Impacts of Adverse Childhood Experiences on Health and ...
Transcript of Impacts of Adverse Childhood Experiences on Health and ...
Melissa T. Merrick, PhD
Division of Violence Prevention
Tribal Leaders Diabetes Committee MeetingApril 14, 2016
Impacts of
Adverse Childhood Experiences
on Health and Wellbeing
Building Brain Architecture
Healthy Brain Injured Brain
Violence Compromises
Early Brain Development
When you think of child abuse & neglect,
you likely picture this…
…..but probably not this
Poor adult health has long been linked to Child
Abuse & Neglect
Categories of ACEs
Neglect Family ChallengesAbuse
Graphic Credit: Robert Wood Johnson Foundation
How Common are ACEs?
# of ACEs:
40.7%
23.6%
13.3%
8.1%
14.3%
ACE Score Prevalence2010 BRFSS ACE Module
Zero One Two Three Four or More
# of ACEs:
36.1%
26.0%
15.9%
9.5%
12.5%
ACE Score PrevalenceCDC-Kaiser ACE Study
Zero One Two Three Four or More
# of ACEs:
ACE Score and Adult Depression
0
1
2
3
4
5
6
Chapman, DP et al. Journal of Affective Disorders 2004;82:217–225
Gonzalez, O et al. MMWR 2010;59(38):1229-1235
Ad
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1 2 3 4 ≥50
ACE Score and Suicide Attempts
Ad
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d O
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Number of ACEs
-Dube et al. JAMA. 2001;286:3089–3096.
0
2
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6
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14
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18
0 1 2 3 4 5 6 ≥7
0
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3.5
Adju
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ACE Score and
Cardiovascular Disease
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Dong, M et al. Circulation. 2004;110:1761–1766.
Number of ACEs
1 2 3 4 5,60 7,8
ACE Score and Adult Diabetes
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Number of ACEs
Gilbert L et al. American Journal of Preventive Medicine. 2015;48(3):345–349.
0
0.5
1
1.5
0 1-3 4-6 7-9
ACE Score and HIV Risks
0
2
4
6
8
10
12
0 1 2 3 ≥4
Number of ACEs
Ever-injected drugs Had ≥50 intercourse partners Ever had an STD
Felitti, VJ et al. American Journal of Preventive Medicine 1998;14:245–258
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ACE Score and Current Smoker
0
0.5
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1.5
2
2.5
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Number of ACEs
-Felitti, VJ et al. American Journal of Preventive Medicine.1998;14(4):245–258
1 2 3 ≥ 40
ACE Score and Considers Self an Alcoholic
0
1
2
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4
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8
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Number of ACEs
-Felitti, VJ et al. American Journal of Preventive Medicine.1998;14(4):245–258
1 2 3 ≥ 40
ACE Score and Severe Obesity
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
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Number of ACEs
-Felitti, VJ et al. American Journal of Preventive Medicine.1998;14(4):245–258
1 2 3 ≥ 40
0
0.5
1
1.5
2
2.5
3
Not GraduatingHigh School
Unemployed Earning a LowIncome
ACEs and Life Potential
0 1 2 3 4 or more
ACE Score:
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ACEs and Financial Stress
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Food Insecurity Rent/Mortgage Stress
0 1 2 3 4 or more
ACE Score:
Leading Causes of Death
in the U.S. in 2013
1. Heart disease
2. Cancer
3. Chronic lower respiratory diseases
4. Unintentional injuries (accidents)
5. Stroke
6. Alzheimer's disease
7. Diabetes
8. Influenza and Pneumonia
9. Nephritis, Nephrotic Syndrome, and Nephrosis (Kidney disease)
10. Intentional self-harm (suicide)
The National Vital Statistics Report (NVSR) “Deaths: Final Data for 2013.”
1. Heart disease
2. Cancer
3. Chronic lower respiratory diseases
4. Unintentional injuries (accidents)
5. Stroke
6. Alzheimer's disease
7. Diabetes
8. Influenza and Pneumonia
9. Nephritis, nephrotic syndrome, and nephrosis (Kidney disease)
10. Suicide
Leading Causes of Death in the U.S. in 2013
With an ACE Score of 0, the
majority of adults have few,
if any, risk factors for these diseases and
health risk behaviors
With an ACE Score of 4 or more, the majority of adults have multiple risk factors for these diseases and health
risk behaviors or the diseases themselves
Violence Across the Lifespan
EARLY
CHILDHOOD ADOLESCENCE ADULTHOOD
Bullying Youth Violence
Child Maltreatment
Dating Violence
Sexual Violence
Intimate Partner Violence
Elder
Maltreatment
Suicide
War and Other Collective Violence
Prevention Response
Role of Public Health
in Violence Prevention
Role of Criminal Justice, Child Welfare, Social Service
Preventing child maltreatment
requires understanding why
some children and families
are at greater risk than others.
Assuring
Safe, Stable, Nurturing
Relationships & Environments
for All Children
Raise Awareness & Commitment
Use Data to Inform Action
Create the Context for Safe, Stable,
Nurturing Relationships & Environments
• Funding Initiative: 5 State Health Departments
– California
– Colorado
– Massachusetts
– North Carolina
– Washington
• Over 30 self-supported states participating in
Essentials for Childhood initiative
GOAL 1: RAISE AWARENESS
AND COMMITMENT
The Raising of America
• Raising explores how a
strong start for all our kids
can lead to a healthier,
stronger, and more equitable
America
• Components:
– Six-part documentary series
– National public engagement
campaign
– Companion website
GOAL 2: USE DATA TO
INFORM SOLUTIONS
30+ States Have Included the ACE Module on
Their BRFSS
Source: ACE Executive Summary - Minnesota Department of Health
• Wisconsin
– Examining ACE “Hotspots”
– Added Poverty and Neglect Items to BRFSS
– Oversampled AI/AN Population
• Washington
– Legislators changed the definition of work
participation for TANF recipients
– Juvenile offenders needed additional support to
mitigate future adverse outcomes
Using Data to Inform Solutions:
State Examples
GOAL 3: CREATE THE CONTEXT FOR
HEALTHY CHILDREN & FAMILIES
THROUGH NORMS CHANGE
Essentials for
Parenting
Essentials for Parenting
Toddlers and Preschoolers
• On-line interactive resource
developed for parents with
toddlers and preschoolers
• Based upon best available
science
• Includes a variety of
content, including:
– Written content, videos, and
interactive activities
www.cdc.gov/parents/essentials
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CDC Resource for Employers
Provides Opportunities for Action for Small and Large Business
• Model safe, stable, nurturing relationships and environments in your organization
• Create a family-friendly workplace
• Take a comprehensive approach to employee wellness
• Provide parenting resources for employees
• Consider the role of state and local policy in improving employees’ and their children’s access to safe, stable, nurturing relationships and environments
GOAL 4: CREATE THE CONTEXT FOR
HEALTHY CHILDREN AND FAMILIES
THROUGH POLICIES
Policies with impacts on risk factors for child
abuse & neglect
Increased minimum wage
Earned Income Tax Credit
Child Tax Credit
Housing vouchers
Head Start
Bans on corporal punishment
Family-friendly work
Technical Packages
A core set of strategies based
on the best available evidence
to help communities and
states sharpen their focus on
prevention activities with the
greatest potential to have
impact on a specific health
outcome.
Technical Package for
Preventing Child Abuse & Neglect
Strategy – preventive direction or actions to achieve
goal of preventing child abuse and neglect
• Approaches – ways to advance the strategy
- Example programs, policies, or practices
Supports Goals 3 & 4 of Essentials for Childhood
• Goal 3: Create the context for healthy children and
families through norms change and programs
• Goal 4: Create the context for healthy children and
families through policies
Technical Package Development
Review of literature
Identification of strategies
& approaches
Written draft
Review by partners
Editing and
formatting of final product
Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Preventing child abuse and neglect: A technical package for policy, norm, and
programmatic activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
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Child Abuse and Neglect Prevention
Technical Package
Strengthen Economic Supports to Families
Change Social Norms to Support Parents and Positive Parenting
Provide Quality Care and Education Early in Life
Enhance Parenting Skills to Promote Healthy Child Development
Intervene to Lessen Harms and Prevent Future Risk
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Sector Involvement
Public health
Education
Government (local, state, federal)
Social services
Health services
Business/labor
Justice
Housing
Media
Other non-governmental organizations
Change in Mind Initiative
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• Alliance for Strong Families and Communities, The Palix Foundation (formerly The Norlien Foundation) & The Robert Wood Johnson Foundation.
• Two country cohort involving 5 non-governmental organizations based in Alberta and 10 U.S. based private, nonprofit human serving organizations.
• Contracting with FrameWorks Institute on framing and strategic communications.
• Contracting with Community Science on the developmental evaluation.
Change in Mind Cohort Sites
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United StatesChildren & Families First, Wilmington, DE
Children’s Home Society of Washington, Seattle, WA
Children’s Hospital of Wisconsin, Milwaukee, WI
East End House, Cambridge, MA
Family Service Association of San Antonio, San Antonio, TX
KVC Health Systems, Olathe, KS
LaSalle School, Albany, NY
Martha O’Bryan Center, Nashville, TN
The Family Partnership, Minneapolis, MN
Wellspring Family Services, Seattle, WA
Change in Mind Cohort Sites
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Alberta, CanadaBig Brothers, Big Sisters of Calgary, Calgary
Boyle McCauley Health Centre, Edmonton
CASA Child, Adolescent, & Family Mental Health, Edmonton
CUPS Health, Education, Housing, Calgary
Sheldon Kennedy Child Advocacy Centre, Calgary
Mobilizing Action for Resilient Communities
• Coordinated by the Health Federation of Philadelphia with:– Funding from the Robert Wood Johnson Foundation and The California
Endowment
– Guidance from the MARC Advisory Committee
• Learning collaborative comprising 14 communities:
AlaskaAlbany/Capital Region, NY
Boston, MABuncombe County, NC
Columbia Gorge Region, ORIllinois
Kansas City, MO
MontanaPhiladelphia, PASan Diego County, CASonoma County, CATarpon Springs, FLWashingtonWisconsin
Child Abuse & Neglect (CAN)
Opportunities and Future Directions
• Integrate violence prevention into the
extraordinary and fast growing movement
in the U.S. to invest in healthy child
development
– Disseminating the CAN technical package
and developing implementation guidance
– Launching new ACE website in April 2016
due to high demand for information
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What it means for our work?
Vision: move in this direction
in a more deliberate way
over next 5 years
Attending to the “dots” and the
“lines”
Goal: maximize impact of
our prevention efforts
IPV
EA
YV
SVCAN
Suicidal
Behavior
TDV
Thank you!
Questions?
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Thank you!
Melissa T. Merrick, PhD
www.cdc.gov/violenceprevention/acestudy
The findings and conclusions in this presentation are those of
the author(s) and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
Policies, Programs, Practices:
Considerations for Inclusion
Examples chosen based on the best available evidence
• Meta-analyses, systematic reviews or rigorous evaluation studies showing impacts on perpetration or victimization behaviors or established risk/protective factors for child abuse & neglect.
• Empirical support or a strong theoretical rationale for changing one or more forms of violence or the conditions that give rise to violence.
• Likelihood of achieving beneficial effects on multiple forms of violence.
Policies, Programs, Practices:
Considerations for Inclusion (continued)
Examples chosen based on the best available
evidence
• Likelihood of similar outcomes with different
populations and/or in different settings.
• No evidence of harmful effects on specific outcomes or
with particular subgroups.
• Feasibility in a U.S. context if the program or policy has
been evaluated in another country
Progress to Date
SME Technical Package Team
• Beverly Fortson (lead); Melissa Merrick (co-lead);
Sandra Alexander; Leah Gilbert; Joanne Klevens
Input received from DVP’s Child Maltreatment Workgroup; branch chiefs; division; center, and agency leadership; external partners
Hot off the press
Draft Narrative of the Technical Package
Describes the strategies, corresponding approaches,
and examples of programs, policies, and practices
with evidence of impact
• Implemented directly by health departments or
collaboration between public health and other sectors
• Implemented by other sectors
Includes a section on monitoring and evaluation
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Preventing Child Abuse and Neglect
CDC’s Technical Package
Strategies:
● Strengthen economic supports
to families
● Change social norms to support
parents and positive parenting
● Provide quality care and
education early in life
● Enhance parenting skills to
promote healthy child
development
● Intervene to lessen harms and
prevent future risk
Helping states and communities take
advantage of the best available
evidence
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Strategy 1: Strengthen Economic Supports to Families
Strengthen household financial security
Use of policies to reduce child abuse and neglect by improving
parents’ ability to satisfy children’s basic needs (e.g., food,
shelter, medical care), provide developmentally appropriate
child care, and reduce parental stress and depression.
Support family-friendly work policies
Use of policies to change the context for families by improving
the balance between work and family, ensuring economic
security, and making positive parenting an easier and more
realistic “choice”.
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Strategy 2: Change Social Norms to Support Parents and Positive Parenting
Public engagement and education campaigns
Attempt to reframe the way people think and talk about child
abuse and neglect and who is responsible for preventing it.
Legislative approaches to reduce corporal
punishment
Help establish norms around safe, more effective discipline
strategies to reduce the harms of harsh physical
punishment.
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Strategy 3: Provide Quality Care and Education Early in Life
Preschool enrichment with family engagement
Provide high quality early education and care to
economically disadvantaged children to build a strong
foundation for future learning and healthy development.
Provide support and educational opportunities for parents.
Improved quality of child care through licensing and
accreditation
Ensure quality, positive, and supportive daily experiences
for children
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Strategy 4: Enhance Parenting Skills to Promote Healthy Child Development
Early childhood home visiting programs
Provide information, caregiver support, and training about child
health, development, and care to families in their homes.
Parenting skill and family relationship approaches
Provide support and teach behavior management and positive
parenting skills to build strong and safe families that protect
children from violence and its long-term consequences.
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Strategy 5: Intervene to Lessen Harms and Prevent Future Risk
Enhanced primary care
Used to identify and address psychosocial problems in the family
that serve as risk factors for child abuse and neglect.
Behavioral parent training programs
Reduce the recurrence of child abuse and neglect while teaching
parents specific skills to build a safe, stable, nurturing relationship
with their children.
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Strategy 5: Intervene to Lessen Harms and Prevent Future Risk (continued)
Treatment for children and families to lessen the
harms of exposure to abuse and neglect
Mitigates the health consequences of abuse and neglect
exposure and decreases the risk for other types of violence
later in life.
Treatment for children and families to prevent
problem behavior and later involvement in violence
Addresses the behavioral consequences of experiencing
child abuse and neglect.
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Preventing Child Abuse and Neglect
CDC’s Technical Package
Fortson, BL, Merrick MT, Klevens J, Gilbert L, Alexander S. Preventing child abuse & neglect: A technical package for policy, norm, and programmatic activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (forthcoming April, 2016).
Strategy Approach
Strengthen economic supports to families • Strengthen household financial security
• Family friendly work policies
Change social norms to support parents and positive
parenting
• Public engagement and education campaigns
• Legislative approaches to reduce corporal
punishment
Provide quality care and education early in life • Preschool enrichment with family engagement
• Improved quality of child care through licensing &
accreditation
Enhance parenting skills to promote healthy child
development
• Early childhood home visitation
• Parenting skill and family relationship approaches
Intervene to lessen harms and prevent future risk • Enhanced primary care
• Behavioral parent training programs
• Treatment to lessen harms of abuse and neglect
exposure
• Treatment to prevent problem behavior and later
involvement in violence