DECEMBER 16, 2013 I S S U E F O C U S to Adverse Childhood Experiences NICOLE DREISBACH, M.P.H., Grantmakers In Health H eart disease, cancer, and chronic lower respiratory dis- eases are the leading causes of death in the U.S., and FIGURE 2 led to more than 1.3 million deaths in 2010 (CDC ADVERSE CHILDHOOD EXPERIENCES 2013a). Researchers are increasingly turning their attention to FRAMEWORK young children and early traumatic stressors to further under- stand the pathway leading to these diseases and their associated Early risk factors. Why this attention? A landmark study conducted Death nearly 20 years ago shone a light on the long-term relationship between prolonged, traumatic stress while growing up—what Disease, Disability, & Social Problems the authors called Adverse Childhood Experiences (ACE)— Scientific and many of the leading causes of death (Felitti et al. 1998). Gaps Adoption of At-risk Behaviors ACEs have been associated with a greater likelihood of heart disease, chronic bronchitis or emphysema, stroke, cancer, sexu- Social, Emotional, Cognitive Impairment ally transmitted infections, and depression, as well as the behavioral risks of excessive drinking, substance use, cigarette Adverse Childhood Experiences smoking, and attempting suicide (Felitti et al. 1998). This growing body of research underscores the importance of early Source: CDC 2013b child and family interventions that can help set a pathway to lifelong health and wellness. and Prevention (CDC), established a framework for under- ORIGINS OF ADVERSE CHILDHOOD standing the relationship between childhood exposures to a EXPERIENCES constellation of maltreatment and household dysfunction types (Figure 1) and subsequent adult health and behaviors. The initial ACE study, conducted in the late 1990s by Dr. Adopting a “whole life perspective,” the framework posits that Vincent Felitti of Kaiser Permanente San Diego, in partner- ACEs are a common pathway to social, emotional, and cogni- ship with Dr. Robert Anda of the Centers for Disease Control tive impairments, leading to the adoption of risky behaviors, which develop into disease or disability and culminate with an early death (Figure 2) (CDC 2013b). FIGURE 1 Although there are still gaps in our understanding of the TYPES OF ADVERSE progression from ACEs to death and disability, the evidence CHILDHOOD EXPERIENCES base for the basic model is strong. Since 1995, more than 17,300 Kaiser Permanente San Diego plan members have • Physical participated in the ACE study. Among the findings, nearly Abuse • Sexual • Emotional two-thirds of the adults (64 percent) had at least one ACE while growing up, and approximately one in eight (13 percent) • Physical had four or more ACEs, suggesting that for many adults multi- Neglect • Emotional ple forms of adversity were present during childhood (Figure 3) (CDC 2013d). The findings also show that the more ACEs • Household member with mental a person experiences while growing up, the greater the risk for illness Household • Household member incarcerated poor health by adulthood. For example, adults with four or • Parents divorced or separated more ACEs had a 10-fold greater odds of injecting drugs, Characteristics • Mother treated violently seven-fold greater odds of identifying themselves an alcoholic, • Household member with substance four-fold greater odds of having chronic bronchitis or emphy- addiction sema, and a two-fold greater odds of having ischemic heart 2 I S S U E F O C U S GIH BULLETIN disease, compared with those who did not have these types of prevention programs, Prevent Child Abuse North Carolina experiences while growing up (Felitti et al. 1998). and Prevent Child Abuse South Carolina. These organizations Since the original Kaiser Permanente-CDC study, statewide are implementing evidence-based and innovative programs surveys have been fielded throughout the U.S., with similar that seek to prevent child maltreatment before it occurs. results. Arkansas, Louisiana, New Mexico, Tennessee, and Working within communities across the Carolinas, these orga- Washington featured the ACE module in their state’s 2009 nizations are striving to create safe and healthy relationships Behavioral Risk Factor Surveillance Survey (BRFSS), an for children through the use of parenting classes, home visiting annual state-based telephone survey of randomly-selected programs, and anti-bullying programs. adults ages 18 or older. Among these states, the prevalence of Blue Shield Against Violence, an initiative of the Blue having at least one ACE ranged from a low of 53 percent Shield of California Foundation, aims to end domestic vio- (Arkansas) to a high of 65 percent (Washington), and the lence in the state. To advance this goal, the foundation is prevalence of having four or more ACEs ranged from a low of investing in a variety of approaches that support: (1) core oper- 12 percent (Louisiana) to a high of 18 percent (Washington) ations of domestic violence shelters; (2) capacity-building and (CDC 2010). Similar with the original study, these findings sustainability of service providers, supporting organizations, suggest that ACEs are common and often occur in multiples; and leaders to reduce domestic violence; (3) innovative state-level differences are also apparent. The BRFSS ACE approaches that reach underserved populations; and (4) module continues to garner interest among other state officials, statewide and regional coalitions and convenings, allowing for with 21 states having adopted it at least once for their state’s policy and advocacy discussions to strengthen prevention survey (Anda 2013). efforts. One example of the foundation’s domestic violence grantmaking is an award provided to Futures Without HEALTH PHILANTHROPY AND CHILDHOOD Violence. This advocacy organization is developing a national ADVERSITY agenda that seeks to maximize opportunities provided by the Affordable Care Act to fund prevention efforts and care for Long before the phrases, “Adverse Childhood Experiences” or children and youth who are exposed to family violence. “toxic stress,” were coined, health funders were investing in Some grantmakers are directly responding to ACEs and trau- strategies to prevent or mitigate experiences like child abuse or matic stressors through research, dissemination, and early domestic violence that may interrupt a child’s healthy develop- childhood and family interventions. ment. ACEs research has sparked even more interest in this The Mid-Iowa Health Foundation has been investing in area of work. research and dissemination strategies to raise awareness about The child care grantmaking portfolio of The Duke ACEs throughout the state. To date, the foundation has Endowment encompasses an array of efforts ensuring that awarded two grants to the Iowa Department of Public Health North and South Carolina’s vulnerable children are provided to include the BRFSS ACE module in the 2012 and 2013 with opportunities to reach their full potential and successfully statewide surveys. Findings from the 2012 Iowa ACE module transition into adulthood. As part of this portfolio, the endow- corroborate previous findings: ACEs are common, frequently ment supports efforts to prevent child maltreatment. For occur in multiples, and are associated with poor health out- example, the endowment funds two statewide child abuse comes (Figure 4) (Central Iowa ACEs Steering Committee 2013). The foundation is also a member of the Central Iowa ACEs 360 Steering Committee that is working to raise aware- FIGURE 3 ness among the general public, policymakers, and other DISTRIBUTION OF ADVERSE CHILDHOOD professionals throughout Iowa about the scope of ACEs as well EXPERIENCES, SAN DIEGO, 1995-1997 as the health impacts. Additionally, committee members have 100% been working to amass a repository of information about other state efforts in collecting ACE-related survey data, and recently 80% convened its first statewide ACE summit, bringing together 63.9% 1 or more ACEs national and local experts to share their efforts in addressing 60% ACEs (ACEs 360 Iowa 2013). Last year the Robert Wood Johnson Foundation (RWJF) 40% 36.1% provided a grant to the Institute for Safe Families (ISF) to sup- 26.0% port ACE-related research among adults residing in 20% 15.9% Philadelphia, PA—a more urban and diverse population than 9.5% 12.5% previously studied. A Task Force developed the Philadelphia 0% Urban ACE Survey, which expanded the content of previous 0 1 2 3 4 or more ACE surveys by adding supplementary items to assess the Source: CDC 2013b health impact of experiences such as witnessing community violence, experiencing racism, being bullied, feeling unsafe in DECEMBER 16, 2013 3 and identify appropriate interventions (ISF 2013). FIGURE 4 In addition to research- and dissemination-funded efforts, KEY FINDINGS, IOWA, 2012 other ACE-related grantmaking efforts are being advanced to identify children who are exhibiting signs of traumatic stress so ACE Prevalence that interventions can begin earlier. Many of these efforts are • 55% of Iowa adults have one or more ACEs meeting children were they are: child care settings and schools. A number of funders serving the Kansas City area have • 14% of Iowa adults have four or more ACEs funded the Crittenton Children’s Center’s Head Start-Trauma ACEs increase likelihood of: Smart program to provide trauma-informed care to young children ages three through five. Local funders included the • Poor mental health, including depression REACH Healthcare Foundation, the Health Care • Poor physical health, including chronic health conditions Foundation of Greater Kansas City, the Hall Family Foundation, and Bank of America. The Head Start-Trauma • Cigarette smoking Smart model promotes trauma awareness, resiliency building, and lifelong coping strategies. Licensed therapists provide Source: Central Iowa ACEs Steering Committee 2013 classroom consultation as well as individual or family therapy while parents and Head Start staff, ranging from teachers to the community, and living in foster care. Findings reveal that custodians, are provided with trainings to develop the skills ACEs are common among an urban population, frequently necessary to sustain the program’s progress. More recently, occur in clusters, and are associated with poor health outcomes RWJF awarded a three-year grant to the Crittenton Children’s (Figure 5) (PHMC 2013). The heterogeneous sample was large Center to support the replication of the Head Start-Trauma enough for racial and economic disparities to be identified. Smart model of care across Missouri. They include that ACEs are more common among lower- As part of their U.S. education grantmaking efforts to income adults than higher-income adults and are more improve school outcomes, the Bill & Melinda Gates common among black adults than white adults (PHMC 2013). Foundation is investing in ACE-related place-based interven- Similar with the communication and convening work in Iowa, tions designed for elementary school students. The foundation Philadelphia Task Force members are engaging in efforts to recently awarded a three-year grant to the Seattle and King spread the word about ACEs and to learn from others working County and Area Health Education Center of Eastern in the field. Additionally, ISF and RWJF representatives con- Washington to replicate and enhance an evidence-based model vened a two-day national summit, which brought together that addresses the needs of children who have experienced national and local experts to share their research, dissemination multiple forms of trauma. This model seeks to improve school tactics, and interventions. In moving forward, task force practices by training teachers and other school staff to help members are meeting regularly to continue these discussions mitigate the effects of trauma. This grant also will provide opportunities to develop ways in which this model can FIGURE 5 enhance existing practices for school-based health clinics. KEY FINDINGS, PHILADELPHIA, 2012 CONCLUSION ACE Prevalence More than 20 years ago, Drs. Felitti and Anda began an • 70% of Philadelphia adults have one or more ACEs inquiry into exposures to traumatic stressors during childhood • 22% of Philadelphia adults have four or more ACEs and subsequent quality of life and health outcomes in adult- hood. Today, with the help of neuroscience, we have an even Including Urban-Specific ACE Items better understanding of the mechanisms by which early expo- • 83% of Philadelphia adults have one or more ACEs sures to traumatic stressors affect healthy brain development among young children. Many health funders are joining this • 37% of Philadelphia adults have four or more ACEs conversation, too. No one approach will solve this complex ACEs increase likelihood of: challenge, and grantmakers are supporting a variety of • Poor mental health, including suicide attempts approaches: child maltreatment or household dysfunction prevention and intervention programs, early childhood inter- • Poor physical health vention programs, and research and communication tactics. • Substance addiction Many of the nation’s leading causes of death and associated • Cigarette smoking risk behaviors may benefit from investments in children’s healthy development through the prevention or mitigation of Source: PHMC 2013 ACEs, thereby helping to pave the way for optimal health and wellness across the lifespan. 4 I S S U E F O C U S GIH BULLETIN RESOURCES ACEs 360 Iowa, 2013 Iowa Adverse Childhood Experiences Summit: Data into Action: Crafting a Response to Iowa’s ACE Score, <http://www.iowaaces360.org/iowa-aces-summit.html>, 2013. Anda, Robert F., “Adverse Childhood Experiences: Where Sciences Unite,” presented at the National Summit on Adverse Childhood Experiences <http://www.instituteforsafefamilies.org/ sites/default/files/isfFiles/ANDASciencesCollide.pdf>, May 2013. Centers for Disease Control and Prevention [CDC], “Adverse Childhood Experiences Reported by Adults—Five States, 2009,” Morbidity Mortality Weekly Report [MMWR], 59(49), December 2010. Centers for Disease Control and Prevention [CDC], National Center for Injury Prevention and Control [NCIPC], “Web-based Injury Statistics Query and Reporting System (WISQARS),” 2010, <www.cdc.gov/ncipc/wisqars>, 2013a. Centers for Disease Control and Prevention [CDC], Pyramid, <http://www.cdc.gov/ace/ pyramid.htm>, 2013b. Centers for Disease Control and Prevention [CDC], “Adverse Childhood Experiences (ACE) Study: ACE Study Participant Demographics” <http://www.cdc.gov/ace/demographics.htm>, 2013c. Centers for Disease Control and Prevention [CDC], “Adverse Childhood Experiences (ACE) Study: Prevalence of Individual Adverse Childhood Experiences,” <http://www.cdc.gov/ace/ prevalence.htm>, 2013d. Central Iowa ACEs Steering Committee, “Adverse Childhood Experiences in Iowa: A New Way of Understanding Lifelong Health,” <http://www.iowaaces360.org/uploads/1/0/9/2/10925571/ iowa_aces_360_pdf_web_new.pdf>, 2013. Felitti, Vincent J., Robert F. Anda, Dale Nordenberg, David F. Williamson, Alison M. Spitz, Valerie Edwards, Mary P. Koss, and James S. Marks, “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine, 14(4):245-258, 1998. Institute for Safe Families [ISF], <http://www.instituteforsafefamilies.org>, 2013. Public Health Management Corporation [PHMC], “Findings from the Philadelphia Urban ACE Survey,” <http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf407836>, 2013.