Laura Porter, DSHS ACE Partnerships March 6, 2013 Adverse Childhood Experience in Washington

Laura Porter, DSHS ACE PartnershipsMarch 6, 2013

Adverse Childhood Experiencein Washington

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(c) DSHS PPA ACE Partnerships, 2013

Brains to Fit the Life We’ll LiveWHY IT WORKSUnder the worst conditions, such as war & famine, both the individual & the species survive.

INDIVIDUALcharacteristics & traits

• Competitive• Impulsive• Hyper vigilant• Hyper reactive• Focused – hard to

shift gearsOR

• Withdrawn• Emotionally Detached• Numb

Toxic Context

INDIVIDUALcharacteristics & traits

• Laid back• Relationship-oriented• Reflective• Shift focus - seize

opportunity• “Process over power”

WHY IT WORKSBy striving for cooperative relationships, individual & species live peacefully & survive.

Protective Context

Predictable Patterns: Electrical & Chemical

Functioning; Brain Mass &

Gene Expression

Neutral Start then…

brains adapt to experience

Dissonance between biological expectations

& social reality fuels psychiatric disorders

The Neurobiology of Toxic Experience

See for example: “Neurobiological and Behavioral Consequences of Exposure to Childhood Traumatic Stress” Stress in Health and Disease; Arnetz & Ekman (eds); Teicher et. al.; 2006“Scars that Won’t Heal: The Neurobiology of Child Abuse” Scientific American; Teicher; March, 2002, pp. 68-75.“Childhood Experience and the expression of Genetic Potential: What Childhood Neglect Tells Us About Nature and Nurture”; Brain and Mind 3:79-100; Perry; 2002

Type of Experience

Gender

Age – Sensitive Periods

Premature BirthFetal Death

Post-partum DepressionAttachment Challenges

Reduced Brain MassDifficult to Sooth

Stress/Hormone Dis-regulationRelationship Challenges

Pre-Natal

Toxic Stress is Hard-Wired Into Biology

Early ChildhoodEmotional Reaction

Verbal MemorySpatial Memory

Judgment Self MonitoringSelf Awareness

Motivation

Right-Left Brain Communication

Social CuesInsight

Movement Language & Math

Visual Memory/Meaning

Middle Childhood

Pre-puberty - Adolescence

AttentionLong Term Memory

Mental Health Goal-oriented ActionRegulating movement through environment

COGNITIVE

SOCIAL

MENTAL HEALTH

SUBSTANCE ABUSE

PHYSICAL AGILITY

SAFETY

CHRONIC DISEASE

PRODUCTIVITY

STATUS

Enduring Effects

Adverse Childhood Experience Study

Largest Study of its Kind

Over 17,000 participants

Both Retrospective and Prospective

Over 100 Peer-Reviewed Journal Articles

Shifting the Paradigm

Helps Us Understand Drivers of Population Health and Wellbeing

Adverse Childhood Experiences are Interrelated

Abuse1. Child physical abuse 2. Child sexual abuse3. Child emotional abuse

Neglect4. Physical Neglect5. Emotional Neglect

Indicators of Family Dysfunction6. Mentally ill, depressed or suicidal person in the home7. Drug addicted or alcoholic family member8. Parental discord – indicated by divorce, separation, abandonment9. Witnessing domestic violence against the mother10. Incarceration of any family member

87%

with 1 ACE have

another

ACEs Have Cumulative Effect: ACE Score = Number of Categories of ACEs (1-10)

ACEs are Common Among Washington Adults

62% have at least one ACE category

26% have ≥ three

5% have ≥ six

Dose-Response RelationshipHigher ACE Score Reliably Predicts Prevalence of Health Problems

Higher ACE Score

Resp

onse

get

s bi

gger

The size of the “dose”— the number of ACE categories

Drives the “response”— the occurrence of health, social, workforce problems & early death


A Significant Portion Of Risk for Disease Is Attributable to ACEs…

Smoking

Heavy Drinking

Binge Drinking

Drinking and Driving

Had a Drug Problem

Addicted to Drugs

Ever Injected Drugs

0 1 2 3 4 or 5 6,7, or 80

5

10

15

20

25

30

10.413.2

11.1

16.3

20.8

28.5

Current Smoking- Wash-ington

Number of ACE CategoriesPerc

ent o

f Pop

ulati

on C

urre

ntly

Sm

okin

g

0 1 2 3 4 ≥50

2

4

6

8

10

12

14

1.33

3.95

7.5

12

Ever Had a Drug Problem

Number of ACE Categories

Perc

ent o

f Pop

ulati

on w

ith P

robl

emOriginal ACE Study


A Significant Portion of Chronic Disease is Attributable to ACEs

Cardio Vascular Disease

Cancer

Diabetes

Asthma

Auto Immune Disease

Chronic obstructive pulmonary disease

Ischemic heart disease

Liver Disease

4.95.6

6.75.6

9.4

8.1

0123456789

10

0 1 2 3 4 or 5 6,7, or 8

% o

f Pop

ulati

on w

ith C

-V D

isea

se


Cardio Vascular Disease

1.3

33.9

5

7.5

12

0

2

4

6

8

10

12

14

0 1 2 3 4 ≥5

% o

f Pop

ulati

on w

ith A

sthm

a

ACE Score

Asthma


A Large Portion of Mental Illness Is Attributable to ACEs…

0 1 2 3 4 or 5 6,7, or 80

2

4

6

8

10

12

14

16

1.92.8

5

7

8.8

15

Anxiety


Perc

ent o

f Pop

ulati

on

Depression

Serious and persistent mental illness

Frequent mental distress

Nervousness

Suicide attempts

Emotional problems that restrict activities

0 1 2 3 4 or 5 6,7, or 80

5

10

15

20

25

30

7.311

14 15.519.3

24.5

Treatment for Mental Health Condition


Perc

ent o

f Pop

ulati

on

A Large Portion of Mental Illness Is Attributable to ACEs…

0 1 2 3 4 or 5 6,7, or 80

2

4

6

8

10

12

14

16

1.92.8

5

7

8.8

15

Anxiety


Perc

ent o

f Pop

ulati

on

Depression

Serious and persistent mental illness

Frequent mental distress

Nervousness

Suicide attempts

Emotional problems that restrict activities

0 1 2 3 4 or 5 6,7, or 80

5

10

15

20

25

30

7.311

14 15.519.3

24.5

Treatment for Mental Health Condition


Perc

ent o

f Pop

ulati

on

A Significant Portion of Disability & Disability-Related Barriers to EmploymentIs Attributable to ACEs…


0 ≥ 3 ≥ 60

5

10

15

20

25

4

9

20


% o

f Peo

ple

Mis

sing

≥ 1

0 W

ork

Day

s in

Pas

t Mon

th

Missing Work Due to Disability

0 1 2 3 4 or 5 6,7, or 8

0

4

8

12

16

5.2 5.2 6.48.6

11.3

14.8

Health Problems Requiring Special Equipment


Perc

ent o

f Pop

ulati

on

Some ACE-Attributable Disabilities are Invisible

ADHDAnxiety Disorders

AsthmaBipolar Disorder

Chronic PainSleep disorders

DepressionDiabetes

HypoglycemiaMajor Depression

Metabolic SyndromePersonality Disorders

Primary ImmunodeficiencyPsychiatric disabilities

ArthritisSchizophrenia

ACEs and Ability to Engage in Work/Life Activities

Attributable to ACEs:

Disability-Related Days when Can’t Do Usual Activities

Worker Injury

Work-related Illness

Drugs/Alcohol

Hopelessness

Health Limits Activity

Serious Job Problems

Serious Financial Problems

0 ≥ 3 ≥ 60

5

10

15

20

25

4

9

20

Missed Work


% M

issi

ng ≥

10

Wor

k D

ays/

Mon

th

0 1 2 3 4, 5 6,7, 80

2

4

6

8

10

12

3.65

76.1

8.910.1

Work-Related Injury or Illness in Past Year

Perc

ent w

ith In

jury

/Ill

ness

29.7% of the Working Age Population (Age 18-64) has 3 or more ACEs

ACEs in WA High Schools

Graphic by Northwest Children’s Fund, 2012

In the average Washington classroom:

·6 students have no ACE

·5 students have 1 ACEs



·7 students have 4-5 ACEs

·3 students have 6+ ACEs

Knowing the prevalence of ACEs and how they affect brain development, it’s clear to see why so many students struggle to focus in an academic environment.

Multiple Mental, Physical,

Relational, &/or Productivity

Problems

Adverse Childhood Experience

Adverse Peer &/or School Experience

Adverse Adult Experience

WA Data Shows Cascade of Experiences …Societal Response Matters

ACETransmission

Risk

Elementary Children12% ≥ 3

ACEs1. Health,

attendance, behavior

2. Academic failure

Court-Involved Youth

Higher ACE ScoresAmong those with ≥4:

51% special ed. (vs. 33% 0-1)

74% below 2.0 GPA (58%)

85% suspended by 2nd (71%)

33% re-offend in 2 years (13%)

Adult AdversityIncarceration

Victim of Intimate Partner Violence

Drug/Alcohol Mental Illness

Divorce

Parenting Adultswith ≥5 ACE14 TIMES

more likely to have two or more conditions that make

ACEs for kids

Work injury- illnessHomelessness

DisabilityPoverty

Health limits activity

Unemployment

In Washington….

High School Youth

42% ≥ 3 ACEs

“Understanding Adverse Childhood Experiences can open doors for the future you would like for yourself and for future generations.”

Dr. Ronald Voorhees, MD, PhDChief Office of Epidemiology & Biostatistics

Allegheny County Health Department


CAPABILITY ATTACHMENT & BELONGING

COMMUNITY, CULTURE,

SPIRITUALITY

• Bonds with parents and/or caregivers

• Positive relationships with competent and nurturing adults

• Friends or romantic partners who provide a sense of security & belonging, help with emotion coaching

• Intellectual & employable skills

• Self regulation – self control, executive function, flexible thinking

• Ability to direct & control attention, emotion, behavior

• Positive self view, efficacy

• Faith, hope, sense of meaning

• Engagement with effective orgs – schools, work, pro-social groups

• Network of supports/services & opportunity to help others

• Cultures providing positive standards, expectations, rituals, relationships & supports

Resilience definition: Iris HeavyRunner

Three Systems For Promoting Resilience

KEY COMPONENTS OF RESILIENCE AS A DEVELOPMENTAL PROCESS

CAPABILITY

ATTACHMENT & BELONGING

COMMUNITY, CULTURE,

SPIRITUALITY

Resilience Index:Hope, Positive View, Social/Emotional Support

Capacity Building Process:Opportunities for Everyone to HelpComing Together – See the Truth ClearlyLearning Together – ReciprocityResults-Based Decisions – Desired Future

Washington Measures

High-Leverage Solutions

Moderate ACE Effects Among Parenting Adults:

Build on Strengths; Improve Functioning &

Coping

81

Prevent ACE accumulation

in next generation

Virtuous CycleFewer ACE

effects

Mercer Isle/Point CitiesIssaquah/Sammamish

Capitol Hill/EastlakeSoutheast King County

NE SeattleBallard-Fremont-Greenlake

RentonN. Seattle/Shoreline

Tukwila/SeaTacRedmond/Union Hill

BellevueBeacon & SE Seattle

KirklandBurien/Des Moines

AuburnQueen Anne/Magnolia

Bothell/WoodinvilleWhite Center/Boulevard Pk

Downtown & CentralCascade & Covington

Lower Valley & Upper SnoqualmieVashon IslandFederal Way

W. Seattle/DelridgeKent

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0

Geographical Differences In Prevalence of 3 or more ACEs Among Health Planning Areas In King County

For Adults In Households With Children

Community Variation

In Some King County Communities…41% of Parenting Adults have an ACE Score of ≥ 3

In Other Communities…6% of Parenting Adults have an ACE Score of ≥ 3

(Washington State Prevalence among all adults is just over 26%)

Preliminary Analysis, BRFSS Data 2009-2011

W. Seattle/DelridgeTukwila/SeaTac

Mercer Isle/Point CitiesBeacon & SE SeattleBurien/Des Moines

Federal WayQueen Anne/Magnolia

BellevueCapitol Hill/Eastlake

Downtown & CentralCascade & Covington

KirklandRedmond/Union Hill

Southeast King CountyBothell/Woodinville

Issaquah/SammamishKent

NE SeattleN. Seattle/Shoreline

Lower Valley & Upper SnoqualmieWhite Center/Boulevard Pk

RentonAuburn

Ballard-Fremont-GreenlakeVashon Island

0 10 20 30 40 50 60 70 80 90 100

Always or usually receive needed emo-tional support

Percent of adults in households with children

Heal

th P

lann

ing

Area

s

ACEs Are… Not The Whole Story

Some Communities with High ACE

Prevalence Also Have High Levels of

Social/Emotional Support

SOCIAL/EMOTIONAL SUPPORT AS A RESILIENCE FACTOR

Cardiovascular Diabetes Receive Treatment for Mental Illness0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

7.50%

10.40%

15.70%

7.00%

9.10%

8.20%

5.70%

7.20%

1.40%

Rarely/Never Sometimes Always/Usually Have SupportRarely/Never Receive Support Sometimes Receive Support Always/Usually Have Support

Support, Positive View & Hope Improve Housing Stability

Low Resiliency High Resiliency0

2

4

6

8

10

12

14

16

18

20

19

2.6

Resiliency Score: Social-Emotional Support, Positive View/Narrative, Hope

Perc

ent W

ho M

oved

≥4

Tim

es in

Pas

t Yea

r

Moved ≥ 4 Times in Past Year

Unemployment: ACEs by Resilience

0 ACEs 1 ACE 2 ACES 3 ACEs 4-5 ACEs 6-8 ACEs0

5

10

15

20

25

30

35

40

High Resilience Low Resilience

% U

nem

ploy

ed

Resilience Measures: Social/Emotional Support, Positive View, Hope

Individual

Family

National, Global, Ecosystem

RESILIENCE OCCURS AT ALL LEVELS

The natural human capacity

to navigate life well.

(HeavyRunner & Marshall, 2003)

Community

Efficacious Community

What Helps?1. Opportunities for Everyone to Help – to Co-Lead

2. Coming Together – Focus on Matters of Importance

3. Learning Together – Reciprocity

4. Results-Based Decisions – Acting from Desired Future

THE POWER OF COMMUNITY CAPACITYLESS DEPRESSION & SERIOUS PERSISTENT MENTAL ILLNESS

Ages 18-34

Serious Mental Illness Mentally Ill Depressed 0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

16.10%

22.70%

43.00%

4.40%

8.20%

28.50%

Ages 18 – 34 with 3-8 ACEs

Significant differences after controlling for age, education, income, race/ethnicity, and ACE score.

High Capacity

High Capacity

Severe Depression

High Capacity

Reduced Prevalence of High ACE Scores Among 18-34 Year Olds

In Communities using Community Capacity Development (CCD) Model

Source: Strength, Stress, Work, Hope; Technical Appendix, in press; Washington Family Policy Council; 2012

Percent with ≥3 ACEs

ACE REDUCTION

Reliably Predicts Improved

HEALTH

WELL-BEING

PRODUCTIVITY

Population Attributable Risk for ACE–related problems ranges from 20% to 70%

“For every ACE that we can prevent or

mitigate…We are improving a child’s chances for a

healthy future.”NW Children’s Fund Annual Report, 2012

Documents

Laura Porter, DSHS ACE Partnerships March 6, 2013 Adverse Childhood Experience in Washington