Adverse Childhood Experiences Adam Zolotor, MD, DrPH Associate Professor of Family Medicine University of North Carolina at Chapel Hill Interim President, North Carolina Institute of Medicine Presentation to the Child Fatality Task Force October 6, 2014
What is an adverse childhood experience? Major traumas of childhood NOT getting a bad grade or being disciplined. May be associated with biological changes that change brain structure, function, neuroendocrine changes, and genetic changes.
Adverse Childhood Experiences Mail survey of adults in HMO Over 9500 respondents (response rate 70%) More than ½ had at least one adversity More than ¼ had at least two adversities Strong correlation with adult health conditions.
Adverse Childhood Experiences Abuse, by Category Psychological (by parents) 11% Physical (by parents) 11% Sexual (anyone) 22% Household Dysfunction, by Category Substance Abuse 26% Mental Illness 19% Mother Treated Violently 13% Imprisoned Household Member 3%
ACE Score and smoking/copd Percent With Problem 20 18 16 14 12 10 8 6 4 2 0 ACE Score: 0 1 2 3 4 or more Regular smoking by age 14 COPD
ACE score and alcoholism 18 16 14 % Alcoholic 12 10 8 6 4 2 0 ACE Score
80 70 60 50 40 30 20 10 0 ACE score and depression Women Men 0 1 2 3 >=4 ACE Score % With a Lifetime History of Depression
Consequences: ACE Study Alcoholism and alcohol abuse Suicide attempts Chronic obstructive pulmonary disease Unintended pregnancies (COPD) Early initiation of smoking Depression Early initiation of sexual activity Fetal death Adolescent pregnancy Health related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking
NC ACEs 10,383 respondents. Module of BRFSS, administered by SCHS. Queries of 11 ACEs. 57% one or more ACEs, 22% had 3 or more ACEs. Most common ACES: Parent separation (27%) Substance Abuse in household (27%) Emotional Abuse (25%) Violence in Household (17%) ACEs were generally more common with lower SES, lower education, and among unemployed.
ACE score and health behaviors Health Behavior No ACE Medium ACE score (1 2) High ACE Score (3+) Current smoker 13.4% 20.4%*** 33.0%*** Heavy drinking 3.6% 4.9%* 7.5%*** Binge drinking 9.4% 13.5%*** 17.9%*** Obesity 26.2% 30.7%** 35.0%*** No exercise (past 30 days) 22.2% 22.5% 26.9%* HIV risk 1.8% 4.4%*** 9.1%*** Current smoker 13.4% 20.4%*** 33.0%***
ACE score and health conditions Health Condition No ACE Score Low ACE Score (1 2) High ACE Score (3+) Current asthma 6.0% 7.8%* 10.0%*** COPDa 5.0% 6.7%** 10.7%*** CVDa 9.2% 8.5% 8.8% Diabetes 11.4% 9.9% 11.1% Arthritis 26.4% 25.2% 28.6% Depressive disorder 10.4% 15.7%*** 33.3%*** Disability 18.6% 20.1%*** 30.2%*** Cancer (other than skin) 7.1% 6.3% 6.3% Kidney disease 2.4% 2.4% 3.3%
LONGSCAN LONGitudinal Studies of Child Abuse and Neglect Funded in 1991 to follow families for 18 years 5 geographically diverse sites 1354 families
Multiple exposures No single type of victimization definitively predicts worse outcomes for children. Maltreated children are typically exposed to multiple forms of maltreatment, including witnessing violence, over their lifetimes
Witnessed violence Violence in the home has negative consequences for children even if not directed at the children. Violence witnessed in the community has impact similar to violence witnessed in the home (anger, depression, aggression, anxiety)
Consequences: LONGSCAN, ADHEALTH) >5 ACEs more likely to report somatic symptoms, poor health and health condition requiring medical attention. Those with history of abuse more likely to report weapon carrying (2 4x more likely), early sex (2 3x more likely), early pregnancy (2 3x more likely) and tobacco use (3x more likely). Increased risk of juvenile delinquency & adult criminality (Adhealth). Violent and Abusive Behavior: elevated risk for perpetration of IPV (Adhealth).
Conclusions Children at greatest risk for maltreatment can often be identified by virtue of risk. Those risks are closely related to adverse childhood experiences. ACEs are common. ACEs and maltreatment confer significant short and long term risk of many physical and mental health conditions. Prevention, screening, and treatment occur throughout a continuum of services. A long term approach for the most vulnerable children.