1 Impact of Adverse Childhood Experience (ACE) Edward Pontius MD, DFAPA MEAPA 26th Annual Winter CME Conference

Objectives: a. a.Participants will learn what Adverse Childhood Experience (ACE) is and how to score it in children and adults. b. b.Participants will learn how ACE alters development, making enduring changes in functioning, and will be able to relate ACE score to risk of physical and mental illness and addiction. c. c.Participants will learn how ACE assessment can be used to improve the relationship between clinician and patient and how knowledge of ACE can help improve health outcome. 2

Objectives: a. a.Participants will learn what Adverse Childhood Experience (ACE) is and how to score it in children and adults. b. b.Participants will learn how ACE alters development, making enduring changes in functioning, and will be able to relate ACE score to risk of physical and mental illness and addiction. c. c.Participants will learn how ACE assessment can be used to improve the relationship between clinician and patient and how knowledge of ACE can help improve health outcome. 3

What is Adverse Childhood Experience (ACE)? Adverse childhood experience (ACE) was a concept developed by Kaiser Permanente Physician Vincent Felitti MD and CDC Physician Robert Anda. 4 Vincent Felitti MD Kaiser-Permanente Robert Anda MD CDC

What is Adverse Childhood Experience (ACE)? Felitti first found his evidence for ACE while attempting to understand why particular patients failed to make lasting progress in overcoming serious chronic health conditions- such as women with morbid obesity- despite effective participation in intensive treatment programs. 5

What is Adverse Childhood Experience (ACE)? Making use of experience with more than 17,000 patients in a health maintenance organization, Felitti and Anda demonstrated a very strong relationship between the level of ACE exposure and the risk of developing serious chronic medical and psychiatric illness. 6

What is Adverse Childhood Experience (ACE)? Some of illnesses and conditions studied have been linked to ACE with odds ratios as high as 46:1 (ACE of 6 and IV drug abuse). 7

Many chronic diseases of adults are determined decades earlier, in childhood… Impact of ACE on critical health outcomes… burden related to ACE in our communities… Not by choice or poor decisions, but by life experiences.

What is Adverse Childhood Experience (ACE)? Felitti discovered the common factor in women who regained weight was a history of CHILDHOOD ABUSE. 9

What is Adverse Childhood Experience (ACE)? Subsequent work has established links between a number of important health conditions with ACE (as calculated by the number of categories of adverse childhood experience encounter prior to age 18). 10 ABUSENEGLECT FAMILY DYSFUNCTION

What are the categories of Adverse Childhood Experience (ACE)?  Physical abuse  Sexual abuse  Emotional abuse  Physical neglect  Emotional neglect  Mother treated violently  Household substance abuse  Household mental illness  Parental separation or divorce  Incarcerated household member 11

Adverse Childhood Experience are common…  Physical abuse - 28%  Sexual abuse - 21%  Emotional abuse – 11%  Physical neglect – 10%  Emotional neglect – 15%  Mother treated violently – 13%  Household substance abuse – 27%  Household mental illness – 17%  Parental separation or divorce – 23%  Incarcerated household member – 6% (Felitti – Anda) 12

Adult Prevalence of ACE Categories

And commonly seen in Maine… 14

Assessing Adverse Childhood Experience

Time to do your own ACE assessment… 16

17 How does ACE Impact health? Epigenetic mechanisms…

How does ACE Impact Brain Development? 18 GENDER Although both boys & girls are affected by maltreatment the effects of sexual abuse are more profound in girls while the effects of neglect are more profound in boys. CRITICAL TIME: AGE OF MALTREATMENT The brain develops over time. The effects of maltreatment correspond to the region and/or function that is developing at the time of maltreatment. TYPE OF ABUSE Different types of maltreatment activate different processes that shape the brain, such as chemicals & hormones, electrical activity, cell growth, & specialization of cells.

19 BRAIN EFFECTS BY CRITICAL PERIODS

20 Challenges associated with untreated ACE escalate over time…

21 ACEs: The Fast Track to Poverty

22 ACEs can Last a Lifetime... But They Don’t Have To The multigenerational cycle can be brokenThe multigenerational cycle can be broken Healing can occurHealing can occur Safe, stable, nurturing relationships promote healing for both parent and childSafe, stable, nurturing relationships promote healing for both parent and child Relationships are central in promoting resilience, reducing negative impact of ACEsRelationships are central in promoting resilience, reducing negative impact of ACEs

Resilience Research ● Child Psychologist Dr. Emmy Werner demonstrated factors contributing to resilience in child development in a 40 year longitudinal study of all 698 infants born on the island of Kauai, Hawaii in ● Her work demonstrated the usual association of risk factors with worse health and social outcomes. ● However 1/3 of high-risk children had good outcomes. ● Key protective factors for children demonstrating resilience included a strong bond with a non-parent caretaker.

NOTE: Assessing ACE in 100,000 patient evaluations lead to 35% Reduction in Doctor Office Visits 11% Reduction in ED visits 3% Reduction in Hospitalizations

Next Steps… ● Add review of ACE to your routine clinical evaluation of new patients with relevant ● Help patients and the community to understand the role that social factors play in illness ● Engage with others concerned about economic policy issues ● Given biologic basis for health consequences of economic inequality, working for a more just society is working to promote health

ACE Resource in Maine… 27

28 Impact of Adverse Childhood Experience (ACE) Edward Pontius MD, DFAPA MEAPA 26th Annual Winter CME Conference

It is no measure of health to be well-adjusted to a profoundly sick society. Krishnamurti

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has. ● Margaret Mead