Transcript Adverse Childhood Experiences (ACE)

Adverse Childhood
Experiences (ACE)
July 25, 2013
Prepared by:
Laura Tomedi, PhD, MPH
Lori Zigich, MPH
Wayne A. Honey, MPH
Adverse Childhood Experiences (ACE) Study
Prospective Cohort Study
 Collaboration between Centers for Disease
Control & Prevention and Kaiser Permanente
Health Appraisal Clinic

17,000+ HMO members enrolled in study
between 1995 and 1997

Initial physical exam and interview

On-going tracking of medical status of study
participants
Adverse Childhood Experiences (ACE) Study, CDC Website: http://www.cdc.gov/ace/index.htm
Conceptual Framework
Findings suggest certain childhood experiences are important risk
factors for the leading causes of illness and death, as well as poor
quality of life.
Source: Adverse Childhood Experiences (ACE) Study. Accessed at http://www.cdc.gov/ace/pyramid.htm. Retrieved
June 6, 2012.
ACE Defined: The following factors occurring
in a person’s first 18 years of life.
Abuse

Emotional - Often or very often a parent or other HH adult:
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
Physical – Sometimes, often, or very often:
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
Swore at you
Insulted you
Put you down
Made you feel that you might be physically hurt
Pushed, grabbed, slapped, or had something thrown at you or
ever hit you so hard that you had marks or were injured.
Sexual – An adult or person at least 5 years older ever:

touched or fondled you in a sexual way, or had you touch their
body in a sexual way or attempted oral, anal, or vaginal
intercourse with you or actually had oral, anal, or vaginal
intercourse with you.
Source: Adverse Childhood Experiences (ACE) Study, http://www.cdc.gov/ace/prevalence.htm. Retrieved June 6, 2012.
ACE Defined: The following factors occurring
in a person’s first 18 years of life.
Neglect

Emotional - Emotional Neglect Subscale of Childhood Trauma
Questionnaire (CTQ), moderate to extreme scores
Asked whether family:

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
made them feel special and loved
was a source of strength, support, and protection.
Physical - Emotional Neglect Subscale of Childhood Trauma
Questionnaire (CTQ), moderate to extreme scores
Asked whether:

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
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Enough to eat
Parents drinking interfered with care
Ever wore dirty clothes
If there was someone to take them to the doctor
Source: Adverse Childhood Experiences (ACE) Study, http://www.cdc.gov/ace/prevalence.htm. Retrieved June 6, 2012.
ACE Defined: The following factors occurring
in a person’s first 18 years of life.
Household dysfunction

Mother treated violently
Sometimes, often, or very often pushed, grabbed, slapped, kicked, bitten, hit with a fist, or hit
with something hard or had something thrown at her, or ever repeatedly hit over at least a few
minutes or ever threatened or hurt by a knife or gun

Household substance abuse
Lived with anyone who was a problem drinker or alcoholic or lived with anyone who used street
drugs (or abused prescription drugs?)

Household mental illness
A household member was depressed or mentally ill or attempted suicide

Parental separation or divorce
Parents were ever separated or divorced

Incarcerated household member
Source: Adverse Childhood Experiences (ACE) Study, http://www.cdc.gov/ace/prevalence.htm. Retrieved June
6, 2012.
The ACE study…has demonstrated that as the number of ACE increase,
the risk for the following health problems increases in a strong and graded
fashion:
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Alcoholism and alcohol
abuse
Early Initiation of Smoking
Current Smoking
Illicit Drug Use
Chronic Obstructive
Pulmonary Disease
Ischemic Heart Disease
Liver Disease
Health-related Quality of Life
Depression
Suicide Attempts

Risk for Intimate Partner
Violence

Multiple Sexual Partners
Sexually Transmitted
Diseases
Early Initiation of Sexual
Activity
Adolescent Pregnancy
Unintended Pregnancies
Fetal Death
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
Source: Adverse Childhood Experiences Study: Major Findings. http://www.cdc.gov/ace/findings.htm. Retrieved June 6, 2012.
Prevalence & Distribution of ACE Among
Adults in NM – 2009
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Telephone survey of randomly selected adults
aged 18 years and older.
Adverse Childhood Experiences (ACE) module
added to Behavioral Risk Factor Surveillance
System (BRFSS) in five states in 2009.
Eleven questions yielding eight categories of
ACE referring to the time before they were aged
18 years.
5,271 adult New Mexicans completed ACE
Module.
Source: Adverse Childhood Experiences Report by Adults --- Five States, MMWR, December 17, 2010 / 59(49);1609-1613.
New Mexico 2009 NM BRFSS – ACE Questions
Introduction:
I’d like to ask you some questions about events that
happened during your childhood. This information will allow
us to better understand problems that may occur early in
life, and may help others in the future. This is a sensitive
topic and some people may feel uncomfortable with these
questions. At the end of this section, I will give you a phone
number for an organization that can provide information and
referral for these issues. Please keep in mind that you can
ask me to skip any question you do not want to answer.
All questions refer to the time period before you were 18
years of age. Now, looking back before you were 18 years
of age--
New Mexico 2009 NM BRFSS – ACE Questions
Did you live with anyone who was depressed, mentally ill, or
suicidal?
Did you live with anyone who was a problem drinker or
alcoholic?
Did you live with anyone who used illegal street drugs or
who abused prescription medications?
Did you live with anyone who served time or was sentenced
to serve time in a prison, jail, or other correctional facility?
New Mexico 2009 NM BRFSS – ACE Questions
Were your parents separated or divorced?
How often did your parents or adults in your home ever
slap, hit, kick, punch or beat EACH OTHER up?
Never, Once, More Than Once
Before age 18, how often did a parent or adult in your home
ever hit, beat, kick, or physically hurt YOU in any way? Do
not include spanking. Would you say--Never, Once, More Than Once
How often did a parent or adult in your home ever swear at
you, insult you, or put you down?
Never, Once, More Than Once
New Mexico 2009 NM BRFSS – ACE Questions
How often did anyone at least 5 years older than you or an
adult, ever touch you sexually?
Never, Once, More Than Once
How often did anyone at least 5 years older than you or an
adult, try to make you touch them sexually?
Never, Once, More Than Once
How often did anyone at least 5 years older than you or an
adult, force you to have sex?
Never, Once, More Than Once
New Mexico 2009 NM BRFSS – Key Limitations

Sample Frame limited to non-institutionalized adults
living in a private residence with a landline
telephone.
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Self-reported information dependent on recall ability
and willingness to report. Also a strength.
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Only current demographic and SES information – no
such information for time ACE’s occurred.
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Extremely limited info on person(s) causing harm

Association Yes; Causation No
Percent of New Mexico adults aged > 18 years reporting an
Adverse Childhood Experience, Five States Study, BRFSS
2009
100%
New Mexico*
80%
All Five States**
60%
40%
20%
28%26%
20%15%
19%19%
13%12%
30%29%
24%27%
19% 16%
7% 7%
0%
*n=5,271 (randomly selected New Mexico residents).
**n=26,229 (includes randomly selected residents from Arkansas, Louisiana, New Mexico, Tennessee, and
Washington).
Source of data: Adverse Childhood Experiences Report by Adults --- Five States, MMWR, December 17, 2010 /
59(49);1609-1613.
Results of 2009 NM BRFSS:
Percent of New Mexico adults* aged >18 years reporting zero
through 5 or more adverse childhood experiences.
16.7%
9.6%
7.1%
38.9%
10.0%
12.6%
0 ACEs
1 ACEs
2 ACEs
3 ACEs
4 ACEs
≥5 ACEs
21.8%
*n=5,271
Source of data: Adverse Childhood Experiences Report by Adults --- Five States, MMWR, December 17, 2010 /
59(49);1609-1613.
Percent of New Mexico Adult ACE’s,
by Age Group – (Significant)
Four+ ACE's
Three ACE's
Two ACE's
One ACE
Zero ACE
75+
65 - 74
55 - 64
45 - 54
35 - 44
25 - 34
18 - 24
0
10
20
30
40
50
60
70
Source of data: Wayne A. Honey, MPH, Behavioral Risk Factor Surveillance System, 2009. New Mexico Department of
Health. Prepared July 25, 2013.
Percent of New Mexico Adult ACE’s,
by Gender – (Significant)
Four+ ACE's
Three ACE's
Two ACE's
One ACE
Zero ACE
Female
Male
0
10
20
30
40
50
60
70
Source of data: Wayne A. Honey, MPH, Behavioral Risk Factor Surveillance System, 2009. New Mexico Department of
Health. Prepared July 25, 2013.
Percent of New Mexico Adult ACE’s,
by Sexual Orientation – (Significant)
Four+ ACE's
Three ACE's
Two ACE's
10
30
One ACE
Zero ACE
Heterosexual
LGBT
0
20
40
50
60
70
Source of data: Wayne A. Honey, MPH, Behavioral Risk Factor Surveillance System, 2009. New Mexico Department of
Health. Prepared July 25, 2013.
Percent of New Mexico Adult ACE’s,
by Race/Ethnicity – (Not Significant)
Four+ ACE's
Three ACE's
Two ACE's
One ACE
Zero ACE
AIAN
AsianNHOPI
BlackAA
Hispanic
White
0
10
20
30
40
50
60
70
Source of data: Wayne A. Honey, MPH, Behavioral Risk Factor Surveillance System, 2009. New Mexico Department of
Health. Prepared July 25, 2013.
Percent of New Mexico Adult ACE’s,
by Region of Residence – (Not Significant)
Four+ ACE's
Three ACE's
Two ACE's
10
30
One ACE
Zero ACE
Southwest
Southeast
Bernalillo Co.
Northeast
Northwest
0
20
40
50
60
70
Source of data: Wayne A. Honey, MPH, Behavioral Risk Factor Surveillance System, 2009. New Mexico Department of
Health. Prepared July 25, 2013.
Percent of New Mexico Adult Demographics
by Number of Adverse Childhood Experiences
Four+ ACE's
Three ACE's
Two ACE's
One ACE
Zero ACE
College Grad.
$50,000+
Unable to Work
No Health Coverage
0
10
20
30
40
50
60
70
Source of data: Wayne A. Honey, MPH, Behavioral Risk Factor Surveillance System, 2009. New Mexico Department of
Health. Prepared July 25, 2013.
Health Behaviors
by Number of Adverse Childhood Experiences
Four+ ACE's
Three ACE's
Two ACE's
One ACE
Zero ACE
No Exercise
Binge Drinking
Current Smoker
0
10
20
30
40
50
60
70
Source of data: Wayne A. Honey, MPH, Behavioral Risk Factor Surveillance System, 2009. New Mexico Department of
Health. Prepared July 25, 2013.
Health Conditions and Disease
by Number of Adverse Childhood Experiences
Four+ ACE's
Three ACE's
Two ACE's
One ACE
Zero ACE
Current Asthma
Fall w/Injury
Hypertension
0
10
20
30
40
50
60
70
Source of data: Wayne A. Honey, MPH, Behavioral Risk Factor Surveillance System, 2009. New Mexico Department of
Health. Prepared July 25, 2013.
Health Conditions and Disease
by Number of Adverse Childhood Experiences
Four+ ACE's
Three ACE's
Two ACE's
One ACE
Zero ACE
High Cholesterol
Disability
CVD
Diabetes
0
10
20
30
40
50
60
70
Source of data: Wayne A. Honey, MPH, Behavioral Risk Factor Surveillance System, 2009. New Mexico Department of
Health. Prepared July 25, 2013.
General Health Status
by Number of Adverse Childhood Experiences
Mean Days of Poor Sleep by Number of ACE’s
None:
One:
Two:
Three:
Four+:
5.9
6.9
8.9
9.3
10.9
(5.2, 6.6)
(6.0, 7.7)
(7.7, 10.0)
(7.9, 10.7)
(9.9, 12.0)
Source of data: Wayne A. Honey, MPH, Behavioral Risk Factor Surveillance System, 2009. New Mexico Department of
Health. Prepared July 25, 2013.
General Health Status
by Number of Adverse Childhood Experiences
Mean Days of Poor Physical or Mental Health
Prevented Usual Activities, by Number of
ACE’s
None:
One:
Two:
Three:
Four+:
1.5
1.7
2.0
2.5
3.9
(1.2, 1.7)
(1.3, 2.1)
(1.4, 2.6)
(1.8, 3.3)
(3.2, 4.6)
Source of data: Wayne A. Honey, MPH, Behavioral Risk Factor Surveillance System, 2009. New Mexico Department of
Health. Prepared July 25, 2013.
Health Disparities
New Mexico residents with >4 ACEs were
more likely to be:

Female (19.3%) than male (13.4%)
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Black (23.9%) and American Indian
(22.7%) than white (14.1%)

Younger - 18 to 44 years old (20.7%)
than 75+ years old (2.9%)
Source: Laura Tomedi, MPH, PhD, New Mexico Behavioral Risk Factor Surveillance System, 2009. New Mexico
Department of Health. Prepared June 7, 2012.
Selected Health Outcomes
Compared to persons with 0 ACEs, New Mexico
residents with >4 ACEs were more likely to
report:

Fair/Poor Health (21.6% vs. 15.4%)

Smoking (33.6% vs. 12.6%)

Injury due to falls (50.3% vs. 26.6%)

But were less likely to report hypertension
(23.1% vs. 28.1%)
Source of data: Laura Tomedi, MPH, PhD, New Mexico Behavioral Risk Factor Surveillance System, 2009. New Mexico
Department of Health. Prepared June 7, 2012.
Conclusion
New Mexico adults with 4+ ACE’s are more
likely to have poor mental health, to have
asthma, to binge drink, to heavily drink, and
are less likely to have health insurance then
adults with 0 ACE. Conversely, there is no
difference in diabetes, arthritis, high
cholesterol, obesity, or physical activity
between the two groups.
Source of data: Laura Tomedi, MPH, PhD, New Mexico Behavioral Risk Factor Surveillance System, 2009. New Mexico
Department of Health. Prepared June 7, 2012.
Conclusion
The high prevalence of ACEs underscores the
need for:
1. additional efforts at the state and local level
to reduce and prevent child maltreatment
and associated family dysfunction; and
2. further development and dissemination of
trauma-focused services to treat stressrelated health outcomes associated with
ACEs.
Source: Adverse Childhood Experiences Report by Adults --- Five States, MMWR, December 17, 2010 / 59(49);16091613.