1. Adverse childhood experiences
Does anyone know what this is referring to?
Behavioral Medicine Toolkit

2. Origins
In 1985, Dr Vincent Felitti was the Chief of Preventative Medicine at Kaiser Permanente San Diego running a clinic for morbidly obese adults
He accidentally discovered a surprising correlation between childhood sexual abuse and adult obesity – eating as a coping mechanism
This led him and Dr Robert Anda, a medical epidemiologist with the CDC, to explore the connection between childhood trauma and adult health
Dr Vincent Felitti
Dr Robert Anda

3. Adverse childhood experiences
Selected from literature regarding childhood trauma and patient- reported experiences
In the original study 17,421 adults who were seen for initial evaluation at Kaiser responded to a survey self- reporting their childhood experiences
What they found has now been replicated in numerous studies around the world
Abuse
- Emotional Abuse: Often or very often a parent or other adult in the household swore at you, insulted you, or put you down and sometimes, often or very often acted in a way that made you think that you might be physically hurt.
- Physical Abuse: Sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at you or ever hit you so hard that you had marks or were injured.
- Sexual Abuse: An adult or person at least 5 years older ever touched or fondled you in a sexual way, or had you touch their body in a sexual way, or attempted oral, anal, or vaginal intercourse with you or actually had oral, anal, or vaginal intercourse with you.
Neglect
- Emotional Neglect: Respondents were asked whether their family made them feel special, loved, and if their family was a source of strength, support, and protection. Emotional neglect was defined using scale scores that represent moderate to extreme exposure on the Emotional Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form.
- Physical Neglect: Respondents were asked whether there was enough to eat, if their parents drinking interfered with their care, if they ever wore dirty clothes, and if there was someone to take them to the doctor. Physical neglect was defined using scale scores that represent moderate to extreme exposure on the Physical Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form constituted physical neglect. Household Dysfunction
- Mother Treated Violently: Your mother or stepmother was sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her and/or sometimes often, or very often kicked, bitten, hit with a fist, or hit with something hard, or ever repeatedly hit over at least a few minutes or ever threatened or hurt by a knife or gun.
- Household Substance Abuse: Lived with anyone who was a problem drinker or alcoholic or lived with anyone who used street drugs.
- Household Mental Illness: A household member was depressed or mentally ill or a household member attempted suicide.
- Parental Separation or Divorce: Parents were ever separated or divorced.
- Incarcerated Household Member: A household member went to prison.
Source: Robert Wood Johnson Foundation, 2013

4. Prevalence of aces
Report by Center for Youth Wellness in San Francisco using data from the California Behavioral Risk Factor Surveillance System, which is a a cross-sectional, population-based telephone survey of non-institutionalized households. Data from 27,745 adults in California surveyed between 2008 and 2013.
*61.7% of adults have experienced at least one ACE
*Most people who have experienced one ACE have experienced more than one; these experiences do not tend to occur in isolation
*For Contra Costa (with Solano County), 39.3 had 0, 21.2 had 1, 24.0 had 2-3, 15.4 had 4 or more
Abuse
- Emotional Abuse: Often or very often a parent or other adult in the household swore at you, insulted you, or put you down and sometimes, often or very often acted in a way that made you think that you might be physically hurt.
- Physical Abuse: Sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at you or ever hit you so hard that you had marks or were injured.
- Sexual Abuse: An adult or person at least 5 years older ever touched or fondled you in a sexual way, or had you touch their body in a sexual way, or attempted oral, anal, or vaginal intercourse with you or actually had oral, anal, or vaginal intercourse with you.
Neglect
- Emotional Neglect: Respondents were asked whether their family made them feel special, loved, and if their family was a source of strength, support, and protection. Emotional neglect was defined using scale scores that represent moderate to extreme exposure on the Emotional Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form.
- Physical Neglect: Respondents were asked whether there was enough to eat, if their parents drinking interfered with their care, if they ever wore dirty clothes, and if there was someone to take them to the doctor. Physical neglect was defined using scale scores that represent moderate to extreme exposure on the Physical Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form constituted physical neglect. Household Dysfunction
- Mother Treated Violently: Your mother or stepmother was sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her and/or sometimes often, or very often kicked, bitten, hit with a fist, or hit with something hard, or ever repeatedly hit over at least a few minutes or ever threatened or hurt by a knife or gun.
- Household Substance Abuse: Lived with anyone who was a problem drinker or alcoholic or lived with anyone who used street drugs.
- Household Mental Illness: A household member was depressed or mentally ill or a household member attempted suicide.
- Parental Separation or Divorce: Parents were ever separated or divorced.
- Incarcerated Household Member: A household member went to prison.

5. Effect of ACEs on adult health
Results are from the California study
An adult with 4 or more ACEs, in comparison to an adult with 0 ACEs, is

6. health behaviors Mental health
10.3 times more likely to use injection drugs
7.4 times more likely to be an alcoholic
3.3 times more likely to engage in risky sexual behavior
3.23 times more likely to binge drink
2.93 times more likely to be a current smoker
12.2 times more likely to attempt suicide
5.13 times more likely to suffer from depression
4.22 times more likely to be diagnosed with dementia
Increased risk for criminal behavior
Risky sexual behavior (any of the following): You have used intravenous drugs in the past year. You have been treated for a sexually transmitted or venereal disease in the past year. You have given or received money or drugs in exchange for sex in the past year. You had anal sex without using a condom in the past year

7. serious disease Sexual health 2.42 times more likely to have COPD
2.4 times more likely to have a stroke
2.2 times more likely to have ischemic heart disease
1.9 times more likely to have cancer
1.86 times more likely to have asthma
1.69 times more likely to have kidney disease
1.6 times more likely to have diabetes
11.6 times more likely to report being forced to have sex after the age of 18
3.2 times more likely to report having 50 or more sexual partners
A woman with 3 violent ACEs is times more likely to become a victim of intimate partner violence
A man with 3 or more violent ACEs is 3.8 times more likely to perpetrate intimate partner violence
Sexual health reports are from other studies

8. The Ace pyramid
If risk factors for disease, disability, and early mortality are not randomly distributed, what influences precede the adoption or development of them?
ACEs occur across the socioeconomic spectrum and correlate to, in a dose-dependent manner, poor health outcomes in adulthood.
Individuals with 6 or more ACEs have a life expectancy 20 years shorter than those with 0

9. Well it’s too late now, right?
And theories about mechanism
The case for primary prevention

10. Aces can cause toxic stress
Just as the stress of ambulation helps promote bone and muscle growth, a child needs to experience some emotional stress to develop healthy coping mechanisms and problem-solving skills.
Positive stress helps develop healthy coping mechanisms and problem-solving skills (e.g. meeting new people, dealing with frustration)
Tolerable stress, which, while not helpful, will cause no permanent damage (potentially negative, buffered by a supportive adult; e.g. loss of a loved one, traumatic accident)
Toxic stress is sufficient to overcome the child’s undeveloped coping mechanisms and lead to long-term impairment and illness

11. Developmental effects
Significant maternal stress during pregnancy and poor maternal care during infancy both affect the developing stress system in young animals and alter genes (epigenetics) that are involved in brain development.
Stress response (HPA axis and sympathetic nervous system) affects the developing brain. In the extreme, such as in cases of severe, chronic abuse, especially during early, sensitive periods of brain development, the regions of the brain involved in fear, anxiety, and impulsive responses (amygdala) may overproduce neural connections while those regions dedicated to reasoning, planning, and behavioral control (prefrontal cortex) may produce fewer neural connections.
Extreme exposure to toxic stress can change the stress system so that it responds at lower thresholds to events that might not be stressful to others, and, therefore, the stress response system (HPA and sympathetic nervous system) activates more frequently and for longer periods than is necessary, like revving a car engine for hours every day. This wear and tear increases the risk of stress-related physical and mental illness later in life (risky behaviors, pro-inflammatory state).
Maternal stress during pregnancy affects the developing fetal stress systems
Critical periods of brain development are influenced by stress
Severe, chronic stress can result in a lower threshold for stress response

12. Secure attachment to a sensitive and responsive caregiver
Early intervention
Toxic Stress
Resilience
ACEs
Secure attachment to a sensitive and responsive caregiver
Adverse experiences and other trauma in childhood, however, do not dictate the future of the child. Children survive and even thrive despite the trauma in their lives. For these children, adverse experiences are counterbalanced with protective factors. Adverse events and protective factors experienced together have the potential to foster resilience (ability to overcome serious hardship).
The single most common factor for children who develop resilience is at least one stable and committed relationship with a supportive parent, caregiver, or other adult. These relationships provide the personalized responsiveness, scaffolding, and protection that buffer children from developmental disruption. They also build key capacities—such as the ability to plan, monitor, and regulate behavior—that enable children to respond adaptively to adversity and thrive. This combination of supportive relationships, adaptive skill-building, and positive experiences is the foundation of resilience.
Research has shown that the presence of a sensitive and responsive caregiver can prevent elevations in cortisol among toddlers, even in children who tend to be temperamentally fearful or anxious.
Other protective factors include building a sense of self-efficacy and perceived control, providing opportunities to strengthen adaptive skills and self-regulatory capacities; and mobilizing sources of faith, hope, and cultural traditions.
Evidence-based, effective clinical treatments for intervening with children who have experienced trauma and adversity include Trauma-Focused Cognitive-Behavioral Therapy and Parent-Child Interactive Therapy. Each of these programs includes attention to parenting ability and works on establishing behaviors that promote resilience in the child and parent. Proactive initiatives like home visitation programs for high-risk families have incredible promise for the prevention or mitigation of parent- and environment-mediated ACEs specifically because they are focused on critical periods in human development—prenatal through the first 2 to 3 years of life

13. Addressing aces & trauma
Review
What ACEs are
Importance in regards to adult health
Proposed mechanism of exposure to toxic stress having maladaptive long term consequences
Counterbalance of developing resilience, which is built upon a stable, committed relationship with an adult
Importance of intervening early to prevent negative effects of toxic stress
with families in the primary care setting

14. When to intervene Prenatal care Infant well child visit
Routine – American Association of Pediatrics recommends universal screening (resources to aid PCPs in developing a system that works for their office and patient population)
Targeted – Based on risk factors and complaints
Adults who have experienced ACEs in their early years can exhibit reduced parenting capacity or maladaptive responses to their children. Research has shown that the children of parents with high ACE scores are at higher risk for experiencing childhood adversity in a dose-dependent fashion. Intergenerational transmission of adversity (epigenetics, responses to children, what they expose their children to or do to their children.)
Four-month exam after initial stress of having a new child but still early in the child’s development
When a child presents with developmental or behavioral issues possibly attributable to trauma, such as sleep or eating disturbance, toileting issues, functional abdominal pain, tension headaches, anxiety/fears, trouble self-regulating emotions or verbally expressing feelings, irritable/aggressive behavior
It is important to note that ACEs have both short- and long-term effects
Prenatal care
Infant well child visit
Developmental or behavioral issues
Subsequent well child visit
Routine or targeted parental screening
Routine or targeted child screening

15. Barriers to identifying aces
PROVIDER
PARENT
inappropriate
shame
effect on relationship
fear
discomfort
time
Identifying children at risk for or who have already had ACEs can be challenging.
Both
Inappropriate: provider or parent may believe addressing ACEs/trauma is the purview of another person (e.g. social worker, faith leader) or private
Discomfort: either may not feel comfortable discussing them out loud
Provider
Effect on relationship: worry about how the parent will receive such questioning
Personal trauma: personal ACEs leading to discomfort discussing those of others
Time: discussing sensitive issues is time-consuming
Inadequate interventions: limitations to provider’s knowledge, access to proven interventions. If it’s not something you can do something about, you’re less likely to address it
Parent
Shame
Fear about judgment: how providers will treat them
Fear of consequences: child abuse and neglect are reportable, drug abuse could result in CFS involvement
judgment
consequences
personal trauma
inadequate interventions
stigma

16. Overcoming these barriers
Universal screening
Parental ACEs
Safe environment
Assure confidentiality
Education
Reassurance
Emphasize child wellbeing
Universal screening: I ask everyone this
Open the conversation by addressing parental ACEs
Create a safe environment (La Casa Ujima) “I’m not here to judge you. I’m here to help you. Please tell me the truth”
As with all sensitive topics, assure confidentiality (within acceptable boundaries of danger to self or others, mandatory reporting of suspected child abuse or neglect)
Educate parents on the effects of ACEs on health during childhood and adulthood to explain why it is relevant to the doctor’s office
Reassure and normalize – ACEs are common and early interventions may improve outcomes
Parent and provider work together for the sake of the child’s current and future wellbeing.

17. Determining parental ACEs and resilience score, from the ACEs too high website.
Standardized (but not validated) form that parents could fill out about themselves.
This could be done during a prenatal visit or an early well child checkup.
Rather than coming off as a judgment of parenting skills, it opens the conversation about experiences that may influence them as parents.
Identify adversities and protective factors in the parent.

18. The CYW model Or you can address the child’s experiences
Center for Youth Wellness is a patient-centered pediatric home with integrated services for children in the underserved neighborhood of Bayview in San Francisco. It was founded by Dr Nadine Burke Harris, who has become a spokesperson for addressing ACEs during childhood.
Given at every initial visit, 9-month WCC, 24-month WCC, and yearly from ages There is a children’s form (3-12, parent completes) and a teen form for both the parent and the teen.
The first section is assessing the original 10 ACEs and the second section is additional 7-9 (depending on age) early life stressors identified by experts and community stakeholders as relevant to the children/youth served in community clinics. Each section is scored separately.
Symptomatology (as previously mentioned, developmental or behavioral issues possibly attributable to trauma): sleep disturbance, developmental regression, high risk behavior in adolescents, weight gain or loss, school failure or absenteeism, unexplained somatic complaints (such as HA or abdominal pain), failure to thrive, aggression, depression, enuresis, encopresis, poor impulse control, anxiety, constipation, frequent crying, interpersonal conflict, hair loss, restricted affect or numbing, poor control of chronic disease (such as asthma or diabetes)
Treatment (besides identifying children who ought to receive close follow-up, interventions that promote resilience): home visits, education, psychotherapy, wellness nursing, psychiatry, biofeedback, referrals)
Their survey in English and Spanish and a user’s guide that includes sample scripts is available online

19. Strategic interviewing
A lot of pertinent information can be obtained from the content of our current well child check-ups
Who lives at home with the child?
Has your home life changed significantly
Developmental or behavioral concerns
School performance, friends
Community and family resilience resources
Has anything bad, sad, or scary happened to your child recently?
How do you deal with stress?
More direct questions may be required to identify domestic violence, substance abuse, bullying, or child abuse
How is the child coping with the traumatic event?
It is important to say that you are screening all families for exposure to trauma. This helps reduce stigma and establishes it as a normal part of practice.
Information about toxic stressors can be solicited in a nonthreatening but trauma-informed manner.

20. Treatment – educational resources
Trauma-informed anticipatory guidance
American Association of Pediatrics Trauma Toolbox for Primary Care
Trauma-informed anticipatory guidance that the PCP can give families in response to a child’s symptoms following exposure to traumatic stress
Bring out the best – help with challenging behavior
When things aren’t perfect – explaining ACEs, child stress, resilience

21. http://www. kidspot. com

23. Treatment – county resources
Home Visits
Hello Baby (West)
Welcome Home Baby (East/Central)
Public Health Nurse
Child Abuse Prevention Council
First Five: free services for expecting parents and children 0-5yo, including home visits, parenting and child development classes, parent-child playgroups, mental health evaluations, services for at-risk children, family homeless shelters, child literacy programs. Bilingual services available. First 5 centers in Antioch, Bay Point, Concord, Brentwood, West County.
Home visits: Hello Baby preg-2yo Eng/Esp First 5, Welcome Home Baby preg-4mo Eng/Esp First 5, PHN referral for developmental services, neglect, school advocacy, exposure to substance abuse, mental health, home evaluation; through the Child Abuse Prevention Council (in particular for families that don’t qualify for county classes and can’t make it to group classes)
Child Abuse Prevention Council – Nurturing Parenting curriculum is designed to build nurturing parenting skills that break the intergenerational cycle of child maltreatment and dysfunction
211 Database, Surviving Parenthood, Parenting Guide (resources for parents throughout the county, including health services, childcare, crisis services)
Contra Costa Crisis Center – 24-hour crisis lines, grief counseling, homeless services
C.O.P.E. – Counseling options and parent education, free (esp First 5) or low-cost parenting classes, Triple P Positive Parenting Program (prevent and treat behavioral, emotional and developmental problems in children by enhancing the knowledge, skills, and confidence of parents. All of this is done through a strength-based and self-reflective approach that builds upon existing parenting strengths) with special classes for special needs, overweight/obese, fathers, etc.
STAND For Families Free of Violence (domestic violence and child abuse): crisis line, emergency shelter for women and children, support groups, counseling, parenting classes (in particular, targeting men ages 16-24), practical information for those being abused
Mental health referral/access line for therapy
Mental health referral for therapy by age and region

24. But really, is it too late?
(besides for the sake of your children’s health)
Couldn’t find anything currently being done!
So much of the medical history is an evaluation of health risk factors, which we now know includes adverse childhood experiences
Educating patients about how their childhood experiences can influence their adult health
Better understand (provide insight) the root cause of maladaptive high-risk behaviors (buprenorphine group, addiction transfer)
Inform motivational interviewing for behavioral change
Build resilience (social support, realistic goals, decisive action, self-discovery, positive view of self, framing/perspective, hopeful/grateful outlook, self-care, meditation/spiritual practices/faith)
Holistic healthcare: interconnections between physical, mental, emotional, and spiritual wellbeing
The case for secondary prevention

25. References
Felitti, Vincent J et al. “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults.” American Journal of Preventive Medicine, Volume 14, Issue 4,
accessed 24 Oct 2015.
“A Hidden Crisis: Findings on Adverse Childhood Experiences in California” Center for Youth Wellness
National Scientific Council on the Developing Child (2005/2014). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. 3. Updated Edition. Retrieved from
Stevens, Jane Ellen. “The Adverse Childhood Experiences Study — the largest, most important public health study you never heard of — began in an obesity clinic.” 3 Oct Aces Too High. Web <acestoohigh.com> Accessed 25 Oct 2015
Randell KA, O’Malley D, Dowd M. Association of Parental Adverse Childhood Experiences and Current Child Adversity. JAMA Pediatr. 2015;169(8): doi: /jamapediatrics
Center for the Developing Child at Harvard University. Web < Accessed 25 Oct 2015.
“The ACE Study” CDC Injury Prevention & Control: Division of Violence Prevention. Web. < Accessed 24 Oct 2015.
Middlebrooks JS, Audage NC. “The Effects of Childhood Stress on Health Across the Lifespan.” Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008
“Trauma Toolbox for Primary Care” American Academy of Pediatrics Web < policy/aap-health-initiatives/healthy-foster-care-america/Pages/Trauma-Guide.aspx> Accessed 24 Oct 2015
Stevens, Jane Ellen. “To prevent childhood trauma, pediatricians screen children and their parents…and sometimes, just parents…for childhood trauma” 29 July Aces Too High. Web. <acestoohigh.com> Accessed 25 Oct 2015