BEYOND ACEOCTOBER 21, 2015

CHANGES MADE FOR THIS SECOND ADMINISTRATION OF THE ACE

SURVEY:

Administration protocols developed by agencies

Standardized training for staff administering ACE

Use of CHOP data system and external researcher

Demographic section broadened to include additional factors, e.g. country of birth, etc.

Additional outcomes included, e.g. trafficked for sex, etc.

Included administration of well being questions from the domains of connection, stress and coping.

PARTICIPATING CRITTENTON AGENCIES

ACE Survey – 16 States and 18 agencies:

1. ARIZONA

2. CALIFORNIA (2)

3. FLORIDA

4. ILLINOIS

5. IOWA

6. KANSAS

7. MISSISSIPPI

8. MISSOURI

9. MONTANA

10.NEW YORK

11.NORTH CAROLINA

12.OHIO

13.PENNSYLVANIA

14.SOUTH CAROLINA

15.TENNESSEE (2)

16.WEST VIRGINIA

FINDINGS FROM THE SECOND CRITTENTON

ACE SURVEY ADMINISTRATION

Dr. Roy Wade, Jr. CHILDREN’S HOSPITAL OF PHILADELPHIAAND STONELEIGH FOUNDATION FELLOW

OUTCOMES ASSOCIATED WITH ADVERSE CHILDHOOD EXPERIENCES:

A LIFE COURSE PERSPECTIVE

CHILDHOOD:

Fetal DeathDevelopment

al DelayBehavioral ProblemsCognitive

Impairment

ADOLESCENCE TO YOUNG ADULTHOOD:Mental Health

Academic Achievement

Juvenile Justice

ADULTHOOD:

Mental Health Physical Health

DisabilityEarly

Mortality

CDC/KAISER ADVERSE CHILDHOODEXPERIENCE STUDY

CHILDHOOD EXPOSURE SUBCATEGORY

Abuse

Psychological

Physical

Sexual

Householddysfunction

Substance abuse

Mental illness

Intimate partner violence

Criminal behavior

Divorce

NeglectEmotional

Physical

Published by CDC/Kaiser in 1998

Surveyed 17,000 policy holders

Understand relationship between childhood adversity & adult health outcomes

Adapted from Felitti et al., 1998

HEALTH OUTCOMES ASSOCIATED WITH ADVERSE CHILDHOOD EXPERIENCES

HEALTH RISK BEHAVIORS

MENTAL HEALTH CONDITIONS

PHYSICAL HEALTH CONDITIONS

SmokingAlcohol Abuse

Drug Abuse/Illicit Drug Use

High Risk Sexual Behavior

DepressionAnxietyPTSD

HallucinationsSuicide

Cardiovascular DiseaseDiabetes

EmphysemaCancerObesity

Liver DiseaseHeadaches

Autoimmune DiseaseSexually Transmitted

InfectionsSelf-Reported Health

DisabilityFetal Death

Mortality

Health outcomes highlighted in pink are among the top ten leading causes of death in the US

PHILADELPHIA ACE STUDY QUESTIONS

CONVENTIONAL ACES EXPANDED ACES

Physical Abuse

Emotional Abuse

Sexual Abuse

Emotional Neglect

Physical Neglect

Domestic Violence

Household Substance Abuse

Incarcerated Care Provider

Mental Illness in the Home

Witnessing Violence

Living in Unsafe Neighborhoods

Experiencing Racism

Living in Foster Care

Experiencing Bullying

PHILADELPHIA STUDY - DISTRIBUTION OF TOTAL ACE

SCORES

0 ACEs 1 - 3 ACEs 4+ ACEs0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Pre

vale

nce

(%

)

ACE Score

TNCF SURVEY RESPONDENTS WERE PRIMARILY FEMALE, WHITE, AND

LESS THAN 18 YEARS OF AGEDEMOGRAPHIC RESPONSE

FEMALE(N = 745)

MALE(N = 270)

TOTAL(N = 1021)

Age in years (%)

10 to 18 72 89 73

19 to 34 19 8 15

35 to 65 9 3 8

Gender (%)Female -- -- 74

Male -- -- 26

Race/Ethnicity (%)

Hispanic/Latino 16 31 19

White 54 50 55

Black 20 11 17

Multiracial 5 6 5

Other 5 2 4

Education (%)

Less than high school

75 92 80

High school 14 5 11

Some college or more

12 3 9

TNCF SURVEY RESPONDENTS PRIMARILY RECEIVED MENTAL

HEALTH SERVICESFEMALE

(N = 745)MALE

(N = 270)TOTAL

(N = 1021)

Early childhood (%) 4 1 1

Family support (%) 4 1 3

Mental & behavioral health (%) 37 62 45

Supportive housing (%) 10 5 8

Residential treatment (%) 20 15 30

Other (%) 5 4 5

Don’t know/refused (%) 19 11 8

TNCF SURVEY RESPONDENTS LIVE IN

A VARIETY OF SETTINGSFEMALE

(N = 745)MALE

(N = 270)TOTAL

(N = 1021)

Foster care/kinship foster care (%) 7 17 9

Group home (%) 12 9 11

Living on my own (%) 13 7 11

Living with friends (%) 1 0 1

Living with my biological or extended family (%)

27 51 35

Residential treatment center (%) 29 11 24

Shelter (emergency, domestic violence, homeless) (%)

9 3 7

Other (%) 2 0 2

TNCF CLIENTS HAVE HIGHERACE SCORES THAN RESPONDENTS

FROM PREVIOUS ACE STUDIES

0 1 2 3 4 or more0

10

20

30

40

50

60

70

ACE Score Prevalence by StudiesTNCF Females TNCF Philadelphia ACE Study Kaiser CDC ACE Study

ACE Score

Preva

lence

(%

)

(TNCF Total N=1,008, TNCF Female N=732, Philadelphia N=1,784, Kaiser-CDC N=17,337)

Physically neglected

Emotionally neglected

Sexually abused

Emotionally abused

Physically abused

Domestic violence in home

Parental separation

Incarcerated care provider

Care provider substance abuse

Care provider mental illness

0 10 20 30 40 50 60 70 80

Prevalence of Individual ACEs by SurveyTNCF-Female TNCF-Total Philadelphia Kaiser CDC

Preva

lence

(%

)

(TNCF Total N=1,008, TNCF Female N=732, Philadelphia N=1,784, Kaiser-CDC N=17,337)

TNCF CLIENTS HAVE HIGHER ACE PREVALENCE THAN INDIVIDUALS FROM PREVIOUS ACE STUDIES

TNCF FEMALE RESPONDENTS HAVE HIGHER ACE SCORES THAN TNCF

MALE RESPONDENTS

0 1 to 3 4 to 7 8 to 100

510

1520

2530

354045

ACE Score Prevalence Among TNCF Respondents by Gender

Female Male Total

ACE Score

Preva

lence

(%

)

(Female N=732, Male N=245)

(Female N=732, Male N=245)

Physically neglected

Emotionally neglected

Sexually abused

Emotionally abused

Physically abused

Domestic violence in home

Parental separation

Incarcerated care provider

Care provider substance abuse

Care provider mental illness

0 10 20 30 40 50 60 70 80

Prevalence of Individual ACEs

Female

Male

Prevalence (%)

TNCF FEMALES HAVE HIGHER PREVALENCE OF ACES THAN MALES

HIGH ACES FOR TNCF FEMALESCUT ACROSS ALL RACIAL/ETHNIC

BACKGROUNDS

0 1 to 3 4 to 7 8 to 100

10

20

30

40

50

60

ACE Score for TNCF Females by Race/Ethnicity

White Black Hispanic/Latino Multiracial Other

ACE Score

Preva

lence

(%

)

Physically neglected

Sexually abused

Physically abused

Parental separation

Care provider substance abuse

0 10 20 30 40 50 60 70 80 90 100

Prevalence of Individual ACEs Among Femaleswith 4 to 7 ACEs and 8 or more ACEs

4 to 7 8 or more

Prevalence (%)

ALL ACES ARE COMMON AMONG TNCF FEMALES WITH SIGNIFICANT CHILDHOOD ADVERSITY (N=732)

FEMALES WITH HIGH ACE SCORES EXPERIENCE MORE PLACEMENT

INSTABILITY

0 1 to 3 4 to 7 8 or more0

1

2

3

4

5

6

7

Average Number of Out of Home Placements by ACE Score and Gender

Female Male

ACE Score

Ave

rage N

um

ber

of

Out

of

Hom

e

Place

ments

A SIGNIFICANT NUMBER OF TNCF FEMALES RECEIVING SERVICES FOR

AT LEAST 1 YEAR HAVE HIGH ACE SCORES

0 1 to 3 4 to 7 8 to 100

10

20

30

40

50

60

ACE Score

Preva

lence

(%

)

A SIGNIFICANT PERCENTAGEOF TNCF FEMALES RECEIVING

RESIDENTIAL TREATMENT SERVICES HAVE HIGH ACE SCORES

7%

28%

38%

27%

0 1 to 3 4 to 7 8 to 10

A SIGNIFICANT PERCENTAGE OF TNCF FEMALES WITH TEENAGE PREGNANCIES OR RAISING CHILDREN HAVE HIGH ACE

SCORES

6%

28%

43%

23%

0 1 to 3 4 to 7 8 to 10

9%

20%

47%

23%

0 1 to 3 4 to 7 8 to 10

ACES ASSOCIATED WITH HISTORY OF TRAFFICKING AMONG TNCF

FEMALES(N=56)

0 1 to 3 4 to 7 8 to 100

10

20

30

40

50

60

ACE Score

Preva

lence

(%

)

CHILD DEMOGRAPHICS(N=109)

DEMOGRAPHICS RESPONSE PERCENT

Age in years (%)

0 to 6 53

7 to 10 8

11 to 18 31

Gender (%)Female 47

Male 53

Race/Ethnicity (%)

Hispanic 26

White 33

Black 27

Multiracial 8

Other 7

Physically neglected

Sexually abused

Physically abused

Parental separation

Care provider substance abuse

0 10 20 30 40 50 60 70

Prevalence (%)

INDIVIDUAL ACES ARE COMMON AMONGST CHILDREN OF TNCF

FEMALES (N=109)

9

8

7

6

5

4

3

2

1

0

0 5 10 15 20 25

Prevalence (%)

AC

E S

core

CHILDREN OF TNCF FEMALES HAVE HIGH ACE SCORES (N=109)

AVERAGE CHILD ACE SCORE BY AGE(N=109)

0 to 6 years 7 to 10 years 10 to 18 years0

1

2

3

4

5

6

Age

Ave

rage C

hild

AC

E

Sco

re

PSYCHOLOGICAL STRESS INCREASES WITH ACE SCORE FOR

TNCF FEMALES (N=664)

0 1 to 3 4 to 7 8 to 100

0.5

1

1.5

2

2.5

3

3.5

Average Psychological Stress Levelby ACE Score for TNCF Females

ACE Score

Incr

easi

ng

Psyc

holo

gic

al S

tress

CONNECTION TO OTHERS DECREASES WITH ACE SCORE FOR

TNCF FEMALES (N=664)

0 1 to 3 4 to 7 8 to 100

0.51

1.52

2.53

3.54

4.5

Average Level of Connectionby ACE Score for TNCF Females

ACE Score

Incr

easi

ng S

ense

of

Connect

ion t

o O

thers

COPING SKILLS DECREASE WITH ACE SCORE FOR TNCF FEMALES

(N=664)

0 1 to 3 4 to 7 8 to 100

0.5

1

1.5

2

2.5

3

3.5

4

Level of Positive Coping Skillsby ACE Score for TNCF Females

ACE ScoreIncr

easi

ng C

opin

g S

kills

POLICY AND PRACTICE IMPLICATIONS

The following policy and practice implications are made based on inferences drawn from the results from respondents in this administration of ACE.

Further research must be completed before definitive findings and recommendations can be

made.

POLICY AND PRACTICE IMPLICATIONS

FINDING: There’s a group of girls for whom ACEs are normative- Policy Implication: We must focus on reducing

overall exposure to ACE’s and other forms of adversity.

FINDING: Girls’ ACE scores are higher than boys and there are differences in prevalence on individual ACEs.- Policy Implication: A gender lens should be used

in all systems to better understand appropriate service responses for girls.

POLICY AND PRACTICE IMPLICATIONS (continued)

FINDING: Girls with very high ACE scores (8+) have a high number of placements and more likely to be trafficked for sex- Policy Implication: The traditional approach of looking

at scores of 4+ misses the unique needs of girls with very high ACE scores. More attention needs to occur for young women with significant childhood adversity

FINDING: ACES are prevalent for individuals across racial and ethnic groups- Policy Implication: It’s important to eradicate the

negative impact of bias in systems against girls of color is eradicated, while also making sure that low income white girls in rural areas are not further marginalized.

POLICY AND PRACTICE IMPLICATIONS (continued)

FINDING: Children of parents with high ACEs experience adversity at young ages:- Policy Implication: A two or multi-generational approach

offers the best opportunity for parents with high scores to break the vicious cycle of childhood adversity, trauma, poor outcomes and poverty.

FINDING: Initial results suggest a connection between ACE scores and well being: - Policy Implication: Further work on how to increase

connections for young people, research on a wider range of well being domains, and follow up research to explore which interventions work to promote well being

NEXT STEPS:BEYOND ACE

Further analysis of the data.

Publication of a policy brief on findings and implications of the TNCF ACE data in late November.

Population specific issue briefs will be generated over the next six months.

NEXT STEPS:EVIDENCE BUILDING PROCESS

Pending funding TNCF will:

Work with Dr. Wade to develop and administer a girl/youth informed survey based on the ACE.

Develop central data base for demographic, ACE and well being data across agencies/states.

Administer well being questions in additional domains beyond connection, stress and coping.