebald (1500-1550): Hercules slaying

63 Beham, (Hans) Sebald ( ): Hercules slaying the Hydra, 1545 from The Labours of Hercules ( ).

64 A Public Health Framework For Change Treatment Education Prevention All must consider Intergenerational transmission

65 The Walk to Paradise Garden W. Eugene Smith

68 ..the prison pipeline extends into adulthood

69 35 ACE Scores Kaiser Health Plan Percent (%) >=5 ACE Score Messina and Greila Am J Pub Health October, 2006

70 35 ACE Scores Kaiser vs Adult Women In Prison Percent (%) >=5 ACE Score Messina and Greila Am J Pub Health October, 2006

71 Preventive Intervention is More Efficient and Produces Higher Returns than Later Remediation Programs targeting the earliest years Rates of return to human capital investment Preschool programs K-12 interventions Job training Age Heckman, J. (2007)

72 In the brain, as in the economy, getting it right the first time is ultimately more effective and less costly than trying to fix it later. James Heckman Nobel Laureate Economist National Scientific Council on the Developing Child, Perspectives: The Cradle of Prosperity. (2006).

73 Art of Hieronymous Bosch

74 Percent of Women Who Ever Had an Unintended Pregnancy by ACE Score Percent or more ACE Score

76 Limits of Understanding by Paul Klee ( )

Understanding Adverse Childhood Experiences. Building Self-Healing Communities

Understanding Adverse Childhood Experiences Building Self-Healing Communities Robert Anda, MD, MS Co-Founder ACE Interface 2013 www.aceinterface.com Building Self-Healing Communities Health Care Child