1. Adverse Childhood Experiences and their Relationship to Adult Well-being, Disease, and Death : Turning gold into lead A collaborative effort between Kaiser Permanente and the Centers for Disease Control Robert F. Anda, M.D. Vincent J. Felitti, M.D. Creating Safe Environments Phoenix, AZ. April 9, 2013

2. Origins of the ACE Study 51 weeks later What is the core diagnosis here? Which photo depicts the problem? 408 132 lbs

3. Summary of t he ACE Study The ACE Study is a retrospective and prospective analysis in 17,337 middle-class adults of the effects of ten categories of adverse life experiences in childhood. The very existence of these experiences was found to be quite unexpectedly high, though unrecognized because they are lost in time and protected by shame, by secrecy, and by social taboos against routinely exploring certain realms of human experience. Their effect a half century later is powerfully and proportionately related to the number of categories of adverse life experiences in childhood, and thereby is a major determinant of well-being, health risks, mental illness, occupational performance, social malfunction, biomedical disease, and premature death.

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

5. Empirically Selected Categories of Adverse Childhood Experiences Abuse, by Category Psychological (by parents)11% Physical (by parents)28% Sexual (anyone, but typically family)22% Major Neglect, by Category Emotional15% Physical10% Household Dysfunction, by Category Alcoholism or drug use in home27% Loss of biological parent <18 23% Depression or mental illness in home17% Mother treated violently13% Imprisoned household member 5% Prevalence (%)

6. Adverse Childhood Experiences Score Number of categories (not events) is summed… ACE Score Prevalence 033% 125% 215% 3 10% 4 6% 5 or more 11%* Two out of three adults 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 a 50% chance of three or more. Women are 50% more likely than men to have an ACE Score >5.

7. Smoking to Self-Medicate Is he describing dysfunctional behavior, or is it functional in realms of which we know nothing?

8. What are conventionally viewed as Public Health problems are often personal solutions to long-concealed adverse childhood experiences. A Public Health Paradox

9. The Hidden Threat of Weight Loss The unspoken benefits of Obesity

10. Adverse Childhood Experiences vs. >1 ppd Smoking as an Adult % P<.001 Health Risks

11. Childhood Experiences vs. Adult Alcoholism 0 1 2 3 4+ Social function

12. ACE Score vs. Intravenous Drug Use p<0.001 p<0.001 Health Risks

13. Molestation in Childhood Obesity runs in this family. So does speaking English. Familial obesity does not mean genetic.

14. Childhood Experiences Underlie Chronic Depression Well-being

15. Childhood Experiences Underlie Later Suicide 1 2 0 3 4+ Death

16. Childhood Experiences Underlie Later Prescription of Antidepressants Prescription rate per 100 person-years) 0 1 2 3 4 5 or more Costs approximately 50 years later ACE Score

17. Social malfunction: ACE Score and Indicators of Impaired Worker Performance 0 5 10 15 20 25 01234 or more ACE Score Absenteeism (>2 days/month) Serious Financial Problems Serious Problems Prevalence of Impaired Performance (%) Performing job

18. ACEs Increase Likelihood of Heart Disease* Emotional abuse1.7x Physical abuse1.5x Sexual abuse1.4x Domestic violence1.4x Mental illness1.4x Substance abuse1.3x Household criminal 1.7x Emotional neglect1.3x Physical neglect1.4x * After correction for age, race, education, and conventional risk factors like smoking and diabetes.Circulation, Sept 2004. Biomedical disease

19. Newly Recognized Biomedical Relationships

20. Childhood Experiences Underlie Rape0 1 2 3 4+ Well-being

21. ACE Score Ever Hallucinated* (%) Abused Alcohol or Drugs *Adjusted for age, sex, race, and education. ACE Score and Hallucinations Disease

23. Turning Research into Practice a beginning Set up properly, and in high volume, comprehensive medical evaluation affordably can be provided to all patients at the outset of ongoing medical care. Comprehensive biomedical evaluation provides a net 11% reduction in DOVs in the subsequent year. Comprehensive biopsychosocial evaluation, which incorporates ACE Study findings, provides a 35% reduction in DOVs in the subsequent year compared to the prior year. ( 125,000 patient sample) Imagine the possibilities!

24. Further Information www.acestudy.org http://www.cdc.gov/NCCDPHP/ACE/ Medline – PubMed (Felitti or Anda as author name) VJFMDSDCA@mac.com AVAHealth.org (Detailed DVD)