1. ACE: Adverse Child events
THE SCIENCE BEHIND THE NUMBERS

4. ACE STUDY DESIGN
ACE QUESTIONNAIRE COMPLETED BY 17,421 HMO MEMBERS OF KAISER PERMANENTE, SAN DIEGO DEPARTMENT OF PREVENTIVE MEDICINE

5. 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

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

8. Effect of ACE’s on Educational outcomes

9. Ace’s are cumulative:

13. 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%

14. 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%

15. The biology of adversity

16. 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

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

18. 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

20. 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

21. 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

22. 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

23. 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

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