the buffer zone: what adverse childhood experiences (ace) study teaches about maximizing health and...

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This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military

Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.

The Buffer Zone: What the Adverse Childhood

Experiences (ACE) Study Teaches about

Maximizing Health & Wellbeing

Connecting military family service providers

and Cooperative Extension professionals to research

and to each other through engaging online learning opportunities

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MFLN Intro

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Today’s Presenters

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Melissa Merrick, PhD

• Behavioral Scientist with the Surveillance

Branch in the Division of Violence

Prevention at CDC’s National Center for

Injury Prevention and Control.

• Serves as the Science Lead for the

Adverse Childhood Experiences (ACE)

Study.

• Research interests focus on the etiology,

surveillance, course, and prevention of child

maltreatment.

National Center for Injury Prevention and Control

The Buffer Zone: What the Adverse Childhood Experiences (ACE) Study Teaches about Maximizing

Health & Wellbeing

Melissa T. Merrick, PhD

Behavioral Scientist

Division of Violence Prevention

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the issue

1 BILLION CHILDREN EXPERIENCE VIOLENCE

ANNUALLYhttps://static.pexels.com/photos/207653/pexels-photo-207653.jpeg

Child Abuse & Neglect

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Physical

Abuse

Sexual

Abuse

Emotional

AbuseNeglect

children experienced child abuse and

neglect in the last year. That is millions of

kids. (self-report data)

About 1 in 7

https://static.pexels.com/photos/262488/pexels-photo-262488.jpeg

Building Brain Architecture

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https://pixabay.com/en/brain-electrical-knowledge-migraine-1845962/https://pixabay.com/en/construction-worker-building-job-642631/

Violence Compromises Early Brain

Development

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How Brains are Built

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http://www.albertafamilywellness.org/resources/video/how-brains-are-built-core-story-of-brain-development

Picture This…

When you think of child abuse and neglect, you likely

picture this

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https://www.flickr.com/photos/k9d/1414360666

https://pixabay.com/en/child-education-fear-terror-1439468/

https://commons.wikimedia.org/wiki/File:Fractured_ribs.jpg

https://commons.wikimedia.org/wiki/File:Orthopedic_cast_Vincent%27s_Gips_Arm.jpg

Picture This…

But probably not this

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https://pixabay.com/en/diabetes-blood-finger-glucose-777001/https://commons.wikimedia.org/wiki/File:Asthma_inhaler_use.PNG

https://pixabay.com/en/body-upper-body-hand-t-shirt-keep-116585/ https://www.flickr.com/photos/amboo213/4020584983

Risky Behaviors Alcohol & DrugAbuse

Unsafe Sex

CancerDiabetes

HIVSTDs

Unintended Pregnancy

PregnancyComplicationsFetal death

DepressionAnxiety

PTSD

Traumatic Brain Injury

FracturesBurns

Violence

Violence in the

Public Health Context

Categories of ACEs

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Abuse Neglect Family Challenges

http://www.rwjf.org/en/library/infographics/the-truth-about-aces.html

How Common are ACEs?

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Lasting Effects

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0

0.5

1

1.5

2

2.5

3

3.5

Dong, M et al. Circulation. 2004;110:1761–1766.

Ad

just

ed O

dd

s R

atio

Number of ACEs

0 1 2 3 4 5,6 7,8

ACE Score and Cardiovascular Disease

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0

1

2

3

4

5

6

Number of ACEs

Ad

just

ed

Od

ds

Rat

io

Chapman, DP et al. Journal of Affective Disorders. 2004;82:217–225

Gonzalez, O et al. MMWR. 2010;59(38):1229-1235

0 1 2 3 4 ≥5

ACE Score and Adult Depression

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Ad

just

ed

Od

ds

Rat

io

Number of ACEs

0

2

4

6

8

10

12

0 1 2 3 ≥4

Number of ACEs

Ever-injected drugs Had ≥50 intercourse partners Ever had an STD

Felitti, VJ et al. American Journal of Preventive Medicine 1998;14:245–258

ACE Score and HIV Risk

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Ad

just

ed

Od

ds

Rat

io

Number of ACEs

Dube et al. JAMA. 2001;286:3089–3096.

ACE Score and Suicide Attempts

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Ad

just

ed O

dd

s R

atio

ACE Score and Life Potential

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Leading Causes of Death in the U.S. in

2014 1. Heart disease

2. Cancer

3. Chronic lower respiratory diseases

4. Unintentional injuries (accidents)

5. Stroke

6. Alzheimer’s Disease

7. Diabetes

8. Influenza and Pneumonia

9. Nephritis, Nephrotic Syndrome, and Nephrosis (Kidney Disease)

10. Intentional Self-Harm (Suicide)

21The National Vital Statistics Report (NVSR) “Deaths: Final Data for 2014”

Leading Causes of Death in the U.S. in 2014

1. Heart disease

2. Cancer

3. Chronic lower respiratory diseases

4. Unintentional injuries (accidents)

5. Stroke

6. Alzheimer’s Disease

7. Diabetes

8. Influenza and Pneumonia

9. Nephritis, Nephrotic Syndrome, and Nephrosis (Kidney Disease)

10. Intentional Self-Harm (Suicide)

22The National Vital Statistics Report ( NCSR) “Deaths: Final Data for 2014”

ACEs in Children and Adolescents

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https://pixabay.com/en/children-silhouette-cheers-1499274/

ACEs in Children & Adolescents

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ACE Constructs NatSCEV NSCAW II LONGSCAN

Physical Abuse • • •

Sexual Abuse • • •

Physical Neglect • • •

Emotional Neglect • •

Psychological / Emotional Abuse• • •

Caregiver Treated Violently • • •

Household Substance Abuse • • •

(caregiver only)

Household Mental Illness • • •

(caregiver depression

only)

Parent Separation or Divorce • •

Incarcerated Household Member • • •

ACE Score

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Total Number of ACEs

% o

f sam

ple

rep

ort

ing A

CE

s

NSCAW II: ACEs by Age Group

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Economic Consequences of Violence

➢ Child Maltreatment

• $124 billion total lifetime cost associated with one year of

confirmed cases of maltreatment

➢ Intimate Partner Violence

• $8.3 billion (1995 estimate adjusted to 2003)

➢ Sexual Violence

• $6.5 billion dollars in 1996 for a single state (Michigan)

• $126 billion annually in US for victim costs

27CDC (2003); Fang, Brown, Florence, & Mercy (2012); National Institutes of Justice (1996); Post et al., (2002)

The Public Health Impact of Violence

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Violence Across the Lifespan

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Role of Public Health Violence Prevention

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Role of Criminal Justice, Child Welfare, Social Services

Preventing child maltreatment

requires understanding

WHYsome children and families

are at greater risk

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CDC’s Strategic Focus on Child

Maltreatment

• Prevent violence through surveillance,

research and development, and capacity

building

• Emphasis on primary prevention

• Commitment to developing rigorous

science base

• A cross-cutting perspective

• A population approach

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https://pixabay.com/en/family-uncle-familia-nephew-child-1804701/

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Safe Stable Nurturing

Assuring safe, stable, nurturing relationships and

environments for all children

CDC’s Essentials for Childhood Framework

CDC’s Essentials for Childhood

➢ CDC’s Essentials for Childhood

Framework

• Raise Awareness and Commitment to

Support Safe, Stable, Nurturing

Relationships and Environments

• Use Data to Inform Action

• Create the Context for Healthy

Children and Families through Norms

Change and Programs

• Create the Context for Healthy

Children and Families through Policies

34http://www.cdc.gov/violenceprevention/childmaltreatment/essentials.html

CDC’s Essentials for Childhood

CDC Funding 5 State Health Departments

• California

• Colorado

• Massachusetts

• North Carolina

• Washington

31 Self Supported States- participating in initiative

in some way

• Training/technical assistance and meetings also available to

self supported states

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GOAL 1: Raise Awareness and Commitment

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https://www.flickr.com/photos/sydneytreasuresphotography/16046410082

The Raising of America

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➢ Raising explores how a strong

start for all our kids can lead to

a healthier, stronger, and more

equitable America

➢ Components:

▪ Six-part documentary series

▪ National public engagement

campaign

▪ Companion website

http://www.raisingofamerica.org/

GOAL 2:

Use Data to Inform Prevention Action

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39+ States Have Included the ACE

Module on their BRFSS

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http://www.health.state.mn.us/divs/cfh/program/ace/content/document/pdf/acereport.pdf

ACE Online Resources

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http://vetoviolence.cdc.gov/apps/phl/images/ACE_Accessible.pdf

https://vetoviolence.cdc.gov/apps/aces/

http://www.cdc.gov/violenceprevention/acestudy/index.html

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https://preventionboard.wi.gov/Pages/OurWork/ACE.aspx

Using Data to Inform Solutions: State

Examples

➢ Wisconsin

• Examining ACE “Hotspots”

• Added Poverty and Neglect Items to BRFSS

• Hosted Midwest Regional ACEs Summit in 2014

➢ Washington

• Legislators changed the definition of work participation for TANF

recipients

• Juvenile offenders needed additional support to mitigate future

adverse outcomes

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GOAL 3: Create the Context for Healthy

Children & Families through Norms Change &

Programs

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https://www.flickr.com/photos/armymedicine/13584554804

Essentials for Parenting: Toddlers and

Preschoolers

➢ Online interactive

resource developed for

parents with toddlers and

preschoolers

➢ Based upon best

available science

➢ Includes a variety of

content, including

• Written content, videos,

and interactive activities

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https://www.cdc.gov/parents/essentials/index.html

GOAL 4: Create the Context for Healthy

Children and Families through Policies

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http://www.buckley.af.mil/News/Photos/igphoto/2000272288/

Policies with impacts on risk factors for

child abuse and neglect

➢ Increased minimum wage

➢ Earned Income Tax Credit

➢ Child Tax Credit

➢ Housing Vouchers

➢ Head Start

➢ Bans on corporal punishment

➢ Family-friendly work

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https://pixabay.com/en/list-hook-check-mark-ticked-off-1030596/

Technical Packages

Select group of strategies with a focus on

PREVENTING child abuse & neglect

from happening in the first place as well

as approaches to LESSEN the

immediate and long-term harms of child

abuse & neglect.

48http://www.cdc.gov/violenceprevention/pdf/can-prevention-technical-package.pdf

Technical Package Development

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CDC’s Technical Package to Prevent Child

Abuse and Neglect

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Strengthen economicsupports for families

Change social norms to support parents and positive

parenting

Provide quality care and education early in life

Enhance parenting skills to promote healthy child

development

Intervene to lessen harms and prevent future risk

http://www.cdc.gov/violenceprevention/pdf/can-prevention-technical-package.pdf

Strengthen Economic Supports to Families

Strengthen household financial security

➢ Child support payments

➢ Tax credits

➢ State nutrition assistance programs

➢ Assisted housing mobility

➢ Subsidized child care

Family friendly work policies

➢ Livable wages

➢ Paid leave

➢ Flexible and consistent schedules

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http://www.59mdw.af.mil/News/Art/igphoto/2000485858/

Change Social Norms to Support Parents &

Positive Parenting

Public engagement and education campaigns

➢ Breaking the Cycle

Legislative approaches to reduce corporal punishment

➢ Bans pertaining to home, school, & other settings

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https://pixabay.com/en/girl-boy-family-together-love-603511/

Provide Quality Care & Education Early in Life

Preschool enrichment

with family

engagement

➢ Child Parent Centers

➢ Early Head Start

Improved quality of

child care through

licensing and

accreditation

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http://www.seymourjohnson.af.mil/News/Photos/igphoto/2000153166/

Enhance Parenting Skills to Promote Healthy

Child Development

Early childhood home visitation

➢ Nurse Family Partnership

➢ Durham Connects

Parenting skill and family relationship approaches

➢ Adults and Children Together Against Violence: Parents Raising

Safe Kids (ACT)

➢ Incredible Years

➢ SafeCare

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http://archive.defense.gov/News/NewsArticle.aspx?ID=120984

Intervene to Lessen Harms & Prevent Future

Risk

Enhanced primary care

➢ Safe Environment for Every Kid (SEEK)

Behavioral parent training programs

➢ Parent-Child Interaction Therapy

➢ SafeCare

➢ Incredible Years

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http://www.travis.af.mil/News/Photos/igphoto/2000266887/

Intervene to Lessen Harms &

Prevent Future Risk

Treatment to lessen harms of abuse & neglect exposure

➢ Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Treatment to prevent problem behavior and later involvement in

violence

➢ Children with Problematic Sexual Behavior Cognitive- Behavioral

Treatment Program: School- age Program

➢ Multisystemic Therapy (MST)

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https://www.pexels.com/photo/blond-haired-girl-wearing-pink-knitted-cap-48789/

Violence Prevention is Strategic

Developing New

Partnerships and

Working Across Sectors

Including:

Public Health, Government, Health

Care Services, Social Services,

Education, Business, Justice,

Housing, Non-Governmental

Organizations, Foundations

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Thank you!

Melissa T. Merrick, PhD

mmerrick@cdc.gov

www.cdc.gov/violenceprevention/acestudy

For more information, contact CDC

1-800-CDC-INFO (232-4636)

TTY: 1-888-232-6348 www.cdc.gov

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The findings and conclusions in this report are those of the authors and

do not necessarily represent the official position of the Centers for

Disease Control and Prevention.

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militaryfamilies.extension.org/webinars

64This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military Family

Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.