Adverse Childhood Experiences (ACE) Research: Extension, Integration & Implications
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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
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%
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
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
(%)
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
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+
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
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
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
??
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
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
Percent of Women Who Ever Had an Unintended Pregnancy by ACE Score
01020304050607080
0 1 2 3 4 or more
Per
cent
ACE Score