# Presentation: 905480

## Adverse Childhood Experiences Study: Implications for Adolescent Health

**Project Director, Adverse Childhood Experiences (ACE) Study**
**Division of Adult and Community Health**

**Adverse Childhood Experiences Study: Implications for Adolescent Health**

## “When I approach a child, he inspires in me two sentiments; tenderness for what he is, and respect for what he may become.”  

***                            — ******Louis Pasteur —***

## Modern Medicine and Health Improvements

-  The burden of infectious diseases
-   (e.g. TB)
-  Childhood mortality due to infectious disease
-   (e.g. measles)

**Vaccines and the advent of antibiotics reduced:**

## Death Rates for Measles in Children Under Age 15, England and Wales, 1850-1970 

**Death Rates for Measles in Children Under Age 15, England and Wales, 1850-1970 **

- Thomas McKeown, The Modern Rise of Population (Academic Press, San Francisco, 1976), pp. 93, 96.

**Notes:**
Despite the reduction in deaths due to measles, children still face multiple challenges that impact their health, well-being beginning in childhood spanning into adulthood.

## Changing Patterns of Disease

-  Changing patterns of disease due to overall
-   improvements in health in the late 19th and early
-   20th Century
-  Mortality rates were dominated by infectious diseases
-  Chronic diseases are now the leading causes of death

- Christopher J. L. Murray and Alan D. Lopez, eds., *The Global Burden of Disease:** **Volume 1* (World Health Organization, Harvard School of Public Health, and The World Bank, Geneva, 1996), p. 18.

## Scientific Gaps Still Remained

-    **What are the underlying factors that lead to chronic diseases?**
**Adverse Childhood Experiences** **(ACE) Study Developed to Examine the Childhood Experiences and the Impact on Later Life Health**

## Death

**Death**

**Conception**

**Notes:**
This slide explains why the Adverse Childhood Experiences Study is important.
Up until the 1940s to 1950s, infectious diseases were the leading causes of death in the U.S.
The advent of antibiotics and vaccines changed this and a transition occurred where chronic
diseases surfaced as leading cause of death in the U.S.
Researchers knew that chronic diseases were caused by the adoption of health risk behaviors.
However, they did not know the underlying factors for the adoption of health risk behaviors.
This is the scientific gap as shown by the arrows.
The 

## The Adverse Childhood Experiences (ACE) Study  The largest study of its kind ever done to examine the   health and social effects of adverse childhood experiences  throughout the lifespan  (17,421 participants)What do we mean by Adverse Childhood Experiences?  Experiences that represent health or social problems  of national importance. 	– childhood abuse and neglect	– growing up with domestic violence, substance 	   abuse or mental illness in the home, parental	   discord, crime

**Notes:**
A large scale research study involving over 17,000 participants from an HMO. 
The goal was to examine the relationship between adverse childhood experiences and health and social problems
in adolescence and adulthood.
Childhood exposure to abuse, neglect, witnessing domestic violence, growing up with substance abuse or mental illness in the home, parental divorce or family member incarcerated. 

## ACE Study Procedure

**Participants who were HMO members seeking an overall health assessment**
**After participants clinic visit, the Family Health History (FHH) was mailed home.**
**The FHH had questions about adverse childhood experiences and other details about current health behaviors**

**Data Collected between 1995-1997 from:**

**Notes:**
Participants were HMO members seeking a health assessment...not a sick visit.
The Family Health History survey was mailed to their home after their clinic visit.
The FHH had detailed questions about their adverse childhood exposures.

## Definition of Adverse Childhood 

**Experiences**

***Abuse By Parents During Childhood:***

***Emotional***

**Often or very often swore at, insulted, or put me down...?**

**often or very often acted in a way that**

**made me afraid that I would be physically hurt?**

***Physical***

**  ****Sometimes, Often or very often pushed, grabbed, shoved, **
**       ****slapped me...**
**  ****Sometimes, often, or very often hit me so hard that I had**
**        ****marks or were injured**

***Sexual ***

***Did an adult or person at least 5 years older ever...):***

**Touch or fondle you in a sexual way?**

**Have you touch their body in a sexual way?**

**Attempt oral, anal, or vaginal intercourse with you?**

**Actually have oral, anal or vaginal intercourse with you?**

**Notes:**
Participants were asked a series of questions to determine the type and number of adverse childhood
experiences. 
This slide presents the questions used to define emotional, physical and sexual abuse.

## Definition of Adverse Childhood Experiences

***Family Exposures:***

***Substance Abuse***

**Live with anyone who was a problem drinker or**

**alcoholic?**

**Live with anyone who used street drugs?**

***Mental Illness***

**Was a household member depressed or mentally ill?**

**Did a household member attempt suicide?**

***Mother Treated Violently***

***Was your mother (or stepmother):***

** ****Sometimes, often, or very often pushed, grabbed,**

**slapped or had something thrown at her?**

**Sometimes, often, or very often kicked, bitten, hit with a**

**fist, or hit with something hard ?**

**Ever repeatedly hit over at least a few minutes?**

**Ever threatened with, or hurt by, a knife or gun?**

***Criminal Behavior in Household***

**Did a household member go to prison?**

**Notes:**
This slide presents the items used to define forms of serious household dysfunction.

## Growing up with: Childhood abuse, neglect domestic violence, substance abuse, mental illness in the home, parental discord, crime

- These experiences:
-  Often go unrecognized
-  Impact developing child in ways that cannot be “seen”

**Growing up with: Childhood abuse, neglect** **domestic violence, substance abuse, mental illness in the home, parental discord, crime**

## Who Was In the Study?

## Characteristics of the Study Population

**Mean age****	****	****	****      57 years**
**	****              **
**Women ****                               ****     54%**
**Education ****	****	****	**
**  ****No H.S. diploma                       7%**
**  ****H.S. diploma or GED**           **17%**
**  ****Some college                         35%**
**  ****College graduate                   39%**

**Notes:**
The mean age of the participants was 57 years. There were slighly more women than men participating in the
Study and a highly educated group. 

## ACE Study Demographics

**Notes:**
Predominately white, followed by 11% Hispanic.

## What percent of persons in the study reported

**adverse childhood experiences?**

## Prevalence of Individual 

**Adverse Childhood Experiences**

*** Wave 2 Only**

**Notes:**
Adverse childhood experiences were found to be common.
Close to 30% reported physical abuse, 1 in 5 reported sexual abuse; and 1 in 4 reported growing up with
substance abuse, which is consistent with all previous studies.

## What was the likelihood that persons experienced more than one type of adverse event?

## Prevalence of reporting additional ACEs if 

**                                                          ****Second ACE      Third ACE**
**    **_**Abuse**_
**    ****Emotional****	****	****	****	****98****	****	****90**
**    ****Physical****	****	****	****	****83****	****	****64**
**    ****Sexual****	****	****	****	****78****	****	****58**
**    **_**Neglect**_
**    ****Physical****	****	****	****	****89                      75****	**
**    ****Emotional****	****	****	****	****93                      79**
**   **_**Household Dysfunction**_**:**
**   ****Battered Mother****	****	****	****95****	****	****82**
**   ****Substance abuse****	****	****	****81****	****	****60**
**   ****Mental illness****	****	****	****84****	****	****65 **
**   ****Parental separation/divorce               82****	****	****60**
**   ****Criminal household member              90****	****	****74**

**Prevalence of reporting additional ACEs if **
**reported any one category**

## Adverse Childhood Experiences (ACE) Score

***ACE score******	******	*****      *****Prevalence***
**    ****0****	****	****	****	****36.4%**
**    ****1****	****	****	****	****26.2%**
**    ****2****	****	****	****	****15.8%**
**    ****3****	****	****	****	****  9.5%**
**    ****4 ****	****	****	****             6.0%**
**    ****5****	****	****	****	****  3.5%**
**    ****6****	****	****	****	****  1.6%**
**7 or more****	****	****	****  0.9%**

**64% reported experiencing one or more**
**37% reported experiencing two or more**

**Number of individual adverse childhood **
**experiences were summed...**

**Notes:**
The ACE score is the way we determine the impact of multiple adverse childhood experiences.. The ACE score is a sum of the total number of ACEs a person reported. Close to 2/3s reported one or more almost 40% reported two or more, demonstrating how common ACEs are.

## The Childhood Environment

**Adverse Childhood Experiences (ACEs)  **

**The Childhood Environment**

**Notes:**
Because one in every four of your students lives in a family where at least one parent is an alcoholic,
let’s look at the relationship between parental alcoholism and other ACEs.

## Prevalence of Parental Alcohol Abuse

***Parental alcohol abuse:***** ****	****	****   Percent **
**  ****At least one parent****	****	****	****	****22**
**  **
**  ****Father****	****	****	****	****	****	****17**
**  ****Mother****	****	****	****	****	****	****  2**
**  ****Both****	****	****	****	****	****	****  3**

**Dube et al., **_**Child Abuse & Neglect**_**, 2001.**

**Notes:**
close to 1 in 4 reported either parent being an alcoholic. Growing up with an alcoholic father was more prevalent than growing up with an alcoholic mother.

## Prevalence of Childhood Abuse and Neglect 

**by History of Parental Alcohol Abuse**

**Notes:**
Examination of who abused alcohol in the family shows that compared to neither parent abusing alcohol,
those participants who reported mother, father or both were at an increased probability of reporting abuse and neglect. 

## Prevalence of Family Dysfunction

** ****by History of Parental Alcohol Abuse**

**Type of Family Dysfunction**

**Percent (%)**

**Battered**
**Mother**

**Substance **
**abuse**

**Mental**
** ****illness**

**Parental **
**separation**

**Crime in Home**

**History of Parental **
**Alcohol Abuse**

**Notes:**
A similar association was found for the 5 forms of family dysfunction.

## When can you expect to begin seeing 

**the impact of adverse childhood experiences **
**during the life span?**

## During Adolescence....

**Alcohol, Drug Use, **
**Tobacco Use, Violence, **
**Sexual Behaviors**

**Notes:**
Now we will look at the relationship between ACEs and the adoption of risk behaviors during adolescence.

## Relationship Between ACE Score and Adolescent Substance Use

**ACE Score**

**Percent (%) **

**Relationship Between ACE Score and Adolescent Substance Use**

- Initiate regular smoking by
- age 14 years

- Initiate illicit drugs use
- 15-18 years

- Initiate alcohol use
- by 14 years

## Relationship Between the ACE Score and Attempting Suicide During Adolescence

**Notes:**
The likelihood of a suicide attempt increases dramatically with increasing numbers of reported ACEs.

## Relationship Between Number of ACEs and 

**First Sexual Intercourse**

**Notes:**
Less than five percent (those with zero ACEs) wait until after age 15 to initiate sexual intercourse.  As the number of ACEs increases, there is a higher likelihood of initiating sexual intercourse by age 14.

## Relationship Between Number of ACEs and Adolescent Pregnancies

**Notes:**
There is a similar graded relationship to adolescent pregnancies.

## During Adulthood.....

**Alcoholism, Illicit drug use,**
**STDs, Intravenous drug use**

## ACE Score and HIV Risks 

**ACE Score and HIV Risks**** **

**Ever Injected**
**    ****Drugs**

**  ****Had 50 or More**
**Intercourse Partners**

**Ever Had an**
**    ****STD**

- Percent with health problem

## Relationship Between ACE Score and the 

**Relationship Between ACE Score and the **
**Risk of Self-Reported Alcoholism**

**Parental Alcoholism**

**ACE Score**

**Prevalence (%)**

- Dube et al., 2002, _Addictive Behaviors._

## ACE Score and Drug Abuse

**Ever addicted**
**to drugs**

**ACE Score and Drug Abuse**

**Ever had a**
**drug problem**

## Despite social and secular influences to change 

**behaviors over the past 100 years:**
**The study found that growing up with ACEs increases the risk for numerous health behaviors and outcomes for 4 consecutive generations.**

**Notes:**
Over 4 consecutive generations within the cohort, the ACE score increased the likelihood of alcohol problems, tobacco use, risky sexual behaviors, and mental health issues in a similar graded manner.

## ACE Study Findings: A Biological Phenomena 

- Studies from neurosciences documenting numerous changes in brain structure and function related to childhood traumatic stress
- Areas of the brain related to memory and emotions

## ACEs and The Life Span

**ACEs and The Life Span**

**Childhood**

**Adolescence**

**Adulthood**

- _ _

** ****Abuse**
** ****Neglect**
** ****Family substance**
** ****abuse**

_**Early Initiation of:**_
** ****Alcohol use**
** ****Tobacco use**
** ****Sexual intercourse**
** ****Illicit drug use**
** ****Suicide attempts**

** ****Alcoholism**
** ****Smoking**
** ****STDs**
** ****Unintended **
**   ****pregnancy**
** ****Depression**
** ****Obesity**
** ****Liver disease**
** ****Cardiovascular**
**  ****disease**
** ****Injection drug use**

**Notes:**
ACEs cut across the human life span. Childhood is when they occur, in adolescence, the first manifestations are observed through adoption of risk behaviors, and in adulthood, disease and chronic risk behaviors are observed.

## Summary

**Adverse childhood experiences are common and****highly interrelated**
**Consistent strong and graded relationships between the ACE score and adolescent risk behaviors**
**Graded relationships are consistent despite****secular changes over the past century**
**Exposure to ACEs increases numerous behaviors****and outcomes that are CDC priorities**

## What Can We Do?

**Healthy Human Development through Coordinated**
**School Health Program’s Eight Components**
** **

**1. **_**School Health Education**_**: Teach about family systems, teach kids where they may get help**
**2. **_**School Nutrition Services**_**: Psychosocial factors related to obesity among kids**
**3. **_**Counseling and Psych Services**_**: Increase services, referrals; effective counseling methods **
**4. **_**Health Services**_**: Better recognition of school indicators (e.g. school attendance) that are associated with stress and trauma**

## What Can We Do? (cont’d)

**6. **_**Family/Community**_**: School health advisory**
**7. **_**Staff Health Promotion**_**: Stress reduction programs**
**8. **_**Physical Education**_**: Use physical education as a way to teach skills and enhance self-esteem**
**                    **

**What Can We Do? (cont’d)**

## CDC Future Directions

**Develop and evaluate holistic interventions****and programs that target at-risk youth, which address ACEs and health behaviors—increase youth “assets”    **
**Promote positive self-development **
**Provide supportive environments**

**CDC Future Directions**