The Impact of Adverse Childhood Experiences Across the Lifespan Challenges and Opportunities.

The Impact of Adverse Childhood Experiences Across the Lifespan

Challenges and Opportunities

Special Acknowledgments

Vincent Felitti, MD, Kaiser Permanente

Robert Anda, MD, CDC and ACE Interface

Frank Putnam, MD, UNC at Chapel Hill, NC

William Harris, PhD, Children’s Research and Education Institute

& New School for Social Research, NYC, NY

Alicia Lieberman, PhD, UCSF, San Francisco, CA

Karen Putnam, PhD, UNC at Chapel Hill, NC

Lisa Amaya-Jackson, MD, Duke University, Durham, NC

Adverse Childhood Experiences Study

How did it all start?

Adverse Childhood Experiences Study

• >17000 patients

• Mostly White or Hispanic

• Insured

• Average age 57

Study Questions

• Abuse: emotional, physical, or contact sexual

• Household dysfunction: substances, mental illness, or incarceration

• Neglect: emotional or physical

ACES Prevalence (%) of Abuse and NeglectIn the Original Study 1

ACE Women Men TotalN=9367 N=7970 N=17337

AbusePhysical Abuse 27.0 29.9 28.3Sexual Abuse 24.7 16.0 20.7Emotional Abuse 13.1 7.6 10.6

NeglectEmotional Neglect 16.7 12.4 14.8Physical Neglect 9.2 10.7 9.9

1 http://www.cdc.gov/violenceprevention/acestudy/prevalence.html

ACES Prevalence (%) of Household DysfunctionIn the Original Study 1

ACE Women Men TotalN=9367 N=7970 N=17337

Household DysfunctionHousehold Substance Abuse 29.5 23.8 26.9Parental Separation or Divorce 24.5 21.8 23.3Household Mental Illness 23.3 14.8 19.4Mother Treated Violently 13.7 11.5 12.7Incarcerated Household Member 5.2 4.1 4.7


ACE, Larkin, U of Florida, Illinois BRFSS

How Common are ACEs?

• 2/3 of study patients reported at least 1 ACE

• In 2009, 85% of a homeless population reported at least 1 ACE, 55% reported 4 or more

• In 2013,50% of adult Illinois residents and 40% of children 17 had at least 1 ACE

• In 2014, Juvenile offenders in Florida had an average composite ACE score of 3.5-4.3

Experiencing 1 ACE

Increases one’s risk for experiencing additional

ACES

Percent of Cumulative Adverse Childhood Experiences ACES in the Original Study 1

Number of ACES Women Men TotalN=9367 N=7970 N=17337

0 34.5 38.0 36.11 24.5 27.9 26.02 15.5 16.4 15.93 10.3 8.6 9.5

4 or more 15.2 9.2 12.5


• The original ACES (in red) are among the most commonly reported traumas in studies that look at additional traumas

• Over 40% of the children and adolescents served by the NCTSN experienced 4 or more different types of trauma and adversity

1Pynoos et. al (2014). Psychological Trauma: Theory, Research, Practice and Policy. 6:S9-S13

The ACES are Among Many Childhood Traumas and Adversities Measured by the National Child Traumatic Stress Network (N= 10,991)1

48.7

45.1

36.4

31.4

26.8

26.2

20.1

14.1

13.3

10.6

10.6

9.7

9.5

8.8

5

4.6

2

1.7

1

0.9

0 10 20 30 40 50 60

Traumatic Loss/Bereavement/Separation

Domestic Violence

Impaired Caregiver

Emotional Abuse

Neglect

Physical Abuse

Sexual Abuse

Community Violence

Sexual Assault/Rape

Serious Injury/Accident

School Violence

Other

Illness/Medical Trauma

Physical Assault

Natural Disaster

Extreme Interpersonal Violence

Kidnapping

Forced Displacement

War/Terrorism/Political Violence (Non-U.S)

War/Terrorism/Political Violence (U.S)

Percent % Reported

Cumulative ACES Increase Risk for Poor Outcomes

1 Data from the National Comorbidity Survey-Replication Sample (NCS-R) - Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013

Cumulative ACES & Mental Health1P

reva

len

ce

%

Mood Disorders Anxiety Disorders Substance Abuse Impulse Control Disorders

0

10

20

30

40

50

60

70

80

0 1 2 3 ≥ 4ACES

1 Felitti et al., (1998) American Journal of Preventive Medicine, 14:245-258.

Cumulative ACES & Chronic Disease1P

reva

len

ce

%

Ischemic Heart Disease

Stroke COPD Diabetes Sexually Transmitted

Disease

0

2

4

6

8

10

12

14

16

18

0 1 2 3 ≥ 4ACES

1 Anda et al., (2004) The Permanente Journal/Winter 8:30-38.

Cumulative ACES & Impaired Worker Performance1

Pe

rce

nt

% R

ep

ort

ed

Absenteeism Financial Problems Job Problems0

5

10

15

20

25

0 1 2 3 ≥ 4ACES

ACEs are the Root Cause of Many Health and Social Problems

Disease and Disability• Major Depression,

Suicide, PTSD• Drug and Alcohol Abuse• Obesity• Diabetes• Heart Disease• Cancer• Chronic Lung Disease• Sexually Transmitted

Diseases

Social Problems• Homelessness• Prostitution• Criminal Behavior• Poor school outcomes• Unemployment• Parenting problems• High utilization of health

and social services• Intergenerational

transmission of abuse

Washington State Family Policy Council

Contribution of ACEs

Synergistic ACES in Females 1,2

• In females synergy occurs with 2 or more ACES

• For females the most potent ACE, sexual abuse, is synergistic with:

– Domestic violence

– Crime victimization

– Poverty

– Parental mental illness (anxiety/depression)

– Loss of a Parent

1 Data from the National Comorbidity Survey-Replication Sample (NCS-R)2 Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013

Synergistic ACES in Males 1,2

• In males synergy occurs with 3 or more ACES

• For males, the most potent ACE, poverty, is synergistic with:

– Sexual abuse

– Parental substance abuse

– Loss of a parent

1 Data from the National Comorbidity Survey-Replication Sample (NCS-R)2 Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013

Synergy between ACES & Other Adversities (e.g., Environmental Pollution1)

• Childhood asthma affects lower income communities more where air pollution & ACES may be elevated

• When they corrected for other possible contributors, researchers found an increased risk between traffic-related air pollution and asthma (OR = 1.63, CI=1.14-2.33) solely among children exposed to violence

• ACES likely interact synergistically with many environmental pollutants and negative social experiences to increase risk for many costly illnesses

1Clougherty et al, (2007) Synergistic effects of traffic-related air pollution and exposureTo violence on urban asthma etiology. Environmental Health Perspectives 115:1140.

Impact of Cumulative ACES & Social Dysfunction 1

• Lower educational, occupational attainment

• Increased social service costs

• Increased medical costs

• Shortened life span (ACE>6 by 20 years)

• Increased risk for HIV infection, teen pregnancy

• Intergenerational transmission of ACES to offspring

1 IOM (Institute of Medicine) and NRC (National Research Council). 2013. New Directions in child abuse and neglect research. Washington, DC: The National Academies Press.

ACES and Toxic Stress

What’s the story????

The Stress Response

• Positive—normal and essential part of healthy development with brief increase in heart rate and mild elevations of stress hormones which return to baseline, eg, the first day of school

• Tolerable—more and longer activation of the body’s alert systems as a result of more severe and longer lasting challenges like death of a loved one. The brain and body can recover fully if the activation is time-limited and buffered by relationships with caring adults

• Toxic—strong, frequent and/or prolonged activation of the stress response, like with ACES, without adequate adult support. Can disrupt the development of the brain and other organ systems, increasing the risk for stress-related disease and cognitive impairment across the life span.

Attachment

• A special emotional relationship that involves an exchange of comfort, care, and pleasure.

• Early attachment styles are established in childhood through the infant/caregiver relationship.

Effects of ACES in Childhood

• Impaired development in the first 3 years• > risk for failing a grade• Score lower on standardized tests• Have language difficulties• Be suspended or expelled• Be designated special ed• Have poorer health• Are at risk for incarceration

Anda, Blodgett, Burke-Harris

Blodgett

ACEs and School

• The main reason that kids miss school or get in trouble

• The second highest predictor of academic failure after being in special ed classes

http://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html

Individual Risk Factors

• Children younger than 4 years of age

• Special needs that may increase caregiver burden (e.g., disabilities, mental retardation, mental health issues, and chronic physical illnesses)

Rates of Maltreatment by Age1

• Most maltreatment happens to younger children• Maltreatment has greater negative effects at younger ages

1 Child Maltreatment 2012. Washington, DC: US Department of Health and Human Services; 2014

Types of Child Maltreatment

PsychologicalMaltreatment

7%

0 1 2 3 4 5 6 7

0-3

4-6

7-9

10-12

13-15

16-17

Percent of Children

Age G

rou

p


Parental Risk Factors

• Parents' lack of understanding of children's needs, child development and parenting skills

• Parents' history of child maltreatment in family of origin• Substance abuse and/or mental health issues including

depression in the family• Parental characteristics such as young age, low education,

single parenthood, large number of dependent children, and low income

• Nonbiological, transient caregivers in the home (e.g., mother’s male partner)

• Parental thoughts and emotions that tend to support or justify maltreatment behaviors


Family Risk Factors

• Social isolation

• Family disorganization, dissolution, and violence, including intimate partner violence

• Parenting stress, poor parent-child relationships, and negative interactions


Community Risk Factors

• Community violence

• High poverty and residential instability

• High unemployment rates

• High density of alcohol outlets

• Poor social connections.

Adverse Childhood Experiences•Abuse and Neglect (e.g., psychological, physical, sexual)•Household Dysfunction (e.g., domestic violence, substance abuse, mental illness)

Impact on Child Development•Neurobiologic Effects (e.g., brain abnormalities, stress hormone dysregulation)•Psychosocial Effects (e.g., poor attachment, poor socialization, poor self-efficacy)•Health Risk Behaviors (e.g., smoking, obesity, substance abuse, promiscuity)

Long-Term Consequences

Disease and Disability•Major Depression, Suicide, PTSD•Drug and Alcohol Abuse•Heart Disease•Cancer•Chronic Lung Disease•Sexually Transmitted Diseases•Intergenerational transmission of abuse

Social Problems•Homelessness•Prostitution•Criminal Behavior•Unemployment•Parenting problems•High utilization of health and social services

How the ACES Work

ACEs and the Next Generation

Experiences that we have turn our genes on or off, making us healthier or sicker. Then we pass those modified genes on to our sons and daughters.

The Great Rat Mother Switcheroo

• Rats born to anxious,non-nurturing mothers become anxious, non-nurturing adults

• Rats born to calm nurturing mothers become calm and nurturing adults

What happens when you switch the

babies???

How ACES Cross Generations

Child

Adolescent

Adult

ChildAbuse

ChildAbuse

AggressionConductProblems

DepressionPTSD

Anxiety

SchoolProblems

Revictim-ization

SchoolDropout

SubstanceAbuse

DepressionPTSD

Anxiety

ParentingProblems

DomesticViolence

MaternalDepression

PTSDPoverty

SubstanceAbuse

Generation 1

Generation 2

Hurt People

Hurt Other People

01.5

34.5

Second Hand Smoke & Lung Cancer2 Versus

Sexual Abuse & Drug Addic-tion1

Od

ds R

ati

o

0

1

2

3

4

5

6

Texting & Crash or Near Fatal Crash3Versus

Physical Abuse & PTSD1

Od

ds R

ati

o

0

1

2

3

4

ADHD & Lead Exposure ADHD with Exposure toDomestic Violence in

Females

ADHD with Exposure toDomestic Violence in

Males

Odds

Rati

o

Lead Exposure & ADHD4

VersusDomestic Violence & ADHD1

0

1

2

3

4

Melanoma Risk & TanningBeds

Conduct Disorder withExposure to Poverty in

Females

Conduct Disorder withExposure to Poverty in

Males

Odd

s Rati

o

Tanning Beds & Melanoma Risk5

VersusPoverty & Conduct Disorder1

1Putnam et. al. JTS, 26:435-442,2013 2Brennan et. al. Int J Cancer, 109:125-31,2004 3Klauer et.al. NEJM, 370:54-59,2014 4Froehlich et. al. Pediatrics, 124:1054-1063,2009 5Lazovich et, al. Cancer Epidemiol Biomarker Prev., 19:1557-1568,2010

Public Health Thresholds of Risk for

Legislation, Regulation or Recommendations

Costs of Cumulative & Synergistic ACES

• Human suffering borne by victims & their families

• Economic costs borne by society

• Social costs borne by society

• Intergenerational transmission of childhood adversity borne by future society

What does it cost to do nothing?Each 2014 First-Time Case of Child Maltreatment Costs U.S. Economy

Approximately $1.8 Million in Total Expenditures over their Lifetime1

1Suffer the Little Children: An Assessment of the Economic Costs of Child MaltreatmentThe Perryman Group, [email protected]

$1.8 Million per 2014 victim1

Graphic from Pew Issue Brief Jan 2011: Paying Later: High Cost of failing to Invest in Young children.

Estimated Lifetime Costs for all 2014 First Time Maltreatment Victims = $5.9 Trillion1

1Suffer the Little Children: An Assessment of the Economic Costs of Child MaltreatmentThe Perryman Group, [email protected]

$5.9 Trillion

Summary

• ACES are cumulative & synergistic

• ACES increase risk for major public health problems far in excess of the usual thresholds (i.e., ORs ≥ 1.4 – 1.8) for interventions

• ACEs may be synergistic with environmental exposures or social experiences, e.g., air pollution & childhood asthma

• ACEs are often transmitted from one generation to the next

What Can We Do?

Maslow’s Hierarchy of Needs

Addressing ACES Offers Critical Public Health Opportunities1

• ACES are the most preventable cause of serious mental illness

• ACES are the most preventable causes of drug and alcohol abuse in women

• ACES are the most preventable causes of HIV high-risk behavior (IV drugs, promiscuity)

• ACES are a significant contributor to leading causes of death (heart disease, cancer, stroke, diabetes, suicide)

1 IOM (Institute of Medicine) and NRC (National Research Council). 2013. New Directions in child abuse and neglect research. Washington, DC: The National Academies Press.

Adopt a Public Health/Systems approach to Child Maltreatment and other ACEs

1. Implement trauma-sensitive legislation and regulations

2. Build capacity in communities and systems to prevent & treat child trauma

3. Integrate trauma services across family-serving systems

4. Increase access to trauma-informed services for children & families

5. Screen for ACEs in systems that serve children and families

6. Integrate and enhance programs to target synergistic ACEs with highest cumulative risks

• California resolution to encourage state policies that decrease exposure to ACEs

• Wisconsin bill encourages policies that attend to brain development, prevention of toxic stress and ACEs, and appropriate early intervention programs

• Massachusetts bill supports creating conditions for “safe and supportive schools

• Vermont bill plans for evaluation of whether ACE-informed medical practice should be part of the state’s health plan

Policy Examples

Protective Factors for Primary Prevention and Treatment

Supportive family environment, social networks, and communities

– Basic family needs– Nurturing parenting skills– Stable family relationships– Household rules and child monitoring– Parental employment– Adequate housing– Access to trauma sensitive health care and social services– Caring adults outside the family who can serve as role models

or mentors– Communities that support parents and take responsibility for

preventing abuse

Prevention, Screening, & Treatment Can Be Embedded In Existing Systems That Serve Children and Adults

• Child care• Education• Medical • Well-child• Home visitation• Military families• Foster Care

• Child welfare• Mental health• Drug and alcohol • Juvenile justice• Immigration• Faith based

Prevention Starts with Parental and Adult Support

• High Quality Home Visiting (Nurse Family Partnership) 40-80% reduction in cases

• Evidence-based Parenting instruction (Triple P) reduced cases, placements and injuries

• Wrap-Around Services embedded in Schools

• Self-care Time and Opportunities for Parents and Staff

• Many current problems faced by the people we serve may be related to traumatic life experiences

• To provide effective services we need to understand the life situations that may be contributing to the person’s current problems

• People who have experienced traumatic life events are often very sensitive to situations that remind them of the people, places or things involved in their traumatic event

• These reminders, also known as triggers, may cause a person to relive the trauma and view our setting/organization as a source of distress rather than a place of healing and wellness

Organizations Can Understand Trauma

SAMHSA/National Council on Behavioral Health 2013


A program, organization or system that is trauma-informed

(1) realizes the prevalence of trauma and taking a universal precautions position;

(2) recognizes how trauma affects all individuals involved with the program, organization, or system, including its own workforce;

(3) responds by putting this knowledge into practice; and

(4) resists retraumatization.

ACEs and the Next GenerationACEs and the Next GenerationSAMHSA’s Concept of a Trauma-Informed

Approach (draft)

• Invasive procedures • Removal of clothing • Physical touch • Personal questions that may be

embarrassing/distressing • Power dynamics of relationship • Gender of healthcare provider • Vulnerable physical position • Loss of and lack of privacy

Why medical settings may be distressing for people with trauma experiences


SAMHSA

A. Train “all” staff about trauma, sensitive practice and sharing critical information

B. Screen and assess for trauma

C. Communicate a sensitivity to trauma issues

D. Create a safe and comfortable environment

E. Provide services in a trauma informed manner – some practical tips

Trauma Sensitive Care and Practices

Neuroplasticity, also called brain plasticity, is the process in which your brain's neural synapses and pathways are altered as an effect of environmental, behavioral and neural changes.

Resilience is the ability to recover quickly from difficulties; toughness, bouyancy

Good News Definitions

van der Kolk

4 Concrete Steps for Working with Trauma

• Start with Self-Regulation• Integrate the Senses Through

Rhythm• Help Your Patients Take Steps

Toward Self-Empowerment• Help Your Patients Learn to

Express Their Inner Experience

• Sensitive acknowledgment of trauma– ACEs screening followed by compassionate listening to the story

• Healing Relationships– HCW’s, teachers, clergy, etc and patients

• Movement– Yoga, marching, martial arts

• Cultivating Awareness– Mindfulness

• Creative self-expression– Dancing, drumming, theater, journaling, COLORING

• Certain Psychotherapies– EMDR, EFT tapping, Ecotherapy, CBT

Treatment

You don’t have to be a therapist to be therapeutic

Treatment can restore normal biology in stress response

systems

Thank You Neuroplasticity!

D. Longhi, Resilience Report, February 2015

Transformation of School Culture: Increasing trust, love, mutual respect, sense of control, clear expectations, pride in achievement allowed students at Lincoln High in Walla Walla to attain high levels of resilience.

Outcomes included better attendance, grades, and test scores even with

increasing ACE scores!!!

Silver Lining—Resilience Trumps ACEs

Prevention & Treatment Cost Savings!

• Are prevention & treatment programs cost-effective?

• High quality home visiting child abuse prevention programs have been found to return ~ $3.00/dollar of cost1

• Evidence-based child trauma treatments such as Parent-Child Interaction Therapy (PCIT) return $3.64/dollar cost1

1http://www.wsipp.wa.gov/rptfiles/04-07-3901a.pdf

What Are The Expected Outcomes?

• Reduced human suffering

• Decreased costly Mental & Medical Illness

• Reduction in health risk behaviors (e.g., smoking, substance abuse, poor diet)

• Improved population Health & Well-being

• Decreased intergenerational transmission of ACES

• Improved Educational & Occupation attainment

• Decreased Crime & Victimization

• Decreased Welfare & Social Services

• Increased Productivity & Life Expectancy

The Impact of Adverse Childhood Experiences Across the Lifespan Challenges and Opportunities.

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