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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

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



2010 leading causes of death in the united states
2010 Leading Causes of Death in the United States

Heart disease

Cancer

Lower respiratory diseases

Stroke and related diseases

Accidents

Alzheimer’s disease

Diabetes

Kidney diseases

9. Influenza, pneumonia

10. Suicide

11. Septicemia

12. Chronic liver disease and cirrhosis

13. Hypertension and related renal disease

14. Parkinson’s disease

15. Pneumonitis

CDC


High medical care cost
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
1O most costly medical conditions

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

July 2011. AHRQ,. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st331/stat331.pdf


Study usa is fattest among advanced countries usa today 9 24 10
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
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 Boys in US, 2009-2010 and Adolescents US, 1999-2010 (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 > 95% in Girls in US, 2009-2010 and Adolescents US, 1999-2010 (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 Boys in US, 2009-2010 and Adolescents US, 1999-2010 (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
Prevalence of BMI > 85% in Girls in US, 2009-2010 and Adolescents US, 1999-2010 (Ogden et al,2012, JAMA, 307(5), 483-490.)


Consequences of childhood obesity
Consequences of Childhood Obesity and Adolescents US, 1999-2010

  • 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
Cost of childhood obesity/diabetes and Adolescents US, 1999-2010

Claims data

Obese child $2907

Child with type 2 diabetes $10,789

Adult with type 2 diabetes $8844

Absenteeism

Absent child or sick child care-related

(Sepulveda, Health Affairs, 29:3)


Increasing rates of childhood chronic conditions
Increasing rates of childhood chronic conditions and Adolescents US, 1999-2010

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
Association of Adolescent Obesity and Adolescents US, 1999-2010 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
Adverse Childhood Experiences (ACE) and Adolescents US, 1999-2010 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 study1
Adverse Childhood Experiences (ACE) and Adolescents US, 1999-2010 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 and Adolescents US, 1999-2010

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 and Adolescents US, 1999-2010

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 and Adolescents US, 1999-2010

Long-Term Consequences

Disease and Disability

  • Heart disease

  • Cancer

  • Chronic lung disease

  • Emphysema

  • HIV/AIDS

  • 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 and Adolescents US, 1999-2010

& Smoking


Ace and copd
ACE and COPD and Adolescents US, 1999-2010


Adverse Childhood Experiences and Adolescents US, 1999-2010

& Attempted Suicide


Adverse Childhood Experiences and Adolescents US, 1999-2010

& Intravenous Drug Use


Adverse Childhood Experiences and Adolescents US, 1999-2010

Death

Early

Death

Disease,

Disability, and

Social Problems

Adoption of

Health-risk Behaviors

Social, Emotional, &

Cognitive Impairment

Adverse Childhood Experiences

Birth


What drives health status and health care costs
What Drives Health Status and Adolescents US, 1999-2010 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

26


Behavioral health issues impact other systems
Behavioral Health Issues and Adolescents US, 1999-2010 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 clinic can a stressful childhood make you a sick adult
The Poverty Clinic and Adolescents US, 1999-2010 Can 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 clinic can a stressful childhood make you a sick adult1
The Poverty Clinic and Adolescents US, 1999-2010 Can 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
Co-occurring mental and medical illness are common. and Adolescents US, 1999-2010

  • 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
Comorbid illnesses and Adolescents US, 1999-2010

  • 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
So What? and Adolescents US, 1999-2010

  • 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 and Adolescents US, 1999-2010

Effective

Collaboration

Prepared, Pro-active

Practice Team

Informed, Activated

Patient

Practice Support


Early intervention
Early Intervention and Adolescents US, 1999-2010

“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
Prevention & Early Intervention: and Adolescents US, 1999-2010 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
Texas Adolescent Mental Health and Adolescents US, 1999-2010 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
The Texas Adolescent Mental Health and Adolescents US, 1999-2010 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 insight a powerful partnership
Project InSight and Adolescents US, 1999-2010 A 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 and Adolescents US, 1999-2010

Brief Intervention

Intervention

Referral

A

B

S

T

A

I

N

AT-RISKUSE

USE

ABUSE

DEP


Some lessons
Some lessons and Adolescents US, 1999-2010

  • 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).


Challenges
Challenges and Adolescents US, 1999-2010

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
What Factors Contribute to Health Disparities? and Adolescents US, 1999-2010

  • 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
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
National High School Graduation Rates, 2003-04 (2000)

  • Native American 49.3%

  • Black 53.4%

  • Latino 57.8%

  • White 76.2%

  • Asian 80.2%

Cities in Crisis, EPE Research Center, 2008


Educational attainment in 2000 in texas for persons 25 years of age by race ethnicity
Educational Attainment in 2000 (2000)in Texas for Persons 25+ Years of Age By Race/Ethnicity

Percent

  • [email protected]


A reprioritization of priorities
A Reprioritization of Priorities (2000)

  • 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
What Will Improve Health? (2000)

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.



Thank you
Thank you! (2000)

Katherine Sanchez, LCSW, PhD

Assistant Professor

UT Arlington

[email protected]


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