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Adverse Childhood Experiences (ACE) and the Impact on Health. 2012 ASTDN Annual Conference Katherine Sanchez, LCSW, Ph.D. Assistant Professor School of Social Work University of Texas at Arlington May 8, 2012. Setting the Stage. 2010 Leading Causes of Death in the United States.

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Adverse Childhood Experiences (ACE)and the Impact on Health

2012 ASTDN Annual Conference

Katherine Sanchez, LCSW, Ph.D.

Assistant Professor

School of Social Work

University of Texas at Arlington

May 8, 2012

Setting the Stage

2010 Leading Causes of Death in the United States

Heart disease


Lower respiratory diseases

Stroke and related diseases


Alzheimer’s disease


Kidney diseases

9. Influenza, pneumonia

10. Suicide


12. Chronic liver disease and cirrhosis

13. Hypertension and related renal disease

14. Parkinson’s disease

15. Pneumonitis


High Medical Care Cost

  • Five percent of the population accounts for 49 percent of total health care expenses.

  • The 15 most expensive health conditions account for 44 percent of total health care expenses.

  • Patients with multiple chronic conditions cost up to seven times as much as patients with only one chronic condition.

AHRQ, Research in Action, 2006

1O most costly medical conditions

Soni, A. Top 10 Most Costly Conditions among Men and Women, 2008: Statistical Brief #331.

July 2011. AHRQ,.

Study: USA is fattest among advanced countries (USA Today 9/24/10)

Prevalence of Obesity and Trends in BMI Among US Children and Adolescents US, 1999-2010

  • The prevalence of childhood obesity increased in the 1980s and 1990s.

  • Almost 1/3 of children and adolescents are overweight or obese

  • In 2009-2010, the prevalence of obesity in children and adolescents was 16.9%

  • 11.3% of children and adolescents are very obese (97th percentile)

(Ogden et al,2012, JAMA, 307(5), 483-490.)

Prevalence of BMI > 95% in Boys in US, 2009-2010(Ogden et al,2012, JAMA, 307(5), 483-490.)

Prevalence of BMI > 95% in Girls in US, 2009-2010(Ogden et al,2012, JAMA, 307(5), 483-490.)

Prevalence of BMI > 85% in Boys in US, 2009-2010(Ogden et al,2012, JAMA, 307(5), 483-490.)

Prevalence of BMI > 85% in Girls in US, 2009-2010(Ogden et al,2012, JAMA, 307(5), 483-490.)

Consequences of Childhood Obesity

  • May reduce life expectancy

  • More likely to develop hypertension, type-2 diabetes, and high cholesterol

  • More likely to become obese adults

  • Reduced quality of life

  • Higher medical expenses

Cost of childhood obesity/diabetes

Claims data

Obese child$2907

Child with type 2 diabetes$10,789

Adult with type 2 diabetes$8844


Absent child or sick child care-related

(Sepulveda, Health Affairs, 29:3)

Increasing rates of childhood chronic conditions

Predicts majorincreases in long-term:

  • pulmonary,

  • cardiovascular,

  • mentalhealth burdens among adults,

  • accompanied by increasing expendituresfor health care and disability programs,

  • decreased workforce participation and

  • poorer quality of life.

Association of Adolescent Obesity With Risk of Severe Obesity in Adulthood

  • Obesity in adolescence was associated with increased risk of severe obesity in adulthood

  • Findings highlight the need for interventions prior to adulthood to prevent the progression of obesity to severe obesity.

  • [And the need for interventions to prevent childhood obesity in the first place.]

The et al, JAMA, Vol. 34, No.18

Adverse Childhood Experiences (ACE) Study

  • In the mid-1980s Kaiser Permanente conducted an obesity program

  • In trying to understand the program’s high dropout rate, they conducted detailed life interviews of almost 300 individuals

  • Researchers discovered that sexual abuse was common among dropouts, & that abuse always predated obesity

Adverse Childhood Experiences (ACE) Study

  • As a follow-up, Kaiser Permanente & CDC conducted ACE study

  • Study involved 19,000 mostly middle class, middle aged adults

  • Results show childhood abuse & household dysfunction led to chronic diseases decades later

  • Traditionally viewed as public health problems, behaviors may also be coping mechanisms

Adverse Childhood Experiences

Child Abuse or Neglect

  • Physical abuse

  • Sexual abuse

  • Abandonment

  • Trauma in Child’s

  • Household

  • Substance Abuse

  • Parental divorce

  • Mentally ill or suicidal household member

  • Violence to mother

  • Imprisoned household member

Adverse Childhood Experiences

Effects of Trauma

  • Difficulty controlling anger

  • Hallucinations

  • Depression

  • Panic reactions

  • Anxiety

  • Health Risk Behaviors

  • Smoking

  • Obesity

  • Suicide

  • Alcoholism

  • Drug abuse

  • Sexually transmitted disease

  • Self-injury

  • Eating disorders

Adverse Childhood Experiences

Long-Term Consequences

Disease and Disability

  • Heart disease

  • Cancer

  • Chronic lung disease

  • Emphysema


  • Mood disorders

  • Anxiety disorders

  • Social Problems

  • Homeless

  • Prostitution

  • Delinquency, violence and criminal behavior

  • Re-victimizations: rape; domestic violence

  • Un-Employment

  • Inter-generational transmission of abuse

Adverse Childhood Experiences

& Smoking


Adverse Childhood Experiences

& Attempted Suicide

Adverse Childhood Experiences

& Intravenous Drug Use

Adverse Childhood Experiences





Disability, and

Social Problems

Adoption of

Health-risk Behaviors

Social, Emotional, &

Cognitive Impairment

Adverse Childhood Experiences


What Drives Health Status and Health Care Costs?

How Can We Encourage and Support Behavior Change?

Source: IFTF and Center for Disease Control and Prevention, Health and Healthcare 2010, January 2000


Behavioral Health Issues Impact Other Systems

  • 75% of children placed in foster care have parents with behavioral health problems

  • 75% of children in the juvenile justice system have behavioral health problems

  • 30% of children in the juvenile justice system will end up in the adult justice system

  • 46% of all ER visits have behavioral health issues as a basic or contributing factor

  • 30% of all truancy is related to behavioral health problems

The Poverty ClinicCan a stressful childhood make you a sick adult?

  • Looks at the relationship between poverty, child development, and health.

  • Childhood trauma should be viewed as a medical issue.

  • “In many cases, what looks like a social situation is actually a neurochemical situation”.

  • Therefore, social issues might be better addressed on the molecular level.

Paul Tough, The New Yorker, 3/21/2011

The Poverty ClinicCan a stressful childhood make you a sick adult?

  • 67 % of Burke’s patients have had one or more ACEs, and 12 % have had four or more.

  • Only 3% of patients with ACE = 0 display learning or behavior problems.

  • 51% of patients with ACE = 4+ display learning or behavior problems.

  • Burke’s goal is a treatment protocol, like the one doctors use when they’re dealing with cancer or diabetes.

Paul Tough, The New Yorker, 3/21/2011

Co-occurring mental and medical illness are common.

  • Patients with common medical disorders have high rates of depression and anxiety which often impair self-care and compliance with treatment of their chronic disease.

  • Major depression increases the burden of chronic illness by increasing perception of symptoms, causing additional impairment in functioning, and increasing medical cost through over utilization of the healthcare system.

  • Poverty and poor health are associated with higher rates of mental disorders.

  • Hispanics and other ethnic minorities experience a disproportionate burden of disability associated with mental disorders because of disparities in mental health care.

Comorbid illnesses

  • Medical illnesses

  • Physical pain

  • Psychiatric illnesses and stressors

    • Anxiety: PTSD, panic, OCD

    • Cognitive impairment,

    • Grief/bereavement,

    • Psychosis

  • Alcohol and substance abuse

  • Major life stressors

    • Marital discord, major losses, abuse / neglect

So What?

  • Culturally considerate, competent, compassionate care

  • Build capacity of primary care providers to appropriately screen, identify, treat and refer across disciplines

  • Reduce barriers to treatment

  • Reduce stigma

  • Further integrate care at the local level

Team Care



Prepared, Pro-active

Practice Team

Informed, Activated


Practice Support

Early Intervention

“Intensive, comprehensive early intervention & education programs can alter development trajectories & substantially improve health, education and social outcomes from middle childhood thru adulthood.”

- Halfon, Inkelas, JAMA 12/17/03 p.3136

Prevention & Early Intervention: Adolescent Health Screening

  • Half of all mental illness begins by age 14

  • ¾ of adults have their symptoms of mental illness by age 24

  • Goal to consider: ensure adolescent behavioral health screening in every primary care setting

Texas Adolescent Mental Health in Primary Care Initiative

Overarching Goal:

to institutionalize behavioral health screening within the scope of primary care practices.

The Texas Adolescent Mental Health in Primary Care Initiative (December 2005 – January 2007)

  • Developed model

    • Screening

    • Assessment

    • Treat or refer

  • Selected screening & assessment tools

  • Was developing training package for pilot sites

Project InSightA Powerful Partnership

  • 5-year $17.5 million national demonstration project in Houston

  • Integrates screening and brief intervention for substance abuse problems into routine medical care

  • Creates a bridge between medical system and substance abuse service system

Between Abstinence & Dependence

Brief Intervention














Some lessons

  • All ‘core components’ are needed.

    Physician, Care Manager, Consulting Psychiatrist

  • Co-location is NOT sufficient

    Effective multidisciplinary collaboration is needed.

    3) Initial treatments are rarely sufficient.

    Changes in treatment require proactive follow-up and effective consultation (measurement based care).


This is a challenging group of patients.

We need to engage patients and follow-up: patients don’t get better if they are not followed.

We need to change treatment if patients don’t improve.

We need to pay closer attention to medications.

We probably need more psychiatric consultation.

We may need to make more / more effective referrals.

What Factors Contribute to Health Disparities?

  • Socioeconomic status

  • Residential segregation and environmental living conditions

  • Occupational risks/exposures

  • Health risk and health seeking behavior

  • Differences in access to care

  • Differences in health care quality

Smedley, 7/21/09

Relationship between Social Determinants and Mortality (2000)

Galea et al, Estimated Deaths Attributable to Social Factors in the United States ,

AJPH, August 2011, Vol 101, No. 8.

National High School Graduation Rates, 2003-04

  • Native American49.3%

  • Black53.4%

  • Latino57.8%

  • White76.2%

  • Asian80.2%

Cities in Crisis, EPE Research Center, 2008

Educational Attainment in 2000 in Texas for Persons 25+ Years of Age By Race/Ethnicity



A Reprioritization of Priorities

  • To achieve health equity, we should pursue interventions in proportion to their ability to affect the determinants of health

    • Fostering social change (educational attainment versusmedical advances)

    • Preventing disease (tobacco cessation versus b-blockers)

    • Delivering care (services delivery system improvements vs. biomedical advances)

    • Choosing effective services (appropriate use of things that work vs. overuse of things that don’t )

Woolf, JAMA, V.297,#5

What Will Improve Health?

Implementing community preventive services, programs and policies aimed at broad population groups.

These address the cultural, environmental, and economic forces that contribute to the leading preventable causes of disease and death.

We will get a MUCH greater return on investment by focusing on health improvement opportunities in communities, schools and worksites rather than focusing solely on what occurs in traditional health care settings.

A Framework for Health

Thank you!

Katherine Sanchez, LCSW, PhD

Assistant Professor

UT Arlington

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