Adverse Childhood Experiences and their Relationship to Adult Well-being and Disease : Turning gold into lead A collaborative effort between Kaiser Permanente and the Centers for Disease Control The ACE Study, involving over 17,000 adults, is about how we get from here to here. How do we go from a newborn with extraordinary potential to the man lying on the street whom we overlook? It relates directly and in unexpected ways to difficult problems of medical practice, public health, and social functioning that we each run into every day. I will give you just a brief sample of our findings that have been published in 70 articles thus far. This Study has attracted international interest, but there has been major resistance to using the information clinically. Invest in Children Conference Cleveland, Ohio November 17, 2011 Robert F. Anda, M.D. Vincent J. Felitti, M.D. 1

ACE Study Design Survey Wave 1 71% response (9,508/13,454) Mortality National Death Index Morbidity Hospital Discharges Doctor Office Visits Emergency Room Visits Pharmacy Utilization All medical evaluations abstracted Present vs. Health Status N= 17,337 Survey Wave II n=13,000 The origins of the Study make an interesting separate story. As a result of major counterintuitive findings in an Obesity Program we were running, we found that many of our patients had seriously abusive childhoods that seemed to be affecting them decades later. The ACE Study was carried out to determine in the general population, the prevalence of abusive experiences in childhood, and how they played out over time. Describe demographics. All medical evaluations abstracted

Prevalence of Adverse Childhood Experiences Abuse, by Category Psychological (by parents) 11% Physical (by parents) 28% Sexual (anyone) 22% Neglect, by Category Emotional 15% Physical 10% Household Dysfunction, by Category Alcoholism or drug use in home 27% Loss of biological parent < age 18 23% Depression or mental illness in home 17% Mother treated violently 13% Imprisoned household member 5% Prevalence (%) Ten categories chosen because of their unanticipated prevalence in a major Obesity Program we were running. There were rather startling prevalence findings in a general, middle-class population as well. Of course, nice people would never ask such questions routinely, so who would ever have a basis for knowing.

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%* Every doctor in the country will see at least two ACE Score 5 or higher patients every day. They will be unrecognized, though they may be the most difficult and troubling cases of the day. 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. 7

Smoking to Self-Medicate This is a very bright and articulate man whose thinking helped change ours. He describes the role of three major addictions in his life. LIFE STORY: Divorce at 3; remarriage at 5. Frequent beatings. “Age 8, “No one is ever going to be there for me.” Imprisoned in RI at 20 for attempted murder. Gets out and good citizen but 3 marriages, heavy alchol, smoking, drugs. Are these dysfunctional or FUNCTIONAL behaviors?

The traditional concept: “Addiction is due to the characteristics intrinsic in the molecular structure of some substance.” He speaks of three common addictions. Addiction is the unconscious, compulsive use of psychoactive agents. Most people believe the above about addiction. I used to believe it. An example would be the belief that if you use heroin enough, you will be unable to stop using it.

We find that: “Addiction highly correlates with characteristics intrinsic to that individual’s childhood experiences.” This is obviously a quite different idea. Here is the evidence for it.

Adverse Childhood Experiences vs. Smoking as an Adult Health Risks Adverse Childhood Experiences vs. Smoking as an Adult % This is not consonant with conventional views about billboard ads and peer pressure making kids take up smoking. It DOES fit in with knowledge about the psychoactive BENEFITS of nicotine: the fact it has potent anti-anxiety activity, anti-depressant activity, and appetite suppressant activity, AND as the Indians showed in their ceremonial use of tobacco leaves in the peace pipe, anger-suppressant activity. But, since the dramatic findings of the Surgeon General’s report in the 1960s, we’ve forgotten all that and hence have been playing in a tough game with only half a deck. p< .001

Childhood Experiences vs. Adult Alcoholism Health Risks Childhood Experiences vs. Adult Alcoholism 4+ 3 2 This is self-acknowledged adult alcoholism. “Have you ever considered yourself an alcoholic?” 1

ACE Score vs Injection Drug Use Health risks ACE Score vs Injection Drug Use At ACE Score 6, there is a 4,600% increase in the likelihood of becoming an injection drug user, as compared with an ACE Score 0 individual. We see a self-worsening exponential curve. p<0.001

Social Costs Estimates of the Population Attributable Risk* of ACEs for Selected Outcomes in Women Here we address the question of how much of the Overall problem in the population can be traced back to childhood experiences. *That portion of a condition attributable to specific risk factors

Molestation in Childhood Root Causes, Coping Mechanisms, & Outcomes Molestation in Childhood As I showed you, c hildhood sexual abuse is common even though its recognition is rare. This woman illustrates the relationship of ACEs to depression, obesity, diabetes, disability, and the social welfare system. In other words, the sequence of Root Cause, Coping Mechanism, and Outcomes both of the root cause and of the coping mechanisms.

Depression: Some say depression is a disease Depression: Some say depression is a disease. Some say depression is genetic. Some say depression is due to a chemical imbalance. Moments later she speaks of her chronic depression. All of these concepts are valid, but they represent intermediary mechanisms and modulating influences, not basic causes.

Might depression be a normal response to abnormal life experiences? Here is the evidence.

Childhood Experiences Underlie Chronic Depression Emotional costs Childhood Experiences Underlie Chronic Depression

Childhood Experiences Underlie Suicide Attempts Emotional costs Childhood Experiences Underlie Suicide Attempts 4+ 3 At ACE Score 6 and higher there is a 31-50 fold, 3,100% to 5,000% increase in the likelihood of attempting suicide as compared to an ACE Score 0 individual. 2 1

ACE Score and Rates of Antidepressant Prescriptions 50 years later Social cost ACE Score and Rates of Antidepressant Prescriptions 50 years later (per 100 person-years) Prescription rate It would appear that depression often has deep roots, extending back decades into childhood. 0 1 2 3 4 >=5 ACE Score ACE Score

Social costs Estimates of the Population Attributable Risk* of ACEs for Selected Outcomes in Women On a population basis, a major portion of mental health outcomes are directly traceable to childhood experiences. *That portion of a condition attributable to specific risk factors

Adverse Childhood Experiences vs. History of STD Biomedical Disease Adverse Childhood Experiences vs. History of STD The third category of outcome of adverse childhood experiences is that of biomedical disease. STDs, most importantly AIDS, are clearly related to adverse childhood experiences. The relationship of ACE Score to high level promiscuity is dramatic.

The ACE Score and the Prevalence of Liver Disease (Hepatitis/Jaundice) Biomedical Disease The ACE Score and the Prevalence of Liver Disease (Hepatitis/Jaundice) Percent (%) The relationship to biomedical disease makes sense, once one routinely looks back in time. AACE CE Score ACE Score

ACE Score vs. COPD Biomedical Disease 0 1 2 3 4 But not everyone with COPD is a smoker or asthmatic. There turns out to be a second pathway that we don’t have time to explore today. 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. Recently we published our findings that ACE Score 6 is associated with almost a 20 year shortening of life.

Many chronic diseases in adults are determined decades earlier, in childhood. Not by DISEASES in childhood as once was the case, but now by understandable responses to unrecognized life experiences in childhood.

Dismissing them as “bad habits” or “self-destructive behavior” comfortably misses their functionality. AND limits our capacity for meaningful and relevant response.

The risk factors underlying these adult diseases are helpful short-term coping devices. Right here we recognize a public health paradox wherein what is properly viewed as a Public Health Problem is ALSO an attempted Solution to personal problems that are lost in time and further protected by shame and secrecy and social taboos against routinely exploring certain areas of human experience like sex and family life.

Evidence from ACE Study Indicates: Adverse childhood experiences are the most basic cause of health risk behaviors, disease, disability, mortality, and healthcare costs. Well hidden by time, shame, secrecy, and social taboo.

Ultimately we are faced with the question of why these problems are so persistent. Why don’t people just get over them?

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? We saw the need to add trauma-oriented questions to our already extensive general medical questionnaire. Routine use of these and related Qs transformed our ability to understand and treat many problems that previously seemed intractable.

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