The Collaborative Adverse Childhood Experiences Study (CACES): Evaluating the Utility of

Adverse Childhood Experiences (ACE) Health Surveillance in US Military Personnel

Jamie D. Davis, PhDClinical Research Psychologist, Associate Investigator

Ronnie Robinson, MSProject Director

COL Charles C. Engel, MD, MPH, MC, USADHCC Chief, Associate Investigator

Background

National Defense Authorization Act - DoD mandate to implement baseline health surveillance

CDC’s ACE results (Dube, et al, 2003): 62% males & 66% females experienced > ACE 65 - 98% chance of experiencing > ACE Negative health outcomes in adulthood

Military populations & ACE (Rosen, et al, 1996; Smikle, et al, 1996): 56% males 66% females experienced > ACE Health risk behaviors & negative health outcomes in adulthood Greater attrition during basic training & first year of service

ASDHA convened a multi-agency collaboration – Army, Navy, Air Force, CDC, and VA – to investigate ACE military health surveillance

Dube, S. R., Felliti, V. J., Dong, M., Giles, W. H., & Anda, R. F. (2003). The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900. Prev Med, 37, 268-277.

Rosen, L. N. & Martin, L. (1996). Impact of Childhood Abuse History on Psychological Symptoms Among Male and Female Soldiers in the U.S. Army. Child Abuse Negl, 20, 1149-1160.

Smikle, C. B., Fiedler, E., Sorem, K. A., Spencer, D. K., & Satin, A. J. (1996). The Impact of Sexual Abuse on Job Attrition in Military Recruits. Mil Med, 161, 146-148.

Literature Review Findings

ACE are relatively common & clearly linked to multiple health risks & outcomes (Dube, et al, 2003)

Acceptability of ACE questions for respondents is unclear & likely linked to response validity (Olson et al., 2004; Young et al., 2006)

Confidentiality assurances

Willingness to respond to questions

As a population health metric ACE surveillance may increase our understanding of risk behavior, social & individual medical problems, & intervention opportunities

Dube, S. R., Felliti, V. J., Dong, M., Giles, W. H., & Anda, R. F. (2003). The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900. Prev Med, 37, 268-277.

Olson, C. B., Stander, V. A., & Merrill, L. L. (2004). The Influence of Survey Confidentiality and Construct Measurement in Estimating Rates of Childhood Victimization Among Navy Recruits. Mil Psychol, 16, 53-69.

Young, S. Y. N., Leard, C. A., Hansen, C. J., Chervak, M. C., Hauret, K. G., Spooner, C. S. et al. (2006). The Recruit Assessment Program (RAP) Experience With Adverse Childhood Experiences (ACE) Questions (Rep. No. NHRC.06-04).

The Expert Review Panel (ERP)

Mission: provide expert input and perspective on ACE surveillance in the military

Membership: Nominated by project steering committee

Nationally respected, multidisciplinary subject matter experts

Expertise in military medicine, psychiatry, psychology, epidemiology, abuse, medical ethics, legal, primary care, & occupational medicine

Representation from key government stakeholders (DoD, DVA, DHHS)

Method: Critically review ACE, public health, & other relevant literature, hear relevant briefs from military and other experts

Deliverable: written recommendations on feasibility & utility of using ACE data for routine military health surveillance

ERP Members

Shanta Dube, PhD, MPH, Centers for Disease Control & Prevention

Charles W. Hoge, PhD, Walter Reed Army Institute of Research James E. McCarroll, PhD, MPH, Uniformed Services University

of the Health Sciences Patricia Resick, PhD, VA Boston Healthcare System & Boston

University Desmond Runyan, MD, DrPH, University of North Carolina Mark Small, PhD, JD Clemson University Sandra M. Stith, PhD, LMFT, Virginia Polytechnic Institute &

State University Cynthia J. Thomsen, PhD, Northern Illinois University

Steering Committee

David W. Armstrong, PhD, FACSM, Deployment Health Clinical Center Jamie D. Davis, PhD, Deployment Health Clinical Center Charles C. Engel, MD, MPH, Deployment Health Clinical Center Cynthia T. Ferguson, MSN, LCDR US Navy Howard N. Garb, PhD, Lackland Air Force Base Roger L. Gibson, PhD, MPH, DVM, Armed Force Epidemiological Board David W. Lloyd, LLM, Office of the Deputy Undersecretary of Defense John Newby, DSW, Uniformed Services University of Health Sciences Michael R. Peterson, DVM, MPH, DrPH, TRICARE Management Activity Bruce Ruscio, DrPH, Office of the Assistant Secretary of Defense, Health Affairs Margaret Ryan, MD, MPH, Center for Deployment Health Research Christina Spooner, MS, Center for Deployment Health Research Katherine A. Surman, CAPT, NC, US Navy, Office of the Assistant Secretary of

Defense for Health Affairs, Clinical and Program Policy Sylvia Young, MD, MPH, Center for Deployment Health Research

ERP Recommendations

Recommendation One: It is premature to implement a DoD-wide ACE surveillance program

Gaps regarding predictive validity

Military & medical goals of ACE surveillance are ambiguous

ACE-specific interventions lack evidence base

Potential for misuse of ACE surveillance data is significant

ERP Recommendations

Recommendation Two: Develop a military program of

longitudinal, prospective studies

Currently a paucity of these data available to support or refute the potential utility of a military ACE surveillance program

Clarify predictive validity

Clarify mediator & moderator variables

ERP Recommendations

Recommendation Three: A thorough examination of the ethical/legal implications of military-wide ACE surveillance

should be considered What are the ultimate goals?

What are the legal risks associated with these data?

Could harm occur as a consequence of collecting these data?

How can data be safeguarded over time and in changing contexts?

ERP Recommendations

Recommendation Four: If a DoD-wide ACE surveillance program is initiated, data should be collected without identifiers

Ensure valid & reliable information

Safeguards against misuse

Protects against data breaches involving highly sensitive information

May reconsider use of identifiers after clarification of current program ambiguities

ERP Recommendations

Recommendation Five: Before implementing a DoD-wide ACE surveillance system, the purposes of this surveillance should be clearly defined

Potential for misuse is real though exact risk unknown

Established link between ACE & several future health risks

Purpose of the program has crucial implications for implementation

Limitations

A panel comprised of different members may have made different conclusions & recommendations

Differences in individual discipline and government agency perspectives

The impact of idiosyncratic views & interests

Influence of group dynamics

Acceptability of ACE Questions in Routine Military Health Surveillance: A Qualitative Study

Background – current research findings & recommendations derived from the CACES Conference

Objective – to explore the perceptions & attitudes of service members & spouses regarding using ACE questions for routine health surveillance

Purposive sample - views may vary in important ways

Recruitment – WAMC primary care clinic & Robinson clinic

Participants

784 individuals were screened

615 individuals completed the questionnaire (78% response rate)

342 (56%) individuals met inclusion criteria (> 1 ACE)

41 (~8%) individuals agreed to participate

Officers were significantly less likely than enlisted personnel or spouses to report an ACE

Participants

Length of Military Affiliation

Gender

Service Member Spouse

< 5 Years > 5 Years < 5 Years > 5 Years

Female 7 6 7 5

Male 8 8--* --*

*Unsuccessful in recruiting male spouses

Qualitative Research StudyMethods

Interviews audio-recorded by 2 experienced qualitative interviewers

Semi-structured interviewer’s guide General military health surveillance Surveillance for psychiatric disorders Surveillance for ACE Implications of including ACE surveillance data in military

medical records

Interviews lasted approximately 30 minutes

Methods

Each interview was transcribed verbatim & analyzed for emerging themes

Independent reviews were conducted of all transcripts

Transcripts were analyzed to determine

How well identified themes matched anticipated thematic area Discover unanticipated themes Generate hypotheses concerning unexpected themes

Qualitative Research StudyResults

Concerns about Confidentiality General beliefs about privacy safeguards

Privacy is perceived to be inherently lacking in military culture

Breaches in patient confidentiality are possible

Many interviewees identified specific examples from personal or peer experience

Results

Value of Standardized Health Surveillance

Service members & spouses are generally receptive to health surveillance programs

Concerns about the potential for information to be used to stigmatize or segregate certain individuals or groups

Intrusiveness, burden, &/or how information may be used moderates views

Results

Value of Mental Health Surveillance

Mental health is viewed as essential to troop readiness & well-being

Some interviewees commented on the devastating consequences of poor mental health

BUT, some commanders are perceived to view mental health issues as outside their scope of command responsibility

Results

Uncertainty over the Usefulness of ACE

Participants questioned how one can treat a childhood event in adults – i.e., the practical usefulness of ACE data

Many participants failed to see or understand the relevance of childhood experiences to current behavior & well-being in adulthood

Many related concerns about potential for negative career impact to markedly reduce response validity

Results

Unanticipated Theme: Building Military Trust & Confidence

Many participants felt that competent implementation of ACE surveillance could foster trust and confidence

Participant suggestions regarding how the military services could foster trust through competent implementation…

– Address the confidentiality of the system– Use anonymous reporting methods (e.g., online

surveys vs. medical records)– Communicate program intent openly & honestly– Communicate the benefits for the service member

Overall Conclusions

Longitudinal, prospective studies are needed to determine predictive validity of ACE

If ACE surveillance is implemented, service members should be fully informed about and consulted with about the program including potential health benefits

Confidentiality reassurances are advised to the maximum extent possible. Lack of same is likely to reduce trust & lead to inaccurate exposure reporting

It is not recommended that DoD implement military health surveillance of ACE at this time although a link between ACE & future behavior is likely

Limitations

Sample included only one military installation

Reliance on retrospective ACE reporting which may be affected by the passage of time on memory

Relatively small sample – a large representative sample may achieve different results

Questions, Information,Assistance

DoD Deployment Health Clinical Center Walter Reed Army Medical CenterBuilding 2, Room 3G046900 Georgia Ave, NWWashington, DC 20307-5001 E-mail: pdhealth@na.amedd.army.milWebsite: www.PDHealth.mil

The views expressed in this presentation are those of the authors and do

not necessarily represent the official policy or position of the Deployment

Health Clinical Center, Walter Reed Army Medical Center, Department of the

Defense, or the United States Government.

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