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The Relationship of Adverse Childhood Experiences to Adult Health Status A collaborative effort of Kaiser Permanente and The Centers for Disease Control Vincent J. Felitti, M.D. Robert F. Anda, M.D. The Adverse Childhood Experiences (ACE) Study

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The Relationship of Adverse Childhood

Experiences to Adult Health Status

A collaborative effort of Kaiser Permanente and The Centers for Disease Control

Vincent J. Felitti, M.D.

Robert F. Anda, M.D.


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  • The Adverse Childhood Experiences (ACE) Study

  • The largest study of its kind ever done to examine the health and social effects of adverse childhood experiences over the lifespan (18,000 participants)


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  • What do we mean by Adverse Childhood Experiences?

  • Experiences that represent medical and social problems of national importance.

  • -childhood abuse and neglect

  • -growing up with domestic violence, substance abuse or mental illness in the home, parental loss, or crime


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ACE Study Design

Survey Wave 1 -- complete

71% response (9,508/13,454)

n=15,000

71% response

Mortality

National Death Index

Morbidity

Hospital Discharge

Outpatient Visits

Emergency Room Visits

Pharmacy Utilization

Present

vs.

&

All medical evaluations

abstracted

Health Status

Survey Wave II

n=15,000

All medical evaluations

abstracted


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  • The Adverse Childhood Experiences (ACE) Study

  • Summary of Findings:

  • Adverse Childhood Experiences (ACEs) are very common

  • ACEs are strong predictors of laterhealth risks and disease

  • This combination makes ACEs the leading determinant of the health and social well-being of our nation


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Category

Prevalence(%)

Abuse, by Category

Psychological (by parents)11%

Physical (by parents)11%

Sexual (anyone)22%

Household Dysfunction, by Category

Substance Abuse26%

Mental Illness19%

Mother Treated Violently13%

Imprisoned Household Member 3%

Categories of Adverse Childhood Experiences


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Adverse Childhood Experiences Score

Number of categories adverse childhood experiences are summed …

ACE score Prevalence

048%

125%

213%

3 7%

4 or more7%

  • More than half have at least one ACE

  • If one ACE is present, the ACE Score is likely to range from 2.4 to 4


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Adverse Childhood Experiences vs. Current Smoking

%


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Smoking to Self-Medicate


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ACE Score vs. Smoking and COPD


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Molestation in Childhood


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Childhood Experiences vs. Adult Alcoholism

4+

3

2

1

0


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Some say depression is genetic.Some say depression is due to a chemical imbalance.


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Might depression be a normal response toabnormal life experiences?


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Childhood Experiences Underlie Chronic Depression


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Childhood Experiences Underlie Suicide

4+

3

2

1

0


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Estimates of the Population Attributable Risk*of ACEs for Selected Outcomes in Women

*That portion of a condition attributable to specific risk factors


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Adverse Childhood Experiences vs.Likelihood of > 50 Sexual Partners


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Adverse Childhood Experiences vs.History of STD


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Adverse Childhood Experiences and the Risk of:

*Adjusted Odds Ratio


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ChildhoodExperiences Underlie Rape

4+

3

2

1

0


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ACE Score and Hallucinations

Abused

Alcohol

or Drugs

Ever Hallucinated* (%)

ACE Score

*Adjusted for age, sex, race, and education.


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Adverse Childhood Experiences and the Risk of:

*Adjusted Odds Ratio


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Estimates of the Population Attributable Risk*of ACEs for Selected Outcomes in Women

*That portion of a condition attributable to specific risk factors


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“Addiction is due to the characteristics intrinsic in the molecular structure of some substance.”

The traditional concept:


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“Addiction highly correlates with characteristics intrinsic to that individual’s childhood experiences.”

We find that:


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ACE Score vs. Intravenous Drug Use

N = 8,022 p<0.001


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Adverse Childhood Experiences and the Risk of:

*Adjusted Odds Ratio


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Estimates of the Population Attributable Risk*of ACEs for Selected Outcomes in Women

*That portion of a condition attributable to specific risk factors


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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 attempt, alcoholism, illicit drug use, injected drug use,

50+ sexual partners, history of STD (sexually transmitted disease).


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With an ACE Score of 0, the majority of adults have few, if any, risk factors for these diseases.


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However, with an ACE Score of 4 or more, the majority of adults have multiple risk factors for these diseases or the diseases themselves.


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Effect of ACEs on Mortality

Age Group


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Many chronic diseasesin adults are determineddecades earlier, in childhood.


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Their risk factors are alsoreliable markers for antecedent problems.“In my end is my beginning.”T.S. Eliot - Quartets


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Dismissing them as “bad habits” or“self-destructive behavior” totallymisses their function.


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ACE Score vs. Serious Job Problems


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Much of what causes time tobe lost from work is actuallypredetermined decades earlierby the adverse experiencesof childhood.


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Premature mortality and excess morbidity are typically the result of a small number of common diseases.

ACE = Parental Loss


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Evidence from ACE Study Suggests:These chronic diseases in adults are determined decades earlier, by the experiences of childhood.

Affective Response


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Evidence from ACE Study Suggests:Risk factors for these diseases are initiated during childhood or adolescence . . .

Seeking to Cope


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Evidence from ACE Study Suggests:. . . and continue into adult life.

Outcome: social and biomedical damage


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Another possible outcome.


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The risk factors underlyingthese adult diseases areeffective coping devices.


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Why is this so difficult to treat later?


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What is conventionallyviewed as a problem is actually a solution to an unrecognized prior adversity.


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Evidence from ACE Study Suggests:Adverse childhood experiences are the most basiccause of health risk behaviors, morbidity, disability, mortality, and healthcare costs.


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Early

Early

Death

Death

Death

Birth

Disease, Disability

Adoption of

Health-risk Behaviors

Social, Emotional, &

Cognitive Impairment

Adverse Childhood Experiences

Adverse Childhood Experiences

The Influence of AdverseChildhood Experiences Throughout Life


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“The truth about childhood is stored up in our bodies and lives in the depths of our souls. Our intellect can be deceived, our feelings can be numbed and manipulated, our perceptions shamed and confused, our bodies tricked with medication, but our soul never forgets. And because we are one, one whole soul in one body, someday our body will present its bill.”

Alice Miller


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Bridging the Chasm

Child

health

and

well-being as it

stands today.

Child

health

and

well-being

as it

could be.

Acknowledgment that the problem exists.

Recognition of casesin medical practice.


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What Can We Do Now?

  • Routinely seek history of adverse childhood experiences from all patients

  • Acknowledge their reality by asking, “How has this affected you later in life?”

  • Arrange a return appointment to discuss possibilities for helping them.


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