1. Adverse Childhood Experiences and their Repressed Relationship to
Adult Well-being, Disease, and Death :
Turning gold into lead
A collaborative effort between
Kaiser Permanente and the Centers for Disease Control
The ACE Study is about how we get from a newborn with its extraordinary potential to the man lying on the street whom we overlook? It relates directly and in unexpected ways to common and difficult problems of medical practice and public health that we run into every day..
Integrating Trauma into Healthcare
San Diego, CA January 29, 2018
Robert F. Anda, M.D. (CDC)
Vincent J. Felitti, M.D. (SCPMG) 1

2. The ACE Study Summary of Findings:
Adverse Childhood Experiences (ACEs) are very common, and disturbing, and hence
are mostly unrecognized.
They are powerful predictors of adult social malfunction,
distress, health risks, disease, and premature death.
This combination makes ACEs the leading determinant of the health, social well-being, and economy of the nation.
Keep these general concepts in mind as I show you the evidence behind them. They have a great deal to do with the lives of all of us and are now attracting increasing legislative and judicial interest around the country. 5

3. Origins of the ACE Study
In 51 weeks:
408 to 132 lbs
Age 8
The ACE Study began with this woman who came to our new Obesity Program in 1985 asking if we could help with her problem. Our first error was in accepting HER diagnosis of what the problem was. Using the technology of supplemented ABSOLUTE fasting we reduced her weight by 276 pounds in the next 51 weeks and exposed the real problem. Ultimately she taught us that what is most obvious is not necessarily the essence of a diagnosis. REGAIN story & Why. Sleep-eating Grandfather incest. Soon another similar case led to routine inquiry re sexual abuse. Overwhelming acknowledgement by patients. Ultimately, Q of whether this exists in a GENERAL population.
Age 28
Age 29
Which photo represents the patient’s problem?

4. ACE Study Design Survey Wave 1 71% response (9,508/13,454) Mortality
National Death Index
Morbidity
Hospital Discharges
Doctor Office Visits
Emergency Room Visits
Pharmacy Costs
Present
vs.
All medical evaluations
abstracted
&
Health Status
Survey Wave II
n=13,000
17,337 adults
When we started finding many patients like her, the ACE Study was designed to determine whether what we found in obese patients like her was significantly present in a GENERAL population, and if so, what were its implications? After significant IRB resistance, we asked 26,000 members, avg age 57, who were coming through an unusual Dept. of Preventive Medicine for comprehensive medical evaluation if they would help us understand how life experiences in childhood affect ADULT health. 17,337 agreed. 74% had been to college. They were uncomfortably like you and me.
All medical evaluations
abstracted

5. Empirically Selected Categories of Adverse Childhood Experiences
Abuse, by Category
Psychological (by parents) %
Physical (by parents) %
Sexual (anyone, but typically family) 22%
Major Neglect, by Category
Emotional %
Physical %
Household Dysfunction, by Category
Alcoholism or drug use in home 27%
Loss of biological parent < %
Depression or mental illness in home 17%
Mother treated violently %
Imprisoned household member %
Prevalence (%)
Here are the categories we studied, selected solely because of their unexpected prevalence in our major Obesity program, once a meaningful and COMPLETE medical history routinely was obtained from all patients. These are the prevalences from a GENERAL population.

6. Adverse Childhood Experiences Score
Number of categories (not events) is summed…
ACE Score Prevalence
0 33%
1 25%
2 15% %
4 6%
5 or more %*
We counted number of categories of ACEs, not the number of events for the ACE Score.
Two out of three adults experienced at least one category of ACE.
If any one ACE is present, there is an 87% chance at least one other category of ACE is present, and a 50% chance of three or more.
Women are 50% more likely than men to have an ACE Score >5. 7

7. The Hidden Threat of Weight Loss
Years after quickly regaining all her weight, our original patient unwisely had bariatric surgery. At a point where she had lost only 96 pounds, she became intractably suicidal, having three courses of ECT and 5 psych hospitalizations in one year. Here, she explains WHY, and we began to see that what may be viewed by Public Health as A Problem, may be viewed by a Patient as a SOLUTION. Mistaking someone’s solution for their problem is a serious error that we commonly make. It is what makes preventive medicine so difficult.
The ‘Problem’ is her SOLUTION!

8. Molestation in Childhood
Sister of the original patient. Tempting to say it must be genetic: two women in the same family >400 pounds. It clearly runs in the family; but so too does speaking English. Parental loss, typically by divorce, is of enormous importance to childhood Obesity, but an untouched topic.
Obesity runs in this family. So does speaking English.
Familial does not mean genetic.

9. Nicotine to Self-Medicate
This man has some very insightful things to say about the functionality of some common addictions that we view as dysfunctional. DESCRIBE CHILDHOOD HX and imprisonment for attempted murder. Discuss psychoactive benefits of nicotine that have been overlooked in the public health onslaught against smoking. Why were these benefits needed? And the alcohol, and the crystal meth?
Is he describing dysfunctional behavior, or is it
functional in realms of which we know nothing?

10. Adverse Childhood Experiences vs. >1 ppd Smoking as an Adult
Health Risks
Adverse Childhood Experiences vs. >1 ppd Smoking as an Adult %
Let’s look at the 3 addictions the man described: Nicotine, alcohol, & crystal meth. This slide is interesting because it does not fit the conventional explanation for smoking as due to advertising or to the mysterious addicting properties of nicotine. This pattern seems to require a explanation such as our patient proposes about needing to close the door to the past. He speaks of the FUNCTIONALITY of what we comfortably MIS-describe as DYSFUNCTIONAL BEHAVIOR.
P< .001

11. Childhood Experiences vs. Adult Alcoholism
Social function
Childhood Experiences vs. Adult Alcoholism 4+ 3 2
This relates to his self-acknowledged alcoholism. It would appear the need to relax varies quite a bit, and it often varies depending on childhood experiences. 1

12. ACE Score vs. Intravenous Drug Use
Health Risks
ACE Score vs. Intravenous Drug Use
We all know about the dangers of injecting street drugs ACE Score 6 effect 4,600% than at ACE Score 0.
p<0.001

13. An ad from the 1940s, for the Profession
Here, to fix in your minds this uncomfortable idea of of these BAD HABITS also having BENEFITS, is an ad from a medical journal in 1943 for Methamphetamine, the highly successful new prescription antidepressant. In impure form and unknown dose, methamphetamine of course is sold on the street as Crystal Meth. Is there a story there?

14. Lost 158 pounds in Program. But, why did he gain it?
Functional aspects of ‘dysfunctional’ behavior
Let’s go back to Obesity to pick up the common underlying thread in these various outcomes.
This man became obese as a child, after his parents divorced and he had to live with his violent, alcoholic grandfather. He vividly recalls eating for solace - as in ‘comfort food’. The AGE at which weight gain beganis the single most important question in the treatment of obesity because the CAUSE of obesity had to be then or before.
As he grew obese, he discovered that obesity offered advantages. We know that at some level: think of the expression, “Throwing your weight around.” And people blame McDonald’s for why kids get fat! McDonalds is merely an intermediary technique.
Lost 158 pounds in Program. But, why did he gain it?

15. The Hidden Threat of Weight Loss
Here’s someone whom you might have known when she was a child who was being molested by multiple people, although that was never recognized by her parents. She ate to feel better and then realized that obesity reduced sexual attention. The key point is that we see that what may be viewed by Public Health as A Problem, may be viewed by a Patient as a SOLUTION. That has a lot to do with why certain problems are so difficult to treat: we’re not treating the core problem. We’re treating someone’s solution to problems we know nothing about.

16. What we conventionally view as Public Health problems are often a patient’s solutions to long-concealed adverse childhood experiences.
A Public Health Paradox
This is a profound idea in Preventive Medicine, and underlies the failure of many of our approaches that mistake someone’s attempted SOLUTION as the core problem. Does it matter that our most commonly sold street drug has potent antidepressant activity? Does it matter that nicotine has potent anti-anxiety and anti-depressant activity?

17. A Former Pediatric Patient Speaks Clearly
CROP
This woman was heavily molested as a child. She treated that with 3 ppd smoking and was thin until her H convinced her to stop at age 35. She explained to me that 3 ppd smoking keeps people at a distance, so when she stopped she started attracting male attention, which she had no experience in handling. This was quite frightening and she ate to ease her anxiety, quickly gaining to 310 pounds. This made manifest the significant lung damage she had been subclinically accumulating, and she had to go on 24 hour/day oxygen. Some years later we took her weight down 150 pounds and she no longer needed the O2. Our great success resulted in the resumption of male attention, which again was very threatening and she CONSCIOUSLY decided to regain the weight and accept the 24 hour use of O2.

18. Childhood Experiences Underlie Chronic Depression
Well-being
Childhood Experiences Underlie Chronic Depression
Shortly she begins talking about her chronic depression. Here's how depression relates to ACE Score.

19. Childhood Experiences Underlie Suicide Attempts
Death
Childhood Experiences Underlie Suicide Attempts 4+ 3
ACE Score 6 effect is 3,100-5,000% increase in attempted suicide. 2 1

20. Costs
Childhood Experiences Underlie Prescription of Antidepressants 50 Years Later
5 or
more 4
per 100 person-years)
Prescription rate 3 2 1
ACE Score

21. ACE Score and Hallucinations
Disease
ACE Score and Hallucinations
Abused
Alcohol
or Drugs
Ever Hallucinated* (%)
Here we see a relationship to the making of madness.
ACE Score*
*Adjusted for age, sex, race, and education.

22. ACE Score and Indicators of Impaired Worker Performance
Social malfunction:
ACE Score and Indicators of
Impaired Worker Performance 5 10 15 20 25 1 2 3
4 or more
ACE Score
Impaired Performance (%)
Prevalence of
And here is how this plays out at work. Toxic environments are real enough at some worksites, but not nearly as prevalent as toxic childhoods. In the middle set, we see reason to consider poverty as an OUTCOME of other more basic causes, rather than a primary cause itself.
Absenteeism
Serious
Serious (
>
2 days/month)
Financial
Problems
Performing job
Problems

23. ACEs Increase Likelihood of Heart Disease*•
Emotional abuse
1.7x
Physical abuse
1.5x
Sexual abuse
1.4x
Domestic violence
Mental illness
Substance abuse
1.3x
Household criminal 1.7x
Emotional neglect
Physical neglect *
After correction for age, race, education, and conventional risk
factors like smoking and
diabetes.
Circulation
, Sept 2004 .
Biomedical disease
Here we’ll make a big switch to BIOMEDICAL DISEASE as an outcome.
Conventional Framingham risk factors are NOT present in about 12% of cases of coronary artery disease. How do they get it then?
Here’s the rest of the story. This is NEW INFORMATION, from recent years. Chronic hyperstimulation of the HPA axis leading to the release of pro-inflammatory chemicals.

24. Newly Recognized Biomedical Relationships
Here’s a woman who looks like she’s doing well. She has a position of responsibility in a big university. But, she’s got serious problems that are masked by intelligence, dressing nicely, and speaking well. We’d never think of asking her these ugly questions because she’s obviously doing well, so she explains the back story and wants her name there so what she says is not minimized by anonymity Relate CA to rx for organ transplantation.
A slender, non-smoker, and non-diabetic, she just died an unexpected cardiac death at age 61.

25. Resilience?
We should say something about resilience which is a popular subject because it helps people reduce the discomfort of child abuse. Resilience is real, but it is partial at best. And, our assessment of resilience is partial. We base it on economic, social, or academic success. But one of the major researchers in the field, Emmy Werner, states on p69 of her book how surprised they were to find such high levels of biomedical disease in high ACE Score individuals whom they had considered resilient.
This remarkably frank autobiography tells the story of a little girl who was the incest victim of her father for many years, was beaten, starved, and sold for sex to strangers in saloons by her father. Somehow, she did not commit suicide or become a mass murderer. She graduated high school. Somehow she got into college and graduated. Somehow she got into law school and graduated and ultimately became a US Federal Judge. Obviously, we would consider her resilient. But here’s the rest of the equation: she has had 5 different kinds of cancer. She also has multiple sclerosis and Lupus. One of the other biomedical outcomes we found related to ACE Score was an association with a significant number of autoimmune diseases including rheumatoid arthritis, multiple sclerosis, and Lupus.

26. ACE Study Summary
Adverse Childhood Experiences are common and they typically affect adult:
Job performance, disability, and social malfunction
Well-being, depression, and earnings
Obesity, smoking, alcoholism, and drug use
Biomedical disease burden and life expectancy
Medical care costs
Subsequent generations.
Another outcome is PRISON:
ACEs in Prison: Garbarino book, “Listening to Killers” re the ACE Study playing out on Death Row.

27. Obtaining the Information
Because none of us are initially comfortable getting this kind of information, using an INERT mechanism to get our initial History is critically important. Here is the kind of patient history we routinely have in hand BEFORE even meeting a patient. A 10-page medical Questionnaire is filled out AT HOME, then on arrival it is fed into a digital scanner that picks up all YES answers and prints them out in a Review of Systems format. What we end up knowing about a person before even meeting them is near unique in practice. How do we use it? A basic starting approach is to say, “I see on the questionnaire that ….. Can you tell me how that has affected you later in your life.” And we LISTEN, and implicitly ACCEPT. ASKING, LISTENING, and implicitly ACCEPTING turns out to be a powerful form of DOING.

28. Turning Research into Practice a beginning
Set up properly, and in high volume, comprehensive medical evaluation affordably can be provided to all patients at the outset of ongoing medical care.
Comprehensive biomedical evaluation provided a net 11% reduction in DOVs in the subsequent year.
Comprehensive biopsychosocial evaluation, which incorporates ACE Study findings, provided a 35% reduction in DOVs in the subsequent year compared to the prior year. (130,000 patient sample)
Imagine the possibilities!
If the findings and apparent benefits are impressive, they pale when compared with the resistance to USING this information in clinical practice. THIS is the number 1 problem to address if progress is to be made.

29. Further Information www.ACEsConnection.com
Internet and YouTube: search “ACE Study”
AVAHealth.org (Detailed 4-hour DVD)
“The Deepest Well”, new book by N. Burke-Harris, MD
You’ve seen a hint of what the ACE Study is about. If you want to learn more about the 85 articles we published so far, here’s how to begin.