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                  874                          ACE Reporter                                                              Volume 1 Number 1
                                                                                                                                April, 2003

                   A Free Research Publication Dealing with the Effects of Adverse Childhood Experiences on Adult Health and Well Being

                                             Co-Principal Investigators
                         Robert F. Anda, MD, MS                                     Vincent J. Felitti, MD,
                         Epidemiologist, Centers for                                              Internist
                         Disease Control, Atlanta                           Kaiser Permanente, San Diego

                                               Origins and Essence of
Dr. Anda earned his MD from Chicago’s                                                        Dr. Felitti, is a graduate of Johns
Rush Medical College in 1979, and is
                                                     the Study                               Hopkins Medical School (1962), and a
Board Certified in Internal Medicine.                                                        Physician in the Department of
After earning an MS in Epidemiology            The Adverse Childhood Experiences             Preventive Medicine, Southern
from the University of Wisconsin School        (ACE) Study is a decade-long and              California Permanente Medical Group.
of Medicine in 1984, he served for 2 years     ongoing collaboration between Kaiser          He founded the Department of
as an Epidemic Intelligence Service            Permanente’s Department of                    Preventive Medicine for Kaiser
Officer for the Centers for Disease            Preventive Medicine in San Diego and          Permanente in San Diego, California, 28
Control and Prevention (CDC). At the           the Centers for Disease Control and           years ago, and served as Chief of
CDC, Dr. Anda has served as an                 Prevention (CDC). However, some of            Preventive Medicine until March 2001.
Epidemiologist in the Nutrition Division,      the concepts for the ACE Study had            Under Dr. Felitti’s leadership, the Health
the Behavioral Risk Factor Surveillance        their beginnings in 1985 when, as a           Appraisal Division of the Department of
Branch, the Cardiovascular Health              specialist in Preventive Medicine, Dr.        Preventive Medicine provided
Studies Branch, and on the Task Force on       Felitti initially set out to help obese       Comprehensive Medical Evaluation to
Genetics in Public Health. From 1992 to        people lose weight through the                1.1 million people; and during his career,
1994, he was the Chief of Epidemiology         Positive Choice programs. To his              the health risk abatement programs
and the Surveillance Section in                amazement, those people most likely           expanded from three (weight loss,
Cardiovascular Health. Since 1993, Dr.         to drop out of the weight loss program        smoking cessation and stress
Anda has been a Co-Principal                   were those who were successfully              management) to a wide range of cutting-
Investigator of the ACE Study. He has          losing weight!                                edge risk abatement programs offered to
authored and co-authored numerous                                                            over 1,000 patients per month at one
publications on the health and social          On digging more deeply, in a careful          facility. Dr. Felitti is also Clinical
implications of adverse childhood              study of 286 such patients, Dr. Felitti       Professor of Medicine at University of
experiences.                                   learned that many had been                    California, San Diego, and a Fellow of
                                               unconsciously using obesity as a              The American College of Physicians,
                                               shield against unwanted sexual                licensed to practice medicine in
                                               attention, or as a form of defense            Maryland, California, and Arizona.
       HIGHLIGHTS                              against physical attack, and that many
  Among the Initial ACE Study                  of them had been sexually and/or
                                               physically abused as children. That is
          Findings:                            to say, although obesity was
                                               conventionally viewed as the problem,         Inside This Issue:
         ACEs Are Common                       it was often found to be the
                                                                                             Meet the Investigators ...................... Page 1
                                               unconscious solution to other, far            Highlights of the ACE Study........... Page 1
 Two-thirds of participants reported at        more concealed, problems. The                 Origins and Essence of
  least one ACE (see page two for the          prevalence and severity of these               the ACE Study ................................ Pages 1-3
    prevalence of individual ACEs).            problems was totally unexpected.              The True Nature of Preventive
                                               Many, like childhood sexual abuse or           Medicine Model .............................. Page 3
                                               suicidality, were shielded by social          Speaking of ACEs
  ACEs Tend to Occur in Groups                                                                2003 Presentations .......................... Page 3
                                               taboos against freely discussing these
                                                                                             Special Thanks to Dr. Rose............... Page 3
                                               topics, even in medical settings.
 Of persons who reported at least one          (Continued on page 2.)
                                                                                             For a Closer Look –
 ACE, 87% reported at least one other                                                         ACE Publications/References ...... Page 4
                                                                                             Professional Spotlight
                ACE.                                                                           Melissa Pierce................................ Page 4
  70% reported 2 or more others, and                                                         Editor’s Corner................................... Page 4
 more than half had 3 or more others!                                                        Disclaimer ........................................... Page 4

                                                              Page 1 of 4
Origins and Essence of the        sexual abuse) and specific         Household Dysfunction         the ACE Study examined
Study, continued                  health problems (usually           Mother treated violently      the relationship of the ACE
                                  mental health issues), the ACE                            13%    Score to many of the
It also became evident that       Study was designed to              Mental illness         20%    leading causes of death in
many obese patients had           simultaneously assess              Substance abuse        28%    the United States. Major
previously used tobacco,          childhood exposure to multiple     Parental separation or        risk factors for these causes
alcohol, and street drugs to      types of abuse, neglect,           divorce                24%    of death—such as smoking,
moderate stress and feelings      domestic violence, and types of    Household member              alcohol abuse, obesity,
of despair before turning to      serious household dysfunction      imprisoned              6%    physical inactivity, use of
food. In many instances,          such as substance abuse.                                         illicit drugs, promiscuity,
obesity—although the              Moreover, the ACE Study            Because the ACE Study         and suicide attempts—
                                  included assessment of a wide      research team found that      were all increased by
most noticeable
finding—was less
                                  array of high priority health      in most cases, not            ACEs.
                                  and social problems ranging                                      Among the more notable
important than other              from adolescence to adulthood.
                                                                     just one, but several,        findings were that
concurrent problems               Thus, the ACE Study is the         of these ACEs                 compared to persons
that were less obvious.           largest study of its kind ever     existed in the child’s        with an ACE score of
                                  conducted (more than 17,000
Simultaneously with the                                              home,                         0, those with an ACE
work that Dr. Felitti was         study participants) and the
                                                                     a simple scoring system       score of 4 or more
doing, Dr. Robert Anda, of        range of adverse childhood
                                                                     was used (called the ACE
the CDC, was studying             experiences and health related                                   were twice as likely to
                                                                     score), in which each
multiple medical and public       outcomes studied was
                                                                     participant was attributed    be smokers, 12 times
health problems including         unprecedented.                                                   more likely to have
                                                                     one point for each category
smoking, alcohol abuse,           The Study determined that an
                                                                     of adverse childhood          attempted suicide, 7
obesity, and numerous             unexpectedly high number of
                                  these people—adults who came
                                                                     experience occurring prior    times more likely to
chronic diseases. His interest                                       to age 18. The percentage
in, and study of, the             to the Department of Preventive                                  be alcoholic, and 10
                                                                     of Kaiser members with
psychosocial origins of           Medicine for comprehensive
                                                                     each ACE score is shown
                                                                                                   times more likely to
health-related behaviors and      medical screening—had                                            have injected street
                                  experienced significant abuse or   below. Note that only 1/3
diseases dovetailed with the
                                                                     of persons reported no        drugs.
clinical observations of Dr.      household dysfunction during
Felitti. Moreover, the CDC        their childhoods. For the          ACEs.                         The behaviors such as
has programs that deal with       purposes of the ACE Study,
                                                                                                   alcohol or drug abuse,
obesity, alcohol related          adverse childhood experiences      ACE score:                    smoking, or sexual
problems, and the use of          were defined as emotional,            0         33%              promiscuity are likely the
illicit street drugs, and high-   physical, or sexual abuse,            1         26%              result of the effects of ACEs
risk sexual behaviors are well    emotional or physical neglect,        2         16%              on childhood development,
known to play an important        and growing up in a household         3         10%              which we now know to be
role in the spread of the         where someone was an                  4          6%              neurodevelopment. In
Human Immunodeficiency            alcoholic, a drug user, mentally      5          5%              many, if not most, cases the
Virus (HIV) which causes          ill, suicidal, where the mother       6          6%              behaviors may act to
AIDs.                             was treated violently, or where
                                                                                                   alleviate the emotional or
Therefore, Dr. Felitti’s          a household member had been        Using the ACE score as a      social distress that results
observations and the research     imprisoned during the patient’s    measure of the burden of      from ACEs. Thus, these
priorities of the CDC came        childhood. Additionally, they      traumatic childhood           behaviors, typically
together. The CDC teamed          included contact sexual abuse      exposures, the ACE Study      considered to be problems,
up with Kaiser Permanente to      and serious physical and           team found that as the ACE    continue because they
develop a large-scale             emotional abuse. The Study         score increased the chances   function as short-term
epidemiologic study of the        found the following burden of      of being a user of street     solutions, even though they
influence of stressful and        individual ACEs:                   drugs, tobacco or having      have detrimental, long-
traumatic childhood                                                  problems with alcohol         term effects. The findings
experiences on the origins of     Abuse:                             abuse increased in a          from the ACE Study
behaviors that underlie the       Emotional                 10%      stepwise fashion. Thus,       suggest that problems such
leading causes of disability,     Physical                  26%      ACEs were not only            as addiction frequently
social problems, health-          Sexual                    21%      unexpectedly common,          have their origins in the
related behaviors, and causes                                        but their effects were        traumatic experiences of
of death in the United States.    Neglect:
                                                                     found to be                   childhood (Continued on
Unlike most prior studies in      Emotional                 15%                                    Page 3.)
this area which had tended to     Physical                  10%      cumulative.                   Origins and Essence of the
focus on single types of                                             The first publication from    Study, continued
childhood abuse (especially

                                                          Page 2 of 4
                                            drugs, tobacco, alcohol, overeating and        May 17, Vallejo, CA; Keynote address
                                            sexual promiscuity. Not the least of these     at Children's Network of Solana
                                            high-ticket medical costs is due to: cardio-   County.
                                            vascular disease, cancer, AIDS and other       Jun 7, San Diego, CA; ACE Study
                                            sexually transmitted diseases, unwanted        presentation at Wexler Conference on
                                            often-high-risk pregnancies, chronic           the Family.
                                            obstructive pulmonary disease, and a           Jun 27, San Diego, CA; ACE
                                            legacy of self-perpetuating child abuse.       presentation at San Diego Academy of
                                                                                           Family Practice Annual Conference.

                                                                                           Presentations by Dr. Anda:

                                                                                           Apr 3, Portland ME; University of
                                            Speaking of ACEs -- 2003                       New England. Symposium on
                                                                                           Domestic Violence. “The Wide
                                            Presentations by Dr. Felitti:                  Ranging Effects of Adverse Childhood
                                            Jan 7, San Diego, CA; State Health Dept        Apr 6, Bethesda, MD; Walter Reed
                                            Conference on Adolescent Obesity.              Army Medical Center. Plenary
                                            "Adverse Childhood Experiences and             Speaker. Forensics Symposium:
                                            Adolescent Obesity."                           Families, Violence and Trauma. “The
 and that the molecular structure of                                                       Role of Domestic Violence and Related
                                            Feb 5, San Diego, CA; San Diego Children's
various chemicals or the physiologic                                                       Adverse Childhood Experiences on
                                            Hospital International Conference.
effects of certain behaviors (e.g.                                                         Health.”
                                            "Adverse Childhood Experiences and
overeating, sexual behaviors)—while                                                        Apr 17; Seattle, WA; Ft. Lewis Army
                                            Adult Health."
ultimately leading to disease and                                                          Center. Keynote Speaker. “The Wide
                                            Feb 15, Denver, CO; National Meeting of
disability, may be particularly effective                                                  Ranging Health and Social Impact of
                                            American Association for the
in ameliorating their effects.                                                             Adverse Childhood Experiences.”
                                            Advancement of Science (AAAS),
                                            "Adverse Childhood Experiences and their       May 10. Columbus, OH; Ohio
The ACE Study also showed that as                                                          Community Forum on Child Abuse.
                                            Relationship to Adult Health."
the ACE score increased the number of                                                      Plenary Speaker. “The Numerous
                                            Feb 15, Denver, CO; Interview about ACE
risk factors for the leading causes of                                                     Effects of Childhood Abuse and
                                            Study with German Public Radio.
death increased. Thus, persons with                                                        Related Adverse Childhood
                                            Mar 3, San Diego, CA; Fox Television
high ACE scores are later at much                                                          Experiences.”
                                            Network Interview on ACE Study and its
higher risk for health and medical                                                         Jun 9. Washington, DC; Annual
                                            Implications for Adolescent Health.
conditions resulting from their choice                                                     Leadership Conference of the National
                                            Mar 10, San Diego, CA; Presentation of
of remedies for their pain. While these                                                    Children’s Alliance. Plenary Speaker.
                                            ACE Study at San Diego State University
approaches are effective in the short                                                      “The Wide-Ranging Health and Social
                                            School of Public Health.
term, they often have dire long-term                                                       Impact of Adverse Childhood
                                            Mar 25, San Diego, CA; Presentation of
consequences such as serious chronic                                                       Experiences”.
                                            ACE Study results at Cities of the Future
health and social problems.
In addition, the underlying causes of
                                            Apr 2, St. Louis, MO; Keynote address
these problems—adverse                      National Conference on Child Abuse.
childhood experiences—would                 Apr 4, Boston, MA; Interviews with press
typically go undetected because             & TV
of shame, secrecy and social                Apr 5, Boston, MA; Keynote address,
                                            Massachusetts Citizens for Children
taboo, which prevent people from
talking about such things. These same
social taboos prevent physicians and
                                            Apr 11, Chico, CA; Keynote at Child Abuse            SPECIAL THANKS
                                            Prevention Council Annual Meeting.                               TO
other health care providers—those
                                            Apr 13-17, Germany; Daily Workshop on
best poised to help victims of child
                                            Relationship of ACEs to Obesity.
                                                                                              Stephen M. Rose, Ph.D.
abuse—from asking the very questions                                                         Prof., College of Health Professions
                                            Apr 15, Germany; Plenary Presentation of
that would help identify these                                                                  University of New England -
                                            ACE Study to Annual Lindau
underlying causes of major                                                                           Westbrook Campus
                                            Psychotherapy Conference.
impediments to Americans’ health and                                                                    Portland, Maine
                                            Apr 29, San Diego, CA; Presentation of
well being.                                                                                                   FOR
                                            ACE Study at Positive Choice.
In combination, the fallout from                                                            Single-handedly increasing the ACE
                                            May 16, San Francisco, CA; Presentation of
various forms of child abuse and                                                            Reporter list of Subscribers by at least
                                            ACE Study to AMA Committee on Family
household dysfunction is                                                                    200, thereby helping countless others
monumental, costing Americans                                                                 benefit from important lessons
untold sums of money because of the                                                           learned from the ACE Study.
health risks such as the use of street                    Page 3 of 4
For a Closer Look: ACE Publications

Data quoted in this issue came from one or more of the following publications:

First ACE Publication
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, et al JS. The
       relationship of adult health status to childhood abuse and household dysfunction. American             Melissa Pierce
       Journal of Preventive Medicine. 1998;14:245-258.
ACEs and Alcohol Abuse
Dube SR, Anda RF, Felitti VJ, Edwards VJ, Croft JB. (2002). Adverse Childhood Experiences and               Melissa Pierce works with the Health
       personal alcohol abuse as an adult. Addictive Behaviors, 2002. 27(5), 713-725.
ACEs and Illicit Drug Use
                                                                                                            Education Division of the Butte
Dube SR, Anda RF, Felitti VJ, Chapman DP, Giles WH. Childhood Abuse, Neglect and                            County Department of Public Health.
       Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood                        She has a Master’s degree in
       Experience Study. Pediatrics 2003; 111(3): 564-572.
ACEs - Prevalence and ACE Score Statistics                                                                  Counseling and provides direct client
Dong M, Anda RF, Felitti VJ, Dube SR, Giles WH. The Relationship of Exposure to Childhood Sexual            services, in addition to writing family
       Abuse to Other Forms of Abuse, Neglect and Household Dysfunction during Childhood. (In press,
       Child Abuse and Neglect).
                                                                                                            violence prevention policy.
ACEs and Smoking
Anda RF, Croft JB, Felitti VJ, Nordenberg D, Giles WH, Williamson DF, Giovino GA. Adverse childhood         Initially my work with the county’s public
       experiences and smoking during adolescence and adulthood. Journal of the American Medical
                                                                                                            health department had been more about
       Association. 1999;282:1652-1658.
ACEs and STDs                                                                                               others and how issues of violence affect all
Hillis SD, Anda RF, Felitti VJ, Nordenberg D, Marchbanks PA. Adverse childhood experiences and              people and our world at large. I soon
       sexually transmitted diseases in men and women: a retrospective study. Pediatrics 2000 106(1):E11.   recognized that my work also held
ACEs and Suicide
Dube SR, Anda RF, Felitti VJ, Chapman D, Williamson DF, Giles WH. Childhood abuse, household                significant personal meaning. While aware
       dysfunction and the risk of attempted suicide throughout the life span: Findings from Adverse        that my family of origin had been
       Childhood Experiences Study. Journal of the American Medical Association. 2001: 286, 3089-3096.      dysfunctional, I had not focused
ACEs and Teen and Unintended Pregnancy
Dietz PM, Spitz AM, Anda RF, Williamson DF, McMahon PM, Santelli JS, Nordenberg DF, Felitti VJ,
                                                                                                            specifically on how several aspects of my
       Kendrick JS. Unintended pregnancy among adult women exposed to abuse or household                    early life—including having witnessed
       dysfunction during their childhood. Journal of the American Medical Association. 1999;282:1359-      violence against my mother—may have
       1364.                                                                                                had a significant impact on my
Anda RF, Felitti VJ, Chapman DP, Croft JB, et al. Abused boys, battered mothers, and male involvement
       in teen pregnancy: New insights for pediatricians. Pediatrics 2001: 107(2), e19.                     development.
ACEs and Violence, Self-perpetuating Cycle of Violence
Whitfield CL, Anda RF, Dube SR, Felitti VJ. Violent Childhood Experiences and the Risk of Intimate          Learning about the ACE Study not only
       Partner Violence in Adults: Assessment in a Large Health Maintenance Organization. Journal of
       Interpersonal Violence 2003; 18(2):166-185.
                                                                                                            validated many of my life’s experiences
Anda RF, Whitfield CL, Felitti VJ, Chapman D, Edwards VJ, Dube SR, Williamson DF. Alcohol-impaired          and those of others close to me, but it has
       parents and adverse childhood experiences: the risk of depression and alcoholism during              given new richness and meaning to my
       adulthood. Journal of Psychiatric Services 2002; 53(8):1001-1009.                                    work with clients. After connecting with
                                                                                                            the ACE Study through the articles in the
                                                                                                            Summer 2001 issue of the Family Violence
                                                                                                            Prevention Fund’s “Health Alert”
                                                                                                            Newsletter, especially Dr. Felitti’s cover
                                                                          The ACE Reporter is a
The Editor’s Corner                                                         privately-funded,
                                                                                                            article, “Reverse Alchemy in Childhood:
                                                                                                            Turning Gold Into Lead”, meeting Dr.
                                                                         independent, volunteer
This is the first of what I hope will be many                         publication. Every reasonable
                                                                                                            Felitti at the 8th International Conference on
editions of the ACE Reporter, created in                             effort has been made to ensure         Family Violence Prevention in San Diego
response to increasing demand, from people of                        the accuracy of the information        was truly a highlight of my year.
all walks of life, who hunger for a deeper                           contained herein. Readers and
understanding of events in their own lives and                           contributors to this free          Throughout the policy writing that went
those of people near them. In short, this                              publication agree to hold the        on for over a year, as well as the direct
                                                                       Editor, and all parties in any       client services I provide in the course of
publication is created for you. I therefore
                                                                         way associated with this
encourage you to make it yours by telling me                                                                counseling and testing people for the HIV
                                                                       publication, free from every
how the content can be improved to suit your                         form of harm that might result
                                                                                                            virus, the ACE Study has been in my heart
needs.                                                               from errors or omissions. Any          and mind. Its relevance feels profound. As
                                                                      subscriber and/or contributor         I speak with people about their HIV risk
This first edition was dedicated to the general                         who does not agree to this          factors, they share about their lives. Lives
nature of the ACE Study; subsequent issues will                       condition should unsubscribe          with pain and histories of pain. I
take a deeper look into each aspect of the                                      by email to:
                                                                                                            wonder if they have made the
Study’s findings.                                            or by
                                                                             standard mail to:              connections between current and
Wishing you peace,
                                                                               C. A. Redding                past pain, and if they were to do this, if it
                                                                                POB 191015                  might give them a sense of clarity and even
                                                                          San Diego, CA 92159.              perhaps restore a sense of sanity to their
Carol A. Redding                                                                                            lives.
                                                                                                                                       Melissa Pierce
                                                                           Page 4 of 4

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