Adverse Childhood Experiences and their Relationship to

1. Adverse Childhood Experiences and their Relationship to Adult Well-being, Disease, and Death : Turning gold into lead A collaborative effort between Kaiser Permanente and the Centers for Disease Control ACMHA Policy Forum Washington, DC December 5, 2012 Robert F. Anda, M.D. Vincent J. Felitti, M.D.

2. ACE Study Design Survey Wave 1 71% response (9,508/13,454) n=13,000 71% response Mortality National Death Index Morbidity Hospital Discharges Doctor Office Visits Emergency Room Visits Pharmacy Costs Present vs. & All medical evaluations abstracted Health Status Survey Wave II n=13,000 17,337 adults All medical evaluations abstracted

3. Abuse, by Category Psychological (by parents) 11% Physical (by parents) 28% Sexual (anyone) 22% Major Neglect, by Category Emotional 15% Physical 10% Household Dysfunction, by Category Alcoholism or drug use in home 27% Loss of biological parent <18 23% Depression or mental illness in home 17% Mother treated violently 13% Imprisoned household member 5% Empirically Selected Categories of Adverse Childhood Experiences Prevalence (%)

4. 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 threeadultsexperienced at least one category of ACE. • If any one ACE is present, there is an 87% chance at least one other category of ACE is present, and a 50% chance of three or more. • Women are 50% more likely than men to have an ACE Score >5.

5. Who would ever suspect – without routinely asking

6. Smoking to Self-Medicate

7. Health Risks Adverse Childhood Experiences vs. >1 ppd Smoking as an Adult % P< .001

8. Health Risks Childhood Experiences vs. Adult Alcoholism 4+ 3 2 1 0

9. Health Risks ACE Score vs. Intravenous Drug Use p<0.001

10. Well-being Childhood Experiences Underlie Chronic Depression

11. Death Childhood Experiences Underlie Later Suicide 4+ 3 2 1 0

12. Well-being ACE Score and theRisk of Perpetrating Domestic Violence__________________________________ 15 Men Women 10 Risk of Perpetration (%) 5 0 0 1 2 3 4 >5 0 1 2 3 4 >5 ACE Score

13. ACEs Increase Likelihood of Heart Disease* Emotional abuse 1.7x • Physical abuse 1.5x • Sexual abuse 1.4x • Domestic violence 1.4x • Mental illness 1.4x • Substance abuse 1.3x • Household criminal 1.7x • Emotional neglect 1.3x • Physical neglect 1.4x • After correction for age, race, education, and conventional risk factors like smoking and * diabetes. Circulation , Sept 2004 .

15. Turning Research into Practicea beginning • Comprehensive biomedical evaluation provides a net 11% reduction in DOVs in the subsequent year. • Comprehensive bio-psycho-social evaluation, which incorporates ACE Study findings, provides a 35% reduction in DOVs in the subsequent year compared to the prior year. (125,000 patient sample) Imagine the possibilities!

16. What Can We Do Today? • Routinely seek a history of traumatic childhood experiences from all patients, inmates, and children in foster care. • Acknowledge their reality by asking, “How has this affected you later in life?” • Develop programs for primary prevention.

17. Further Information www.acestudy.org http://www.cdc.gov/NCCDPHP/ACE Google Scholar (search: Felitti or Anda or ACE Study) VJFMDSDCA@mac.com AVAHealth.org(Detailed DVD) www.ACEsTooHigh.com (useful blog on the subject)