ACE: Adverse Child events THE SCIENCE BEHIND THE NUMBERS

ACE STUDY DESIGN 1995-1997 ACE QUESTIONNAIRE COMPLETED BY 17,421 HMO MEMBERS OF KAISER PERMANENTE, SAN DIEGO DEPARTMENT OF PREVENTIVE MEDICINE

What are ACE’s Adverse Childhood Events (ACEs): 10 types: Abuse: Psychological Physical Emotional Neglect Household Dysfunction Substance Abuse (Alcoholism/drug use) Loss of biological parent before age 18 (includes divorce) Depression/mental health issues Mother treated violently Incarceration of relative

LEADING CAUSES OF DEATH IN us AND ace SCORE OF 4 OR MORE 1. Ischemic heart disease 220% 2. Cancer 190% 3. COPD 260% 4. Accidents 5. Stroke 240% 6. Alzheimer’s 420% 7. Diabetes 160% 8. Influenza and Pneumonia 9. Kidney Disease 10.Suicidality 1220%

Effect of ACE’s on Educational outcomes

Ace’s are cumulative:

ACES ACROSS Race and ethnicity WHITE 16.4% 24% 23% 36.7% HISPANIC 17.3% 25.3% 21.7% 35.7% ASIAN 11.1% 16.5% 17.9% 54.6% AFRICAN/ AMERICAN 16.5% 28.1% 21.0% 34.3%

Ace prevalence across the us STATE % of adults with > 1 ace % of adults with > 4 aces California Iowa Minnesota Montana Vermont Washington Wisconsin 61.7% 55% 61% 57% 61.9% 56% 16.7% 14% 13% 17%

The biology of adversity

Multi-systemic impacts Neurologic HPA( hypothalamic pituitary adrenal) Axis Dysregulation VTA and reward center dysregulation Hippocampal neurotoxicity Neurotransmitter and receptor dysregulation Immunologic Increased inflammatory mediators and markers of inflammation such as interleukins, TNF alpha, IFN-y Altered microbiome Genetic Shortening of the telomeres of the chromosomes increases cellular aging, heart disease, diabetes and cancer

How do we address ACEs in school based health Routine screening The Center for Youth Wellness in California www.centerforyouthwellness.org Allows for early detection and intervention Reducing the dose of adversity American Academy of Pediatrics

Accumulation of Aces during childhood In a multisite study of children exposed to or at risk for maltreatment, it was found that: By age 6 children had an average ACE score of 1.94 Between ages 6 and 12, on average they accumulated an additional 1.53 ACEs And then between ages 12 to 16 another 1.15

symptoms Poor control of chronic disease (asthma, diabetes) Aggression Poor impulse control Frequent crying Restricted affect or numbing High risk behavior in adolescents Unexplained somatic complaints(i.e. headaches, abd pain, chest pain) Sleep disturbance Weight gain or loss Enuresis, encopresis Constipation Hair loss Developmental regression School failure or absenteeism Failure to thrive

Next steps routine screening at well child exam Ace score 0-3 w/o symptoms Anticipatory guidance Ace 1-3 with symptoms or > 4 Counsel and refer

Interventions and promising practices Integrated primary care and behavioral health Psychotherapy- child parent psychotherapy, client centered therapy Home visits Health education Biofeedback Exercise Nutrition Mindfulness and coping skills

Closer look Exercise Mindfulness Based Awareness Nutrition Regulation of heart rate and blood pressure Regulation of HPA axis Decrease depression and anxiety Regulation of cerebral neurotransmitters including dopamine and serotonin Endorphin release Mindfulness Based Awareness Anti-inflammatory effects Decrease in post traumatic symptoms Nutrition Increasing fruits and vegetables in the diet and decreasing sugar sweetened beverages has been shown to preserve the telomeres thus reducing cellular aging, heart disease, diabetes and other chronic diseases It also has positive impact on our microbiome of the GI tract

At the end of the day we all want happy healthy children