The ACES Study, Toxic Stress, and Building Resiliency

What Happens in Childhood Matters!

December 4, 2015Kelly L. Dauk, M.D.Erin R. Frazier, M.D.

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Objectives

• Discuss the research on Adverse Childhood Experiences

• Toxic Stress• Resiliency• Practice changes• Advocacy

“It is easier to build strong children than to repair broken men”

Frederick Douglass (1817-1895)

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With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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Origins of the ACE Study

51 weeks later

What was the core problem here?

408 132 lbs

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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Week

Weigh

t in Lb

s

100

150

200

250

300

350

400

450

Start 10 20 30 40 50 60 70 80 90

>400 lbs. in a shorter

period of time than the weight

was lost.

WeeksWith permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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ACE Study Design

Survey Wave 171% response (9,508/13,454) n=13,000

Survey Wave II n=13,000

All medical evaluationsabstracted

PresentHealth Status

Mortality National Death Index

Morbidity Hospitalization Doctor Office Visits Emergency Room Visits Pharmacy Utilization

All medical evaluationsabstracted

vs.

17,337 adults

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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Source: http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/05/Infographic-The-Truth-About-ACEs.html?cid=xsh_rwjf_tw

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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 (%)

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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Childhood Experiences Underlie Chronic Depression

0

10

20

30

40

50

60

70

80

% W

ith a

Life

time

His

tory

of

Dep

ress

ion

0 1 2 3 >=4

ACE Score

Women

Men

Well-being

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

L O U I S V I L L E . E D UWith permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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 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.

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Childhood Experiences Underlie Suicide Attempts

0

5

10

15

20

25

% A

ttem

ptin

g S

uici

de

ACE Score

12

0

3

4+

Well-being

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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ACE Score and Rates of Anti-Depressant Medication Prescriptions

0

10

20

30

40

50

60

70

80

90

100

P

resc

rip

tio

n r

ate

p

er

10

0 p

ers

on

-ye

ars

0

1

23

45 or more

Costs

approximately 50 years later

ACE ScoreWith permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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Adverse Childhood Experiences vs. Smoking as an Adult

0

2

4

6

8

10

12

14

16

18

20

0 1 2 3 4-5 6 or more

ACE Score

%

p< .001

Health Risks

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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Childhood Experiences vs. Adult Alcoholism

0

2

4

6

8

10

12

14

16

18

% A

lcoh

olic

ACE Score

0

1

23

4+

Health Risks

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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ACE Score vs Injection Drug Use

0

0.5

1

1.5

2

2.5

3

3.5

% H

ave

Inje

cted

Dru

gs

0 1 2 3 4 or more

ACE Score

p<0.001

Health risks

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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ACE Score and Teen Sexual Behavior Looking for love

0

5

10

15

20

25

30

35

40

45

Perc

en

t W

ith

Healt

h P

rob

lem

(%

)

0 1 2 3 or more 4

ACE Score

Intercourse by Age 15

Teen Pregnancy Teen Paternity

Social function

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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ACE Score and theRisk of Perpetrating Domestic

Violence__________________________________

Ris

k o

f P

e rp

etr

at i

on

(%

)

0

5

10

15Women Men

0 1 2 3 4 >5 0 1 2 3 4 >5

ACE Score

Social function:

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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Social function:

ACE Score and Indicators of Impaired Worker Performance

0

5

10

15

20

25

0 1 2 3 4 or more

ACE Score

Absenteeism(>2 days/month)

SeriousFinancialProblems

SeriousProblems

Pre

vale

nce

of

Imp

aire

d P

erfo

rman

ce (

%)

Performing job

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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{

Childhood Sexual Abuse and theNumber of Unexplained Symptoms

0

5

10

15

20

25

30

35

40

45

Per

cen

t Ab

use

d (%

)

Number of Unexplained Symptoms

01

2

34

56

7

8

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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ACE Score vs. COPD

Biomedical Disease

0

2

4

6

8

10

12

14

16

18

COPD

Per

cent

with

Pro

blem

0 1 2 3 4

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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{

ACEs Increase Likelihood of Heart Disease*

• Emotional abuse 1.7x• Physical abuse 1.5x• Sexual abuse 1.4x• Domestic violence 1.4x• Mental illness 1.4x• Substance abuse 1.3x• Household criminal 1.7x• Emotional neglect 1.3x• Physical neglect 1.4x

*After correction for age, race, education, and conventional risk factors like smoking anddiabetes. Circulation, Sept 2004.

Biomedical disease

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Effect of ACEs on Death Rate(Null hypothesis)

0

10

20

30

40

50

60Pe

rcen

t in

Age

Gro

up

0 2 4

ACE Score

19-3435-4950-6465=>

Age Group

>=6 ACE shortens lifespan by 20 yrs.

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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{

In Summary, the ACE Study indicates:

Adverse childhood experiences are the most basic and long-lasting cause of health risk behaviors, mental illness, social malfunction, disease, disability, death, and healthcare costs.With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

L O U I S V I L L E . E D UWith permission: Anda, RF.. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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ADVERSE CHILDHOOD EXPERIENCES SURVEY

SOURCE: http://www.childhealthdata.org/browse/rankings/maps?s=108

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• 30% of KY children with

ACE>=2 (22.6% nationally)

• 1:5 KY children experience

>=2 ACES by age 5 (1:8

nationally)

• KY children with ACE scores

>=3, one of the highest

rates in the country

ACES and KENTUCKY’s CHILDREN 2011-2012 National Survey of Children’s Health

Source: 2014 KY Kids Count Data Book

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KY’s Most Common ACES

Sources: http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/05/Infographic-The-Truth-About-ACEs.html?cid=xsh_rwjf_tw; 2014 KY Kids Count Data Book

30%Economic hardship

29%

14%

13%

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What is their ACE score?

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Aces passed on to the next generation

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A public health perspective

What are conventionally viewed as Public Health problems are often personal solutions to long-concealed

adverse childhood experiences.

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Types of stress

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Toxic Stress

“In my beginning

is my end”

T.S. Eliott

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Toxic Stress

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Toxic Stress

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-Transient activation of the

stress response is necessary for

survival

-Additionally inflammatory

cytokines are released and

parasympathetics activated

Physiology of Stress

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-The stress response is overstimulated

and is not able to regulate normally

-Disrupts normal brain wiring and

architecture in important areas such

as the amygdala, hippocampus, and

prefrontal cortex

-Long periods of exposure to high

cortisol levels especially before age 2

leads to negative consequences on

physical and mental health

-Damage to the hippocampus worsens

reaction to stress in the future

What does toxic stress do?

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-The plasticity of the young

infant/child’s brain makes it

particularly vulnerable to

increases in stress hormones

- Negative consequence on

physical and mental health and

increase stress responses in the

future

Bottom line

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CHRONICSTRESS

HypothalmusProinflammatory cytokines

Effects on Developing BrainEffects on Biomedical Disease

With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

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When positiveexperiencesoutweighnegative one- a child’s “scale”tips toward positive outcomes

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“Its not where you

begin its about where

you end up”

Reverend Darrell

ArmstrongShiloh Baptist Church

Trenton, New Jersey

RESILIENCY

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What is resiliency?

-How we deal with the problems

or set backs in our life

-Resiliency comes naturally to

some but it can also be learned

-Using your skills and strengths

to turn negatives into positives

-Protective factors reduce the

effects of adverse experiences

It can be improved at

any age!!

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Building Resiliency

“If we are to prepare children to become the healthy, productive, contributing adults that

will repair our world and lead us into the future, we must set our vision for the long

term goal”Dr. Kenneth R. Ginsberg

Building Resilience in Children and Teens:Giving Kids Roots and Wings

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Resiliency and the 7cs

• Competence• Confidence• Connection• Character• Contribution• Coping• Control

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Wealth of resources on

the American Academy

of Pediatrics website

aap.org/theresilienceproj

ect

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Asking the Questions

-Does your child have any behavior changes

seemingly without cause (trouble sleeping or

changes in school performance)?

-Has anyone come or gone from the household

lately?

-Has the child had stomach pains, headaches, or

other somatic complaints?

-Has your child ever witnessed anyone being harmed

in the home or in the community?

-We talk more about violence and its effect on

children’s health…….

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Types of violence

-Bullying or

cyberbullying

-Community violence

-Child abuse and

neglect

-Domestic and intimate

partner violence

-Sexual abuse

-Teen dating violence

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-Frame the question

-Actions to take

-Tools

-Vignettes and webinars

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YOU can foster resiliency

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“the practice of supporting someone to

make their voice heard”

-Target the preventable triggers of toxic stress

(poverty, crime, mental illness, substance abuse,

discrimination, and community violence) and help

families and parents create resiliency

Advocacy

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Advocacy

-CHIP-Children’s Health

Insurance Program

-Home health visitation

programs

-SNAP-Supplemental Nutrition

Assistance Program

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-Foster and kinship care

-Increase access to mental

health resources

-Head start programs

-Rethink Child Protective

Services

-HANDS

-Medical homes

-Medical-legal partnership

-Promote early literacy

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Find your legislator

http://lrc.ky.gov

http://www.lrc.ky.gov/

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Call to action

1. Begin to assess patients and their families in the context of

what their ACES score may be

2. Ask the hard questions-obesity, abdominal pain, somatic

complaints, headaches

“Talking to you about what has happened in your life

helps me take better care of your health”

3. Understand that children under toxic stress have differences in

the hard wiring of their brains and this will manifest in their

behavior and school performance

4. Foster resiliency in your patients and all children

5. Praise foster parents and kinship care providers

6. Become an active child advocate

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Resources:

1. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction

to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.

Am J Prev Med. 1998;14(4):245-58.

2. Felitti, VJ. The ACE Study Powerpoint. Academy of Violence and Trauma. April, 2011. Minneapolis,

MN.

3. http://

www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/05/Infographic-The-Truth-About-

ACEs.html?cid=xsh_rwjf_tw

. Accessed May 2015.

4. Anda, RF.. The ACE Study Powerpoint. Academy of Violence and Trauma. April, 2011. Minneapolis,

MN.

5. http://www.childhealthdata.org/browse/rankings/maps?s=108. Accessed May 2015.

6. 2014 Kentucky Kids Count County Data Book. KY Youth Advocates. p. 9-17.