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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
Creating Safe Environments
Phoenix, AZ.
April 9, 2013
Robert F. Anda, M.D.
Vincent J. Felitti, M.D.
Origins of the ACE Study
51 weeks later
408
132 lbs
What is the core diagnosis here?
Which photo depicts the problem?
Summary of the 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.
ACE Study Design
Survey Wave 1
71% response (9,508/13,454)
n=13,000
71% response
All medical evaluations
abstracted
Survey Wave II
n=13,000
All medical evaluations
abstracted
vs.
Mortality
National Death Index
Present
Health Status &
17,337 adults
Morbidity
Hospital Discharges
Doctor Office Visits
Emergency Room Visits
Pharmacy Costs
Empirically Selected Categories of
Adverse Childhood Experiences
Abuse, by Category
Psychological (by parents)
Physical (by parents)
Sexual (anyone, but typically family)
Prevalence (%)
11%
28%
22%
Major Neglect, by Category
Emotional
Physical
15%
10%
Household Dysfunction, by Category
Alcoholism or drug use in home
Loss of biological parent <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 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.
Smoking to Self-Medicate
Is he describing dysfunctional behavior, or is it
functional in realms of which we know nothing?
A Public Health Paradox
What are conventionally viewed
as Public Health problems are often
personal solutions to long-concealed
adverse childhood experiences.
The Hidden Threat of Weight Loss
The unspoken benefits of Obesity
Health Risks
Adverse Childhood Experiences
vs. >1 ppd 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
Social function
18
Childhood Experiences vs.
Adult Alcoholism
16
4+
% Alcoholic
14
12
3
10
2
8
6
1
4
2
0
0
ACE Score
Health Risks
ACE Score vs. Intravenous Drug Use
% Have Injected Drugs
3.5
3
2.5
2
1.5
1
0.5
0
0
1
2
ACE Score
3
4 or more
p<0.001
Molestation in Childhood
Obesity runs in this family. So does speaking English.
Familial obesity does not mean genetic.
Well-being
Childhood Experiences
Underlie Chronic Depression
% With a Lifetime History of
Depression
80
70
60
50
40
Women
Men
30
20
10
0
0
1
2
ACE Score
3
>=4
Death
25
Childhood Experiences
Underlie Later Suicide
4+
% Attempting Suicide
20
15
3
10
2
5
0
1
0
ACE Score
Costs
Childhood Experiences Underlie
Later Prescription of Antidepressants
Prescription rate
per 100 person-years)
approximately 50 years later
100
90
80
70
60
50
40
30
20
10
0
5 or
4
3
2
1
0
ACE Score
more
Social malfunction:
ACE Score and Indicators of
Impaired Worker Performance
25
ACE Score
20
0
1
2
3
4 or more
15
10
5
0
Absenteeism
(>2 days/month)
Serious
Financial
Problems
Serious
Problems
Performing job
Biomedical disease
ACEs Increase Likelihood of Heart Disease*
•
•
•
•
•
•
•
•
•
Emotional abuse
Physical abuse
Sexual abuse
Domestic violence
Mental illness
Substance abuse
Household criminal
Emotional neglect
Physical neglect
1.7x
1.5x
1.4x
1.4x
1.4x
1.3x
1.7x
1.3x
1.4x
* After correction for age, race, education, and conventional risk factors like smoking and
.
diabetes.
Circulation , Sept
2004
Newly Recognized Biomedical Relationships
Well-being
Childhood Experiences Underlie Rape
35
4+
30
% Reporting Rape
25
20
3
15
2
10
1
5
0
0
ACE Score
Disease
Ever Hallucinated* (%)
ACE Score and Hallucinations
Abused
Alcohol
or Drugs
ACE Score
*Adjusted for age, sex, race, and education.
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!
Further Information
www.acestudy.org
http://www.cdc.gov/NCCDPHP/ACE/
Medline – PubMed
(Felitti or Anda as author name)
[email protected]
AVAHealth.org
(Detailed DVD)