Adverse Childhood Experiences and their Relationship to

1. Adverse Childhood Experiences and their Relationship to Adult Well-being and Disease : Turning gold into lead A collaborative effort between Kaiser Permanente and the Centers for Disease Control Invest in Children Conference Cleveland, Ohio November 17, 2011 Robert F. Anda, M.D. Vincent J. Felitti, M.D.

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

3. Abuse, by Category Psychological (by parents) 11% Physical (by parents) 28% Sexual (anyone) 22% Neglect, by Category Emotional 15% Physical 10% Household Dysfunction, by Category Alcoholism or drug use in home 27% Loss of biological parent < age 18 23% Depression or mental illness in home 17% Mother treated violently 13% Imprisoned household member 5% Prevalence 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 threeexperienced 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 50% chance of 3 or >. • * Women are 50% more likely than men to have a Score >5.

5. Smoking to Self-Medicate

6. “Addiction is due to the characteristics intrinsic in the molecular structure of some substance.” The traditional concept:

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

8. Health Risks Adverse Childhood Experiences vs. Smoking as an Adult % p< .001

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

10. Health risks ACE Score vs Injection Drug Use p<0.001

11. Social Costs Estimates of the Population Attributable Risk*of ACEs for Selected Outcomes in Women *That portion of a condition attributable to specific risk factors

12. Root Causes, Coping Mechanisms, & Outcomes Molestation in Childhood

13. Depression:Some say depression is a disease. Some say depression is genetic. Some say depression is due to a chemical imbalance.

14. Might depression be a normal response toabnormal life experiences?

15. Emotional costs Childhood Experiences Underlie Chronic Depression

16. Emotional costs Childhood Experiences Underlie Suicide Attempts 4+ 3 2 1 0

17. Social cost ACE Score and Rates of Antidepressant Prescriptions50 years later Prescription rate (per 100 person-years) 0 1 2 3 4 >=5 ACE Score ACE Score

18. Social costs Estimates of the Population Attributable Risk*of ACEs for Selected Outcomes in Women *That portion of a condition attributable to specific risk factors

19. Biomedical Disease Adverse Childhood Experiences vs.History of STD

20. Biomedical Disease The ACE Score and the Prevalence of Liver Disease (Hepatitis/Jaundice) Percent (%) AACE CE Score ACE Score

21. Biomedical Disease ACE Score vs. COPD 0 1 2 3 4

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

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

24. Many chronic diseasesin adults are determineddecades earlier, in childhood.

25. Dismissing them as “bad habits” or“self-destructive behavior” comfortably misses their functionality.

26. The risk factors underlying these adult diseases are helpful short-term coping devices.

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

29. What Can We Do Today? • Routinely seek a history of adverse childhood experiences from all patients, by questionnaire. • Acknowledge their reality by asking, “How has this affected you later in life?” • Use existing systems to help with current problems. • Develop systems for primary prevention.

30. Unconventional Questions of Demonstrated Value • Have you lived in a war zone? • Have you ever been a combat soldier? • Who in your family has committed suicide? • Who in your family has been murdered? • Who in your family has had a nervous breakdown? • Were you molested as a child? • Have you ever been held prisoner? • Have you been tortured? • Have you been raped?

31. Outcomes of a Biopsychosocial Preventive Approach Biomedical evaluation: 11% reduction in DOVs, subsequent year (700 patient sample) Biopsychosocial evaluation: 35% reduction in DOVs (125,000 patient sample)

32. Final Insights from the ACE Study Adverse childhood experiences are common but typically unrecognized. Their link to disease and life expectancy is powerful and proportionate. They are the nation’s most basic public health problem. We often mistake intermediary mechanism for basic cause. What presents as the ‘Problem’ may in fact be an attempted solution. Treating the solution may be threatening and cause flight from treatment. Primary preventionis presently the only feasible population approach.

33. Further Information www.AceStudy.org Medline/PubMed, Google (Anda or Felitti as author) VJFMDSDCA@mac.com www.HumaneExposures.com (3 Important Books) www.CavalcadeProductions.com (Documentary DVDs) http://xnet.kp.org/PermanenteJournal/winter02/deardoc.pdf