Post on 19-Jan-2016
description
Adverse Childhood Experiences and their Relationship to
Adult Well-being and Disease : Turning gold into lead
A collaborative effort between
Kaiser Permanente and the Centers for Disease Control
Robert F. Anda, M.D. Vincent J. Felitti, M.D.
Invest in Children Conference Cleveland, Ohio November 17, 2011
QuickTime™ and a decompressor
are needed to see this picture.
ACE Study Design
Survey Wave 1 71% response (9,508/13,454)
Survey Wave II n=13,000
All medical evaluationsabstracted
PresentHealth Status
Mortality National Death Index
Morbidity Hospital Discharges Doctor Office Visits Emergency Room Visits Pharmacy Utilization
All medical evaluationsabstracted
vs.
N= 17,337
Prevalence of Adverse Childhood Experiences
Abuse, by Category Psychological (by parents) 11% Physical (by parents) 28% Sexual (anyone) 22%
Neglect, by Category Emotional 15% Physical 10%
Household Dysfunction, by Category Alcoholism 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%
Prevalence (%)
Adverse Childhood Experiences ScoreNumber of categories (not events) is summed…
ACE Score Prevalence 0 33% 1 25% 2 15% 3 10% 4 6% 5 or more 11%*
• Two out of three 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 >.
* Women are 50% more likely than men to have a Score >5.
Smoking to Self-Medicate
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“Addiction is due to the characteristics intrinsic
in the molecular structure of some substance.”
The traditional concept:
“Addiction highly correlates with characteristics intrinsic to that
individual’s childhood experiences.”
We find that:
Adverse Childhood Experiences vs. Smoking as an Adult
0
2
4
6
8
10
12
14
16
18
20
0 1 2 3 4-5 6 or more
ACE Score
%
p< .001
Health Risks
Childhood Experiences vs. Adult Alcoholism
0
2
4
6
8
10
12
14
16
18%
Alc
oh
olic
ACE Score
0
1
23
4+
Health Risks
ACE Score vs Injection Drug Use
0
0.5
1
1.5
2
2.5
3
3.5
% H
ave
Inje
cted
Dru
gs
0 1 2 3 4 or more
ACE Score
p<0.001
Health risks
Estimates of the Population Attributable Risk*
of ACEs for Selected Outcomes in Women
Drug Abuse PAR
Alcoholism 65%
Drug abuse 50%
IV drug use 78%
*That portion of a condition attributable to specific risk factors
Social Costs
Molestation in Childhood
Root Causes, Coping Mechanisms, & Outcomes
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Depression:
Some say depression is a disease. Some say depression is genetic. Some say depression is due to a chemical imbalance.
Might depression be a normal response to
abnormal life experiences?
Childhood Experiences Underlie Chronic Depression
0 1 2 3 >=40
10
20
30
40
50
60
70
80
% W
ith
a L
ife
tim
e H
isto
ry o
f D
ep
res
sio
n
0 1 2 3 >=4
ACE Score
WomenMen
Emotional costs
Childhood Experiences Underlie Suicide Attempts
0
5
10
15
20
25%
Att
emp
tin
g S
uic
ide
ACE Score
11
22
00
33
4+4+
Emotional costs
ACE Score and Rates of Antidepressant Prescriptions
50 years later
0
10
20
30
40
50
60
70
80
90
100
ACE Score
0 1 2 3 4 >=5
P
resc
rip
tio
n r
ate
(p
er
10
0 p
ers
on
-ye
ars)
ACE Score
Social cost
Estimates of the Population Attributable Risk*
of ACEs for Selected Outcomes in Women
Mental Health PAR
Current depression 54%
Chronic depression 41%
Suicide attempt 58%
*That portion of a condition attributable to specific risk factors
Social costs
Adverse Childhood Experiences vs.History of STD
0 1 2 3 4 ormore
0
0.5
1
1.5
2
2.5
3
Ad
just
ed O
dd
s R
atio
0 1 2 3 4 ormore
ACE Score
Biomedical Disease
The ACE Score and the Prevalence of Liver Disease (Hepatitis/Jaundice)
0
2
4
6
8
10
12
0 1 2 3 >=4
AACE CE Score
Perc
en
t (
%)
ACE Score
Biomedical Disease
ACE Score vs. COPD
Biomedical Disease
0 1 2 3 4
0
24
68
1012
1416
18
ACE Score
Per
cent
wit
h P
robl
em
With an ACE Score of 0, the majority of adults have few,
if any, risk factors for these diseases.
However, with an ACE Score of 4 or more, the majority of adults have
multiple risk factors for these diseases or the diseases themselves.
Many chronic diseasesin adults are determined
decades earlier, in childhood.
Dismissing them as “bad habits” or“self-destructive behavior” comfortably misses their functionality.
The risk factors underlying these adult
diseases are helpful short-term coping devices.
Evidence from ACE Study Indicates:
Adverse childhood experiences are the most basicbasic cause of health risk behaviors, disease, disability, mortality, and healthcare costs.
What Can We Do Today?
• Routinely seek a history of adverse childhood experiences from allall patients, by questionnaire.
• Acknowledge their reality by asking, “How has this How has this affected you later in life?”affected you later in life?”
• Use existing systems to help with current problems.
• Develop systems for primary prevention.
Unconventional Questions of Demonstrated Value
• Have you lived in a war zone?• Have you ever been a combat soldier?• Who in your family has committed suicide?• Who in your family has been murdered?• Who in your family has had a nervous
breakdown?• Were you molested as a child?• Have you ever been held prisoner?• Have you been tortured?• Have you been raped?
Outcomes of a Biopsychosocial Preventive Approach
Biomedical evaluation: 11% reduction in DOVs, subsequent year (700 patient sample)
Biopsychosocial evaluation: 35% reduction in DOVs (125,000 patient sample)
Final Insights from the ACE StudyFinal Insights from the ACE Study• Adverse childhood experiences are common but typically unrecognized.
• Their link to disease and life expectancy is powerful and proportionate.
• They are the nation’s most basic public health problem.
• We often mistake intermediary mechanism for basic cause.
• What presents as the ‘Problem’ may in fact be an attempted solution.
• Treating the solution may be threatening and cause flight from treatment.
• Primary prevention is presently the only feasible population approach.
Further InformationFurther Informationwww.AceStudy.org
Medline/PubMed, Google (Anda or Felitti as author)
VJFMDSDCA@mac.com
www.HumaneExposures.com (3 Important Books)
www.CavalcadeProductions.com (Documentary DVDs)
http://xnet.kp.org/PermanenteJournal/winter02/deardoc.pdf