1. No category

Adverse Childhood
Experiences (ACE) Study:
Consequences of Childhood Trauma
The Great Plains Tribal Chairmen’s Health
Summit
August 6-7, 2013
Aberdeen, South Dakota
© Sparrow Consulting LLC - 2013 All Rights Reserved
Disclaimer
The views expressed in this presentation are solely
those of the presenter and do not represent those of
Kaiser Permanente, the Centers for Disease Control
and Prevention, or any other agency.
ACE Study Preview
1.
ACEs are very common, and they happen in clusters.
2.
ACEs damage individuals, families, communities, nations,
and economies.
3.
The ACE Score is key to understanding the Study’s
findings, and to understanding individuals.
© Sparrow Consulting LLC - 2013 All Rights Reserved
Today’s Goals

Origins of the ACE Study

Who Participated?

The ACE Score: What is it? How’s it calculated?

What’s your ACE Score?

What resulted from the ACE Study?

Audience Comments/Questions Throughout
© Sparrow Consulting LLC - 2013 All Rights Reserved
Origins of the Study

Kaiser Permanente Weight Loss Program

Obesity Linked to Childhood Sexual Assault

A Pilot Study

The Centers for Disease Control and Prevention

The ACE Study is Born
© Sparrow Consulting LLC - 2013 All Rights Reserved
The Investigators
Robert F. Anda, MD, MS
Centers for Disease Control
and Prevention
Atlanta, GA
Vincent J. Felitti, MD
Department of Preventive
Medicine
Kaiser Permanente
San Diego, CA
© 2013 Sparrow Consulting LLC All Rights Reserved
Who Participated?
 17,337 Volunteer HMO Members
 Part of a Routine Health Screening
Appointment
 Multi-part Gender-specific
Questionnaires
© Sparrow Consulting LLC - 2013 All Rights Reserved
Gender
Female: 54%
Male:
46%
© Sparrow Consulting LLC - 2013 All Rights Reserved
Race
White:
74.8%
Hispanic/Latino:
11.2%
Asian/Pacific Islander:
7.2%
African-American:
4.6%
Other:
1.9%
© Sparrow Consulting LLC - 2013 All Rights Reserved
Age
19-29:
5.3%
30-39:
9.8%
40-49:
18.6%
50-59:
19.9%
60+:
46.4%
© Sparrow Consulting LLC - 2013 All Rights Reserved
Education
Not High School Graduate:
7.2%
High School Graduate:
17.6%
Some College:
35.9%
College Graduate or Higher: 39.3%
The ACE Score
The number of categories—not instances
or intensity—of abuse experienced in the
household prior to the age of 18 years.
The ACE Categories
ABUSE
Physical
HOUSEHOLD DYSFUNCTION
Caregiver
Mother Treated Violently
Emotional
Substance Abuse
Sexual
Mental Illness
NEGLECT
Emotional
Physical
DSMIV Not Nec
Separation / Divorce
/Death
Incarcerated Household Member
10 Questions
If “yes, but” is the first thought
that springs to mind, then
don’t doubt yourself, go for
the “yes”.
The ACE Score Calculator:
During your first 18 years of
life:
1. Did a parent or other adult in the household often or very often…
Swear at you, insult you, put you down, or humiliate you?
or
Act in a way that made you afraid that you might be physically
hurt?
Yes No
If yes enter 1 ________
2. Did a parent or other adult in the household often or very often…
Push, grab, slap, or throw something at you?
or
Ever hit you so hard that you had marks or were injured?
Yes No
If yes enter 1 ________
The ACE Score Calculator
3. Did an adult or person at least 5 years older than you ever…
Touch or fondle you or have you touch their body in a sexual way?
or
Attempt or actually have oral, anal, or vaginal intercourse with you?
Yes No
If yes enter 1 ________
4. Did you often or very often feel that …
No one in your family loved you or thought you were important or
special?
or
Your family didn’t look out for each other, feel close to each other,
or support each other?
Yes No
If yes enter 1 ________
The ACE Score Calculator
5. Did you often or very often feel that …
You didn’t have enough to eat, had to wear dirty clothes, and
had no one to protect you?
or
Your parents were too drunk or high to take care of you or take
you to the doctor if you needed it?
Yes No
If yes enter 1 ________
6. Were your parents ever separated or divorced?
Yes No
If yes enter 1
________
The ACE Score Calculator
7. Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had
something thrown at her?
or
Sometimes, often, or very often kicked, bitten, hit with a fist,
or hit with something hard?
or
Ever repeatedly hit at least a few minutes or threatened with a
gun or knife?
Yes No
If yes enter 1 ________
8. Did you live with anyone who was a problem drinker or
alcoholic or who used street drugs?
Yes No
If yes enter 1 ________
The ACE Score Calculator
9. Was a household member depressed or mentally ill, or did a
household member attempt suicide?
Yes No
If yes enter 1 ________
10. Did a household member go to prison?
Yes No
If yes enter 1
_______
Now add up your “Yes” answers: _______
This is your ACE Score.
What’s your ACE Score?
Compare with the Study
Participants
The Study Results:
ACE Score
0
1
2
3
4 or more
Women
34.5
24.5
15.5
10.3
15.2
Men
38.0
27.9
16.4
8.6
9.2
Total
36.1
26.0
15.9
9.5
12.5
The Study ACE Score Results:
36% - 0 ACEs (34.5 female; 38, male)
26% - 1 ACE (24.5 female; 27.9 male)
16% - 2 ACEs (15.5 female; 16.4 male)
9.5% - 3 ACEs (10.3 female; 8.6 male)
12.5% - 4 or more ACEs (15.2 female; 9.2 male)
Category
Sub-category
F
M
Total
Emotional
Physical
Sexual
13.1
27.0
24.7
7.6
29.9
16.0
10.6
28.3
20.7
Emotional
Physical
16.7
9.2
12.4
10.7
14.8
9.9
Violence - Mom
13.7
11.5
12.7
Substance Abuse
29.5
23.8
26.9
Mental Illness
Divorce/Separation
23.3
24.5
14.8
21.8
19.4
23.3
Incarceration
5.2
4.1
4.7
ABUSE
NEGLECT
DYSFUNCTION
Gender-specific Summary

Women reported more emotional neglect and abuse,
and sexual abuse, than men.

Physical abuse and neglect, similar for both genders.

Women reported higher rates in all categories of
household dysfunction than men.
Summary of ACE Study Findings
• Adverse Childhood Experiences (ACEs) are very common.
• They occur in clusters.
• They are strong predictors of health behaviors in adolescence
and adult life.
• This combination makes ACEs one of the leading, if not the
leading determinants of the health and social well-being of
nations.
ACEs & Brain
Development
The “dose-response” Curve
The higher the ACE Score, the greater
the behavior (smoking, alcoholism, drug
use), the condition (e.g. depression,
obesity, STDs), or risk.
An ACE Score of 4+ is the “tipping point”
where behaviors, conditions, and risk
increase dramatically.
ACEs and Smoking
ACE SCORE 0
1
2
3
4
5+
ACEs and Currently* Smoking
 Less than 6% of participants with an ACE Score of 0
reported being current smokers.
 Leapt to 16% with an ACE Score of 5+.
* At the time the participant completed the questionnaire.
ACEs and Alcoholism
ACEs and Self-reported
Alcoholism
 Less than 3% of participants with an ACE Score of 0
reported being alcoholic.
 Doubled to 6% with an ACE Score of 1.
 More than tripled to 10% with an ACE Score of 2.
 Leapt to 16% with an ACE Score of 4+.
ACEs Smoking-related Disease
Smoking by Age 14 & COPD*
 Less than 4% of participants with an ACE Score of 0 had
started smoking by age 14.
 More than 12% of those with an ACE Score of 4+ had started
smoking by age 14.
 Over 6% of smoking participants with an ACE Score of 0 had
COPD.
 Nearly 18% of those with an ACE Score of 4+ had COPD.
COPD = Chronic Obstructive Pulmonary Disease (e.g. Emphysema, chronic bronchitis,
lung cancer).
ACES & IV Drug Use
ACEs & IV Drug Use
 Less than ½% of participants with an ACE Score of 0 had
ever injected illicit (i.e. “street”*) drugs.
 More than 3% of those with an ACE Score of 4+ had injected
illicit drugs.
*The phrase “street drugs” was left to participants’ interpretation.
ACEs & HIV Risks
 50+ Sexual Partners: 3% at ACE Score 0; 6% at ACE Score 4+.
 Ever Had an STD: 6% at ACE Score 0; 18% at 4+.
ACEs & Teen Sex
 About 7% at ACE Score 0 had intercourse by age 15; ACE
Score 4+, 27%.
 Teen pregnancy with an ACE Score of 0, 20%; an ACE Score
of 4+, 41%.
 Teen paternity with an ACE Score of 0, nearly 15%; with an
ACE Score of 4+, rises to 34%.
Percent who ever had an unintended
pregnancy or an elective abortion (%)
Percent of Women Who Ever Had an Unintended
Pregnancy or an Elective Abortion by ACE Score
Red = unintended pregnancy
Orange = elective abortion
80
70
60
50
40
30
20
10
0
0
1
2
ACE Score
3
4 or more
Unintended Pregnancy / Elective Abortion
 Unintended Pregnancy: 37% at 0; approximately 68% at 4+.
 Elective Abortion: 5% at 0; 20% at 4+.
ACE Score and the
Risk of Being Sexually Assaulted as an Adult
40
Women
Men
30
20
10
0
0
1
2 3 4 >5
ACE Score
0
1
2 3 4 >5
Risk of Sexual Assault as an Adult
 WOMEN: 1% at 0, to 30% with a 5+.
 MEN: Less than 1% at 0, to 9% with a 5+.
Risk of Perpetrating Domestic Violence
15
Women
Men
10
5
0
0 1
2 3 4 >5
0 1
ACE Score
2 3 4 >5
Risk of Perpetrating Domestic Violence
 WOMEN: 2.5% at 0 to 10% with a 5+.
 MEN: 2.5% to 14% with a 5+.
Risk of Being a Domestic Violence Victim
 WOMEN: 3.5% at 0, to 10% at 5+.
 MEN: Less than 2% at 0, to 4% at 5+.
Lifetime Depression
 WOMEN: 19% at 0, to 61% at 5+.
 MEN: 14% at 0, to 35% at 5+.
ACEs and Suicide
Attempted Suicide
 Less than 1% at 0, to 18% with a 4+.
Warriors and ACEs
Courtesy of Brian L. Meyer, PhD, LCP
Interim Assoc. Chief of Mental Health/Supervisory Psychologist
H.H. McGuire VAMC
1201 Broad Rock Blvd., Room 1E 144
Richmond, VA 23249
Tel: 804-675-5000 X 2953
Fax: 804-675-6853
Child Maltreatment and Deployment

Rate of maltreatment is more than 3 times greater when the spouse is
deployed compared to when the spouse is not deployed

Rate of neglect is almost 4 times greater

Rate of physical abuse is twice as large

Rates of moderate and severe abuse are 1.6 times greater (Gibbs et al.,
2007)

Child maltreatment in military families increases by 30% for each 1%
increase in deployments or returns from deployment

Child maltreatment rises both after deployment and after return
(Rentz et al., 2007)
© 2013 Brian L. Meyer, PhD, LCP
Child Maltreatment in Military
Families

Physical abuse and neglect are the most common
forms of substantiated child maltreatment in military
families

Because the Navy and the Marines have not been
publishing rates of child maltreatment, it is not
possible to estimate differences between services
(Rentz et al., 2006)
© 2013 Brian L. Meyer, PhD, LCP
Child Maltreatment
in Military Families

Military families are 3.5 times more likely to have
infants with shaken baby syndrome than civilian
families (Gessner & Runyan, 1995)

The child abuse homicide rate in children from
military families in two North Carolina counties
with large military populations over 18 years was
more than double the state rate of child abuse
homicide (Herman-Giddens & Vitaglione, 2005)

Child abuse in Army families rose 43% from
2006-2011 (DOD, 2012)
© 2013 Brian L. Meyer, PhD, LCP
© 2013 Brian L. Meyer, PhD, LCP
Child Maltreatment in Army Families
PTSD, SUDs, and Child Maltreatment in
Military Families

Families with military service members who have PTSD are at
greater risk of child maltreatment (Prigerson et al., 2002; Rentz et
al., 2006)

Service members who commit severe child neglect or emotional
abuse have elevated rates of substance abuse (Gibbs et al., 2008)

Alcohol use associated with child abuse in Army families increased
by 40% from 2006-2011 (DOD, 2012)
© 2013 Brian L. Meyer, PhD, LCP
Alcohol Involvement in Child Maltreatment
in Army Families
DOD 2012
© 2013 Brian L. Meyer, PhD, LCP
Child Maltreatment by Veterans

Child maltreatment in military families is tracked because
each branch of the armed services has a Family Advocacy
Program (FAP) tasked with preventing and responding to child
maltreatment

After a veteran is discharged from the military, there are no
FAPs tracking children or assisting veteran families

© 2013 Brian L. Meyer, PhD, LCP
High Prevalence of
Prior Child Maltreatment
Studies of Army soldiers:

Rosen & Martin, 1996:

17% of males and 51% of females reported childhood sexual abuse

50% of males and 48% of females reported physical abuse

11% of males and 34% of females experienced both

Seifert et al., 2011 (combined males and females):

46% reported childhood physical abuse

25% reported both physical and sexual abuse

Soldiers with both reported more severe PTSD symptoms and more
problem drinking
© 2013 Brian L. Meyer, PhD, LCP
Pre-military Trauma in Women

Female service members and veterans report more premilitary trauma
than servicemen and female civilians

More than half of female veterans experienced premilitary physical or
sexual abuse

1/3 of female veterans report a history of childhood sexual abuse,
compared to 17-22% of civilian women

1/3 of female veterans report a history of adult sexual assault, compared
to 13-22% of civilian women
Schultz et al., 2006; Zinzow et al., 2007; Merrill et al., 1999
© 2013 Brian L. Meyer, PhD, LCP
Prior Child Maltreatment
and PTSD

Two or more adverse childhood experiences (ACEs) are associated
with increased risk of PTSD, beyond combat exposure (Cabrera et al.,
2007)

Veterans with PTSD are more likely to have been physically abused as
children than those without PTSD (Bremner et al., 1993; Zaidi and Foy,
1994)

Physical abuse as a child also associated with greater severity of
PTSD (Zaidi and Foy, 1994)

Childhood physical abuse and combat-related trauma both increase
later anxiety, depression, and PTSD (Fritch et al., 2010)
© 2013 Brian L. Meyer, PhD, LCP
Risk of Maltreatment:
Domestic Violence

Rate of domestic violence is higher in military than civilian
population, especially severe aggression (Bray & Marsden, 2000:
Heyman & Neidig, 1999)

90% of spouse abuse in military families is physical abuse (Rentz et
al., 2006)

Domestic violence increases with both deployments and with longer
deployments (McCarroll et al., 2000)

Domestic violence in Army families rose 33% from 2006-2011
(DOD, 2012)

Military families with DV have twice as much child abuse (Rumm et
al., 2000)
© 2013 Brian L. Meyer, PhD, LCP
Domestic Violence and Substance
Abuse

Heavy drinking among soldiers who drink:

Heavy drinkers are 66% more likely to be spouse abusers than
non-drinkers

Moderate and heavy drinkers are 3 times as likely, and light
drinkers are twice as likely, to be drinking at the time of the
domestic violence incident (Bell et al., 2006)

Alcohol use associated with domestic violence in Army families
rose 54% from 2006-2011 (DOD, 2012)
© 2013 Brian L. Meyer, PhD, LCP
Domestic Violence
and Child Abuse

Spouse abuse among soldiers increases likelihood
of physical abuse of a child 2.4 times and sexual
abuse of a child 1.5 times (Rumm et al., 2000)

Offender substance abuse is almost three times
greater when both spouse abuse and child abuse
are involved in the same incident (Gibbs, 2008)
© 2013 Brian L. Meyer, PhD, LCP
Supports for Children of Active
Duty Military Men and Women

Structural:







Housing
Financial/Employment
Education
Health Care
Child Care
Family Advocacy Programs
Functional:


The presence of other
military families on base
Children attend school with
other military children
© 2013 Brian L. Meyer, PhD, LCP
These supports buffer them
from risk (Sheppard et al, 2010)
Children
in Families of Veterans
Families of veterans have fewer supports:

No Family Assistance Programs

Loss of presence of other military families

Children of veterans attend school with many other children,
not just military children

Veterans have higher rates of unemployment than civilians

No guaranteed income

Veterans have higher rates of homelessness than civilians

Veterans receive health care from the VA, but their spouses
and children do not
© 2013 Brian L. Meyer, PhD, LCP
Supports for
Children and Families
Military Families
There are 120 DOD
programs that
address
psychological
health and
traumatic brain
injury that serve
families (Weinick
et al., 2011)
Veteran Families
One program
serves families of
veterans: The
Wounded Warrior
Program, mostly
with camps and
retreats
© 2013 Brian L. Meyer, PhD, LCP
ACEs and the Workplace
“We found strong evidence that the relationship
between ACE Score and worker performance was
mediated by interpersonal relationship problems,
emotional distress, somatic symptoms, and substance
abuse.”
Anda RF, Felitti VJ, Fleisher VI, Edwards VJ, Whitfield CL, Dube SR, Williamson DF.
Childhood abuse, household dysfunction and indicators of impaired worker
performance in adulthood. The Permanente Journal 2004;8(1):30–38.
ACEs and Disease - Increased Risk of:










Alcoholism and Liver Disease
Early Onset of Smoking and COPDs
Depression and Attempted Suicide
Illicit Drug Use and STDs
Ischemic Heart Disease (e.g. heart attack)
Intimate Partner Violence
Early Teen Sex and Multiple Sexual Partners
Adolescent and Unintended Pregnancy
Elective Abortion and Fetal Death
Diseases of the Auto-immune Systems (e.g. Multiple
Sclerosis, cancers)
 Workplace Problems
 Increased Psycho-social Problems During/After
Military-service
 Shortened Lifespan (about 20 years fewer)
ACEs and Lifespan
“ACEs are associated with an
increased risk of premature death.”
(Brown, et al., 2009)
Life doesn’t have to be this hard:
• Resilience
• Treatment
Defining Resilience
“Good outcomes in spite of serious threats to
adaptation or development.”
(Masten,2001. Resilience Processes in Development,
American Psychologist, 56(3), 227-238.)
“… resilience
is common and…it usually arises
from the normative functions of human
adaptational systems.”
(Masten,2001. Resilience Processes in Development,
American Psychologist, 56(3), 227-238.)
Some Sources of Collective Wisdom
Bruce Perry, M.D., Ph.D.
Child Trauma Academy
Ann S. Masten, Ph.D.
Univ. of Minnesota
Mary A. Steinhardt, Ed.D.,
LCP
Univ. of Texas at Austin
What creates “resilience”?
 Natural capacity
 Environment
Successful Therapies
(“best practices”)
"There is no agony like bearing an
untold story inside of you."
-- Maya Angelou
Phases of Integrated Treatment
Safety and Stabilization
II. Remembrance and mourning
III. Reconnection
I.
After Herman, 1992
© 2013 Brian L. Meyer, PhD, LCP
Treatment of Substance Use Disorders
 Medications:
 Alcohol:
 Antabuse (Disulfiram)
 Naltrexone
 Acamprosate
 Opiates:
 Methadone
 Buprenorphine
© 2013 Brian L. Meyer, PhD, LCP
Treatment of
Substance Use Disorders
Evidence-Based Treatments:

Motivational Interviewing

Motivational Enhancement Therapy

Cognitive-Behavioral Therapy (CBT)

Contingency Management

Twelve-step Facilitation Therapy

Behavioral Couples Therapy
© 2013 Brian L. Meyer, PhD, LCP
Treatment of PTSD: Medication
Medication for trauma symptom management and co-morbid
disorders

Antidepressants

Mood stabilizers

Atypical antipsychotics

Anticonvulsants

Anxiolytics

Sleep aids

There is no medication that specifically treats PTSD; only
Prozac, Paxil, and Prazosin have been approved
© 2013 Brian L. Meyer, PhD, LCP
PTSD and Substance Abuse
Treatment
 PTSD symptoms may worsen in the early
stages of abstinence
 PTSD exposure therapies may trigger
substance abuse relapses
 Some aspects of 12-Step groups are difficult
for some trauma patients



Powerlessness
Higher Power
Issues of forgiveness
© 2013 Brian L. Meyer, PhD, LCP
Treatment of PTSD and SUDs
Evidence-Based Psychotherapies for Integrated Phase
I Treatment:

Seeking Safety

Dialectical Behavior Therapy (DBT)

Therapies for specific problems



Imagery Rehearsal Therapy
Cognitive-Behavioral Therapy
EMDR resource building, safe place, etc.
© 2013 Brian L. Meyer, PhD, LCP
Resources
 What It Is Like to Go to War by Karl Marlantes
 Once a Warrior--Always a Warrior: Navigating the
Transition from Combat to Home--Including
Combat Stress, PTSD, and mTBI by Charles Hoge
 After the War Zone: A Practical Guide for
Returning Troops and Their Families by Matthew
Friedman and Laurie Slone
© 2013 Brian L. Meyer, PhD, LCP
Resources
 When Someone You Love Suffers from
Posttraumatic Stress: What to Expect and
What You Can Do by Claudia Zayfert and
Jason Deviva
 The PTSD Workbook: Simple, Effective
Techniques for Overcoming Traumatic Stress
Symptoms by Mary Beth Williams and Soili
Poijula
© 2013 Brian L. Meyer, PhD, LCP
Internet Resources

Military culture:


http://www.ptsd.va.gov/professional/ptsd101/ coursemodules/military_culture.asp
PTSD:




www.ptsd.va.gov
PTSD 101 courses:
http://www.ptsd.va.gov/professional/ptsd101/ coursemodules/course-modules.asp
http://mghcme.org/courses/course-detail/from_the_
war_zone_to_the_home_front_supporting_the_
mental_health_of_veteran
© 2013 Brian L. Meyer, PhD, LCP
Internet Resources

Helping family members get veterans into treatment:
Coaching Into Care
 http://www.mirecc.va.gov/coaching/index.asp

Adjustment after deployment:
 http://www.afterdeployment.org/
 http://maketheconnection.net/
© 2013 Brian L. Meyer, PhD, LCP
Internet Resources

Parenting in military families:





www.militarychild.org
Age-based parenting tool kits for OEF/OIF veterans
and their partners: ouhsc.edu/VetParenting
http://stayingstrong.org
Operation Enduring Families
http://www.ouhsc.edu/OEF/
A 5-session family education and support program for
veterans who have recently returned from a combat theater
and their family members.
© 2013 Brian L. Meyer, PhD, LCP
Internet Resources

Children in military families:





www.va.gov/kids
https://www.militarykidsconnect.org/
http://www.facebook.com/SesameStreetForMili
taryFamilies and
http://archive.sesameworkshop.org/tlc/
http://www.militarychild.org/ Military Child
Education Coalition
http://www.operationmilitarykids.org/public/h
ome.aspx (New Mexico is currently not an official
Operation: Military Kids State)
© 2013 Brian L. Meyer, PhD, LCP
Sesame Street Media
http://www.sesamestreet.org/parents/topicsandactivities/tool
kits/tlc
Mobile App:
© 2013 Brian L. Meyer, PhD, LCP
Mobile Applications
http://www.t2health.org/mobile-apps







PTSD Coach
T2 MoodTracker
Breathe 2 Relax
Mild TBI
Tactical Breather
New! LifeArmor (includes family section)
More to come!
© 2013 Brian L. Meyer, PhD, LCP
Contact:
Brian L. Meyer, Ph.D.
[email protected]
Bruce D. Perry, MD, PhD
Trauma and Terror in Childhood: The Neuropsychiatric Impact of Childhood
Trauma
(for Handbook of Psychological Injuries: Evaluation, Treatment, and Compensible Damages)
Draft, August 20, 2000
SEE: http://www.childtrauma.org/ctamaterials/trauma_and_terror.asp
HOPE:
Give it, and Live it!
Carol A.Redding, MA
ACE Study Fellow (20032006)
[email protected]