Adverse Childhood Experiences and their Relationship to Adult Well-being and Disease : Turning gold...
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Transcript of Adverse Childhood Experiences and their Relationship to Adult Well-being and Disease : Turning gold...
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.
“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.
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
However, with an ACE Score of 4 or more, the majority of adults have
multiple risk factors for these diseases or the diseases themselves.
Dismissing them as “bad habits” or“self-destructive behavior” comfortably misses their functionality.
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)
www.HumaneExposures.com (3 Important Books)
www.CavalcadeProductions.com (Documentary DVDs)
http://xnet.kp.org/PermanenteJournal/winter02/deardoc.pdf