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

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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