Adverse Childhood Experiences and their Relationship to Adult Well Being

1. Adverse Childhood Experiences and their Relationship to Adult Well Being How OB Nurses Can Help Prevent Turning Gold Into Lead!

3. “There is no trust more sacred than the one the world holds with children. There is no duty more important than ensuring that their rights are respected, that their welfare is protected, that their lives are free from fear and want and that they grow up in peace” Kofi A. Annan

5. Origin of the ACE Study? Dr. Vincent Filetti, head of the Department of Preventative Medicine in San Diego, wanted to understand the high dropout rate of his most successful patients in a weight loss study. Patients with the greatest success losing weight were most likely to drop out of his study. WHY?

6. Prevalence of Adverse Childhood Experiences Abuse by Category Psychological (by parents) 11% Physical (by parents) 28% Sexual Contact (by anyone) 22% (28% F, 16% M) Neglect by Category Emotional 15% Physical 10% Household Dysfunction by Category Alcoholism or drug use in the Home 27% Loss of biological parent at < 18 23% Depression or Mental Illness in the Home 17% Mother treated Violently 13% Imprisoned household member 5%

7. What Are the ACE Questions? When you were growing up, during your first 18 years of life: • Did a parent or other adult in the household often or very often push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? • Did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt. • Did an adult or person at least 5 years older than you ever Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? • Did you often or very often feel that No one in your family loved you or thought you were important or special? or Your family didn’t look our for each other, feel close to each other, or support each other? • Did you often or very often feel that You didn’t have enough to eat, had to wear dirty clothes, or had no one to protect you? Or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

8. What Are the ACE Questions? When you were growing up, during your first 18 years of life: • Were your parents ever separated or divorced? • Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? • Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? • Was a household member depressed or mentally ill, or did a household member attempt suicide? • Did a household member go to prison?

9. Importance of Witnessing Threats or Assaults toward Mother, Father, or Siblings Percent Experiencing Symptoms

10. The ACE Study Definitively Finds • Adverse Childhood Experiences (ACES) are very common, but largely un-recognized. • ACES are strong predictors of adult DEATH, health risks, social functioning, well-being, and health care costs. • ACES are the major cause of much of adult medicine and many major public health and social problems. • ACES cluster. They are not isolated. • This combination makes Adverse Childhood Experiences the primedeterminant of the health, social, and economic well being of the nation.

11. Investing in Our Children “The issue is not are we going to pay – it’s are we going to pay now, up front, or are we going to pay a whole lot more later on?” Marian Wright Edelman

12. US Financial Savings from the Infant Primary Vaccination Series (A Yearly Cohort Group- 2009) • Total Direct Cost Savings (DtaP, Hib, IPV, MMR, Hep B, VZV, Hep A, PCV 7, Rotavirus) = 13.6 billion • Total Societal Costs of the Above = 68.9 billion • Total Direct and Indirect Cost Savings = 82.5 Billion • Total Direct and Societal Costs Savings for Rotavirus Immunization = “Despite a higher burden of serious rotavirus disease than estimated previously, routine rotavirus vaccination would unlikely be cost-saving in the United States at present” Zhou et al, Economic Evaluation of the Routine Childhood Immunization Program in the United States, 2009, Pediatrics, 3/2014 online published Pediatrics, 2007 April, 119(4): 684-97

14. So What Are the Financial Costs of ACES? • The estimated average lifetime cost per victim of nonfatal child maltreatment is 210,012 in 2010 dollars (this compares to the annual cost of obesity treatment starting at age 20 years of $5,600 to $30,770). • The estimated lifetime cost per death is $1,272,900. • The estimates of lifetime economic burden resulting from new cases of fatal and nonfatal child maltreatment in the U.S. for 2008 is approximately 124 billion annually at the NIS Harm Standard. The total burden is estimated to be as large as 585 billion annually based on the NIS Endangerment Standard. • The cost of Substance Abuse (tobacco, alcohol and drugs) in the United States is over 600 billion annually. • Child Maltreatment costs more on an Annual Basis then treating two Leading Health Concerns, Stroke and Type 2 Diabetes Combined. The Economic Burden of Child Maltreatment in the United States and Implications for Prevention, Fang et al, Child Abuse and Neglect. 2012 February; 36 (2) 156-166 4th Annual National Incidence Study of Child Abuse and Neglect (NIS-4) Report to Congress 2010 National Institute on Drug Abuse. Xiangming, Brown, Florence and Mercy: 2012, Child Abuse and Neglect 36(2), 156-165

15. Vaccination Is Important to Pediatrics But so Is the Prevention of ACES (Saving Lives and Costs)

16. US Financial Savings from the Infant Primary Vaccination Series (A Yearly Cohort Group- 2009) • Total Direct Cost Savings (DtaP, Hib, IPV, MMR, Hep B, VZV, Hep A, PCV 7, Rotavirus) = 13.6 billion • Total Societal Costs of the Above = 68.9 billion • Total Direct and Indirect Cost Savings = 82.5 Billion • Total Direct and Societal Costs Savings for Rotavirus Immunization = “Despite a higher burden of serious rotavirus disease than estimated previously, routine rotavirus vaccination would unlikely be cost-saving in the United States at present” Zhou et al, Economic Evaluation of the Routine Childhood Immunization Program in the United States, 2009, Pediatrics, 3/2014 online published Pediatrics, 2007 April, 119(4): 684-97

17. Adverse Childhood Experiences ScoreACEs Cluster Ace Score Prevalence 0 33% 1 25% 2 15% 3 10% 4 6% 5-> 11% If any one ACE category is present, there is an 87% chance of at least one other category of ACE and a 50% chance of 3->

19. ACE Score and Teen Pregnancy

21. Further Breakdown of the Original Teen Pregnancy Ace Data Published in Pediatrics 2004 The Association Between Adverse Childhood Experiences and Adolescent Pregnancy, Long-Term Psychosocial Consequences, and Fetal Death Susan Hillis, PhD, MS; Robert Anda, MD, MS; Shanta R. Dube, MPH; Vincent Felitti, MD; Polly Marchbanks, PhD; and James Marks, MD, MPH Pediatrics Vol 113 No. 2 February 2004: 320-7.

22. Odds Adjusted Ratio Between Teen Pregnancy and Multiple Factors Including Increased Fetal Death The Negative Psychosocial Sequalae and Fetal Death Commonly Attributed to Adolescent Pregnancy seems to Result from Underlying ACEs rather than Adolescent Pregnancy

23. More Recent Publications with Similar Implications: Risk Factors for Unfavorable Pregnancy Outcome in Woman with Adverse Childhood Experiences Journal of Perinatal Medicine. 2013 Dec 14: 1-8, Leeners B, Rath W, Block E, Gorres G, Tschudin S. SUMMARY: Woman with CSA, Physical Abuse, and Adverse Childhood Experiences present with a variety of abuse-associated obstetrical risk factors and an increased risk for premature delivery. Therefore, all types of abusive and other ACE should be considered in prenatal care.

24. ACE Score and Unintended Pregnancy or Elective Abortion

25. Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners (Adjusted Odds Ratio)

26. Adverse Childhood Experiences and History of STD

27. ACE Score and the % Risk of Perpetrating Domestic Violence

28. ACE Score and the % Risk of Being a Victim of Domestic Violence

29. Childhood Experiences Underlie Homelessness Washington State ACE Experience

31. Depression: Many physicians call depression a disease. Maybe it’s genetic? Maybe it’s a chemical imbalance? BUT

33. ACE Score and % Lifetime Depression and Antidepressant Scripts

35. Childhood Experiences Underlie Suicide

36. Incest is thought to occur in approximately 1 out of 1.1 million women. There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology. The father-daughter liaison satisfies instinctual drives in a setting where mutual alliance with an omnipotent adult condones the transgression… The ego’s capacity for sublimation is favored by the pleasure afforded by incest…such incestuous activity diminishes the subject’s chance of psychosis and allows for a better adjustment to the external world. There is often found little deleterious influence on the subsequent personality of the incestuous daughter...one study found that the vast majority of them were none the worse for the experience.Freedman and Kaplan, Comprehensive Textbook of Psychiatry, 1972

37. Self-Injury and Suicide and Unaddressed Childhood Sexual Abuse “The sexual and physical violation of children results in alterations in self-perception which are immediate, last throughout the life-span, and contribute to suicidalityas a way to cope.” Judith Herman, MD (Harvard), 1992 “Childhood sexual abuse is significantly related to adolescent and adult self-harm, including suicide attempts, cutting, and self-starving.” Bessel Van der Kolk, MD (Harvard), 1991

38. Childhood Sexual Abuse and the Number of Unexplained Somatic SymptomsHorizontal Axis Number of SymptomsVertical Axis Percent Abused

39. ACE Score and % Experiencing Hallucinations (adjusted for age, sex, race, and education). Blue No OH/Drug Abuse - Red OH/Drug Abuse

40. ACE Score and Impaired Memory of Childhood

42. Childhood Experiences and Self-Acknowledged Adult AlcoholismNumbing the Past

43. Addiction the Traditional Concept “Addiction is due to the characteristics intrinsic in the molecular structure in some substance.” HOWEVER

44. The ACE Study Challenges that by Showing: “Addiction highly correlates with characteristics intrinsic to that individual’s childhood experiences.”

45. ACE Score and % Intravenous Drug Use

47. Percent Currently Smoking Based on ACE Score – Smoking to Self-Medicate

48. Childhood Experiences Underlie Rape

49. Estimates of Population Attributable Risk of ACES for Selected Outcomes in Women Drug Abuse: • Alcoholism 65% • Drug Abuse 50% • IV Drug Abuse 80% Mental Health: • Current Depression 54% • Suicide Attempt 60% Crime Victim: • Sexual Assault 62% • Domestic Violence 52%