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![Page 1: Using the Adverse Childhood Experiences Scale (ACES) Misty McIntyre Goodsell, LCSW Chris Adams Hill, LCSW South Valley Therapy.](https://reader038.fdocuments.net/reader038/viewer/2022110212/56649e105503460f94afb51c/html5/thumbnails/1.jpg)
www.southvalleytherapy.com
Using the Adverse Childhood Experiences Scale (ACES)
Misty McIntyre Goodsell, LCSW
Chris Adams Hill, LCSW
South Valley Therapy
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Objectives
• Background of ACES Study• ACES Questionnaire• ACES Outcomes• Implementing in practice• Macro
South Valley Therapy
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ACES Background
• Collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the Center for Disease Control and Prevention (CDC)
• Dr. Vincent Felitti & Dr. Robert F. Anda
South Valley Therapy
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ACES Background
• 10 year study• 17,000 participants• Correlated ACES score to health and
behaviors occurring over participants’ lifespans
• Largest study of its kind
South Valley Therapy
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Demographics
South Valley Therapy
Gender
Male 46%
Female 54%
Race
White 74.8%
Hispanic (Latin/Chicano) 11.2%
Asian/Pacific Islander 7.2%
African-American 4.6%
Other 1.9%
Age
19-29 5.3%
30-39 9.8%
40-49 18.6%
50-59 19.9%
60 and over 46.4%
Education
Less than HS 7.2%
High School 17.6%
Some College 35.9%
College Grad or Higher 39.3%
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Questionnaire
South Valley Therapy
Additional questions:• Have you ever been a combat soldier?• Have you ever lived in a war zone?• Have you ever been physically abused as a child?• Have you ever been sexually molested as a child or
adolescent?• Have you ever been raped?• Who in your family has been murdered?• Who in your family has had a nervous breakdown?• Who in your family has been a suicide?• Who in your family has been an alcoholic or drug
user?
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OutcomesNumber of categories (not events) is summed
ACE Score Prevalence0 33%1 25%2 15%3 10%4 6%5 or more 11%
• 2 out of 3 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 50% chance of 3 or more
• Women are 50% more likely than men to have a Score of 5<
South Valley Therapy
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Prevalence of Adverse Childhood Experiences
Abuse, by CategoryPrevalence (%)
Psychological (by parents) 11%Physical (by parents) 28%Sexual (anyone) 22%
Neglect, by CategoryEmotional 15%Physical 10%
Household Dysfunction, by CategoryAlcoholism or drug use in home 27%Loss of biological parent <age 18 23%Depression or mental illness in home 17%Mother treated violently 13%Imprisoned household member 5%
South Valley Therapy
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Adverse Childhood Experiences Are Common
Of the 17,000 HMO Members:• 1 in 4 exposed to 2 categories of
ACES• 1 in 16 was exposed to 4 categories• 22% were sexually abused as
children• 66% of the women experienced
abuse, violence or family strife in childhoodSouth Valley
Therapy
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Adverse Childhood Experience CategoriesAbuse of Child Recurrent Severe Emotional abuse Recurrent Physical abuse Contact Sexual abuse
Trauma in Child’s Household Environment Substance abuse Parental separation or divorce - Chronically depressed, emotionally disturbed or suicidal household member Mother treated violently Imprisoned household member Loss of parent – (by death, by suicide, - or by abandonment)
Neglect of Child Abandonment Child’s basic physical and/or emotional needs unmet
Impact of Trauma and Health Risk Behaviors to Ease the PainNeurobiologic Effects of Trauma Disrupted neuro-development Difficulty controlling anger-rage Hallucinations Depression Panic reactions Anxiety Multiple (6+) somatic problems Sleep problems Impaired memory Flashbacks Dissociation
Health Risk Behaviors Smoking Severe obesity Physical inactivity Suicide attempts Alcoholism Drug abuse 50+ sex partners Repetition of original trauma Self Injury Eating disorders Perpetrate interpersonal violence
Long-Term Consequences of Unaddressed Trauma (ACEs)Disease and Disability Ischemic heart disease Cancer Chronic lung disease Chronic emphysema Asthma Liver disease Skeletal fractures Poor self rated health Sexually transmitted disease HIV/AIDS
Serious Social Problems Homelessness Prostitution Delinquency, violence, criminal behavior Inability to sustain employment Re-victimization: rape, DV Compromised ability to parent Intergenerational transmission of abuse Long-term use of health, behavioral health, correctional, and social services
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ACEs BackgroundThe higher the ACE score, the greater the likelihood of:• Severe and persistent emotional
problems• Health risk behaviors• Serious social problems• Adult disease and disability• High health and mental health care costs• Poor life expectancy
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ACES Background
• Big Finding:– Childhood experiences are POWERFUL
determinants of adult health outcomes
South Valley Therapy
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The following information and slides are being used with permission from three sources: 1. September 2003 Presentation of the Child
Trauma Treatment Network of the Intermountain West, by Vincent Felitti, MD
2. Powerpoint presentation of Ann Jennings, Ph.D. of The Anna Institute
3. Felitti & Anda (2010). The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: implications for healthcare. In Ruth Lanius, Eric Vermetten & Clare Pain (Eds.), The Impact of Early Life Trauma on Health and Disease: 77-87. Massachusettes: Cambridge University Press. South Valley
Therapy
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Emotional Problems
South Valley Therapy
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Childhood Experiences Underlie Chronic Depression
South Valley Therapy
0 1 2 3 >=40
10
20
30
40
50
60
70
80
Women
Men
ACE Score
% W
ith
a L
ifet
ime
His
tory
of
Dep
ress
ion
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Childhood Experiences Underlie Suicide
South Valley Therapy
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ACE Score and Hallucinations
South Valley Therapy
Ever
Hallu
cin
ate
d*
(%)
AbusedAlcohol
or Drugs
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ACE Score and Impaired Childhood Memory
South Valley Therapy
Series10
5
10
15
20
25
30
35
40
0 1 2 3 >=4
Perc
en
tag
e W
ith
Mem
ory
Im
pair
men
t (%
)
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Social Issues
South Valley Therapy
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ACE vs. Smoking as an Adult
South Valley Therapy
0 1 2 3 4-5 6 or more02468
101214161820
ACE Score
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ACE vs Adult Alcoholism
South Valley Therapy
Series10
2
4
6
8
10
12
14
16
180 1 2 3 4 or more
% A
lco
ho
lic
ACE Score
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ACE vs IV Drug Use
South Valley Therapy
0 1 2 3 4 or more0
0.5
1
1.5
2
2.5
3
3.5
ACE Score
% H
av
e I
nje
cte
d D
rug
s
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Childhood Experience Underlie Rape
South Valley Therapy
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ACE and Likelihood of >50 Sexual Partners
South Valley Therapy
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Sexual Abuse of Male Children and Their Likelihood of Impregnating a Teenage Girl
South Valley Therapy
Series10
5
10
15
20
25
30
35
Perc
en
tage W
ho Im
pre
gnate
A T
een
age
Gir
l
Not Abused 16-18 Years 11-15 Years <=10 Years
Age When First Abused
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Frequency of a girl being physically abused or witnessing one’s mother being abused and the
likelihood of ever having a teen pregnancy
Series10
5
10
15
20
25
30
35
Perc
en
t w
ho h
ad
a t
een
p
reg
nan
cy
Never Once, Twice Sometimes Often Very
SelfMotherr
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Health Outcomes
South Valley Therapy
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ACE vs. History of STD
South Valley Therapy
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ACEs vs. Obesity
South Valley Therapy
0
2
4
6
8
10
12
5.4
7
9.510.3
12
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Effect of ACEs on Mortality
South Valley Therapy
0 2 40
10
20
30
40
50
60 19-34
35-49
50-64
>=65
ACE Score
Per
cen
t in
Ag
e G
rou
p
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What changes were seen?
• 35% reduction in doctor office visits was found in the year following the assessment (compared to the year before)
• 11% decrease in ER visits• 3% reduction in hospitalizations
• These changes returned to baseline after two years when medial staff returned to previous medical
model without asking about ACEs or including treatment for the identified trauma
Felitti & Anda, 2010South Valley Therapy
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Power of the ACE StudySimplicity
The Data Tell A Simple Story• ACEs are common• ACEs are highly interrelated• ACEs pile up and have a cumulative
impact• ACEs account for a large percentage
of health and social problems• Biologic Plausability
South Valley Therapy
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What presents as the PROBLEM may in fact be an
attempted solution
South Valley Therapy
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Assessment
• ACES is an assessment tool– 24 Hour Hotline
• Your ACE score never changes• How do we track progress?– BDI, BAI, OQ, YOQ, Suicide Assessments,
PCL-C– Resiliency: Empowerment Scale, Youth
Self-Efficacy Scale
South Valley Therapywww.southvalleytherapy.com
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Approach
• Use a Trauma Lens– Shifting from What is wrong with this person?
to What has this person been through?
• Routinely seek a history of adverse childhood experiences from ALL patients
• Acknowledge their reality by asking, “How has this affected you later in life?”
• Transparency
South Valley Therapy
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Intergenerational Impact
• Children of Parents with ACE scores are secondary victims– Historical Trauma
• Parents with ACE scores will often lack coping and resilience that fosters effective parenting–What does this mean for the extended
family of our adult patients?
South Valley Therapy
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Therapy• There is no SINGLE recommended
approach• Trauma Based Therapies:– Trauma Based CBT– EMDR– DBT– EFT (Tapping)–Mindfulness–Mindfulness CBT (MCBT)
• Family TherapySouth Valley Therapy
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Therapy
• Depression• Psycho-Education– i.e. DBT Skills, Communication, Stress
Management
• Whole-Person Approach• Referrals
South Valley Therapy
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Strength Building
South Valley Therapy
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Micro Recommendations
• Implementation– Private Practice– Health Facilities– Senior Living– Corrections– Education System
• Make Personal Connections to MDs and Nurses
• Connect Children to Resiliency Activities• Mind-Body ConnectionsSouth Valley
Therapy
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Macro Recommendations• ACEs becoming a primary assessment
tool in mental and physical health agencies and organization
• Encourage clinical research on trauma and its treatment
• Providing funding to treat trauma should become a priority for Insurance, business, government etc. – Good for individuals, families and
communities– High Economic Impact
Whitfield, 1998South Valley Therapy
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Macro Recommendations• Effective parenting programs– Parenting education starting as part of
K-12 Education
• Recognition of ACES/trauma and appropriate treatment should be a mandatory component of education for all health professionals
• Create and Endorse Primary Prevention Efforts
Whitfield, 1998South Valley Therapy
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Considerations
• Baby Boomers and Older Persons are a population that didn’t access or talk about mental health (cultural norm)
South Valley Therapy
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Local Resources
• Trauma Informed Care Network– www.ticn.org
• Rape Recovery Center• UCASA– 40 Hour Training
• Utah Domestic Violence Council– uuadvt.org
• Utah Department of Health– BRFSS StudySouth Valley
Therapy
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National Resources
• ACEs Connection– Online Community of Researchers,
Clinicians and Policy Makers
• The Anna Institute– www.theannainstitute.org
• ACE Response– www.aceresponse.org
South Valley Therapy
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References
Anda RF, Butchart A, Felitti VJ, Brown DW. (2010). Building a Framework for Global Surveillance of the Public Health: Implications of Adverse Childhood Experiences. Preventive Medicine, 39 (1): 93-98.
Felitti & Anda (2010). The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: implications for healthcare. In Ruth Lanius, Eric Vermetten & Clare Pain (Eds.), The Impact of Early Life Trauma on Health and Disease: 77-87. Massachusettes: Cambridge University Press.
Whitfield CL. (1998). Adverse Childhood Experiences and Trauma (editorial). American Journal of Preventive Medicine, 14:361–363.
South Valley Therapy