The “ACE” Study The Tragic Consequences of Unaddressed Childhood Trauma Presented by Ann Jennings Ph.D Federal Roundtable on Women and Trauma April 29, 2010 Anna’s Story This is Anna at age one and a half This is Anna years later – in a mental institution What happened? Anna Caroline Jennings 1960 - 1992 The Adverse Childhood Experiences Study (ACE Study) “In my beginning is my end.” T.S. Eliot, Four Quartets What is the Adverse Childhood Experiences (ACE) Study? CDC and Kaiser Permanente Collaboration Over decade long. 17,000 people involved. Looked at effects of adverse childhood experiences over the lifespan. Largest study ever done on this subject. ACE Study Findings Childhood experiences are powerful determinants of who we become as adults Adverse Childhood Experience* ACE Categories (Birth to 18) Abuse of Child Emotional abuse Physical abuse Contact Sexual abuse Trauma in Child’s Household Environment Alcohol and/or Drug User Chronically depressed, emotionally disturbed or suicidal household member Mother treated violently Imprisoned household member Not raised by both biological parents (Loss of parent – best by death unless suicide, - Worst by abandonment) Neglect of Child Physical neglect Emotional neglect Impact of Trauma and Health Risk Behaviors to Ease the Pain Neurobiologic Effects of Trauma Health Risk Behaviors * Above types of ACEs are the “heavy end” of abuse. *1 type = ACE score of 1 Disrupted neuro-development Difficulty controlling anger-rage Hallucinations Depression - other MH Disorders Panic reactions Anxiety Multiple (6+) somatic problems Sleep problems Impaired memory Flashbacks Dissociation Smoking Severe obesity Physical inactivity Suicide attempts Alcoholism Drug abuse 50+ sex partners Repetition of original trauma Self Injury Eating disorders Perpetrate interpersonal violence Long-Term Consequences of Unaddressed Trauma (ACEs) Disease and Disability Ischemic heart disease Cancer Chronic lung disease Chronic emphysema Asthma Liver disease Skeletal fractures Poor self rated health Sexually transmitted disease HIV/AIDS Serious Social Problems Homelessness Prostitution Delinquency, violence, criminal Inability to sustain employment Re-victimization: rape, DV, bullying Compromised ability to parent Negative alterations in self perceptions and relationships with others Altered systems of meaning Intergenerational trauma Long-term use of multiple human service systems HMO Members in ACE Study 80% White, including Hispanic About 50% men, 50% women 10% Black 10% Asian 74% had attended college 62% age 50 or older Adverse Childhood Experiences are Common Of the 17,000 HMO Members: 1 in 4 exposed to 2 categories of ACEs 1 in 16 was exposed to 4 categories. 22% were sexually abused as children. 66% of the women experienced abuse, violence or family strife in childhood. Women were 50% more likely than men to have experienced 5 or more ACEs The higher the ACE Score, the greater the likelihood of : Severe and persistent emotional problems Health risk behaviors Serious social problems Adult disease and disability High health, behavioral health, correctional and social service costs Poor life expectancy For example: Emotional Problems % With a Lifetime History of Depression Childhood Experiences Underlie Chronic Depression 80 70 60 50 40 30 20 Women Men 10 0 0 1 2 ACE Score 3 >=4 Childhood Experiences Underlie Suicide 25 4+ % Attempting Suicide 20 15 3 10 2 5 0 1 0 ACE Score 2/3rd (67%) of all suicide attempts 64% of adult suicide attempts 80% of child/adolescent suicide attempts Are Attributable to Childhood Adverse Experiences Women are 3 times as likely as men to attempt suicide over the lifespan. Childhood sexual abuse is strongest most independent risk factor for suicidality As many as 42% of girls are sexually abused before age 18 79.8% of American Indian Alaskan Native (AIAN) girls experience sexual abuse in early childhood. Young AIAN women are over 3 ½ times more likely to commit suicide than females in the general population Childhood Experiences Underlie Serious and Persistent Mental Health Problems Are We Misdiagnosing? ACE Score and Hallucinations Ever Hallucinated* (%) 12 10 Abused Alcohol or Drugs 8 No Yes 6 4 2 0 0 1 2 3 4 5 6 ACE Score *Adjusted for age, sex, race, and education. >=7 Health Risk Behaviors Adverse Childhood Experiences and Current Smoking 20 18 16 14 12 % 10 8 6 4 2 0 0 1 2 3 ACE Score 4-5 6 or more Childhood Experiences and Adult Alcoholism 18 16 4+ % Alcoholic 14 12 3 10 2 8 6 1 4 2 0 0 ACE Score ACE Score and Intravenous Drug Use % Have Injected Drugs 3.5 3 2.5 2 1.5 1 0.5 0 0 1 2 3 4 or more ACE Score N = 8,022 p<0.001 Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners Adjusted Odds Ratio 4 3 2 1 0 0 1 2 ACE Score 3 4 or more Serious Social Problems Childhood Experiences Underlie Rape 35 4+ % Reporting Rape 30 25 20 3 2 15 10 5 1 0 0 ACE Score % have Unintended PG, or AB ACE Score and Unintended Pregnancy or Elective Abortion 80 Unintended Pregnancy 70 Elective Abortion 60 50 40 30 20 10 0 0 1 2 ACE Score 3 4 or more ACE Score and Indicators of Impaired Worker Performance 25 Prevalence of Impaired Performance (%) ACE Score 20 0 1 2 3 4 or more 15 10 5 0 Absenteeism (>2 days/month Serious Financial Poblems Serious Job Problems Adult Disease and Disability Higher ACE Score = significant rise in chronic health conditions: Sexually Transmitted Disease Liver Disease COPD Ischemic Heart Disease Autoimmune Disease Lung Cancer Poor Life Expectancy Effect of ACEs on Mortality Age Group Percent in Age Group 60 19-34 35-49 50-64 >=65 50 40 30 20 10 0 0 2 4 ACE Score 0 ACE 60% live to 65 4 ACE less than 3% live to 65 The Many Faces of Women and Trauma The Costs Are High 1992 Analysis of Cost of Anna’s Care Over 17 years, Anna was hospitalized a total of 4,124 days. At $648 a day the cost was $2,639,360. Other costs – entitlements, residential treatment, case management, legal, medical – were estimated to be over $1,000,000, bringing total cost to nearly $4,000,000. Adjusted for inflation (2005) total cost = $5,417,032 1992 Analysis of Cost of Anna’s Care Intensive trauma based psychotherapy, figured at $150 a session, 2 sessions a week, for 17 years, would have cost a total of $265,200 - (compared to $2,639,360) Had trauma been recognized and treated at age 3, costs would have been significantly less. If parents had been trauma-informed, the abuse may not have occurred. The financial burden to society of childhood abuse and trauma is staggering. Annual Direct Costs: Hospitalization, Mental Health Care System, Child Welfare Service System and Law Enforcement = $33,101,302,133.00 Annual Indirect Costs: Special Education, Juvenile Delinquency, Mental Health and Health Care, Adult Criminal Justice System, Lost productivity to Society = $70,652,715,359.00 Total Annual Cost: $103,754,017,492.00 (Over $184 million dollars a day) Economic Impact Study. (September, 2007). Prevent Child Abuse America “The solution of adult problems tomorrow depends in large measure upon the way our children grow up today. Margaret Mead Thank You www.TheAnnaInstitute.Org Handouts Chart of Adverse Childhood Experiences Study Finding Your ACE Score: A Questionnaire ACE Publications on Major findings by Health Outcomes “The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease” Sources ACE Publications: For comprehensive list see CDC ACE Study website: Publications on Major Findings By Health Outcomes: This site was updated (March 1, 2010) and links to related articles on all subjects. http://www.cdc.gov/nccdphp/ACE/outcomes.htm The Damaging Consequences of Violence and Trauma: See Trauma-Informed Resources : www.TheAnnaInstitute.Org Documents and articles on women and trauma: Presentation Bibliography in preparation. Available upon request: Ann Jennings, firstname.lastname@example.org ACE Study slides are from: Robert F. Anda MD at the Center for Disease Control and Prevention (CDC) September 2003 Presentation by Vincent Felitti MD “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West “The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare” Book Chapter for “The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease” Lanius & Vermetten, Ed) Presentation Artwork All artwork in this presentation was created by Anna Caroline Jennings. Although she had no formal training, her work is stark, sophisticated and haunting. It has been exhibited at conferences across the country. Through her paintings and drawings she vividly and poignantly expresses her abuse at the hands of perpetrators and within the mental health system. Her work and story are displayed on the website: www.TheAnnaInstitute.org. Trauma Informed Resources http://mentalhealth.samhsa.gov/nctic/default.asp SAMHSA National Center for Trauma-Informed Care www.TheAnnaInstitute.org: The Anna Institute Inc: ACE Study Section: Powerpoint presentation slides and notes; 41 full downloadable ACE Study articles; related materials; collection of ACE Study powerpoint slides Annotated list of Trauma Websites Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services, 2008 Downloadable trauma-informed articles, powerpoints, educational materials; links; Anna’s story and art exhibit.