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The Childhood Adversities Narrative (CAN)

The document outlines the impact of adverse childhood experiences (ACEs) on children, emphasizing their significant link to various mental, physical, and social issues throughout life. It highlights the prevalence of different types of maltreatment and dysfunction in households, the long-term costs of child maltreatment, and the importance of proven prevention and treatment interventions to mitigate these effects. The narrative aims to inform policymakers and advocates about the urgency of addressing childhood adversity to improve outcomes for vulnerable populations.

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Opportunities To Change The Outcomes Of Traumatized Children 2015 The Childhood Adversity Narratives CAN CANarratives.orgV2
CAN Contributors Frank Putnam, MD, UNC at Chapel Hill, NC William Harris, PhD, Children’s Research and Education Institute & New School for Social Research, NYC, NY Alicia Lieberman, PhD, UCSF, San Francisco, CA Karen Putnam, PhD, UNC at Chapel Hill, NC Lisa Amaya-Jackson, MD, Duke University, Durham, NC CANarratives.org
Childhood Adversity Narratives • This is a Narrative that we are seeking to collectively construct with others. • The purpose is to help inform policy makers and the public about the costs and consequences of child maltreatment and adversity. • The goal is to show that there are proven interventions and opportunities to change these personally tragic and socially costly outcomes. • Feel free to use all or part of this Narrative (with appropriate attribution) if helpful to advocate for children and families. CANarratives.org
Developmental Trauma Disorder? Allostatic Load? Complex Trauma? Chronic Stress? Post Traumatic Stress Disorder? Toxic Stress? ACES? Child Traumatic Stress? Complex PTSD? Acute vs. Chronic Trauma? Even the Experts are Confused as to Which Term is Best CANarratives.org
There is No Single “Best” Term • Child trauma and adversity come in many forms and no term covers all of them. • In this Narrative we use ACES (Adverse Childhood Experiences) because it is one of the better known terms among the many audiences this Narrative seeks to reach. • The basic findings of the original ACES research1 have been independently replicated by many different studies. 1http://www.cdc.gov/violenceprevention/acestudy/prevalence.html CANarratives.org
ACES (Adverse Childhood Experiences)1 • In this Narrative, ACES is used generically to refer to overlapping sets of traumatic and adverse childhood experiences and home environment factors that substantially increase a child’s risk for serious, lifelong medical and mental illnesses. • As the number of ACES increases, the negative outcome of interest (e.g., mental, medical, social, fiscal) increases in a graded (roughly stepwise) fashion. • This cumulative “ACES-effect” occurs at multiple levels from biological markers of stress within a person to population-based markers of health such as rates of childhood asthma in a neighborhood. 1http://www.cdc.gov/violenceprevention/acestudy/prevalence.html CANarratives.org
ACES Prevalence (%) of Abuse and Neglect In the Original Study1 ACE Women Men Total N=9367 N=7970 N=17337 Abuse Physical Abuse 27.0 29.9 28.3 Sexual Abuse 24.7 16.0 20.7 Emotional Abuse 13.1 7.6 10.6 Neglect Emotional Neglect 16.7 12.4 14.8 Physical Neglect 9.2 10.7 9.9 1http://www.cdc.gov/violenceprevention/acestudy/prevalence.html CANarratives.org
ACES Prevalence (%) of Household Dysfunction In the Original Study1 ACE Women Men Total N=9367 N=7970 N=17337 Household Dysfunction Household Substance Abuse 29.5 23.8 26.9 Parental Separation or Divorce 24.5 21.8 23.3 Household Mental Illness 23.3 14.8 19.4 Mother Treated Violently 13.7 11.5 12.7 Incarcerated Household Member 5.2 4.1 4.7 1http://www.cdc.gov/violenceprevention/acestudy/prevalence.html CANarratives.org
Percent of Cumulative Adverse Childhood Experiences ACES in the Original Study1 Number of ACES Women Men Total N=9367 N=7970 N=17337 0 34.5 38.0 36.1 1 24.5 27.9 26.0 2 15.5 16.4 15.9 3 10.3 8.6 9.5 4 or more 15.2 9.2 12.5 1http://www.cdc.gov/violenceprevention/acestudy/prevalence.html CANarratives.org
• The original ACES (in red) are among the most commonly reported traumas in studies that look at additional traumas. • Over 40% of the children and adolescents served by the NCTSN experienced 4 or more different types of trauma and adversity. 1Pynoos et. al (2014). Psychological Trauma: Theory, Research, Practice and Policy. 6:S9-S13. The ACES are Among Many Childhood Traumas and Adversities Measured by the National Child Traumatic Stress Network N=10,9911 48.7 45.1 36.4 31.4 26.8 26.2 20.1 14.1 13.3 10.6 10.6 9.7 9.5 8.8 5 4.6 2 1.7 1 0.9 0 10 20 30 40 50 60 Traumatic Loss/Bereavement/Separation Domestic Violence Impaired Caregiver Emotional Abuse Neglect Physical Abuse Sexual Abuse Community Violence Sexual Assault/Rape Serious Injury/Accident School Violence Other Illness/Medical Trauma Physical Assault Natural Disaster Extreme Interpersonal Violence Kidnapping Forced Displacement War/Terrorism/Political Violence (Non-U.S) War/Terrorism/Political Violence (U.S) Percent % Reported CANarratives.org
Rates of Maltreatment by Age1 • Most maltreatment happens to younger children. • Maltreatment has greater negative effects at younger ages. 1Child Maltreatment 2012. Washington, DC: US Department of Health and Human Services; 2014. Types of Child Maltreatment Psychological Maltreatment 7% 0 1 2 3 4 5 6 7 0-3 4-6 7-9 10-12 13-15 16-17 Percent of Children AgeGroup CANarratives.org
Adverse Childhood Experiences •Abuse and Neglect (e.g., psychological, physical, sexual) •Household Dysfunction (e.g., domestic violence, substance abuse, mental illness) Impact on Child Development •Neurobiologic Effects (e.g., brain abnormalities, stress hormone dysregulation) •Psychosocial Effects (e.g., poor attachment, poor socialization, poor self-efficacy) •Health Risk Behaviors (e.g., smoking, obesity, substance abuse, promiscuity) Long-Term Consequences Disease and Disability •Major Depression, Suicide, PTSD •Drug and Alcohol Abuse •Heart Disease •Cancer •Chronic Lung Disease •Sexually Transmitted Diseases •Intergenerational transmission of abuse Social Problems •Homelessness •Prostitution •Criminal Behavior •Unemployment •Parenting problems •High utilization of health and social services •Shortened Lifespan How the ACES Work CANarratives.org
How ACES Cross Generations Child Adolescent Adult Child Abuse Child Abuse Aggression Conduct Problems Depression PTSD Anxiety School Problems Revictim- ization School Dropout Substance Abuse Depression PTSD Anxiety Parenting Problems Domestic Violence Maternal Depression PTSD Poverty Substance Abuse Generation 1 Generation 2 CANarratives.org
Cumulative ACES Increase Risk for Poor Outcomes
Cumulative ACES & Mental Health1,2Prevalence% 0 10 20 30 40 50 60 70 80 Mood Disorders Anxiety Disorders Substance Abuse Impulse Control Disorders 0 1 2 3 ≥ 4ACES CANarratives.org 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013.
1Felitti et al., (1998) American Journal of Preventive Medicine, 14:245-258. Cumulative ACES & Chronic Disease1Prevalence% 0 2 4 6 8 10 12 14 16 18 Ischemic Heart Disease Stroke COPD Diabetes Sexually Transmitted Disease0 1 2 3 ≥ 4ACES CANarratives.org
1Anda et al., (2004) The Permanente Journal/Winter 8:30-38. Cumulative ACES & Impaired Worker Performance1 Percent%Reported 0 5 10 15 20 25 Absenteeism Financial Problems Job Problems 0 1 2 3 ≥ 4ACES CANarratives.org
Impact of Cumulative ACES & Social Dysfunction1 • Lower educational, occupational attainment. • Increased social service costs. • Increased medical costs. • Shortened life span. • Increased risk for HIV, teen pregnancy, maternal depression2. • Intergenerational transmission of ACES to offspring. 1IOM (Institute of Medicine) and NRC (National Research Council). 2013. New Directions in child abuse and neglect research. Washington, DC: The National Academies Press. 2http://www.movingbeyonddepression.org/ CANarratives.org
Implications of Cumulative ACES • “Dose-Effect” – increasing ACES increases the number of problems. • Child maltreatment victims have 2-7 times higher risk of being re-victimized in the future compared with non- victims1. • Preventing future ACES in previously traumatized children is an important intervention. • Systems that serve traumatized children – e.g., child protection, juvenile justice, mental health – should include trauma screening & prevention interventions. 1Finkelhor et. al (2007). Re-victimization patterns in a national longitudinal sample of children and youth. Child Abuse & Neglect 31:479-502. CANarratives.org
A principle finding of recent work is the extent to which two or more adverse experiences interact so that the risk of a psychological disturbance following is multiplied, often many times over. John. Bowlby, The origins of attachment theory, 1988 Synergy CANarratives.org
Synergistic ACES Increase Complex Adult Psychopathology1 • People who experience one ACE are statistically likely to experience two or more ACES. • Synergy is the interaction of two or more ACES so that their combined effect is greater than the sum of their individual effects. • Complex Adult Psychopathology is defined as having diagnoses crossing 2 or more DSM diagnostic categories (Mood, Anxiety, Substance Abuse or Impulse Control). CANarratives.org 1Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013.
1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. 0 2 4 6 8 10 Sexual Abuse Domestic Violence Synergistic- Co-Existing Childhood Sexual Abuse & Household Domestic Violence ACES are Synergistic & Increase Risk of Complex Adult Psychopathology1,2 RelativeRisk&AdditiveInteraction Increased Risk Due to ACE Synergy Childhood Sexual Abuse & Household Domestic Violence Females (N=3310)) CANarratives.org
Increased Risk Due to ACE Synergy 0 2 4 6 8 10 Substance Abuse Mental Illness Synergistic- Increased Risk Due to ACE Synergy Parental Substance Abuse & Parental Mental Illness Co-Existing Parental Substance Abuse & Parental Mental Illness ACES are Synergistic & Increase Risk of Complex Adult Psychopathology1,2 RelativeRisk&AdditiveInteraction 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. Males (N=2382) CANarratives.org
Synergistic ACES in Females 1,2 • In females synergy occurs with 2 or more ACES. • For females the most potent ACE, sexual abuse, is synergistic with: – Domestic violence – Crime victimization – Poverty – Parental mental illness (anxiety/depression) – Loss of a Parent 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. CANarratives.org
Synergistic ACES in Males 1,2 • In males synergy occurs with 3 or more ACES. • For males, the most potent ACE, poverty, is synergistic with: – Sexual abuse – Parental substance abuse – Loss of a parent 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. CANarratives.org
Synergy between ACES & Other Adversities (e.g., Environmental Pollution1) • Childhood asthma disproportionally affects lower income communities where air pollution & ACES may be elevated. • Correcting for potential confounders – researchers found an increased risk between traffic-related air pollution and asthma (OR = 1.63, CI=1.14-2.33) solely among children exposed to violence. • ACES likely interact synergistically with many environmental pollutants and negative social experiences to increase risk for many costly illnesses. 1Clougherty et al, (2007) Synergistic effects of traffic-related air pollution and exposure To violence on urban asthma etiology. Environmental Health Perspectives 115:1140. CANarratives.org
Addressing ACES Offers Critical Public Health Opportunities1 • ACES are the most preventable cause of serious mental illness. • ACES are the most preventable causes of drug and alcohol abuse in women. • ACES are the most preventable causes of HIV high-risk behavior (IV drugs, promiscuity). • ACES are a significant contributor to leading causes of death (heart disease, cancer, stroke, diabetes, suicide). 1IOM (Institute of Medicine) and NRC (National Research Council). 2013. New Directions in child abuse and neglect research. Washington, DC: The National Academies Press. CANarratives.org
Costs of Cumulative & Synergistic ACES • Human suffering borne by victims & their families. • Economic costs borne by society. • Social costs borne by society. • Intergenerational transmission of childhood adversity borne by future society. CANarratives.org
What does it cost to do nothing? Each 2014 First-Time Case of Child Maltreatment Costs U.S. Economy Approximately $1.8 Million in Total Expenditures over their Lifetime1 1Suffer the Little Children: An Assessment of the Economic Costs of Child Maltreatment The Perryman Group, Nov. 2014: http://perrymangroup.com/special-reports/chlld-abuse-study/ $1.8 Million per 2014 victim1 Graphic from Pew Issue Brief Jan 2011: Paying Later: High Cost of failing to Invest in Young children. CANarratives.org
Costs of Child Maltreatment* NonFatal Fatal Adult Health* Child Health Child & Adolescent Adult Mental Health Medical Health Child Welfare Juvenile Justice Education* $24 Billion* $99 Billion* Mental Health Medical Health Social Welfare Criminal Justice Productivity* $93 Billion* $59 Billion* $4.8 Trillion* Estimated Impact $25 Billion* $224 Billion* $552 Billion* Estimated Lifetime Costs for all 2014 First Time Maltreatment Victims = $5.9 Trillion1 1Suffer the Little Children: An Assessment of the Economic Costs of Child Maltreatment The Perryman Group, Nov. 2014: http://perrymangroup.com/special-reports/chlld-abuse-study/ $5.9 Trillion CANarratives.org
Can We Do Anything?
What Do We Have Available Now? • Proven (evidence-based) prevention & treatment interventions. • Existing programs provide opportunities within which to embed screening, prevention & treatments. • Replication strategies (e.g., National Child Traumatic Stress Network (NCTSN)1 Learning Collaboratives) to expand access to services. • Web networking & data collection tools to support large scale interventions. • Prevention & quality improvement science to enhance interventions while they are being delivered. CANarratives.org 1www.nctsn.org
Child Abuse Prevention • Evidence-based prevention programs exist (e.g., high quality home visitation, Triple P - Promoting Positive Parenting). • CDC meta-analysis of home visitation - median 40% reduction with maximum 80% in official case reports. • Triple-P population-based clinical trial – population effect size d = 0.51 (reduces substantiated cases, out-of-home placements, maltreatment injuries). • Dissemination strategies for ‘going to scale’ with these models exist. • Economic analyses exist documenting cost-effectiveness of the best prevention programs. CANarratives.org
Treatment • Proven treatments exist for traumatized children, e.g., - TF CBT -Trauma-Focused Cognitive Behavioral Therapy - CPP - Child Parent Psychotherapy - PCIT -Parent Child Interaction Therapy • Children with 4 or more ACEs respond as well to treatment as children with fewer adversities1. • Therapists who follow guidelines carefully get the best results. • Treatments can improve both children and parents’ mental health outcomes. • Treatment appears to restore normal biology in stress response systems in some instances. 1Ghosh Ippen C., et al.,(2011) Child Abuse & Neglect, doi:10.1016/j.chiabu.2011.03.009. CANarratives.org
The National Child Traumatic Stress Network (NCTSN) Centers and Affiliated Agencies Provide Proven Treatments to Traumatized Youth Nationwide1 NCTSN Centers and Affiliates as of 2013 1www.nctsn.org CANarratives.org
1The National Child Traumatic Stress Network CDS September 2010 – www.nctsn.org NCTSN Children & Adolescents At Baseline and Last Follow up1 Percentage% 0 5 10 15 20 25 30 35 40 45 Behavioral Problems (n=8880) PTSD (n=2665) Traumatic Stress (n=8839) Baseline Follow-Up CANarratives.org
Prevention & Treatment Costs • Are prevention & treatment programs cost-effective? • High quality home visiting child abuse prevention programs have been found to return ~ $3.00/dollar of cost1. • Evidence-based child trauma treatments such as Parent- Child Interaction Therapy (PCIT) return $3.64/dollar cost1. 1Benefits and Costs of Early Intervention and Prevention Programs, Sept, 2004. http://www.wsipp.wa.gov/rptfiles/04-07-3901a.pdf. CANarratives.org
Preventing ACES is Protective Within & Across Generations • Having Zero (0) ACES significantly protects against child & adult mental illness1,2. • Developmental models postulate that resilience decreases as ACES increase. • Positive childhood experiences3 (“Angels in the Nursery”4) can offset negative childhood experiences. 1Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. 2Bethell, CD, et al, (2014). Health Affairs, 33:2106-2115. 3Chung et al, Ambulatory Pediatrics 2008; 8:109-116. 4Lieberman, et al, Infant Mental Health Journal 2005, 26(6) 504-520. CANarratives.org
Measuring Risk • An Odds Ratio (OR) is a statistic quantifying the strength of association between two factors in a population, e.g., fatty diet and heart disease, smoking and lung cancer. • If the OR is greater or less than 1, then the two factors are significantly associated. If the OR equals 1 there is not a significant association. • ORs are often used to quantify how much a certain factor (e.g., a gene, diet, habit) increases or decreases a person’s risk for a negative outcome. CANarratives.org
0 1 2 3 4 5 Lung Cancer with Exposure from 2nd hand smoke Drug Addiction with Exposure to Sexual Abuse in Females Drug Addiction with Exposure to Sexual Abuse in Males OddsRatio Second Hand Smoke & Lung Cancer2 Versus Sexual Abuse & Drug Addiction1 0 1 2 3 4 5 6 Near Fatal Crash While Experienced Driver Texted PTSD with Exposure to Physical Abuse in Females PTSD with Exposure to Physical Abuse in Males OddsRatio Texting & Crash or Near Fatal Crash3 Versus Physical Abuse & PTSD1 0 1 2 3 4 ADHD & Lead Exposure ADHD with Exposure to Domestic Violence in Females ADHD with Exposure to Domestic Violence in Males OddsRatio Lead Exposure & ADHD4 Versus Domestic Violence & ADHD1 0 1 2 3 4 Melanoma Risk & Tanning Beds Conduct Disorder with Exposure to Poverty in Females Conduct Disorder with Exposure to Poverty in Males OddsRatio Tanning Beds & Melanoma Risk5 Versus Poverty & Conduct Disorder1 1Putnam et. al. JTS, 26:435-442,2013. 2Brennan et. al. Int J Cancer, 109:125-31,2004. 3Klauer et.al. NEJM, 370:54-59,2014. 4Froehlich et. al. Pediatrics, 124:1054-1063,2009. 5Lazovich et, al. Cancer Epidemiol Biomarker Prev., 19:1557-1568,2010. Public Health Thresholds of Risk for Legislation, Regulation or Recommendations CANarratives.org
0 1 2 3 4 5 6 7 Childhood ADHD Alcohol Dependence Conduct Disorder Drug Addiction Explosive Disorder Major Depression PTSD OddsRatio Sexual Abuse Physical Abuse Domestic Violence Poverty OR = 1.4 e.g., OR for second hand smoke and lung cancer Sexual Abuse, Physical Abuse, Domestic Violence & Poverty Each Increase Risk for Mental Health Problems in Females 1,2 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. CANarratives.org
0 1 2 3 4 5 6 Childhood ADHD Alcohol Dependence Conduct Disorder Drug Addiction Explosive Disorder Major Depression PTSD OddsRatio Sexual Abuse Physical Abuse Domestic Violence Poverty OR = 1.4 Sexual Abuse, Physical Abuse, Domestic Violence & Poverty Each Increase Risk for Mental Health Problems in Males 1,2 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. e.g., OR for second hand smoke and lung cancer CANarratives.org
• Child care • Education • Medical • Well-child • Home visitation • Military families • Foster Care • Child welfare • Mental health • Drug and alcohol • Juvenile justice • Immigration • Faith based CANarratives.org
Summary • ACES are cumulative & synergistic. • Females and males have different (but overlapping) combinations of synergistic ACES. • ACES increase risk for major public health problems far in excess of the usual thresholds (i.e., ORs ≥ 1.4 – 1.8) for interventions. • ACEs may be synergistic with environmental exposures or social experiences, e.g., air pollution & childhood asthma. CANarratives.org
What More Can We Do? Adopt a Public Health approach to Child Maltreatment and other ACEs by: 1. Screening for ACEs in systems that serve children and families. 2. Building capacity to prevent & treat child trauma. 3. Increasing access to trauma-informed services for children & families. 4. Integrating and enhancing programs to target synergistic ACEs with highest cumulative risks. 5. Integrating trauma services across family-serving systems. CANarratives.org
How Would We Do It? • Disseminate proven interventions (e.g., NCTSN learning collaboratives). • Incentive-based credentialing and/or rostering of trained clinicians. • Continuous monitoring of intervention outcomes. • Internet systems to manage large scale programs: – Clinical data collection for referrals, outcome analyses & clinician feedback – Interactive training and education – Program management – Networking among providers and stakeholders • Continuous Quality Improvement (CQI) – to improve working programs while delivering services in the field. CANarratives.org
What Are The Expected Outcomes? • Reduced Human Suffering. • Decreased costly Mental & Medical Illness. • Reduction in Health Risk Behaviors (e.g., smoking, substance abuse, poor diet). • Improved Population Health & Well-Being. • Decreased Intergenerational Transmission of ACES. • Improved Educational & Occupation Attainment. • Decreased Crime & Victimization. • Decreased Welfare & Social Services. • Increased Productivity & Life Expectancy. CANarratives.org
How Can a Public Effort Help Us?
Christof Wieland, the German man of letters, wrote in 1798 that public opinion was “ . . . an opinion that gradually takes root among a whole people; especially among those who have the most influence when they work together as a group. In this way it wins the upper hand to such an extent than one meets it everywhere… It then only requires some small opening that will allow it air, and it will break out with force. Then it can change whole nations in a brief time and give whole parts of the world a new configuration.” 1 Christof Wieland, 1798 1Daniel J. Boorstin, Democracy and Its Discontents Reflections on Everyday America, Vintage Books p14, 1975. CANarratives.org
ACES • TED Talk - www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_lifetime • CDC - www.cdc.gov/violenceprevention/acestudy/index.html Evidence Based Treatment & Prevention • NCTSN www.nctsn.org • Children’s Bureau http://www.acf.hhs.gov/programs/cb • SAMHSA http://www.samhsa.gov/ebp-web-guide • Maternal Depression http://www.movingbeyonddepression.org/ Advocacy & Policy • AAP www.aap.org/en-us/Pages/Default.aspx • APAs www.apa.org & www.psychiatry.org • AACAP www.aacap.org Additional Resource URLs: CANarratives.org Resource URLs CANarratives.org

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The Childhood Adversities Narrative (CAN)

  • 1.
    Opportunities To ChangeThe Outcomes Of Traumatized Children 2015 The Childhood Adversity Narratives CAN CANarratives.orgV2
  • 2.
    CAN Contributors Frank Putnam,MD, UNC at Chapel Hill, NC William Harris, PhD, Children’s Research and Education Institute & New School for Social Research, NYC, NY Alicia Lieberman, PhD, UCSF, San Francisco, CA Karen Putnam, PhD, UNC at Chapel Hill, NC Lisa Amaya-Jackson, MD, Duke University, Durham, NC CANarratives.org
  • 3.
    Childhood Adversity Narratives •This is a Narrative that we are seeking to collectively construct with others. • The purpose is to help inform policy makers and the public about the costs and consequences of child maltreatment and adversity. • The goal is to show that there are proven interventions and opportunities to change these personally tragic and socially costly outcomes. • Feel free to use all or part of this Narrative (with appropriate attribution) if helpful to advocate for children and families. CANarratives.org
  • 4.
  • 5.
    There is NoSingle “Best” Term • Child trauma and adversity come in many forms and no term covers all of them. • In this Narrative we use ACES (Adverse Childhood Experiences) because it is one of the better known terms among the many audiences this Narrative seeks to reach. • The basic findings of the original ACES research1 have been independently replicated by many different studies. 1http://www.cdc.gov/violenceprevention/acestudy/prevalence.html CANarratives.org
  • 6.
    ACES (Adverse ChildhoodExperiences)1 • In this Narrative, ACES is used generically to refer to overlapping sets of traumatic and adverse childhood experiences and home environment factors that substantially increase a child’s risk for serious, lifelong medical and mental illnesses. • As the number of ACES increases, the negative outcome of interest (e.g., mental, medical, social, fiscal) increases in a graded (roughly stepwise) fashion. • This cumulative “ACES-effect” occurs at multiple levels from biological markers of stress within a person to population-based markers of health such as rates of childhood asthma in a neighborhood. 1http://www.cdc.gov/violenceprevention/acestudy/prevalence.html CANarratives.org
  • 7.
    ACES Prevalence (%)of Abuse and Neglect In the Original Study1 ACE Women Men Total N=9367 N=7970 N=17337 Abuse Physical Abuse 27.0 29.9 28.3 Sexual Abuse 24.7 16.0 20.7 Emotional Abuse 13.1 7.6 10.6 Neglect Emotional Neglect 16.7 12.4 14.8 Physical Neglect 9.2 10.7 9.9 1http://www.cdc.gov/violenceprevention/acestudy/prevalence.html CANarratives.org
  • 8.
    ACES Prevalence (%)of Household Dysfunction In the Original Study1 ACE Women Men Total N=9367 N=7970 N=17337 Household Dysfunction Household Substance Abuse 29.5 23.8 26.9 Parental Separation or Divorce 24.5 21.8 23.3 Household Mental Illness 23.3 14.8 19.4 Mother Treated Violently 13.7 11.5 12.7 Incarcerated Household Member 5.2 4.1 4.7 1http://www.cdc.gov/violenceprevention/acestudy/prevalence.html CANarratives.org
  • 9.
    Percent of CumulativeAdverse Childhood Experiences ACES in the Original Study1 Number of ACES Women Men Total N=9367 N=7970 N=17337 0 34.5 38.0 36.1 1 24.5 27.9 26.0 2 15.5 16.4 15.9 3 10.3 8.6 9.5 4 or more 15.2 9.2 12.5 1http://www.cdc.gov/violenceprevention/acestudy/prevalence.html CANarratives.org
  • 10.
    • The originalACES (in red) are among the most commonly reported traumas in studies that look at additional traumas. • Over 40% of the children and adolescents served by the NCTSN experienced 4 or more different types of trauma and adversity. 1Pynoos et. al (2014). Psychological Trauma: Theory, Research, Practice and Policy. 6:S9-S13. The ACES are Among Many Childhood Traumas and Adversities Measured by the National Child Traumatic Stress Network N=10,9911 48.7 45.1 36.4 31.4 26.8 26.2 20.1 14.1 13.3 10.6 10.6 9.7 9.5 8.8 5 4.6 2 1.7 1 0.9 0 10 20 30 40 50 60 Traumatic Loss/Bereavement/Separation Domestic Violence Impaired Caregiver Emotional Abuse Neglect Physical Abuse Sexual Abuse Community Violence Sexual Assault/Rape Serious Injury/Accident School Violence Other Illness/Medical Trauma Physical Assault Natural Disaster Extreme Interpersonal Violence Kidnapping Forced Displacement War/Terrorism/Political Violence (Non-U.S) War/Terrorism/Political Violence (U.S) Percent % Reported CANarratives.org
  • 11.
    Rates of Maltreatmentby Age1 • Most maltreatment happens to younger children. • Maltreatment has greater negative effects at younger ages. 1Child Maltreatment 2012. Washington, DC: US Department of Health and Human Services; 2014. Types of Child Maltreatment Psychological Maltreatment 7% 0 1 2 3 4 5 6 7 0-3 4-6 7-9 10-12 13-15 16-17 Percent of Children AgeGroup CANarratives.org
  • 12.
    Adverse Childhood Experiences •Abuseand Neglect (e.g., psychological, physical, sexual) •Household Dysfunction (e.g., domestic violence, substance abuse, mental illness) Impact on Child Development •Neurobiologic Effects (e.g., brain abnormalities, stress hormone dysregulation) •Psychosocial Effects (e.g., poor attachment, poor socialization, poor self-efficacy) •Health Risk Behaviors (e.g., smoking, obesity, substance abuse, promiscuity) Long-Term Consequences Disease and Disability •Major Depression, Suicide, PTSD •Drug and Alcohol Abuse •Heart Disease •Cancer •Chronic Lung Disease •Sexually Transmitted Diseases •Intergenerational transmission of abuse Social Problems •Homelessness •Prostitution •Criminal Behavior •Unemployment •Parenting problems •High utilization of health and social services •Shortened Lifespan How the ACES Work CANarratives.org
  • 13.
    How ACES CrossGenerations Child Adolescent Adult Child Abuse Child Abuse Aggression Conduct Problems Depression PTSD Anxiety School Problems Revictim- ization School Dropout Substance Abuse Depression PTSD Anxiety Parenting Problems Domestic Violence Maternal Depression PTSD Poverty Substance Abuse Generation 1 Generation 2 CANarratives.org
  • 14.
    Cumulative ACES IncreaseRisk for Poor Outcomes
  • 15.
    Cumulative ACES &Mental Health1,2Prevalence% 0 10 20 30 40 50 60 70 80 Mood Disorders Anxiety Disorders Substance Abuse Impulse Control Disorders 0 1 2 3 ≥ 4ACES CANarratives.org 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013.
  • 16.
    1Felitti et al.,(1998) American Journal of Preventive Medicine, 14:245-258. Cumulative ACES & Chronic Disease1Prevalence% 0 2 4 6 8 10 12 14 16 18 Ischemic Heart Disease Stroke COPD Diabetes Sexually Transmitted Disease0 1 2 3 ≥ 4ACES CANarratives.org
  • 17.
    1Anda et al.,(2004) The Permanente Journal/Winter 8:30-38. Cumulative ACES & Impaired Worker Performance1 Percent%Reported 0 5 10 15 20 25 Absenteeism Financial Problems Job Problems 0 1 2 3 ≥ 4ACES CANarratives.org
  • 18.
    Impact of CumulativeACES & Social Dysfunction1 • Lower educational, occupational attainment. • Increased social service costs. • Increased medical costs. • Shortened life span. • Increased risk for HIV, teen pregnancy, maternal depression2. • Intergenerational transmission of ACES to offspring. 1IOM (Institute of Medicine) and NRC (National Research Council). 2013. New Directions in child abuse and neglect research. Washington, DC: The National Academies Press. 2http://www.movingbeyonddepression.org/ CANarratives.org
  • 19.
    Implications of CumulativeACES • “Dose-Effect” – increasing ACES increases the number of problems. • Child maltreatment victims have 2-7 times higher risk of being re-victimized in the future compared with non- victims1. • Preventing future ACES in previously traumatized children is an important intervention. • Systems that serve traumatized children – e.g., child protection, juvenile justice, mental health – should include trauma screening & prevention interventions. 1Finkelhor et. al (2007). Re-victimization patterns in a national longitudinal sample of children and youth. Child Abuse & Neglect 31:479-502. CANarratives.org
  • 20.
    A principle findingof recent work is the extent to which two or more adverse experiences interact so that the risk of a psychological disturbance following is multiplied, often many times over. John. Bowlby, The origins of attachment theory, 1988 Synergy CANarratives.org
  • 21.
    Synergistic ACES Increase ComplexAdult Psychopathology1 • People who experience one ACE are statistically likely to experience two or more ACES. • Synergy is the interaction of two or more ACES so that their combined effect is greater than the sum of their individual effects. • Complex Adult Psychopathology is defined as having diagnoses crossing 2 or more DSM diagnostic categories (Mood, Anxiety, Substance Abuse or Impulse Control). CANarratives.org 1Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013.
  • 22.
    1Data from theNational Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. 0 2 4 6 8 10 Sexual Abuse Domestic Violence Synergistic- Co-Existing Childhood Sexual Abuse & Household Domestic Violence ACES are Synergistic & Increase Risk of Complex Adult Psychopathology1,2 RelativeRisk&AdditiveInteraction Increased Risk Due to ACE Synergy Childhood Sexual Abuse & Household Domestic Violence Females (N=3310)) CANarratives.org
  • 23.
    Increased Risk Due toACE Synergy 0 2 4 6 8 10 Substance Abuse Mental Illness Synergistic- Increased Risk Due to ACE Synergy Parental Substance Abuse & Parental Mental Illness Co-Existing Parental Substance Abuse & Parental Mental Illness ACES are Synergistic & Increase Risk of Complex Adult Psychopathology1,2 RelativeRisk&AdditiveInteraction 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. Males (N=2382) CANarratives.org
  • 24.
    Synergistic ACES inFemales 1,2 • In females synergy occurs with 2 or more ACES. • For females the most potent ACE, sexual abuse, is synergistic with: – Domestic violence – Crime victimization – Poverty – Parental mental illness (anxiety/depression) – Loss of a Parent 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. CANarratives.org
  • 25.
    Synergistic ACES inMales 1,2 • In males synergy occurs with 3 or more ACES. • For males, the most potent ACE, poverty, is synergistic with: – Sexual abuse – Parental substance abuse – Loss of a parent 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. CANarratives.org
  • 26.
    Synergy between ACES& Other Adversities (e.g., Environmental Pollution1) • Childhood asthma disproportionally affects lower income communities where air pollution & ACES may be elevated. • Correcting for potential confounders – researchers found an increased risk between traffic-related air pollution and asthma (OR = 1.63, CI=1.14-2.33) solely among children exposed to violence. • ACES likely interact synergistically with many environmental pollutants and negative social experiences to increase risk for many costly illnesses. 1Clougherty et al, (2007) Synergistic effects of traffic-related air pollution and exposure To violence on urban asthma etiology. Environmental Health Perspectives 115:1140. CANarratives.org
  • 27.
    Addressing ACES OffersCritical Public Health Opportunities1 • ACES are the most preventable cause of serious mental illness. • ACES are the most preventable causes of drug and alcohol abuse in women. • ACES are the most preventable causes of HIV high-risk behavior (IV drugs, promiscuity). • ACES are a significant contributor to leading causes of death (heart disease, cancer, stroke, diabetes, suicide). 1IOM (Institute of Medicine) and NRC (National Research Council). 2013. New Directions in child abuse and neglect research. Washington, DC: The National Academies Press. CANarratives.org
  • 28.
    Costs of Cumulative& Synergistic ACES • Human suffering borne by victims & their families. • Economic costs borne by society. • Social costs borne by society. • Intergenerational transmission of childhood adversity borne by future society. CANarratives.org
  • 29.
    What does itcost to do nothing? Each 2014 First-Time Case of Child Maltreatment Costs U.S. Economy Approximately $1.8 Million in Total Expenditures over their Lifetime1 1Suffer the Little Children: An Assessment of the Economic Costs of Child Maltreatment The Perryman Group, Nov. 2014: http://perrymangroup.com/special-reports/chlld-abuse-study/ $1.8 Million per 2014 victim1 Graphic from Pew Issue Brief Jan 2011: Paying Later: High Cost of failing to Invest in Young children. CANarratives.org
  • 30.
    Costs of ChildMaltreatment* NonFatal Fatal Adult Health* Child Health Child & Adolescent Adult Mental Health Medical Health Child Welfare Juvenile Justice Education* $24 Billion* $99 Billion* Mental Health Medical Health Social Welfare Criminal Justice Productivity* $93 Billion* $59 Billion* $4.8 Trillion* Estimated Impact $25 Billion* $224 Billion* $552 Billion* Estimated Lifetime Costs for all 2014 First Time Maltreatment Victims = $5.9 Trillion1 1Suffer the Little Children: An Assessment of the Economic Costs of Child Maltreatment The Perryman Group, Nov. 2014: http://perrymangroup.com/special-reports/chlld-abuse-study/ $5.9 Trillion CANarratives.org
  • 31.
    Can We DoAnything?
  • 32.
    What Do WeHave Available Now? • Proven (evidence-based) prevention & treatment interventions. • Existing programs provide opportunities within which to embed screening, prevention & treatments. • Replication strategies (e.g., National Child Traumatic Stress Network (NCTSN)1 Learning Collaboratives) to expand access to services. • Web networking & data collection tools to support large scale interventions. • Prevention & quality improvement science to enhance interventions while they are being delivered. CANarratives.org 1www.nctsn.org
  • 33.
    Child Abuse Prevention •Evidence-based prevention programs exist (e.g., high quality home visitation, Triple P - Promoting Positive Parenting). • CDC meta-analysis of home visitation - median 40% reduction with maximum 80% in official case reports. • Triple-P population-based clinical trial – population effect size d = 0.51 (reduces substantiated cases, out-of-home placements, maltreatment injuries). • Dissemination strategies for ‘going to scale’ with these models exist. • Economic analyses exist documenting cost-effectiveness of the best prevention programs. CANarratives.org
  • 34.
    Treatment • Proven treatmentsexist for traumatized children, e.g., - TF CBT -Trauma-Focused Cognitive Behavioral Therapy - CPP - Child Parent Psychotherapy - PCIT -Parent Child Interaction Therapy • Children with 4 or more ACEs respond as well to treatment as children with fewer adversities1. • Therapists who follow guidelines carefully get the best results. • Treatments can improve both children and parents’ mental health outcomes. • Treatment appears to restore normal biology in stress response systems in some instances. 1Ghosh Ippen C., et al.,(2011) Child Abuse & Neglect, doi:10.1016/j.chiabu.2011.03.009. CANarratives.org
  • 35.
    The National ChildTraumatic Stress Network (NCTSN) Centers and Affiliated Agencies Provide Proven Treatments to Traumatized Youth Nationwide1 NCTSN Centers and Affiliates as of 2013 1www.nctsn.org CANarratives.org
  • 36.
    1The National ChildTraumatic Stress Network CDS September 2010 – www.nctsn.org NCTSN Children & Adolescents At Baseline and Last Follow up1 Percentage% 0 5 10 15 20 25 30 35 40 45 Behavioral Problems (n=8880) PTSD (n=2665) Traumatic Stress (n=8839) Baseline Follow-Up CANarratives.org
  • 37.
    Prevention & TreatmentCosts • Are prevention & treatment programs cost-effective? • High quality home visiting child abuse prevention programs have been found to return ~ $3.00/dollar of cost1. • Evidence-based child trauma treatments such as Parent- Child Interaction Therapy (PCIT) return $3.64/dollar cost1. 1Benefits and Costs of Early Intervention and Prevention Programs, Sept, 2004. http://www.wsipp.wa.gov/rptfiles/04-07-3901a.pdf. CANarratives.org
  • 38.
    Preventing ACES isProtective Within & Across Generations • Having Zero (0) ACES significantly protects against child & adult mental illness1,2. • Developmental models postulate that resilience decreases as ACES increase. • Positive childhood experiences3 (“Angels in the Nursery”4) can offset negative childhood experiences. 1Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. 2Bethell, CD, et al, (2014). Health Affairs, 33:2106-2115. 3Chung et al, Ambulatory Pediatrics 2008; 8:109-116. 4Lieberman, et al, Infant Mental Health Journal 2005, 26(6) 504-520. CANarratives.org
  • 39.
    Measuring Risk • AnOdds Ratio (OR) is a statistic quantifying the strength of association between two factors in a population, e.g., fatty diet and heart disease, smoking and lung cancer. • If the OR is greater or less than 1, then the two factors are significantly associated. If the OR equals 1 there is not a significant association. • ORs are often used to quantify how much a certain factor (e.g., a gene, diet, habit) increases or decreases a person’s risk for a negative outcome. CANarratives.org
  • 40.
    0 1 2 3 4 5 Lung Cancer with Exposurefrom 2nd hand smoke Drug Addiction with Exposure to Sexual Abuse in Females Drug Addiction with Exposure to Sexual Abuse in Males OddsRatio Second Hand Smoke & Lung Cancer2 Versus Sexual Abuse & Drug Addiction1 0 1 2 3 4 5 6 Near Fatal Crash While Experienced Driver Texted PTSD with Exposure to Physical Abuse in Females PTSD with Exposure to Physical Abuse in Males OddsRatio Texting & Crash or Near Fatal Crash3 Versus Physical Abuse & PTSD1 0 1 2 3 4 ADHD & Lead Exposure ADHD with Exposure to Domestic Violence in Females ADHD with Exposure to Domestic Violence in Males OddsRatio Lead Exposure & ADHD4 Versus Domestic Violence & ADHD1 0 1 2 3 4 Melanoma Risk & Tanning Beds Conduct Disorder with Exposure to Poverty in Females Conduct Disorder with Exposure to Poverty in Males OddsRatio Tanning Beds & Melanoma Risk5 Versus Poverty & Conduct Disorder1 1Putnam et. al. JTS, 26:435-442,2013. 2Brennan et. al. Int J Cancer, 109:125-31,2004. 3Klauer et.al. NEJM, 370:54-59,2014. 4Froehlich et. al. Pediatrics, 124:1054-1063,2009. 5Lazovich et, al. Cancer Epidemiol Biomarker Prev., 19:1557-1568,2010. Public Health Thresholds of Risk for Legislation, Regulation or Recommendations CANarratives.org
  • 41.
    0 1 2 3 4 5 6 7 Childhood ADHD Alcohol Dependence Conduct Disorder Drug Addiction Explosive Disorder Major Depression PTSD OddsRatio Sexual Abuse Physical Abuse DomesticViolence Poverty OR = 1.4 e.g., OR for second hand smoke and lung cancer Sexual Abuse, Physical Abuse, Domestic Violence & Poverty Each Increase Risk for Mental Health Problems in Females 1,2 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. CANarratives.org
  • 42.
    0 1 2 3 4 5 6 Childhood ADHD Alcohol Dependence Conduct Disorder Drug Addiction Explosive Disorder Major Depression PTSD OddsRatio Sexual Abuse Physical Abuse DomesticViolence Poverty OR = 1.4 Sexual Abuse, Physical Abuse, Domestic Violence & Poverty Each Increase Risk for Mental Health Problems in Males 1,2 1Data from the National Comorbidity Survey-Replication Sample (NCS-R). 2Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013. e.g., OR for second hand smoke and lung cancer CANarratives.org
  • 43.
    • Child care •Education • Medical • Well-child • Home visitation • Military families • Foster Care • Child welfare • Mental health • Drug and alcohol • Juvenile justice • Immigration • Faith based CANarratives.org
  • 44.
    Summary • ACES arecumulative & synergistic. • Females and males have different (but overlapping) combinations of synergistic ACES. • ACES increase risk for major public health problems far in excess of the usual thresholds (i.e., ORs ≥ 1.4 – 1.8) for interventions. • ACEs may be synergistic with environmental exposures or social experiences, e.g., air pollution & childhood asthma. CANarratives.org
  • 45.
    What More CanWe Do? Adopt a Public Health approach to Child Maltreatment and other ACEs by: 1. Screening for ACEs in systems that serve children and families. 2. Building capacity to prevent & treat child trauma. 3. Increasing access to trauma-informed services for children & families. 4. Integrating and enhancing programs to target synergistic ACEs with highest cumulative risks. 5. Integrating trauma services across family-serving systems. CANarratives.org
  • 46.
    How Would WeDo It? • Disseminate proven interventions (e.g., NCTSN learning collaboratives). • Incentive-based credentialing and/or rostering of trained clinicians. • Continuous monitoring of intervention outcomes. • Internet systems to manage large scale programs: – Clinical data collection for referrals, outcome analyses & clinician feedback – Interactive training and education – Program management – Networking among providers and stakeholders • Continuous Quality Improvement (CQI) – to improve working programs while delivering services in the field. CANarratives.org
  • 47.
    What Are TheExpected Outcomes? • Reduced Human Suffering. • Decreased costly Mental & Medical Illness. • Reduction in Health Risk Behaviors (e.g., smoking, substance abuse, poor diet). • Improved Population Health & Well-Being. • Decreased Intergenerational Transmission of ACES. • Improved Educational & Occupation Attainment. • Decreased Crime & Victimization. • Decreased Welfare & Social Services. • Increased Productivity & Life Expectancy. CANarratives.org
  • 48.
    How Can aPublic Effort Help Us?
  • 49.
    Christof Wieland, theGerman man of letters, wrote in 1798 that public opinion was “ . . . an opinion that gradually takes root among a whole people; especially among those who have the most influence when they work together as a group. In this way it wins the upper hand to such an extent than one meets it everywhere… It then only requires some small opening that will allow it air, and it will break out with force. Then it can change whole nations in a brief time and give whole parts of the world a new configuration.” 1 Christof Wieland, 1798 1Daniel J. Boorstin, Democracy and Its Discontents Reflections on Everyday America, Vintage Books p14, 1975. CANarratives.org
  • 50.
    ACES • TED Talk- www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_lifetime • CDC - www.cdc.gov/violenceprevention/acestudy/index.html Evidence Based Treatment & Prevention • NCTSN www.nctsn.org • Children’s Bureau http://www.acf.hhs.gov/programs/cb • SAMHSA http://www.samhsa.gov/ebp-web-guide • Maternal Depression http://www.movingbeyonddepression.org/ Advocacy & Policy • AAP www.aap.org/en-us/Pages/Default.aspx • APAs www.apa.org & www.psychiatry.org • AACAP www.aacap.org Additional Resource URLs: CANarratives.org Resource URLs CANarratives.org