1. Adverse Childhood Experiences A Brief Review of the Facts
I am a professor at Michigan State University who, over the past 40 years, has served in a variety of capacities in state government, including in support and volunteer roles for several governors, and I am a retired health care executive. I am making this presentation in my capacity as a volunteer member of the CDC child maltreatment prevention task force. Through my association with CDC, the Children’s Trust Fund of Michigan and Prevent Child Abuse America, I heard about the studies I am going to share with you. I am not advocating any specific policy or state action. Everyone is entitled to their own opinion, but hopefully we will all benefit from understanding these facts.
As reported by: Richard T. Cole PhD
Professor, Michigan State University

2. Origins of ACE studies
CDC and Kaiser Permanente (Robert Anda, MD Vincent Felitti, MD et al, 60 medical studies, )
“Adverse Childhood Experiences and Population Health, State of Washington: The Face of a Chronic Public Health Disaster” (Robert Anda and David Brown, July 2, 2010)
*Available on request
Drs. Vincent Feletti (Kaiser Permanente) and Robert Anda (CDC), around 1995 began to look at results of questionnaires of adults regarding traumatic experiences they may have had as children. They compared reports of childhood trauma with the personal medical records of the people they talked to. Now, 60 studies have been done thus far, and their work has been replicated in the State of Washington, and elsewhere. It’s important to point out that, for reasons we don’t necessarily know, not all children who are traumatized show signs of having problems as adults. This is important to understand.

3. The findings are in
10 Specific Adverse Child Experiences (ACEs) have been identified
Patient-reported childhood experiences matched against more than 17,300 HMO medical records
The researchers identified 10 types of ADVERSE CHILDHOOD EXPERIENCES (ACEs), which I will identify in a moment, and they matched these reports with medical records. The initial population studied was an HMO population, which means largely working people with health care coverage.

4. Childhood “stressors” directly connected to costly adult psychological, emotional and physical illnesses
They found what they expected. Children with ACEs (stressors in childhood) were more likely to have psychological and emotional problems as adults. No surprise here. But what was shocking to the teams of medical researchers was the connection they found between childhood stress and serious adult physical illness.

5. Studies Identified 10 ACE Categories -“Stressors”
1. Recurrent emotional abuse
2. Recurrent physical abuse
3. Sexual abuse
4. Witnessed domestic violence
5. Household alcohol or drug abuse
6. Household mental illness
7. Parents separated/divorced
8. Incarcerated household member
9. Emotional neglect
10. Physical neglect
These are the ten categories of ACEs. I’ll walk you through each one next.

6. ACE 1. Recurrent Emotional Abuse
As a child, did you experience… Excessive verbal abuse such as yelling, swearing? Fear of physical harm?
The questionnaires asked about recurrent emotional abuse rising to the level of fear of physical harm.

7. ACE 2. Recurrent Physical Abuse
As a child, did your parent or guardian…
Push you, grab you, slap you, throw something at you?
Hit you so hard it left marks?
We are not talking about occasional spanking here, everyone has an opinion on that. We are talking about physical abuse.

8. ACE 3. Sexual Abuse Stressor
As a child… Were you touched in sexual way? Were you sexually molested?
Most people are shocked to find out that about 15% of the US adult population reports having been sexually abused as a child. This is the kind of heinous act that grabs headlines, as it should, but it sometimes causes us to overlook other kinds of trauma that kids go through.

9. ACE 4. Domestic Violence Stressor
As a child, did you witness a male …
Push grab, slap or throw something at your mother?
Kick, bite or hit her with his fist?
Threaten her with a knife or gun?
We think about how horrible domestic abuse is – normally, but not always – male on female. Imagine what it must be like for a child to live in a situation where he or she is witnessing a parent being constantly yelled at or beaten or threatened with a weapon.

10. ACE 5. Household Alcohol or Drug Abuse
As a child, did you… Live with a problem drinker or alcoholic? Live with someone who used street drugs?
Living with a problem drinker or a street drug user is a terrible problem for kids. Of course, this condition is also more likely accompanied by other forms of trauma to children.

11. ACE 6. Household Mental Illness
As a child… was anyone in your house mentally ill or depressed?
The same is true of a child who is raised with a mentally ill or depressed family member. The trauma associated with this condition is also often compounded by other stressors that may also be present in the house or neighborhood.

12. ACE 7. Divorce or Separation
As a child… were your parents separated or divorced?
Of course, we all understand that a divorce may under certain circumstances improve the conditions within which a child is living, but imagine that under those circumstances what lead up to the divorce most likely was very traumatic to the child, and the divorce itself is most often very difficult for a child to deal with.

13. ACE 8. Incarcerated Household Member
As a child, was anyone in your family in jail?
This is one that I had never thought of and have wondered what we are doing as a society to intervene in the lives of the children left behind when a parent is put in jail or prison?

14. ACEs 9 and 10: Emotional and Physical Neglect
Neglect is harder to identify, perhaps, but the impact of neglect on a child can be very damaging.

15. Prepare yourself for a sample of the findings from several studies
What I am about to show are the results from about a dozen of the 60 (or more) studies that have been done to identify the impact that adverse experiences in childhood (ACEs) can have on adult psychological, emotional and physical health.

16. Research Confirms Compounding Effects of ACES (Stressors) -- The more ACEs and, -- The more intense the ACEs … …The more adult emotional, mental and physical health illness.
Roughly half of the US population reports having experienced at least one category of ACEs – “stressors” – as children. It turns out that as you would expect, the more of these stressors an adult experienced as a child, and the more intense the ACEs were, the more adult emotional, mental and PHYSICAL illness the researchers have found. I put emphasis on PHYSICAL illness because, to me, this was the most unexpected finding in the studies.

17. Suicidal Ideation and ACEs
Children with adverse childhood experiences tend to think more about killing themselves.
(Cicchetti et al, 2010)
We know that even as children, people undergoing dangerous stress think more about suicide, and we know more.

18. Adult Suicide Attempts and ACEs
Adverse Childhood Experiences compound the risk of suicide attempts in adulthood.
(Dube et al, 2001)
As you would expect, adult suicide attempts increase with the number of ACEs a person has experienced as a child.

19. Adult Mental Illness and ACEs
ACEs increase incidence of mental illness in adulthood.
(Edwards et al, 2003)
And the more ACEs – stressors – experienced as a child, the more likely an adult is to have mental illness, and

20. Adult Depression and ACEs
The more ACEs, the greater the likelihood of adult depression.
(Chapman et al, 2004)
With childhood adverse experiences comes an increased likelihood of the child having depression as an adult.

21. Promiscuity and ACEs
ACEs increase the likelihood of sexual intercourse by age 15 increasing the likelihood of AIDS and other STDs.
(Hillis et al, 2001, Anda et al, 2002b)
Children with more adverse childhood experiences are more likely to engage in sex as a young teenager, and besides pregnancy, a by-product of early sexual experimentation is sexually transmitted disease.

22. Teen Drug Use and ACEs The more ACEs, the more teenage drug use.
(Dube et al 2003 (b)
And, of course, no one was very surprised to find that children who experience ACES are more likely to experiment with drugs as teenagers. The early ACEs studies contain commentary suggesting that what the researchers were finding were “coping mechanisms”, self-medication, if you will. But the researchers started to dig deeper, and what they began to find were serious physical illness directly connected to experiences that happened in an adult’s childhood.

23. Adult Health Problems and ACEs
The more stressors in childhood, the more adults show increased physical health problems.
(Dube et al, 2003a)
Researchers found problems in various organs – and most recently have uncovered a connection to lung cancer that cannot be explained simply by higher rates of cigarette smoking.

24. Adult Heart Disease and ACEs
ACEs are linked to a higher rate of Ischemic heart disease in adults.
(Dong et. al, 2004)
Then they looked at the hearts of adults who have been abused or neglected or suffered other serious stressors as children. They found a higher incidence of ischemic heart disease – How could this be?

25. Changed Brain Structure and ACEs
Child maltreatment is linked to a variety of changes in brain structure.
(Anda et al, 2004) (
Then they used new MRI technology to look at brains, and they found differences in the brain structure, sometimes, of people who as children experienced significant stress. Now they began to consider that there is such a thing as “toxic stress.”

26. Lasting Health Effects of ACEs
Attributed to the neurological and biological effects of “toxic stress” on children.
(Dube et al, 2003a)
And the medical researchers began to say that this toxic stress may be producing chemicals in the body that young, developing organs are simply incapable of handling without suffering some kind of damage.

27. Explanation for lifetime effect of ACEs
Increases in
heart rate, blood pressure, serum glucose, stress hormones, “fight or flight”…
Related to long-term disruptions in
brain architecture, immune systems, metabolic regulation, cardio-vascular function
(Center on Developing Child, Harvard University)
Think about the different kinds of harmful stress to which a small child is being exposed. The increase in heart rate, blood pressure, serum glucose, stress hormones, adrenaline – whatever – cannot be good for a developing brain, heart, immune system. I think about this almost as the kind of post traumatic stress syndrome we see in soldiers, but a child witnessing his mother being beaten has no physical or emotional training for that, no weapon to fight back with, and, unlike a soldier, his or her organs are still developing.

28. This is a chart the CDC developed to show us a sequence that is leading to tremendous loss of human potential, tremendous tragedy as stressors are passed from generation to generation, and a tremendous cost of physical and mental health care that we are allowing to be passed on to our grandchildren. Where will it stop?

29. The power of STRESSORS
ACEs have differing effects on children (Fortunately not all ACEs result in adult conditions)
Some children and adults appear more resilient than others
Not all childhood “stress” is harmful
Some harm from ACEs may be reparable
Some stressors may be “toxic”
Each childhood STRESSOR exaggerates the effects of others
This is kind of my caveat – to remind the person learning about this for the first time that just because they have experienced some of these situations as a child does not mean they themselves are “damaged” in any way. Some people have miraculous resistance or resilience. And its also true that not all stress is harmful. We even say sometimes that successful people are driven by their insecurity and that insecurity produces a certain kind of stress, but its not thought of as TOXIC to an adult worrying about a promotion or the results of their next election.

30. The words of Dr. Anda explain my mission
The chronic public health disaster of adverse childhood experiences and their effects on human development are real. The public health impact of ACEs can now only be ignored as a matter of conscious choice. Thus, with this information comes the responsibility to use it.
Robert Anda, MD
Center for Disease Control and Prevention
July 2, 2010
So, when you ask me why I decided to see how many legislators I could tell this story to in February of 2011 – what was I thinking? The cover letter to the report that Dr. Anda, from the CDC, attached to a study that was done on the population of the State of Washington addressed the huge cost of this “public health disaster”, and dumped this message in our laps.
“The public health impact of adverse childhood experiences can now only be ignored as a matter of conscious choice. Thus, with this information comes the responsibility to use it.”

31. SAMPLE SOURCES -- MORE THAN 60 STUDIES…
Anda et al, “Adverse Child Experiences, Alcoholic Parents, and Later Risk of Alcoholism and Depression”, J Psychiatric Serve 53: , August 2002 (a)
Anda et al, “Adverse Childhood Experiences and Risk of Paternity in Teen Pregnancy”, Obstetrics and Gynecology, Volume 100, Issue 1, pp , July 2002 (b)
Anda et al, “The Enduring Effects of Abuse and Related Adverse Experiences in Childhood”, Child Abuse and Neglect, Volume 28, Issue 7, pp , July 2004
Chapman et al, Adverse Childhood Experiences and the Risk of Depressive Disorders in Adulthood, Journal of Affective Disorders, 2004, Volume 82, Pages
Cicchetti et al, “Interaction of Child Maltreatment and 5-HTT Polymorphisms: Suicidal Ideations among Children…” Journal of Pediatric Psychology, 2010; 35:
Dong et al, “Insights Into Causal Pathways for Ischemic Heart Disease”, American Heart Association Journal, 2004, 110:
Dube, et al, “Child Abuse, Household Dysfunction and the Risk of Attempted Suicide Through the Life Span”, JAMA 2001; 28:
Dube, et al, “Adverse Childhood Experiences and Personal Alcohol Abuse as an Adult…”, Addictive Behaviors, Volume 27, Issue 5, September-October 2002, pp
Dube (a), et al, “The impact of adverse childhood experiences on health problems…” Preventive Medicine, Volume 37, Issue 3, September 2003 (a), Pages
Dube, et al, Child Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use…, Pediatrics, Volume 111, No. 3, March 2003 (b), pp
Edwards, et al, “Relationship Between Multiple Forms of Childhood Maltreatment and Adult Mental Health…” Am J Psychiatry 160: (August, 2003)
Hillis et al, “Adverse Child Experiences and Sexually Transmitted Diseases in Men and Women…”Pediatrics, Vol 106, No 1, July 2000, p. e11
Hillis et al, “Adverse Childhood Experiences and Sexual Risk Behaviors in Women…” Family Planning Perspectives, Volume 33, No % (September-October, 2001, pp
Hillis et al, “The Association Between ACEs and Adolescent Pregnancy, Long-Term Psychosocial Consequences and Fetal Death”, Pediatrics, Vol 113, No2, Feb 2004, pp
MORE FINDINGS AVAILABLE __ CDC DOCUMENT

32. For more Information
Centers for Disease Control and Prevention Children’s Trust Fund of Michigan Prevent Child Abuse America