Adverse Childhood Experiences
and their Relationship to
Adult Well-being and Disease :
Turning gold into lead
A collaborative effort between
QuickTime™ and a
decompressor
are needed to see this picture.
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.
ACE Study Design
Survey Wave 1
71% response (9,508/13,454)
All medical evaluations
abstracted
Survey Wave II
n=13,000
All medical evaluations
abstracted
vs.
Mortality
National Death Index
Present
Health Status
N= 17,337
Morbidity
Hospital Discharges
Doctor Office Visits
Emergency Room Visits
Pharmacy Utilization
Prevalence of Adverse
Childhood Experiences
Abuse, by Category
Psychological (by parents)
Physical (by parents)
Sexual (anyone)
Prevalence (%)
11%
28%
22%
Neglect, by Category
Emotional
Physical
15%
10%
Household Dysfunction, by Category
Alcoholism or drug use in home
Loss of biological parent < age 18
Depression or mental illness in home
Mother treated violently
Imprisoned household member
27%
23%
17%
13%
5%
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 three experienced 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.
Smoking to Self-Medicate
QuickTime™ and a
Cinepak decompressor
are needed to see this picture.
The traditional concept:
“Addiction is due to the
characteristics intrinsic
in the molecular structure
of some substance.”
We find that:
“Addiction highly correlates with
characteristics intrinsic to that
individual’s childhood experiences.”
Health Risks
Adverse Childhood Experiences
vs. Smoking as an Adult
20
18
16
14
12
%
10
8
6
4
2
0
0
1
2
3
ACE Score
4-5
6 or more
p< .001
Health Risks
Childhood Experiences vs.
Adult
Alcoholism
18
16
4+
% Alcoholic
14
12
3
10
2
8
6
1
4
2
0
0
ACE Score
Health risks
ACE Score vs Injection Drug Use
% Have Injected Drugs
3.5
3
2.5
2
1.5
1
0.5
0
0
1
2
3
4 or more
ACE Score
p<0.001
Social Costs
Estimates of the Population Attributable Risk*
of ACEs for Selected Outcomes in Women
Drug Abuse
PAR
Alcoholism
Drug abuse
65%
50%
IV drug use
78%
*That portion of a condition attributable to specific risk factors
Root Causes, Coping Mechanisms, & Outcomes
Molestation in Childhood
QuickTime™ and a
Cinepak decompressor
are needed to see this picture.
Depression:
Some say depression is a disease.
Some say depression is genetic.
Some say depression is due to a chemical imbalance.
Might depression be a normal response to
abnormal life experiences?
Emotional costs
Childhood Experiences
Underlie Chronic Depression
% With a Lifetime History of
Depression
80
70
60
50
40
30
20
10
Women
Men
0
0
1
2
ACE Score
3
>=4
Emotional costs
Childhood Experiences
Underlie Suicide Attempts
25
4+
% Attempting Suicide
20
15
3
10
2
5
0
1
0
ACE Score
Social cost
ACE Score and Rates of
Antidepressant Prescriptions
Prescription rate
(per 100 person-years)
50 years later
100
90
80
70
60
50
40
30
20
10
0
0
1
2
ACEACE
Score
Score
3
4
>=5
Social costs
Estimates of the Population Attributable Risk*
of ACEs for Selected Outcomes in Women
Mental Health
PAR
Current depression
Chronic depression
54%
41%
Suicide attempt
58%
*That portion of a condition attributable to specific risk factors
Biomedical Disease
Adverse Childhood Experiences vs.
History of STD
Adjusted Odds Ratio
3
2.5
2
1.5
1
0.5
0
0
1
2
ACE Score
3
4 or
more
Biomedical Disease
The ACE Score and the Prevalence of Liver
Disease (Hepatitis/Jaundice)
12
Percent (%)
10
8
6
4
2
0
0
1
2
AACE CE Score
ACE Score
3
>=4
Biomedical Disease
Percent wit h Problem
ACE Score vs. COPD
18
16
14
12
10
8
6
4
2
0
ACE Score
0
1
2
3
4
With an ACE Score of 0, the
majority of adults have few,
if any, risk factors for these diseases.
However, with an ACE Score of 4
or more, the majority of adults have
multiple risk factors for these
diseases or the diseases themselves.
Many chronic diseases
in adults are determined
decades earlier, in
childhood.
Dismissing them as “bad habits” or
“self-destructive behavior” comfortably
misses their functionality.
The risk factors
underlying these adult
diseases are helpful
short-term coping devices.
Evidence from ACE Study Indicates:
Adverse childhood experiences
are the most basic cause of
health risk behaviors, disease,
disability, mortality, and
healthcare costs.
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.
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?
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)
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 prevention is presently the only feasible population approach.
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