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Adverse Childhood Experiences (ACE) and the Impact on Health


Adverse Childhood Experiences (ACE) and the Impact on Health 2012 ASTDN Annual Conference Katherine Sanchez, LCSW, Ph.D. Assistant Professor School of Social Work – PowerPoint PPT presentation

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Title: Adverse Childhood Experiences (ACE) and the Impact on Health

Adverse Childhood Experiences (ACE)and the
Impact on Health
  • 2012 ASTDN Annual Conference
  • Katherine Sanchez, LCSW, Ph.D.
  • Assistant Professor
  • School of Social Work
  • University of Texas at Arlington
  • May 8, 2012

  • Setting the Stage

2010 Leading Causes of Death in the United States
  1. Heart disease
  2. Cancer
  3. Lower respiratory diseases
  4. Stroke and related diseases
  5. Accidents
  6. Alzheimers disease
  7. Diabetes
  8. Kidney diseases
  • 9. Influenza, pneumonia
  • 10. Suicide
  • 11. Septicemia
  • 12. Chronic liver disease and cirrhosis
  • 13. Hypertension and related renal disease
  • 14. Parkinsons disease
  • 15. Pneumonitis

High Medical Care Cost
  • Five percent of the population accounts for 49
    percent of total health care expenses.
  • The 15 most expensive health conditions account
    for 44 percent of total health care expenses.
  • Patients with multiple chronic conditions cost up
    to seven times as much as patients with only one
    chronic condition.

AHRQ, Research in Action, 2006
1O most costly medical conditions
Condition National Cost
Heart disease 90.9 B
Cancer 71.4
Trauma-related 67.3
Mental disorders 59.9
Osteoarthritis 56.2
Hypertension 47.3
Diabetes 45.5
COPD, Asthma 44.5
Hyperlipidemia 38.5
Back problems 34.6
Soni, A. Top 10 Most Costly Conditions among Men
and Women, 2008 Statistical Brief 331. July
2011. AHRQ,. http//
Study USA is fattest among advanced countries
(USA Today 9/24/10)
Country Women Men
US 36 35
Mexico 35 24
Chile 32 19
NZ 27 26
UK 25 24
Prevalence of Obesity and Trends in BMI Among US
Children and Adolescents US, 1999-2010
  • The prevalence of childhood obesity increased in
    the 1980s and 1990s.
  • Almost 1/3 of children and adolescents are
    overweight or obese
  • In 2009-2010, the prevalence of obesity in
    children and adolescents was 16.9
  • 11.3 of children and adolescents are very obese
    (97th percentile)

(Ogden et al,2012, JAMA, 307(5), 483-490.)
Prevalence of BMI gt 95 in Boys in US,
2009-2010(Ogden et al,2012, JAMA, 307(5),
Age Range (in years) Whites Blacks Latinos
2-5 11.9 20.5 17.8
6-11 16.8 29.5 23.9
12-19 17.5 22.6 26.5
Prevalence of BMI gt 95 in Girls in US,
2009-2010(Ogden et al,2012, JAMA, 307(5),
Age Range (in years) Whites Blacks Latinas
2-5 6.0 17.0 14.6
6-11 10.7 27.8 21.0
12-19 14.7 24.8 19.8
Prevalence of BMI gt 85 in Boys in US,
2009-2010(Ogden et al,2012, JAMA, 307(5),
Age Range (in years) Whites Blacks Latinos
2-5 26.0 30.5 34.1
6-11 29.7 40.9 39.7
12-19 32.2 37.4 42.9
Prevalence of BMI gt 85 in Girls in US,
2009-2010(Ogden et al,2012, JAMA, 307(5),
Age Range (in years) Whites Blacks Latinas
2-5 21.3 27.0 32.1
6-11 25.2 44.2 39.6
12-19 27.6 45.1 41.9
Consequences of Childhood Obesity
  • May reduce life expectancy
  • More likely to develop hypertension, type-2
    diabetes, and high cholesterol
  • More likely to become obese adults
  • Reduced quality of life
  • Higher medical expenses

Cost of childhood obesity/diabetes
  • Claims data
  • Obese child 2907
  • Child with type 2 diabetes 10,789
  • Adult with type 2 diabetes 8844
  • Absenteeism
  • Absent child or sick child care-related

(Sepulveda, Health Affairs, 293)
Increasing rates of childhood chronic conditions
  • Predicts major increases in long-term
  • pulmonary,
  • cardiovascular,
  • mental health burdens among adults,
  • accompanied by increasing expenditures for health
    care and disability programs,
  • decreased work force participation and
  • poorer quality of life.

Association of Adolescent Obesity With Risk of
Severe Obesity in Adulthood
  • Obesity in adolescence was associated with
    increased risk of severe obesity in adulthood
  • Findings highlight the need for interventions
    prior to adulthood to prevent the progression of
    obesity to severe obesity.
  • And the need for interventions to prevent
    childhood obesity in the first place.

The et al, JAMA, Vol. 34, No.18
Adverse Childhood Experiences (ACE) Study
  • In the mid-1980s Kaiser Permanente conducted an
    obesity program
  • In trying to understand the programs high
    dropout rate, they conducted detailed life
    interviews of almost 300 individuals
  • Researchers discovered that sexual abuse was
    common among dropouts, that abuse always
    predated obesity

Adverse Childhood Experiences (ACE) Study
  • As a follow-up, Kaiser Permanente CDC conducted
    ACE study
  • Study involved 19,000 mostly middle class, middle
    aged adults
  • Results show childhood abuse household
    dysfunction led to chronic diseases decades later
  • Traditionally viewed as public health problems,
    behaviors may also be coping mechanisms

Adverse Childhood Experiences
  • Child Abuse or Neglect
  • Physical abuse
  • Sexual abuse
  • Abandonment
  • Trauma in Childs
  • Household
  • Substance Abuse
  • Parental divorce
  • Mentally ill or suicidal household member
  • Violence to mother
  • Imprisoned household member

Adverse Childhood Experiences
  • Effects of Trauma
  • Difficulty controlling anger
  • Hallucinations
  • Depression
  • Panic reactions
  • Anxiety
  • Health Risk Behaviors
  • Smoking
  • Obesity
  • Suicide
  • Alcoholism
  • Drug abuse
  • Sexually transmitted disease
  • Self-injury
  • Eating disorders

Adverse Childhood Experiences
Long-Term Consequences
  • Disease and Disability
  • Heart disease
  • Cancer
  • Chronic lung disease
  • Emphysema
  • Mood disorders
  • Anxiety disorders
  • Social Problems
  • Homeless
  • Prostitution
  • Delinquency, violence and criminal behavior
  • Re-victimizations rape domestic violence
  • Un-Employment
  • Inter-generational transmission of abuse

Adverse Childhood Experiences
Adverse Childhood Experiences
Attempted Suicide
Adverse Childhood Experiences
Intravenous Drug Use
Adverse Childhood Experiences
Early Death
Disease, Disability, and Social Problems
Adoption of Health-risk Behaviors
Social, Emotional, Cognitive Impairment
Adverse Childhood Experiences
What Drives Health Status and Health Care Costs?
How Can We Encourage and Support Behavior Change?
Source IFTF and Center for Disease Control and
Prevention, Health and Healthcare 2010, January
Behavioral Health Issues Impact Other Systems
  • 75 of children placed in foster care have
    parents with behavioral health problems
  • 75 of children in the juvenile justice system
    have behavioral health problems
  • 30 of children in the juvenile justice system
    will end up in the adult justice system
  • 46 of all ER visits have behavioral health
    issues as a basic or contributing factor
  • 30 of all truancy is related to behavioral
    health problems

The Poverty ClinicCan a stressful childhood make
you a sick adult?
  • Looks at the relationship between poverty, child
    development, and health.
  • Childhood trauma should be viewed as a medical
  • In many cases, what looks like a social
    situation is actually a neurochemical situation.
  • Therefore, social issues might be better
    addressed on the molecular level.

Paul Tough, The New Yorker, 3/21/2011
The Poverty ClinicCan a stressful childhood make
you a sick adult?
  • 67 of Burkes patients have had one or more
    ACEs, and 12 have had four or more.
  • Only 3 of patients with ACE 0 display learning
    or behavior problems.
  • 51 of patients with ACE 4 display learning
    or behavior problems.
  • Burkes goal is a treatment protocol, like the
    one doctors use when theyre dealing with cancer
    or diabetes.

Paul Tough, The New Yorker, 3/21/2011
Co-occurring mental and medical illness are
  • Patients with common medical disorders have high
    rates of depression and anxiety which often
    impair self-care and compliance with treatment of
    their chronic disease.
  • Major depression increases the burden of chronic
    illness by increasing perception of symptoms,
    causing additional impairment in functioning, and
    increasing medical cost through over utilization
    of the healthcare system.
  • Poverty and poor health are associated with
    higher rates of mental disorders.
  • Hispanics and other ethnic minorities experience
    a disproportionate burden of disability
    associated with mental disorders because of
    disparities in mental health care.

Comorbid illnesses
  • Medical illnesses
  • Physical pain
  • Psychiatric illnesses and stressors
  • Anxiety PTSD, panic, OCD
  • Cognitive impairment,
  • Grief/bereavement,
  • Psychosis
  • Alcohol and substance abuse
  • Major life stressors
  • Marital discord, major losses, abuse / neglect

So What?
  • Culturally considerate, competent, compassionate
  • Build capacity of primary care providers to
    appropriately screen, identify, treat and refer
    across disciplines
  • Reduce barriers to treatment
  • Reduce stigma
  • Further integrate care at the local level

Team Care
Effective Collaboration
Prepared, Pro-active Practice Team
Informed, Activated Patient
Practice Support
Early Intervention
  • Intensive, comprehensive early intervention
    education programs can alter development
    trajectories substantially improve health,
    education and social outcomes from middle
    childhood thru adulthood.
  • - Halfon, Inkelas, JAMA 12/17/03 p.3136

Prevention Early Intervention Adolescent
Health Screening
  • Half of all mental illness begins by age 14
  • ¾ of adults have their symptoms of mental illness
    by age 24
  • Goal to consider ensure adolescent behavioral
    health screening in every primary care setting

Texas Adolescent Mental Health in Primary Care
Overarching Goal to institutionalize
behavioral health screening within the scope of
primary care practices.
The Texas Adolescent Mental Health in Primary
Care Initiative (December 2005 January 2007)
  • Developed model
  • Screening
  • Assessment
  • Treat or refer
  • Selected screening assessment tools
  • Was developing training package for pilot sites

Project InSightA Powerful Partnership
  • 5-year 17.5 million national demonstration
    project in Houston
  • Integrates screening and brief intervention for
    substance abuse problems into routine medical
  • Creates a bridge between medical system and
    substance abuse service system

Between Abstinence Dependence
Brief Intervention
Intervention Referral
Some lessons
  • All core components are needed.
  • Physician, Care Manager, Consulting Psychiatrist
  • Co-location is NOT sufficient
  • Effective multidisciplinary collaboration is
  • 3) Initial treatments are rarely sufficient.
  • Changes in treatment require proactive follow-up
    and effective consultation (measurement based

This is a challenging group of patients. We
need to engage patients and follow-up patients
dont get better if they are not followed. We
need to change treatment if patients dont
improve. We need to pay closer attention to
medications. We probably need more psychiatric
consultation. We may need to make more / more
effective referrals.
What Factors Contribute to Health Disparities?
  • Socioeconomic status
  • Residential segregation and environmental living
  • Occupational risks/exposures
  • Health risk and health seeking behavior
  • Differences in access to care
  • Differences in health care quality

Smedley, 7/21/09
Relationship between Social Determinants and
Mortality (2000)
Galea et al, Estimated Deaths Attributable to
Social Factors in the United States , AJPH,
August 2011, Vol 101, No. 8.
National High School Graduation Rates, 2003-04
  • Native American 49.3
  • Black 53.4
  • Latino 57.8
  • White 76.2
  • Asian 80.2

Cities in Crisis, EPE Research Center, 2008
Educational Attainment in 2000 in Texas for
Persons 25 Years of Age By Race/Ethnicity
A Reprioritization of Priorities
  • To achieve health equity, we should pursue
    interventions in proportion to their ability to
    affect the determinants of health
  • Fostering social change (educational attainment
    versusmedical advances)
  • Preventing disease (tobacco cessation versus
  • Delivering care (services delivery system
    improvements vs. biomedical advances)
  • Choosing effective services (appropriate use of
    things that work vs. overuse of things that dont

Woolf, JAMA, V.297,5
What Will Improve Health?
  • Implementing community preventive services,
    programs and policies aimed at broad population
  • These address the cultural, environmental, and
    economic forces that contribute to the leading
    preventable causes of disease and death.
  • We will get a MUCH greater return on investment
    by focusing on health improvement opportunities
    in communities, schools and worksites rather than
    focusing solely on what occurs in traditional
    health care settings.

A Framework for Health
Thank you!
  • Katherine Sanchez, LCSW, PhD
  • Assistant Professor
  • UT Arlington
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