1. Overcoming Adverse Childhood Experiences: Creating Hope for a Healthier Arizona Arizona Public Health Association Spring Conference April 9, 2015 Marcia Stanton, MSW

2. The Birth Lottery

3. Future Prosperity of Any Society
Depends on a continuing investment in the healthy development of the next generation.

4. Scientific Advances
Are driving a paradigm shift in understanding how child development impacts human health and disease across the lifespan

5. The Adverse Childhood Experiences (ACE) Study
“Probably the most important public health study you never heard of”
ACEs sometimes referred to as toxic stress or childhood trauma
Slide 3- What are ACES? 5

6. Science is Clear
Toxic stress caused by ACEs can profoundly alter the otherwise healthy development of a child
“Children’s exposure to ACEs is the greatest unaddressed public health threat of our time.” Dr. Robert Block, former president, American Academy of Pediatrics

7. Getting on Board
Public and policymakers are catching on to science of toxic stress
Prestigious organizations collecting and reporting on data

9. ACEs Legislation Washington, Wisconsin, Vermont, California
Could Arizona be next?

10. Two Categories of ACEs Abuse or Neglect - Recurrent physical abuse
- Recurrent emotional abuse
- Sexual abuse
- Emotional or physical
neglect
2) Household Dysfunction
Alcohol or drug abuser
Incarcerated household member
Someone chronically depressed,
suicidal, institutionalized or mentally ill
Mother being treated violently
One or no parents
Slides 8-9- There are 2 general categories: child maltreatment and family/household dysfunction.
Note: If you have the ability, consider showing the PBS Horizon interview with Dr. Felitti. Link to the study: Video is 10 minutes long and provides a nice introduction to the ACE study. 10

11. What Do ACEs Look Like?
Slides 7 & 8 - There are 2 general categories: child maltreatment and family/household dysfunction.
Note: If you have the ability, consider showing the PBS Horizon interview with Dr. Felitti. Link to the study: Video is 10 minutes long and provides a nice introduction to the ACE study.

12. Why is This Study So Important?
ACEs are:
Surprisingly common
Strong predictors of later social functioning, well-being, health risks, disease, and death
Slide 10 – Some of the key outcomes discovered were how common ACE’s are with 2/3’s participants having at least one ACE. As the ACE score increases so does the risk of numerous health and social problems throughout life. These health and social problems are not randomly distributed across the population. For example: Addictions are highly correlated to experiences in childhood; 97% of adult alcoholics had history of ACE’s.
In other words, stressful or traumatic experiences lead to increased risk of unhealthy behaviors, risk of violence or re-victimization, disease, disabilities and premature mortality.

13. ACE Scores 1/3 of Adults have ACE Score of 0 Majority of adults with
ACE score of 0, have few,
if any, risk factors for
diseases that are common
causes of death in US 13

14. If Any One ACE is Present
87% chance at least one other ACE is present, and
50% chance of 3 others
Slide 18 – The key findings of the study are that stressful or traumatic experiences lead to increased risk of unhealthy behaviors, risk of violence or re-victimization, disease, disabilities and premature mortality.

15. 6 or more may result in a 20 year decrease in life expectancy
4 or more may result in multiple risk factors for chronic diseases or disease themselves
6 or more may result in a 20 year decrease in life expectancy
Slide 27- The key findings of the study are that stressful or traumatic experiences lead to increased risk of unhealthy behaviors, risk of violence or re-victimization, disease, disabilities and premature mortality. 15

16. Out of 100 people… 33% Report No ACEs 51% Report 1-3 ACEs 16%
With 0 ACEs
1 in 16 smokes
1 in 69 are alcoholic
1 in 480 use IV drugs
1 in 14 has heart disease
1 in 96 attempts suicide
With 3 ACEs
1 in 9 smokes
1 in 9 are alcoholic
1 in 43 use IV drugs
1 in 7 has heart disease
1 in 10 attempts suicide
With 7+ ACEs
1 in 6 smokes
1 in 6 are alcoholic
1 in 30 use IV drugs
1 in 6 has heart disease
1 in 5 attempts suicide
These ratios are based on the original data. This slide highlights the assertion that chronic diseases occur as a result of high risk behaviors often initiated in adolescence.

17. ACEs are Interrelated and Predictive
Without interruption, ACEs escalate across generations
Slide 25- Very much like the spread of a virus, without an interruption or an intervention, ACEs will spread.

18. ACEs Have Cumulative Stressor Effect
It’s the number of different categories, not the intensity or frequency, that determine health outcomes
Slide 24- ACE’s are highly interrelated and commonly occur in clusters. If any ACE is present, there is an 87% chance at least one other category of ACE is present. ACE’s are so interrelated that trying to determine the impact of one ACE does not make sense.

19. Evidence Suggests
Many chronic diseases in adults are determined decades earlier, by experiences in childhood
Risk factor/ behaviors for these diseases are initiated during childhood and adolescents and continue into adult life

20. Solutions
What are conventionally viewed as Public Health problems are often personal solutions to long-concealed adverse childhood experiences.

21. It’s Not All About High Risk Coping Measures
Even if individuals with high ACE Scores do not adopt high risk behaviors, they are still much more likely to have negative health consequences

22. Toxic Stress
“Extreme, frequent or extended activation of the body’s stress response, without the buffering presence of a supportive adult.”
Sara B. Johnson, et al., The science of early life toxic stress for pediatric practice and advocacy, 131 PEDIATRICS 319 (2013), available at

23. Toxic Stress Early in Development
Affects functioning of 3 highly integrated systems:
the immune system
the neuroendocrine system
the central nervous system
(Danese & McEwen, 2012)

24. Children and Stress
Biologically predisposed to more physiologic stress
Brain structures that modulate this stress mature later
Young children need safe, stable, and nurturing relationships to assist them in regulating their stress

25. “The 4th Vital Sign” 4) Relationships
Respiration 2) Heart Rate 3) Blood pressure
4) Relationships
To heal from toxic stress, children need recognition and understanding from their caregivers
Slide 61- Given the research emerging on essential role of early caregiver-child relationships on lifelong health, Chair of the American Academy of Pediatrics (AAP) Early Brain and Child Development Initiative David Willis proposed a “4th Vital Sign”. Adding this fourth vital sign places the spotlight on early relationships in pediatric assessments.

26. Brain Architecture Built in a cumulative, bottom-up manner
Solid foundation required for future skills
Interaction between genes and experience shapes the architecture of the developing brain

27. Brain Plasticity Declines with Age
Brain’s ability to rewire itself in response to changes in the environment is waning by kindergarten
Remediation, while possible, is much more difficult

28. Getting It Right the First Time
Creating the right conditions in early childhood is more effective and far less costly than addressing a multitude of problems later on

29. Consequences of Not Getting It Right

30. Impact of Stress on Children
Flight, fight or fright (freeze) response
Short attention span
Struggle learning; fall behind in school
Respond to world as
constant danger
Distrustful of adults
Unable to develop healthy peer relationships
Feel failure, despair

31. “Dropouts Cost AZ $7.6 Billion” The Arizona Republic, June 26, 2014
AZ Dept. of Education: 22 percent of Arizona 9th graders will not finish high school
By 2018, more than 60 percent of jobs in AZ will require some post-secondary education

32. ACEs are a Pipeline to Prison
Childhood and Adult Trauma Experiences of Incarcerated Persons and Their Relationship to Adult Behavioral Health Problems and Treatment) Intl. Journal of Environ Res Public Health May; 9(5): 1908–1926. Published online 2012 May 18. Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense.

33. ACEs and Addiction Findings suggest:
A major factor, if not the main factor, underlying addiction is ACEs that
have not healed and are
concealed from awareness
by shame, secrecy, and
social taboo.
“It’s hard to get enough of something that almost works.” Vincent Felitti, MD

34. ACEs in Foster Care
More than half of kids reported for CM experienced 4 or more ACEs by time of contact with child welfare
More than 90% referred to child welfare have experienced multiple ACEs
(Nat’l Survey Child and Adolescent Well-Being (NSCAW), No. 20: Adverse Child Experiences in NSCAW, 2013)

35. Economic Impact US - $5.8 Trillion AZ - $141.8 Billion
Total Estimated Lifetime Impact of All Social Costs and Lost Earnings Associated with Non-Fatal and Fatal Child Maltreatment Incidence in 2014 on Business Activity:
(Suffer the Little Children Report, November 2014, The Perryman Group)

36. National Survey of Children’s Health
Telephone survey
Tracks parent report of their
children’s ACEs (does not
include child maltreatment
or neglect)
2011/12 data

37. Arizona Children Estimated 69,213 have 5+ ACEs
Ethnic minority children have disproportionately higher share of 6+ ACEs

38. AZ Kids with 5+ ACES Would Fill University of Phoenix Stadium

39. Out of 100 people… 33% Report No ACEs 51% Report 1-3 ACEs 16%
With 0 ACEs
1 in 16 smokes
1 in 69 are alcoholic
1 in 480 use IV drugs
1 in 14 has heart disease
1 in 96 attempts suicide
With 3 ACEs
1 in 9 smokes
1 in 9 are alcoholic
1 in 43 use IV drugs
1 in 7 has heart disease
1 in 10 attempts suicide
With 7+ ACEs
1 in 6 smokes
1 in 6 are alcoholic
1 in 30 use IV drugs
1 in 6 has heart disease
1 in 5 attempts suicide
These ratios are based on the original data. This slide highlights the assertion that chronic diseases occur as a result of high risk behaviors often initiated in adolescence.

40. Arizona Children, 0 – 17 (2011/2012 National Survey of Children’s Health)
No ACEs %
One ACE %
Two + ACEs %
(Natl. average: %)

41. Arizona Children, 0 - 5 (2011/2012 National Survey of Children’s Health)
No ACEs – 54.7%
One ACE – 28.6%
Two or More ACEs – 16.7%
(National Average 12.5%)

42. Arizona Children, 12 – 17 (2011/2012 National Survey of Children’s Health)
44.4% have experienced two or more ACEs
(Natl. average 30.5%)

43. Some AZ Counties Hit Harder

44. Special Health Care Needs

45. Health Status Rated Fair/Poor

46. Presence of Emotional, Behavioral or Developmental Needs

47. AZ Children Overweight or Obese

48. Missed 11 or More Days of School

49. Repeated 1 or More Grades

50. Received Treatment from Mental Health Professional Past 12 Months

51. So Where is the Hope? Better understanding of the mechanism
ACEs are not destiny
Helps us develop better responses and reduces judgment
Multiple evidence-based approaches to healing

52. Positive Factors That Counterbalance Adversity52

53. At Least 1 Stable, Caring and Supportive Relationship

54. Building Sense of Mastery over Their Life Circumstances

55. Strong Executive Function and Self-Regulation Skills

56. Affirming Faith or Cultural Traditions

57. Huge Social, Public Health Problem
Current investments in response; prevention must be part of solution
Broad societal and community level change needed
Individual level change not sufficient

60. What It Takes
“If we want breakthrough outcomes for kids, then we have to transform the lives of the adults that care for them.” (Jack Shonkoff, MD)

61. Two Generation Approach
Connect the dots between past, present and future
“Parents’ outcomes and children's outcomes are so tightly linked, developing two-generational policies is imperative, not optional.”

62. Requires a Public Health Response
Need Coordinated Multi-level Prevention Effort that Reaches Every Community

63. Where to Start? Increase Public Understanding
Enhance Capacity of Families and Providers to Prevent and Respond
Improve Effectiveness of Messages
Promote Identification and Early Intervention
Continue to Collect and Share Data

64. A Better World
Eliminating toxic stress among children would have a profound impact on the health and well-being of individuals and entire populations.

65. ACEs Often Last a Lifetime . . . But They Don’t Have To
Healing can occur
Cycle can be broken
Safe, stable, nurturing relationships heal parent and child
Slide 4 – Be sure to highlight this slide. It is important for participants to know that there are things that can be done to mediate impact of ACEs. Just talking with a caring, nurturing person about your experiences can have a positive impact. Acts of kindness can go a long way. Learning new behaviors - ways to cope and parenting skills - can break the cycle. 65

66. Marcia Stanton, MSW, mstanto@phoenixchildrens.com
In Summary
“It is easier to build strong children than to repair broken men” ~ Frederick Douglass ( )
Marcia Stanton, MSW,