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The CDC Adverse Childhood Experiences Study: Childhood Mental Health and Lifetime Health Early Child

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Title: The CDC Adverse Childhood Experiences Study: Childhood Mental Health and Lifetime Health Early Child


1
The CDC Adverse Childhood Experiences
StudyChildhood Mental Health and Lifetime
Health Early Childhood Mental Health
InstituteMay 11-13, 2009Anchorage, AlaskaMark
Erickson, MDSouthcentral Foundation
2
Childhood Maltreatment and Mental Health
  • Over the last 25 years many studies have explored
    whether childhood maltreatment influences later
    mental health.
  • It does but
  • Earlier studies were too small and narrowly
    focused to answer a crucial question.
  • Q. To what extent does severe stress, in the
    childhood home, influence later mental and
    physical health?

3
Childhood Maltreatment and Health
  • Needed
  • Study with a large number of participants.
  • Participants of age to have significant medical
    histories.
  • Medical records available for all participants.
  • Expanded conceptualization of child maltreatment
  • Include sexual and physical abuse, neglect
  • But also other child stressors, e.g., parental
    alcoholism, marriage discord, etc.

4
Childhood Maltreatment and Health
  • CDC Adverse Childhood Experiences (ACE) Study
  • Over 17,000 men and women surveyed.
  • Average age 57 years
  • Members of San Diego HMO
  • Participants surveyed on 10 types of adverse
    childhood experiences .
  • Now over 25 peer reviewed publications from CDC
    study (1998-present).

5
ACE Study
  • Expanded definition of child maltreatment
  • 10 types of adverse experiences surveyed.
  • 1. Sexual abuse 2. Emotional abuse 3. Emotional
    neglect. 4. Physical abuse 5. Physical neglect
    6. Substance abuse in home. 7.Mental
    illness in home. 8. Incarceration of family
    member. 9. Parental separation or divorce. 10.
    Witness violence against mother.

6
ACE Study
  • Key finding 1 Expanding definition of childhood
    maltreatment had real life significance Each
    of the 10 types of adverse childhood experiences
    influence adult health.
  • Key Finding 2 Adverse childhood experiences
    can have an astonishingly broad based, harmful
    influence on adult health.
  • Key finding 3 The health effects of adverse
    childhood experiences may not manifest for
    decades.

7
ACE Study
  • Key Finding 4 The more kinds of adverse
    childhood experiences a participant reported the
    greater the risk for a given health problem
    (trauma-dose relationship).
  • Key Finding 5 The more kinds of adverse
    childhood experiences a participant reported the
    greater the risk for more health problems
    (co-morbidity).

8
Health Elements Influenced by ACEs(broad based
life long)
  • Heart disease
  • Teen pregnancy
  • Cancer
  • COPD
  • STDs
  • Liver dis.
  • Smoking
  • Alcohol abuse
  • Promiscuity
  • Obesity
  • Drug dependence
  • IV drug use
  • Somatization
  • Depression
  • Anxiety disorders
  • Hallucinations
  • Sleep disturbances
  • Memory disturbances
  • Anger problems
  • Domestic violence risk
  • Early intercourse
  • Job problems
  • Relationship problems
  • Skeletal fractures
  • Anda et al. (2008) BMC Public Health 8,
    doi10.1186/1471-2458/8/198

9
Cardiovascular Disease and ACEs
  • Risk factors for heart disease
  • History of smoking 1.2x
  • Domestic violence in home 1.4x
  • Childhood physical abuse 1.5 x
  • Hypertension
    1.9x
  • Complex childhood abuse 3.6x (trauma
    dose)

  • M Dong et al. (2004) Circulation v1101761-66

10
Lifetime Risk for Attempted Suicide and ACEs
  • CDC Adverse Childhood Experiences Study (2001)
  • Key Findings on suicide risk (trauma dose
    relationship)
  • 0 adverse childhood experiences baseline
    1.0x
  • 1 adverse childhood experience increased lifetime
    risk of suicide attempt 1.9x
  • 2 adverse childhood experiences increased
    lifetime suicide attempt risk 3.3x
  • 3 adverse childhood experiences increased
    lifetime suicide attempt risk 4.3x
  • 4 6.2x
  • 5 10.6x
  • 6 16.5x
  • 7 or more adverse childhood experiences increased
    lifetime risk 31x
  • S.H. Dube et al. (2001) JAMA v 2863089-96

11
ACE Study Trauma-dose relationship
  • I. Common diseases influenced by trauma-dose
  • Heart disease
  • Cancer
  • COPD
  • Skeletal fractures
  • Sexually transmitted diseases
  • Liver disease

12
ACE Study Trauma-dose relationship
  • III. Mental health problems influenced by
    trauma-dose
  • - Depressive disorders
  • - Anxiety disorders
  • - Panic attacks
  • - Hallucinations
  • - Sleep disturbances
  • - Autobiographical memory disturbances
  • - Poor anger control
  • - Suicide attempts
  • - Risk of perpetrating or being a victim of
    domestic violence.

13
Trauma Dose Why Any Success at Prevention of
Child Maltreatment is Important
  • Example A prevention effort that reduces ACEs
    in family from 3 to 1.
  • Suicide risk cut 84
  • Alcohol dependence risk cut in half
  • and so on for 33 measures of health

14
Why Do Adverse Childhood Experiences, Alone,
Increase the Risk for Diseases,Such as Cancer,
Decades Later?
  • Child maltreatment can cause
  • Chronic inflammation - elevated C-reactive
    protein. A.Danese et al., (2008) Arch Gen Psych,
    v65 409-416.
  • Chronic dysregulation of stress hormones ACTH and
    cortisol G Gerra et al.(2007) Addiction Biology
    v1395-104.
  • Chronic inhibition of protein synthesis in the
    hippocampus an area of the brain linked to
    emotion and memory P McGowan et
    al.,(2008).PLoS,v3.5 e2085.

15
Southcentral Foundation Family Wellness
Objectives
  • FMW1 Reduce the rate child abuse and neglect
  • --------------------------------------------------
    ----------------------
  • FMW1 Reduce the rate of domestic
    violenceFMW2 Reduce the rate of preventable
    cancersFMW3 Reduce the incidence of
    suicideFMW4 Reduce the rate of obesityFMW5
    Reduce the rate of substance abuseFMW6 Reduce
    the rate of diabetesFMW7 Improve oral
    healthFMW8 Reduce the rate of cardiovascular
    disease

16
CDC Study concluding comment
  • Current practices of medicineare fragmented by
    a symptom based system of medical care.
    Prevention of our nations leading health
    problems is likely to benefit from understanding
    that many of these problems tend to be co-morbid
    and may have common origins in the enduring
    ...consequences of abuse andexperiences during
    childhood.

17
The CDC Adverse Childhood Experiences
StudyChildhood Mental Health and Lifetime
Health Early Childhood Mental Health
InstituteMay 11-13, 2009Anchorage, AlaskaMark
Erickson, MDSouthcentral Foundation
18
Preventing Child Maltreatment
  • Leveraging Nature The Biology of Parental
    Bonding.
  • - Dena A Coy
  • Teaching Parenting Skills and Providing Support.
  • - Nutaqsiivik
  • The Power of Story Generational Healing.
  • - FWWI Beauty for Ashes, Arrigah House
  • No prevention study has ever used more than one
    of the above types of preventative intervention.

19
Leveraging Nature France 1800s
  • La Maternité Charity hospital in Paris.
  • In 1830 - 64 of infants born at La Maternité
    were abandoned.
  • Rachel Fuchs (1987). Journal of Interdisciplinary
    History, v1855-80

20
Leveraging Nature France 1800s
  • In 1837 hospital policies were changed at La
    Maternite
  • Mothers were asked to stay and nurse.
  • Abandonment decreased 40
  • Policies changed over the decades
  • Key finding the longer mothers stayed and nursed
    the less likely they were to abandon infant.
  • Rachel Fuchs (1987). Journal of Interdisciplinary
    History, v1855-80.

21
Leveraging Nature Global Data
  • Costa Rica - Policy change increased
    mother-infant post-partum contact and reduced
    abandonment 70 (n78,000) L. Mata et al.
    (1988) In Programs to Promote Breastfeeding, ed
    B. Jelliffe, Oxford Univ. Press
  • Thailand - Hospital adopts UNICEF proposal
    increasing mother-infant contact resulting in
    decreased abandonment, n4000 births B Baranasin
    (1991) Asia-Pacific J Public Health v5217-220.
  • Russia - Large maternity hospital increased
    mother-infant contact in at-risk women resulting
    in 46 reduction in infant abandonment,
    n20,000. N. Lvoff et al. (2000) Arch Pediatr
    Adolesc Med v154474-77.

22
Teaching Parenting Skills
  • Nurse-family partnerships
  • Nurses visit home, teach and support parents.
  • This approach can prevent child abuse.
  • Key Finding At risk families visited by a nurse
    during the first two years of life were 48 less
    likely to have abused or neglected offspring.
  • David Olds et al. (1997) J. Community Psych.
    v259-25

23
The Power of Story and Generational Healing
  • Numerous studies have shown that generational
    patterns of parenting exist.
  • About 70 of parents who abuse were abused in
    their childhood
  • Good parenting tends to beget good parenting
  • Abusive parenting tends to beget abusive
    parenting.

24
The Power of Story and Generational Healing
  • The CDC Adverse Childhood Experiences study shows
    that adults, traumatized as children, have
    difficulty remembering their childhood.
  • Attachment research, similarly, shows that many
    adults, traumatized as children, have difficulty
    describing their childhood - or telling their
    story.

25
The Power of Story and Generational Healing
  • Attachment research also shows that adults who
    remember and tell their story in a full and
    honest way are unlikely to repeat generational
    abuse M Main and R Goldwyn (1984) Child
    Abuse and Neglect v8203-17.
  • This is just one of the several important things
    that FWWI does. FWWI helps people remember their
    story.

26
Family Wellness Warriors Initiative
  • Created in 1998 by Alaska Native and American
    Indian Peoples
  • Goal To end child abuse and neglect in this
    generation.
  • Method Helping people to tell their story in 3-5
    day gatherings that integrates spiritual and
    cultural renewal with evidence-based psychology.

27
Family Wellness Warriors Initiative
  • Over 1,300 have attended
  • Research findings show that in follow-up with
    participants of Beauty for Ashes and Arrigah
    House the association between real family and
    ideal family is much closer (p.00039).
  • Q. If parents start telling their story in the
    months before and/or after birth of their child
    does this result in a greater level of
    prevention?

28
Childhood Mental Health and Long Term HealthThe
CDC-ACE StudyEarly Childhood Mental Health
InstituteUniversity of Alaska May 11-13,
2009Mark Erickson, MDSouthcentral Foundation
29
Leveraging Nature
  • Landmark Study (Klaus, Kennel et al. 1972)
  • 1. Half of mothers received hospital care as
    usual (separation)
  • 2. The remaining mothers roomed in with infant
    until discharge
  • Key findings
  • At one month mothers who roomed in with infant
    were
  • more responsive to infants cry
  • more reluctant to leave infant
  • more direct eye contact
  • more affectionate
  • At one year mothers who roomed in still doing
    better.
  • M Klaus, J Kennell, et al. (1972) NEJM,
    v286460-463
  • J. Kennel et al. (1974) Dev. Med. Child Neur.
    v16172-79

30
Leveraging Nature Breastfeeding
  • 6,621 mother-infant pairs followed over 15 years
    (Australia)
  • Mothers who breastfed more than 4 months were
    4.8x less likely to maltreat child.
  • After controlling for 18 potential confounding
    variables still 2.6x less neglect L Strathearn
    et al (2009). Pediatrics v123483-93.

31
Leveraging Nature Dena A Coy
  • Mothers at Dena A Coy are extremely high risk.
  • Yet, of approximately 50 mothers who initially
    planned to give their baby up for adoption, less
    than 10 have. (Personal communication, Carolee
    Kukahindin, 2008)
  • Q. Is the pre- and post-partum support for the
    highest risk mothers at Dena A Coy leveraging
    maternal bonding and reducing abandonment?

32
Leveraging Nature SCF/ANMC
  • 1400 births per year at ANMC.
  • 800 Anchorage area births per year.
  • 46 (370) of local mothers are at-risk (e.g.,
    homeless, single, inadequate income, abused as
    children).
  • Average maternity admit 2.1 days.
  • Risk for abandonment, neglect and abuse entering
    next generation is high.
  • Q. Should we create a maternal post-partum home
    to offer to risk mothers?

33
Teaching Parenting Skills SCF Nutaqsiivik
  • Nutaqsiivik - started in 1994 to reduce SIDS
    deaths and in this regard has been successful.
  • Program has similarities to evidence based
    nurse-family partnership model.
  • Nutaqsiivik nurses visit mother during pregnancy
    and mother and child for first year in Olds
    model two years.
  • Nurses teach mother about infant health, maternal
    care and provide support as in Olds model.
  • Nutaqsiivik may be preventing child maltreatment
    - but we havent measured it - measuring may be
    possible through collaboration with AK State
    Dept. Epidemiology.

34
Preventing Child Maltreatment
  • Leveraging Nature The Biology of Parental
    Bonding.
  • - Dena A Coy
  • Teaching Parenting Skills and Providing Support.
  • - Nutaqsiivik
  • The Power of Story FWWI and Inter-generational
    Healing.
  • - Beauty for Ashes, Arrigah House
  • No prevention study has ever used more than one
    of the above types of preventative intervention.

35
Costs of Child Abuse USA
  • 104 billion spent annually for the direct costs
    of child abuse.
  • An additional 69.5 billion spent for indirect
    costs including special education, mental and
    physical health care and juvenile delinquency.
  • Cost per maltreated child 182,000
  • C Wang and J Holton (2007) Economic Impact Study
    funded by Pew Charitable Trusts, and S. Fromm
    (2001) Total estimated costs of child abuse and
    neglect in the United States Statistical
    evidence, http//member.preventchildabuse.org/site
    /
  • PageServer?pagenameresearch_child_abuse )

36
CDC Study concluding comment
  • The mind-body dichotomy that persists in Western
    medical training may lead clinicians away from
    understanding the role that childhood trauma and
    stress has on the health of their adult
    patients.understanding the role of these
    childhood experiences on adult health will become
    increasingly important in making decisions about
    prognosis, diagnosis and treatment.
  • CDC research group (2008) BMC Public Health
    8198.
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