1. Mental, Physical, Behavioral Health
ACEs in Washington
&
Mental, Physical, Behavioral Health  

2. ADVERSE CHILDHOOD EXPERIENCES (ACEs)?
WHAT ARE THE
ADVERSE CHILDHOOD EXPERIENCES (ACEs)?
Child physical abuse
Child sexual abuse
Child emotional abuse
Neglect
Mentally ill, depressed or suicidal person in the home
Drug addicted or alcoholic family member
Witnessing domestic violence against the mother
Loss of a parent to death or abandonment, including abandonment by divorce
Incarceration of any family member
In the first wave of the study—about 8,000 people, Drs. Anda and Felitti asked about 8 of the experienced listed in the slide —they didn’t include neglect. In the next wave, they did ask about neglect. If you read articles about the ACE study, you will see some reference to 8 ACE categories, and in other articles you’ll see reference to 9 ACE categories. That’s the difference.
ACEs include:
Four forms of abuse: physical, emotional, sexual and violence against the mother;
Neglect; and
Indicators of household functioning: mentally ill, depressed or suicidal person in the home, drug addicted or alcoholic family member, incarceration of a family member, and loss of a parent.
The researchers did ask about severity of abuse, duration and other kinds of questions that are important to folks working in child safety. But when it comes to health outcomes, they found that what matters is the number of kinds of adverse childhood experiences.
I want to acknowledge that this information can be hard for us, for a variety of reasons. We all know people who have struggled with these experiences. Many of us have served children who are struggling with them. And adverse childhood experiences are personal to most people in this room. The study found that over 60% of Americans has one or more of these experiences, so the data can really hit home.
I want to let you know that over 2,000 Washingtonians have seen this Power Point to date. Some folks have been very deeply touched by the data—moved to tears, even. And that’s really okay. I want you to know that many of those folks have said afterwards that they feel liberated. They will often say: “Oh, these things in my life are connected. My life is hard for some very good reasons.”
Some people have asked if there are other ACEs. The answer is “probably yes”. These nine types of experience are proxy for toxic stress – the kind that creates elevated stress hormones for prolonged periods of time – through critical or sensitive developmental periods. Researchers at Washington State University Area Health Education Center discuss these issues using the term “complex trauma”. They explain that complex trauma includes episodic traumatic events – when the child doesn’t know when the next blow is coming – stress hormones remain elevated for long periods of time.

3. The ACE Score is the number of categories of adverse childhood
COUNTING ACEs
The ACE Score is the number of
categories of adverse childhood
experience to which a person was
exposed.
The ACE Study found that the number of categories, not necessarily the frequency or severity of the experiences within a category, determine health outcomes across the population as a whole.
When this presentation says “3 ACEs” it means that an individual experienced 3 different categories from this list. It’s important to understand that growing up with 2 alcoholic parents counts as one point—for drug addicted or alcoholic family member; being beaten repeatedly by the same parent counts as 1 ACE—for physical abuse; being molested by 3 different people counts as 1 ACE—for sexual abuse. When taken across the population, this understates the very clear and compelling results you will see here.
The researchers asked participants several questions about each of the adverse childhood experiences so that they could test whether each variable made a difference with respect to physical, mental and behavioral health outcomes across the population.
The findings are very, very clear: the more categories of ACES experienced, the poorer the physical, mental and behavioral health outcomes across the lifespan.
It’s very possible that these findings do not surprise you, but instead confirm what you have observed in the course of your personal or professional life. About 3 years ago, the Family Policy Council interviewed over 300 community leaders across Washington State and found that over 80% of you believe that child abuse, child neglect & witnessing domestic violence lead to: youth substance abuse; youth violence; teen pregnancy; youth suicide; and dropping out of school—in that order.
The ACE Study either did not ask about youth violence or dropping out or their findings in those areas are not yet available. But among the health outcomes the investigators have analyzed for, it’s clear that you, as Washington’s leaders are on to something!

4. PHYSICAL, MENTAL & BEHAVIORAL OUTCOMES
LIFE LONG
PHYSICAL, MENTAL & BEHAVIORAL OUTCOMES
Alcoholism & alcohol abuse
Chronic obstructive pulmonary disease & ischemic heart disease
Depression
Fetal death
High risk sexual activity
Illicit drug use
Intimate partner violence
Liver disease
Obesity
Sexually transmitted disease
Smoking
Suicide attempts
Unintended pregnancy
Early Death
Adverse Childhood Experiences account for a significant portion of a wide array of health problems – ranging from depression and hallucinations to heart disease, liver disease, unintended pregnancy and early death.
Because of the number of different health problems attributable to ACEs and the proportion of each disease in the population that is attributable to ACEs, we know that ACEs are the most powerful determinate of the public’s health.
This is a partial list. As the scientists have continued to analyze the data, they have found a dose response relationship with other important outcomes as well, such as 3 or more marriages, emergency room use, pharmacy use and significant financial problems.
It is important to note that these outcomes are not the only outcomes attributable to ACEs; and that only a portion of each of these diseases can be is attributable to ACEs. Some alcoholism, for example, does not have it’s origins in Adverse Childhood Experience; Some heart disease does not have it’s origins in Adverse Childhood Experience.
The higher the ACE Score, the greater the incidence of
co-occurring conditions from this list.

5. YES – Findings Meet All 9 Criteria
ADVERSE CHILDHOOD EXPERIENCE DRAFT
Do ACEs Cause Problems?
YES – Findings Meet All 9 Criteria
A strong association between the causative agent and the outcome
Consistency of findings across research sites and methods
Specificity “The ACE Score is associated with numerous outcomes, so specificity is lacking, but this in no way detracts from the argument of causation. ACEs would be expected to be associated with multiple outcomes because of their effects on a variety of brain structures and functions; and this is found to be true.” Anda, 2009
Temporal sequence – ACEs occur before associated mental, physical, behavioral disorders
Biological gradient -The “dose-response” relationship between the number of ACEs and each of the outcomes (as well as the number of resulting health problems) is strong and graded.” Anda, 2009
Biological plausibility - strength of the convergence between epidemiology and neurobiology is most evident
Coherence - The cause and effect interpretation for an association does not conflict with what is known about the natural history and biology of the disease)
Analogous evidence - We all know the analogy for exposure causing multiple outcomes: smoking causes cardiovascular diseases, neoplasms, lung disease, and more.
Experimental evidence - For ethical reasons randomized experiments depend on animal studies: Evidence in rodents & primates show that stressful exposures induce neurologic differences, aggression , drug seeking
The ACE study helps us understand what happens to health across the whole population when individuals are exposed to adverse childhood experience. The study is epidemiological research designed by a Senior Scientist at the CDC, Dr. Robert Anda. Dr. Anda has won many prestigious awards for his scientific achievements. – including his achievements with the ACE Study. Epidemiologists, like Dr. Anda, use a systematic approach to determine whether a relationship between a factor and a population health effect is causal.
Once they discover causal factors, they can develop sound methods for preventing and controlling health problems. Public health research provides a basis for action even when the exact causal mechanism for disease is unknown. For example, in 1854, knowing that polluted water led to cholera enabled authorities to adopt policy requiring all water companies in London to filter their water. Although the specific bacterium causing the infection was unknown, cholera was largely controlled, and health improved.
They know a causal relationship exists when an exposure to a disease agent produces a regular and predictable change in the risk of the disease. Epidemiologists work with information about the population as a whole; they don’t do experiments with individual people to see if a disease agent causes disease in each individual. They use a set of criteria, established by Sir Austin Bradford Hill and further developed by the US Surgeon General’s office in to infer cause. That criteria has nine factors which are listed on this slide. Using the criteria, epidemiologists argue that evidence supports or detracts from making a causal judgment. In the case of the ACE study, there is no evidence that detracts from making a causal judgment ; all of the criteria are met for inferring cause. Therefore, we can say that ACEs cause many mental, physical, and behavioral health problems that occur through a lifetime. In fact, ACEs are the most powerful determinate of the public’s health.
You may not be an epidemiologist, but you do have expertise that is valuable. Everyone who is willing to help is needed at this time. We believe that knowing the ACE study will help you improve your own health and the health of your family, and also improve the ways that we, as a society, help children and families to thrive. community and society. You can contribute better if you understand the ACE study.

6. What’s the potential? ACEs in WASHINGTON
Bend the health care cost curve
Drastically reduce mental health disorders and disability driven by mental health disorders
Stop disastrous cycles of intergenerational poverty
Afford for all children
optimal development,
school completion,
arrival at adulthood with full potential for employment success and a lifetime of well-being.
Washington will be first in the nation to have state-specific data about ACE effects on Medicaid cost centers like heart disease, diabetes, depression and anxiety. This information is vital to DSHS efforts for transformation, integration of behavioral and physical health systems, and for achieving the impacts we are focused to deliver.

7. ACEs in WASHINGTON
“Understanding Adverse Childhood Experiences isn’t to know one’s life path.
It is to open doors for the future you would like for yourself and for future generations.”
Dr. Ronald Voorhees, MD, PhD
Chief Office of Epidemiology & Biostatistics
Allegheny County Health Department

8. What’s the potential? ACEs in WASHINGTON
Bend the health care cost curve
Drastically reduce mental health disorders and disability driven by mental health disorders
Stop disastrous cycles of intergenerational poverty
Afford for all children
optimal development,
school completion,
arrival at adulthood with full potential for employment success and a lifetime of well-being.

9. Contributing Partners The Best Indicator of Healthy Collaboration
ACEs in WASHINGTON
Contributing Partners
The Best Indicator of Healthy Collaboration
Research Institutions & Researchers
Dennis Culhane; University of Pennsylvania
Paula Nurius, University of Washington
David Takeuchi, University of Washington
Paul Flaspohler, Miami University, Ohio
Julie Grevstad, Tacoma Urban Network
Geof Morgan, Seattle University and
Joel Gaffney, Miami University, Ohio
Rob Anda
David Brown
Dr. Chris Blodgett and Dr. Roy Harrington, WSU
Philanthropy
Bill and Melinda Gates Foundation
Sherwood Trust
Children’s Trust Foundation
Stuart Foundation
Government
Family Policy Council
Mental Health Transformation Grant - Prevention Advisory Group
Children and Families of Incarcerated Parents Advisory Committee
Office of the Superintendent of Public Instruction
Department of Health
Department of Social and Health Services, Office of the Secretary
Department of Social and Health Services, Children’s Administration
Community Public Health & Safety Networks

10. ADVERSE CHILDHOOD EXPERIENCE DATA
ACEs in WASHINGTON
Washington
ADVERSE CHILDHOOD EXPERIENCE DATA
Will Help Washingtonians:
Derive More Meaning From Archival and Survey Data (e.g.: HYS)
Identify High-Risk Communities with Greater Precision
Understand Drivers of Mental, Behavioral, Physical Health
Invest More Wisely – Lower Costs
Leverage Resources & Partnerships - Achieve Greater Impacts

11. ACEs in WASHINGTON
Population
Average

12. Preview of BRFSS-ACE Findings
ACEs in WASHINGTON
Preview of BRFSS-ACE Findings
ACEs are common in Washington
17% of adults report physical abuse during childhood
17% of women and 7% of men report sexual abuse during childhood
One in four adults report parental separation or divorce during childhood
A third of adults grew up with substance abuse in the household
62% of adults have at least one ACE

13. ACEs add up—more is worse
ACEs in WASHINGTON
ACEs add up—more is worse
(As captured by the ACE Score)
One in four adults report three or more ACEs
5% of adults have six or more ACEs

14. ACEs tend to co-occur / cluster
ACEs in WASHINGTON
ACEs tend to co-occur / cluster
In the lives of Washingtonians
Among adults exposed to physical abuse, 84% reported at least 2 additional ACEs
Among adults exposed to sexual abuse, 72% reported at least 2 additional ACEs

15. ACEs in WASHINGTON SMOKING As the ACE Score increases
risk of numerous health & social problems increase dramatically
SMOKING
Compared to adults without exposure to ACEs, the risk of smoking – a risk factor for many chronic diseases – was increased:
1.2 times for those with 1 ACE, * 1.5 times with 2 ACEs, * 1.9 times with 3 ACEs, * 2.8 times with 4 or 5 ACEs, * 4.6 times with 6 or more ACEs

16. ACEs in WASHINGTON Life Dissatisfaction Activity Limitation
As the ACE Score increases
risk of numerous health and social problems increase dramatically
Life Dissatisfaction
Activity Limitation
The likelihood of life dissatisfaction – a risk factor for suicide – increased with increasing ACE score
adults with 6 or more ACEs 9 times more likely to report life dissatisfaction compared to those with an ACE score of zero

17. ACEs in WASHINGTON
Health and Social Problems Shown to Have a Graded Relationship to the ACE Score in the 2009 Washington BRFSS
Type of Problem Outcome Associated with Adverse Childhood Experience
Prevalent Diseases
Cardiovascular disease, cancer, asthma
Risk Factors for Common Diseases/Poor Health
Smoking, heavy drinking, binge drinking, obesity, high perceived risk of AIDS, taking painkillers to get high, marijuana use
Poor Mental Health
Sleep disturbances, frequent mental distress, nervousness, mental health or emotional problem requiring medication, emotional problems that restrict activities
General Health and Social Problems
Fair or poor health, life dissatisfaction, health-related quality of life
Risk for Intergenerational Transmission
Mental Illness: anxiety, emotional problems that restrict activities, medication for mental health conditions
Drugs and Alcohol: Use of painkillers to get high, use of marijuana, smoking, heavy drinking, binge drinking
Loss of a Parent: Divorced-widowed-separated

18. Consistent with Earlier FPC Research, Community Capacity Matters
ACEs in WASHINGTON
Consistent with Earlier FPC Research, Community Capacity Matters

19. Consistent with Earlier FPC Research, Community Capacity Matters
ACEs in WASHINGTON
Consistent with Earlier FPC Research, Community Capacity Matters

20. ACEs in WASHINGTON

21. ACEs in WASHINGTON
“The Washington ACE data call for integrated approaches to prevent ACEs, and intervene early on children growing up being abused, neglected, witnessing domestic violence, or with substance abusing, mentally ill, or criminal household members.
All of these childhood stressors are interrelated and usually co-occur.
Prevention and treatment of one ACE frequently can mean that similar efforts are needed to treat multiple persons in affected households and other social systems.
Better identification and treatment of the effects of ACEs among persons and systems interacting with children is necessary to minimize the impact of their intergenerational transmission.”
Dr. Rob Anda, Dr. David Brown

22. ACE Reduction: a powerful framework for thriving
Washington is among the first in the nation to have state-specific data about ACE effects on Medicaid cost centers like heart disease, diabetes, depression and anxiety. This information is vital to our efforts for transformation, integration of behavioral and physical health systems, and for achieving the impacts we are focused to deliver.
As we move from research to new policy and practice, it is important to recognize two critical arenas where work with children, families, and communities needs to improve.
One focus needs to improve foundations of healthy development, especially the environment of relationships and community conditions that relationships and community environments with an eye toward reducing the median ACE score from one generation to the next.
Another focus needs to be improving societal response to people with high ACE histories, helping to surface strengths and fit those strengths into school, work, community life. One way to think about this is to remember the days before our society had a commitment to accommodation for people with physical disabilities to fully participate in community life. Now accommodations like curb-cuts – the ramps that link the sidewalk to the street at crossing locations – are a norm. We will need to develop the equivalent of curb-cuts as accommodation for high ACE folks. We don’t know what those are exactly, but we will be developing them, and need systematic means for evaluation.