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
Conference on Health and Domestic Violence
Göteborg, Sweden
May 23, 2013
Robert F. Anda, M.D.
Vincent J. Felitti, M.D.
The Adverse Childhood Experiences
(ACE) Study
The largest study of its kind
ever to examine over the lifespan
the medical, social, and economic
consequences in adults of adverse
life experiences in childhood.
(>17,000 participants)
Summary of the ACE Study
•
The ACE Study is a retrospective and prospective analysis in
17,337 middle-class adults of the effects of ten categories of adverse
life experiences in childhood.
•
The very existence of these experiences was found to be quite
unexpectedly high, though unrecognized because they are lost in time
and protected by shame, by secrecy, and by social taboos against
routinely exploring certain realms of human experience.
•
Their effect a half century later is powerfully and proportionately
related to the number of categories of adverse life experiences in
childhood, and thereby is a major determinant of well-being, health
risks, mental illness, occupational performance, social malfunction,
biomedical disease, and premature death.
What is the Core Diagnosis Here?
In 51 weeks:
Age 8
408
Age 28
132 lbs.
Age 29
Which photo represents the patient’s problem?
>400 lbs. (185 Kg)
again in a shorter
period of time
than the weight
was lost.
Weeks
ACE Study Design
Survey Wave 1
71% response (9,508/13,454)
Mortality
National Death Index
n=13,000
All medical evaluations
abstracted
Survey Wave II
n=13,000
All medical evaluations
abstracted
vs.
Present
Health Status
N = 17,337
Morbidity
Hospitalization
Doctor Office Visits
Emergency Room Visits
Pharmacy Utilization
What are Adverse Childhood Experiences?
Life experiences in childhood or adolescence
that lead to medical or social problems
of national importance:
-
childhood abuse and neglect.
growing up with domestic violence,
substance abuse, mental illness,
parental loss, or crime in the home.
Prevalence of Adverse
Childhood Experiences
Abuse, by Category
Psychological (by parents)
Physical (by parents)
Sexual (contact with anyone)
Prevalence (%)
11%
28%
22%
Neglect, by Category
Emotional
Physical
15%
10%
Household Dysfunction, by Category
Alcoholism or drug use in home
Loss of biological parent from home < age 18
Depression, mental illness, or suicide in home
Mother treated violently
Imprisoned household member
27%
23%
17%
13%
5%
ACEs do not occur alone
For example, if you had a battered mother, the
likelihood of additional ACEs is notable:
Probability of more ACEs
# of additional ACEs
95% 82
1
2
64
48
52
3
4
>5
Adverse Childhood Experiences Score
Number 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.
• Women are 50% more likely than men to have ACE Score >5.
• If any one ACE is present, there is an 87% chance at least one
other ACE category is present, and a 50% chance of 3 others.
Loss of a Biological Parent in Childhood
(Patient has lost 158 lbs in Weight Program.)
Why did he originally gain it ?
‘Addictions’
What is the functionality of Addiction?
Addiction is the unconscious,
compulsive use of psychoactive
materials or agents.
“It’s hard to get enough of something
that almost works.”
The traditional concept:
“Addiction is due to the
characteristics intrinsic
in the molecular structure
of some substance.”
The ACE Study shows that:
Addiction highly correlates with
characteristics intrinsic to that
individual’s childhood
experiences.
Health Risks
Adverse Childhood Experiences
vs. Smoking as an Adult
20
18
16
14
12
%
10
8
6
4
2
0
0
1
2
3
ACE Score
4-5
6 or more
p< .001
ACE Score vs. Smoking and COPD
20
Percent With Problem
18 ACE Score:
16
0
1
2
3
4 or more
14
12
10
8
6
4
2
0
Regular smoking by age 14
COPD
Biomedical Disease:
ACEs Increase the Likelihood of Heart Disease*
•
•
•
•
•
•
•
•
•
Emotional abuse
Physical abuse
Sexual abuse
Domestic violence
Mental illness
Substance abuse
Household criminal
Emotional neglect
Physical neglect
1.7x
1.5x
1.4x
1.4x
1.4x
1.3x
1.7x
1.3x
1.4x
After correction for age, race, education, and conventional risk factors like smoking and
diabetes. Circulation, Sept 2004.
Biomedical Disease:
The ACE Score and the Prevalence of Liver
Disease (Hepatitis/Jaundice)
12
Percent
10
8
6
4
2
0
0
1
2
AACE
Score
ACE CE
Score
3
>=4
Health Risks:
Childhood Experiences vs.
Adult Alcoholism
18
16
4+
% Alcoholic
14
12
3
10
2
8
6
4
2
1
0
0
ACE Score
Health risks
ACE Score vs Intravenous Drug Use
% Have Injected Drugs
3.5
3
2.5
2
1.5
1
0.5
0
0
1
2
3
4 or more
ACE Score
p<0.001
Estimates of the Population Attributable Risk*
of ACEs for Selected Outcomes in Women
PAR
Alcoholism
Drug abuse
65%
50%
IV drug use
78%
*That portion of a condition attributable to specific risk factors
The Hidden Threat of Weight Loss
A Public Health Paradox
Many of our most common and intractable
public health problems are unconsciously
attempted solutions to personal problems
dating back to childhood, buried in time,
and concealed by shame, by secrecy, and
by social taboo.
Molestation in Childhood
Familial obesity does not mean genetic
Depression:
Most say depression is a disease.
Many say depression is genetic.
Some say it is due to a chemical imbalance.
What if depression were not a disease,
but a normal response to
abnormal life experiences?
Well-being
Childhood Experiences
Underlie Chronic Depression
% W ith a Lifetime History of
Depression
80
70
60
50
40
Women
Men
30
20
10
0
0
1
2
ACE Score
3
>=4
Death
Childhood Experiences
Underlie Suicide Attempts
25
4+
% Attempting Suicide
20
15
3
10
2
5
0
1
0
ACE Score
Premature mortality and excess morbidity
are typically the result of a small number of
common diseases.
ACE = Parental Loss
Evidence from ACE Study Indicates:
These diseases and the
life-expectancy of adults
are often determined,
decades earlier, by the life
experiences of childhood.
Affective Response
Evidence from ACE Study indicates:
Risk factors for these
diseases are initiated during
childhood or adolescence . . .
Seeking to Cope
Evidence from the ACE Study indicates:
. . . and continue
into adult life.
Outcome: social and
biomedical damage
Another possible outcome.
“In my beginning is my end.”
.
T S.Eliot, Quartets
Costs
ACE Score and Rates of Antidepressant
Prescriptions
Prescription rate
per 100 person-years)
approximately 50 years later
100
90
80
70
60
50
40
30
20
10
0
5 or
4
3
2
1
0
ACE Score
more
Estimates of the Population Attributable Risk*
of ACEs for Selected Outcomes in Women
Mental Health
PAR
Current depression
Chronic depression
54%
41%
Suicide attempt
58%
*That portion of a condition attributable to specific risk factors
Well-being
Childhood Experiences Underlie
Later Being Raped
35
% Reporting Rape
30
4+
25
20
3
15
2
10
1
5
0
0
ACE Score
Health risks
Promiscuity: Looking for Love
ACE Score vs > 50 Sexual Partners
Adjusted Odds Ratio
4
3
2
1
0
0
1
2
ACE Score
3
4 or more
Disease
Adverse Childhood Experiences vs.
Sexually Transmitted Diseases
Adjusted Odds Ratio
3
2.5
2
1.5
1
0.5
0
0
1
2
ACE Score
3
4 or more
Health risks
% have Unintended PG, or AB
ACE Score vs. Unintended
Pregnancy or Elective Abortion
80
Unintended Pregnancy
70
Elective Abortion
60
50
40
30
20
10
0
0
1
2
ACE Score
3
4 or more
Adverse Childhood Experiences
and the Likelihood of:
ACE Score
>50 Sexual
Partners*
3 or M ore
M arriages*
Unwanted
Pregnancy*
(abortion)
0
1.0
1.0
1.0
1
2
1.6
1.9
1.5
1.6
1.5
1.7
3
4
>5
3.4
4.4
5.8
2.3
2.9
3.8
2.3
2.1
2.9
*Adjusted Odds Ratio
Well-being
Risk of Perpetration (%)
ACE Score and the
Risk of Perpetrating Domestic Violence
__________________________________
15
Men
Women
10
5
0
0
1
2
3
4
>5
0
ACE Score
1
2
3
4
>5
Intergenerational transfer
Number of Household Alcoholics
vs Risk of Child Abuse
50
45
>2
Percent Abused (%)
40
35
30
>2
25
2
>2
20
1
2
15
2
10
5
1
1
0
Emotional
Physical
Sexual
Adverse Childhood Experiences
and the Likelihood of:
ACE Scor e
Victim of
I ntimate Partner
Violence *
Being Raped*
0
1.0
1.0
1
2
1.9
2.1
2.0
2.8
3
4
>5
2.7
4.5
5.1
4.2
5.3
8.9
*Adjusted Odds Ratio
Population Attributable Risk* of ACEs
for Selected Outcomes in Women
Crime Victim of:
PAR
Sexual Assault
Domestic Violence
62%
52%
*That portion of a condition attributable to specific risk factors
ACE Score and Impaired Memory of Childhood
ACE Score
Percent With Memory
Impairment (%)
40
35
0
1
2
3
>=4
5
30
25
4
20
3
15
10
1
2
5
0
ACE Score
ACE Score
Disease
Ever Hallucinated* (%)
ACE Score and Hallucinations
12
Abused
Alcohol
or Drugs
10
8
No
Yes
6
4
2
0
0
1
2
3
4
5
6
ACE Score
*Adjusted for age, sex, race, and education.
>=7
Costs
ACE Score and Rates of
Antipsychotic Prescriptions
Prescription rate
(per 100 person-years)
A half-century later, on average
12
10
8
6
4
2
0
00
11
22 3 3 4
ACE Score
4>=5 >5
ACE Score and Rates of
Anxiolytic Prescriptions
Prescription rate
(per 100 person-years)
35
30
25
20
15
10
5
0
0
1
2
3
ACE Score
4
>=5
Effect of ACEs on Death Rate
(Null hypothesis)
Age Group
Percent in Age G roup
60
19-34
35-49
50-64
>=65
50
40
30
20
10
0
0
2
ACE Score
4
Adverse Childhood Experiences
determine the likelihood of the
ten most common causes of
death in the United States.
Top 10 Risk Factors: smoking, severe obesity, physical inactivity,
depression, suicide, alcoholism, illicit drug use, injected drug use,
50+ sexual partners, STDs.
With an ACE Score of 0, the
majority of adults have
few, if any, risk factors
for these diseases.
With an ACE Score of 4 or more,*
the majority of adults have
multiple risk factors for these
diseases or the diseases themselves.
* One in six persons
Many chronic diseases
in adults are determined
decades earlier, in
childhood.
The risk factors
for these chronic disease
are reliable markers
for earlier problems.
“In my end is my beginning.”
T.S. Eliot - Quartets
Dismissing health risks as “bad
habits” or “self-destructive behavior”
comfortably hides
their functionality.
Social functioning
ACE Score and Indicators of
Impaired Worker Performance
25
Prevalence of
Impaired Performance (%)
ACE Score
20
0
1
2
3
4 or more
15
10
5
0
Absenteeism
(>2 days/month)
Serious
Financial
Problems
Serious
Job
Problems
How and why do
Adverse Childhood Experiences
exert their influence throughout life?
Why is treatment so difficult?
Where is resilience?
Why are the long-term consequences so difficult to treat?
Interventions
Child
health
and
well-being
as it
stands
today.
Improving the Future
Acknowledgment that
the problem exists.
Recognition of cases
in clinical practice.
Adult
health
and
well-being
as it
could be.
Interventions
What Can We Do Today?
• Routinely seek a history of adverse childhood
experiences from all persons, by questionnaire.
• Acknowledge their reality by asking, “How has
this affected you later in your life?”
• Use existing systems to help with current
problems.
• Develop systems for early prevention.
Won’t people be upset or harmed by these questions?
Interventions
What can we do tomorrow?
• Primary prevention –
universal parenting programs
home visitation
therapeutic use of broadcast TV, theatre
• Secondary prevention –
programs for high-risk and imprisoned parents
• Tertiary prevention and treatment –
medical school involvement in physician training
internet-based medical history
Interventions
Translating Research into Practice
a beginning
6th Floor
1.2 million comprehensive patient evaluations since 1975
An Individual, Population-based
Health Appraisal System:
A Biopsychosocial Concept
• Comprehensive history
(not symptom-initiated)
obtained at home by
detailed questionnaire,
better by Internet.
Includes ACE Questions
Interventions
Unconventional R.O.S. Questions
of Demonstrated Value
•
•
•
•
•
•
•
•
•
Have you ever lived in a war zone?
Have you been a combat soldier?
Who in your family has committed suicide?
Who in your family has been murdered?
Who in your family had a nervous breakdown?
Were you molested as a child?
Have you ever been held prisoner?
Have you been tortured?
Have you been raped?
Extract from an actual case
A combat veteran of Home & Vietnam
Results of Interventions
Benefits of a Biopsychosocial
Preventive Approach
Biomedical evaluation:
11% reduction in DOVs,
subsequent year.
(700 patient sample)
Biopsychosocial evaluation: 35% reduction in DOVs
subsequent year.
(130,000 patient sample)
Impact of Childhood Traumas
Disrupted neurodevelopment
Difficulty controlling Anger
Depression
Suicide
Hallucinations
Anxiety and Panic reactions
Disturbed sleep
Multiple somatic symptoms
Impaired memory
Flashbacks
Dissociation
Biomedical Disease
Coping Behaviors
Smoking
Overeating and Obesity
Physical inactivity
Withdrawal
Suicide attempts
Alcoholism
Illicit drug use
Promiscuity
Repetition of the original trauma
Self-injury - cutting
Teen pregnancy
Some Long-Term Physical
Consequences of Unaddressed
Trauma (ACEs)
Ischemic heart disease
Liver disease
Lung disease: Emphysema, Asthma
Skeletal fractures
Overall poor health
Miscarriage of pregnancy
Sexually transmitted diseases, AIDS
Serious Consequent Social Problems
Homelessness
Alcoholism
Addiction
Prostitution
Violence
Unemployment
Domestic violence
Rape
Inability to parent
Interventions
Practice Implications of the ACE Study
• A biopsychosocial and trauma-oriented approach to medical care
has been demonstrated to be feasible, affordable, and acceptable.
• It may be possible to rescue Primary Medical Care from its current
symptom-reactive mode of practice, start dealing with basic
causes, and also reduce the social burden of medical care costs.
• A novel concept of Preventive Medicine is proposed as the
standard entry mechanism into all ongoing medical care.
• It has been significantly resisted.
Final Insights from the ACE Study
• Adverse childhood experiences are common but typically unrecognized.
• Their link to major problems later in life is strong, graded, and logical.
• They are the nation’s most basic public health and social problem.
• It is comforting to 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.
• The resistance to introducing these changes is major.
Your work matters:
• Now
• Decades from now
• In the next generation
Further Information
ACEsConnection.com
Medline or Google
(Felitti or Anda as author name)
[email protected] (DVDs)
www.HumaneExposures.com
[email protected]