Impact of Childhood
Adversity on Development
and Future Health and
Wellness
Equity at the Core
February 10, 2016
The ACE Study:
The Most Important
Public Health Study
You Never Heard About
The healthy development of all
children benefits all of society by
providing a solid foundation for
responsible citizenship, economic
productivity, lifelong physical and
mental health, strong communities,
and sustainable democracy and
prosperity.
What We Know About Brain
Development
•Brains are built over time, shaped by the
interaction between genetics and experience.
•Social, emotional, and cognitive development are
highly interrelated.
•Brain architecture and skills are built in a
hierarchical “bottom-up” sequence.
•Brain plasticity and the ability to change behavior
decrease over time.
Relationships are the
“Active Ingredients"
of Early Experience
• Nurturing and responsive relationships build
healthy brain architecture that provides a strong
foundation for learning, behavior, and health.
• When protective relationships are not provided,
elevated levels of stress hormones (i.e., cortisol)
disrupt brain architecture by impairing cell
growth and interfering with the formation of
healthy neural circuits.
Types of Stress
• Normal – Moderate, short-lived stress responses
(meeting new people)
• Tolerable – Could disrupt brain architecture, but
are buffered by supportive relationships that
facilitate adaptive coping (death of a loved one)
• Toxic – Strong and prolonged activation of the
body’s stress management systems in the absence
of the buffering protection of adult support (ongoing abuse and neglect)
Childhood Trauma is
the Most Critical
Public Health Issue
in the United States…
and
Nobody is Talking About It
THE RELATIONSHIP OF
ADVERSE CHILDHOOD EXPERIENCES
TO ADULT HEALTH STATUS
A collaborative effort of Kaiser Permanente and The
Center for Disease Control
Vincent J. Felitti, M.D.
Robert F. Anda, M.D.
The Adverse Childhood Experiences
(ACE Study)
Largest study of its kind ever
(almost 18,000 participants)
Examined the health and social effects
of adverse childhood experiences
over the lifespan
Majority of participants were 50 or older (62%),
were white (77%) and
had attended college (72%)
ADVERSITY BY CATEGORIES
CHILDHOOD (18 years or younger)
ABUSE
HOUSEHOLD
Psychological (by parents)
Substance Abuse
Physical (by parents)
Mental Illness
Sexual (anyone)
Parental separation/divorce
Emotional neglect
Mother Treated Violently
Physical neglect
Imprisoned Household Member
Other Adversities
• Food insecurity
• Racism
• Poverty
• Community violence
• Homelessness
• Disasters
• Death of a loved one
• Immigration
• Learning difficulties
Categories of adverse childhood
experiences
Abuse, by Category
Psychological (by parents)
10.5%
Physical (by parents)
28%
Sexual (anyone)
20%
Household Dysfunction, by Category
Substance Abuse
26%
Mental Illness
19%
Mother Treated Violently
13%
Imprisoned Household Member
5%
ACE Score
Only one-third had a
zero ACE score
One in four had ACE score
of 2 or more
16% had an ACE score
of 4 or more
ACE Study
Strong, graded relation to childhood adversity and the
following…
Smoking
Attempted suicide
COPD
Re-victimization
Heart Disease
Teen pregnancy
Diabetes
Fractures
Obesity
Promiscuity
Hepatitis
Sexually transmitted disease
Alcoholism
Poor job performance
Other substance abuse
Poor self-rated health
Depression
Violent relationships
ACE Study
Top 10 Risk Factors:
Smoking
Alcoholism
Severe Obesity
Illicit drug use
Physical inactivity
IV drug use
Depression
50+ sexual partners
Suicide
HX of STDs
ACEs and Chronic Depression
60
Women
Men
50
40
%
30
20
10
0
0
1
2
ACEs Score
3
4 or
more
ACE Score and Rates of Prescribed
Antidepressant
140
Rate per 100 P-Y
120
100
80
60
40
20
0
0
1
2
3
4
5+
0
1
2
3
4
5+
0
1
2
3
4
ACE Score
ACE Score
ACE Score
18-44 yrs
45-64 yrs
65-89 yrs
Relative rates are adjusted for age, sex, race/ethnicity, and education. Adults with an ACE Score of 0 are the referent.
5+
ACEs and Attempted Suicide
20
18
16
14
12
%
10
8
6
4
2
0
0
1
2
ACE Score
3
4 to 5
ACEs and Adult Alcoholism
20
18
16
14
12
%
10
8
6
4
2
0
0
1
2
ACEs Score
3
4 to 5
ACEs and >50 Sexual Partners
4
3
Adjusted
Odds 2
Ration
1
0
0
1
2
Aces Score
3
4 to 5
ACEs and STDs
3
Adjusted
Odds
Ration
2
1
0
0
1
2
Aces Score
3
4 to 5
ACEs and Rape
35
30
25
%
20
15
10
5
0
0
1
2
ACEs Score
3
4 or more
ACE Score
and Teen Sexual Behaviors
45
Percent With Health Problem (%)
40
0
1
ACE Score
2 3 4 or more
35
30
25
20
15
10
5
0
Intercourse by
Age 15
Teen
Pregnancy
Teen Paternity
The ACE Score and the Prevalence
of Severe Obesity (BMI >35)
Percent obese (%)
14
12
10
8
6
4
2
0
0
1
2
ACE Score
3
>=4
ACE Score and the Risk of Being
a Victim of Domestic Violence
Men
Women
15
10
5
0
0
1
2
3
4
>5
ACE Score
0
1
2
3
4 >5
ACE Score and Drug Abuse
Percent With Health Problem (%)
14
0
12
1
ACE Score
2 3 4 >=5
10
8
6
4
2
0
Ever had a
drug problem
Ever addicted
to drugs
Ever injected
drugs
ACE Score and HIV Risks
20
18
Percent With Health Problem (%)
0
ACE Score
1 2 3 4 or more
16
14
12
10
8
6
4
2
0
Ever
Injected
Drugs
Had 50 or More
Intercourse Partners
Ever Had
an STD
ACEs, Smoking, & Lung Disease
20
ACE Score
Percent With Health Problem (%)
18
0
1
2
3
4 or more
16
14
12
10
8
6
4
2
0
Early smoking
initiation
Current smoking
COPD
The ACE Score and the Prevalence
of Ischemic Heart Disease
6
Percent (%)
5
4
3
2
1
0
0
1
2
ACE Score
3
>=4
ACEs in School
Spokane Elementary School
Academic
Failure
Severe
Attendance
Problems
Severe School
Behavior
Concerns
Frequent
Reported
Poor
Health
Three or
More ACEs
2.9X
4.9X
6.1X
3.9X
Two ACEs
2.5X
2.6X
4.3X
2.4X
One ACE
1.5X
2.2X
2.4X
2.3X
1.0
1.0
1.0
1.0
No Known
ACEs
Data from research conducted by Chris Blodgett, University of Washington
Incidents of Physical Abuse
by a Family Member
ACE Study: 28%
Sonoma Valley
2,240
Sonoma County
33,019
Greater Bay Area
448,000
California
2,492,971
US
20,093,920
Number of children under 18
(2010 census)
Sonoma
Valley
8,000
Sonoma
County
117,928
Greater Bay
Area
1,600,000
California
8,900,000
US
71,764,000
Children with ACE Score of 4 or more
ACE Study: 16%
Number of children under 18
(2010 census)
Sonoma Valley
1,280
Sonoma County
18,868
Greater Bay Area
256,000
California
1,424,000
US
11,482,240
Sonoma
Valley
8,000
Sonoma
County
117,928
Greater Bay
Area
1,600,000
California
8,900,000
US
71,764,000
• Behavioral responses resemble common
delinquent behaviors and are under-identified as
trauma symptoms
• Stress manifestation is different by ages, stages,
expression
• Many just don’t connect the symptoms to trauma
…Thus leading to punishment rather than
help
The Threat Occurs Over and Over
CNS reset
Affect
Modulation
Numbness
Brain
Changes
Cognitive
Development
Reenactment
Aggression
Dissociation
Between Stimulus and Response
Stimulus
Response
Between Stimulus and Response
Stimulus
Traumatic
Reminder
Response
Socialenvironmental
intervention
Traumatic State
Neuroregulatory
Intervention
Intervention
Between Stimulus and Response
Stimulus
Traumatic
Reminder
COGNITION!!!
Response
Traumatic State
Socialenvironmental
Intervention
Neuroregulatory
Intervention
Intervention
Between Stimulus and Response
Cortex
Hippocampus
Slower
Amygdala
Sensory Thalamus
Very Fast
Stimulus
Response
(LeDoux, 1996)
Between Stimulus and Response
Cortex
Hippocampus
Slower
Amygdala
Sensory Thalamus
Very Fast
Stimulus
Response
(LeDoux, 1996)
Between Stimulus and Response
Cortex
Hippocampus
Slower
Amygdala
Sensory Thalamus
Very Fast
Stimulus
Response
(LeDoux, 1996)
What Does This Mean
for Our Programs and Services?
 Think about how childhood adversity might have shaped
kids’ behavior & your choices
 People receiving services are not sick or bad…they are
injured
 The question is not “What is wrong with you?“ but what
happened to you?”
 The way out is not the same as the way in…pain based
interventions do not work
 Things change when you change things
 Kids need hopeful, optimistic, positive, caring people in their
lives
What Does This Mean
for Schools?
 Kids are doing the best they can, most days. They lack
the skills they need
 Things change when you change things
 Kids need hopeful, optimistic, positive, caring people in
their lives
 We are doing life and death work
• Visit the ACE Website www.acestudy.org
So, What Can I Do?
• Take nothing personally / Never mirror negative
behavior or affect
• Remain calm and supportive…staff with a heart rate
of 100 cannot help kids with a heart rate of 100
• Make and practice emergency management plans
• Process, Pattern Recognition, Feelings Drive
Behavior, Integration
• Take it at 45…not head on
So, What Else Can I Do?
• Calm the heart…yours and theirs
• Identify reenactments - riveting on threat,
encourages reenactment
• Be creative, be crazy creative…Change is risky
business – take some risks
• Sometimes do the opposite of what feels right
• Discipline is important…love, attachment,
relationship is the secret sauce. Way more
important.
…Oh, By the Way What
About You?
As Waves are the Practice
of Water, so Violence is
the Practice of Trauma
- Robert Macy
Brian Farragher, MSW, MBA
Executive Director
Hanna Boys Center
(707) 787-8949
bfarragher@hannacenter.org