The Impact of Adverse Childhood Experiences Across

The Life Course

Robert Anda, MD, MS

ACE Study Concepts

www.RobertAndaMD.com

www.cdc.gov/ACE www.ACEstudy.org

“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). http://www.developingchild.net

The Walk to Paradise Garden W. Eugene Smith

Stress (adrenaline, cortisol)

Unpredictable Predictable Severe Moderate

Number of Episodes Chronicity

Resilience Vulnerability

Epigenetics Intrauterine exposures Gene mutations

Barriers to Educational Achievement Emerge at a Very Young Age

16 mos. 24 mos. 36 mos.

Cum

ulat

ive

Voca

bula

ry (W

ords

)

College Educated Parents

Working Class Parents

Welfare Parents

Child’s Age (Months)

200

600

1200

Source: Hart & Risley (1995)

400

800

1000

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…

Follow-up

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

N = 17,421

Adverse Childhood Experiences Ten Categories

Substance abuse Parental sep/divorce Mental illness Battered mother Criminal behavior

Household dysfunction:

Abuse: Emotional Physical Sexual Neglect: Emotional Physical

Adverse Childhood Experiences Are Common

Substance abuse 27% Parental sep/divorce 23% Mental illness 17% Battered mother 13% Criminal behavior 6%

Household dysfunction:

Abuse: Psychological 11% Physical 28% Sexual 21% Neglect: Emotional 15% Physical 10%

Adverse Childhood Experiences Rarely Occur in Isolation…

They come in groups.

Prevalence of Childhood Abuse by Frequency of Witnessing Domestic Violence

Childhood Abuse Emotional Physical Sexual 0

20

40

60

80

100

Never Once,Twice Sometimes Often Very often

Frequency of witnessing domestic violence

Perc

ent (

%)

ACEs tend to come in groups… Additional ACEs (%) 1 2 3 4 >5 If you had: A battered mother 95 82 64 48 52

Adverse Childhood Experiences Score Biologic Stress “ Dose”

ACE Score Prevalence 0 33% 1 26% 2 16% 3 10% 4 or more 16%

0

2

4

6

8

10

12

14

16

18

20

Perc

ent W

ith H

ealth

Pro

blem

(%

) 0 1 2 3 4 or more

ACE Score

Early smokinginitiation

Current smoking COPD

ACEs, Smoking, and Lung Disease

ACE Score and HIV Risks

0

2

4

6

8

10

12

14

16

18

20

Perc

ent W

ith H

ealth

Pro

blem

(%

)

0 1 2 3 4 or moreACE Score

Ever Injected Drugs

Had 50 or More Intercourse Partners

Ever Had an STD

The ACE Score… Alcohol Use and Abuse

0

5

10

15

20

25

30

35

40

0 1 2 3 4 or moreACE Score

Alcoholic Married an Alcoholic

Perc

ent w

ith a

lcoh

ol

rela

ted

prob

lem

ACEs are a Pathway to Leading Causes of Death…

The ACE Score and the Prevalence of Liver Disease (Hepatitis/Jaundice)

0

2

4

6

8

10

12

0 1 2 3 >=4

ACE Score

Perc

ent

(%)

The ACE Score and the Prevalence of Coronary Heart Disease

0

1

2

3

4

5

6

0 1 2 3 >=4

ACE Score

Perc

ent

(%)

A Focus on Mental Health…

The ACE Score and a Lifetime History of Depression

0

10

20

30

40

50

60

70

0 1 2 3 >=4

Women Men

ACE Score

Perc

ent d

epre

ssed

(%)

The ACE Score and the Prevalence of Attempted Suicide

0

5

10

15

20

0 1 2 3 >=4

ACE Score

Perc

ent a

tem

pted

(%)

Cumulative ACEs Increase the Number of Lifetime DSM-IV Diagnoses*

0

1

2

3

4

5

6

7

8

9

CCAP0 CCAP1 CCAP2 CCAP3 CCAP4

N=5692

Num

ber o

f Life

time

DSM

-IV D

iagn

oses

*Putnam, Harris, Putnam unpublished data, 2011

National Comorbidity Survey – Replication Sample

Increasing ACEs

Art of: Hieronymous Bosch

“The Creation of Adam” Michelangelo 1508-1512

0

10

20

30

40

50

60

Relationship Between Number of Adverse Childhood Experiences and Adolescent Pregnancy

ACE Score

0 1 2 3 4 5 6 7-8

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

01020304050607080

0 1 2 3 4 or more

Per

cent

ACE Score

02468

1012141618

Relationship Between Number of Adverse Childhood Experiences and Fetal Death—First or Second

Pregnancy

ACE Score

0 1-2 3-4 5+

The Costs of the Status Quo..

Reflect the Costs of Impairing

Early Childhood Development

ACEs and High School Sophomores and Seniors

Population Average

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

Costs of the Status Quo

Criminal Justice

..the prison pipeline

ACEs Among Youth on Probation Pierce County, Washington

TacomaUrbanNetworkACE Exposure and

Youth Outcomes

History of Alcohol & Drug Use and ACE Score

50%63%

71% 74% 72%81%

54%68%

77% 80%74%

84%

0%

20%

40%

60%

80%

100%

0 1 2 3 4 ≥ 5

Alcohol Drug

ACE Score and Repeated Suspension/Expulsion Youth on Probation, Pierce County, WA

History of > 7 expulsions or suspensions since the first grade

39.4%(n=148)

38.6%(n=124)

35.7%(n=148)

35.3%(n=158)25.5%

(n=69)16.9%(n=11)

0

10

20

30

40

50

0 1 2 3 4 5+

ACE Score

Prev

alen

ce (%

)

0.1

1

10

aOR

(95%

CI)

ACE Score and Poor Academic Performance Youth on Probation, Pierce County, WA

Poor academic performance during most recent school term

35.7%(n=135)

32.3%(n=105)28.1%

(n=117)29.1%

(n=132)25.0%(n=68)16.9%

(n=11)

0

10

20

30

40

50

0 1 2 3 4 5+

ACE Score

Prev

alen

ce (%

)

0.1

1

10

aOR

(95%

CI)

TacomaUrbanNetworkACE Score and Felony

Re-offense

Felony Re-offense Post Probation and ACE Score

12% 10%16%

11%

19%23%

16% 18%

25%20%

25%

31%

0%

10%

20%

30%

40%

0 1 2 3 4 ≥ 5

Within One Year Within Two YearsACE Score

JULY 2004 46

WASHINGTON STATE Department of Social and

Health Services

Office of the Secretary

One of Many Public Policy Responses

Values Drive

Decisions

SOURCE: Caseload Forecast Council, June 2001.

0%

250%

500%

750%

1000%

1925 1950 1975 2000

Annual Populations As a Percent of the 1925 Population

Washington State Crime Rate Per 1,000 Males Age 12-39

0

100

200

300

400

1986 1989 1992 1995 1998

Murder Rape Robbery Assault Burglary Theft Auto Theft

258

313

Down 16 percent since 1988

State Population

War on Drugs

Prison Population

States With ACE Studies in 2008

Source: Behavioral Risk Factor Surveillance System, CDC.

No data

No data

Source: Behavioral Risk Factor Surveillance System, CDC.

2009

6 States

States With ACE Studies in 2009

No data

Source: Behavioral Risk Factor Surveillance System, CDC.

2010 2009

13 States

States With ACE Studies in 2009-2010

Source: Behavioral Risk Factor Surveillance System, CDC.

No data 2010 2009 2011

18 States

States With ACE Studies in 2009-2011

Source: Behavioral Risk Factor Surveillance System, CDC.

No data 2010 2009 2011

19 States

States With ACE Studies 2009-2012

2012

Source: Behavioral Risk Factor Surveillance System, CDC.

No data 2010 2009 2011

21 States

States With ACE Studies 2009-2013

2012 2012

??

The paradigm is shifting…

An the word is getting around

0

10

20

30

40

50

60

70

80

ACE Scores of 4 or More Women in the Kaiser Health Plan

Vs Young Women Served by Crittendon

Per

cent

with

AC

E Sc

ore

of

4 or

mor

e (%

)

Kaiser All Young Moms on Moms Mothers Welfare in Juv Just

Crittendon Foundation Survey

Panic reac tions , depres s ion , anxie ty, ha lluc ina tions Somatic Issues Sleep d is turbances , s evere obes ity, pa in Substance Use Smoking, a lcoholis m, illic it d rug us e , IV drug us e Sexuality Early in te rcours e , promis cuity, s exua l d is s a tis fac tion Memory Amnes ia (ch ildhood) Arousal High s tres s , p roblems with anger, pe rpe tra ting domes tic vio lence

ACEs Effect An Array of Brain Functions

Affect Regulation

Neurobiology and Epidemiology Converge

Complex Trauma—Trauma Spectrum Disorders and the mean number of a variety of problems

0

1

2

3

4

5

6

ACE Score 0 1 2 3 4 5 6 7-8

*

Mea

n N

umbe

r of

Co-

occu

rrin

g O

utco

mes

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

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 the Hydra, 1545 from The Labours of Hercules (1542-1548).

Treatment Education Prevention

All must consider Intergenerational transmission

A Public Health Framework For Change

The Walk to Paradise Garden W. Eugene Smith

..the prison pipeline extends into adulthood

0

5

10

15

20

25

30

35

0 1 2 3 4 >=5

ACE Scores Kaiser Health Plan

Perc

ent (

%)

ACE Score Messina and Greila Am J Pub Health October, 2006

0

5

10

15

20

25

30

35

0 1 2 3 4 >=5

ACE Scores Kaiser vs Adult Women In Prison Pe

rcen

t (%

)

ACE Score Messina and Greila Am J Pub Health October, 2006

Preventive Intervention is More Efficient and Produces Higher Returns than Later Remediation

Heckman, J. (2007)

0-3 4-5 6-18 19+

Rates of return to

human capital investment

Preschool programs

K-12 interventions

Job training

Programs targeting the earliest years

Age

“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). http://www.developingchild.net

Art of Hieronymous Bosch

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

01020304050607080

0 1 2 3 4 or more

Per

cent

ACE Score

Limits of Understanding

by Paul Klee (1879-1940)