Impacts of Adverse Childhood Experiences on Health and

Melissa T. Merrick, PhD

Division of Violence Prevention

Tribal Leaders Diabetes Committee MeetingApril 14, 2016

Impacts of

Adverse Childhood Experiences

on Health and Wellbeing

Building Brain Architecture

Healthy Brain Injured Brain

Violence Compromises

Early Brain Development

When you think of child abuse & neglect,

you likely picture this…

…..but probably not this

Poor adult health has long been linked to Child

Abuse & Neglect

Categories of ACEs

Neglect Family ChallengesAbuse

Graphic Credit: Robert Wood Johnson Foundation

How Common are ACEs?

# of ACEs:

40.7%

23.6%

13.3%

8.1%

14.3%

ACE Score Prevalence2010 BRFSS ACE Module

Zero One Two Three Four or More

# of ACEs:

36.1%

26.0%

15.9%

9.5%

12.5%

ACE Score PrevalenceCDC-Kaiser ACE Study

Zero One Two Three Four or More

# of ACEs:

ACE Score and Adult Depression

0

1

2

3

4

5

6

Chapman, DP et al. Journal of Affective Disorders 2004;82:217–225

Gonzalez, O et al. MMWR 2010;59(38):1229-1235

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1 2 3 4 ≥50

ACE Score and Suicide Attempts

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d O

dd

s R

ati

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Number of ACEs

-Dube et al. JAMA. 2001;286:3089–3096.

0

2

4

6

8

10

12

14

16

18

0 1 2 3 4 5 6 ≥7

0

0.5

1

1.5

2

2.5

3

3.5

Adju

ste

d O

dds R

atio

ACE Score and

Cardiovascular Disease

-

Dong, M et al. Circulation. 2004;110:1761–1766.

Number of ACEs

1 2 3 4 5,60 7,8

ACE Score and Adult Diabetes

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Number of ACEs

Gilbert L et al. American Journal of Preventive Medicine. 2015;48(3):345–349.

0

0.5

1

1.5

0 1-3 4-6 7-9

ACE Score and HIV Risks

0

2

4

6

8

10

12

0 1 2 3 ≥4

Number of ACEs

Ever-injected drugs Had ≥50 intercourse partners Ever had an STD

Felitti, VJ et al. American Journal of Preventive Medicine 1998;14:245–258

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ACE Score and Current Smoker

0

0.5

1

1.5

2

2.5

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o

Number of ACEs

-Felitti, VJ et al. American Journal of Preventive Medicine.1998;14(4):245–258

1 2 3 ≥ 40

ACE Score and Considers Self an Alcoholic

0

1

2

3

4

5

6

7

8

Ad

juste

d O

dd

s R

ati

o

Number of ACEs

-Felitti, VJ et al. American Journal of Preventive Medicine.1998;14(4):245–258

1 2 3 ≥ 40

ACE Score and Severe Obesity

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

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dd

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o

Number of ACEs

-Felitti, VJ et al. American Journal of Preventive Medicine.1998;14(4):245–258

1 2 3 ≥ 40

0

0.5

1

1.5

2

2.5

3

Not GraduatingHigh School

Unemployed Earning a LowIncome

ACEs and Life Potential

0 1 2 3 4 or more

ACE Score:

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atio

ACEs and Financial Stress

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Food Insecurity Rent/Mortgage Stress

0 1 2 3 4 or more

ACE Score:

Leading Causes of Death

in the U.S. in 2013

1. Heart disease

2. Cancer

3. Chronic lower respiratory diseases

4. Unintentional injuries (accidents)

5. Stroke

6. Alzheimer's disease

7. Diabetes

8. Influenza and Pneumonia

9. Nephritis, Nephrotic Syndrome, and Nephrosis (Kidney disease)

10. Intentional self-harm (suicide)

The National Vital Statistics Report (NVSR) “Deaths: Final Data for 2013.”

1. Heart disease

2. Cancer

3. Chronic lower respiratory diseases

4. Unintentional injuries (accidents)

5. Stroke

6. Alzheimer's disease

7. Diabetes

8. Influenza and Pneumonia

9. Nephritis, nephrotic syndrome, and nephrosis (Kidney disease)

10. Suicide

Leading Causes of Death in the U.S. in 2013

With an ACE Score of 0, the

majority of adults have few,

if any, risk factors for these diseases and

health risk behaviors

With an ACE Score of 4 or more, the majority of adults have multiple risk factors for these diseases and health

risk behaviors or the diseases themselves

Violence Across the Lifespan

EARLY

CHILDHOOD ADOLESCENCE ADULTHOOD

Bullying Youth Violence

Child Maltreatment

Dating Violence

Sexual Violence

Intimate Partner Violence

Elder

Maltreatment

Suicide

War and Other Collective Violence

Prevention Response

Role of Public Health

in Violence Prevention

Role of Criminal Justice, Child Welfare, Social Service

Preventing child maltreatment

requires understanding why

some children and families

are at greater risk than others.

Assuring

Safe, Stable, Nurturing

Relationships & Environments

for All Children

Raise Awareness & Commitment

Use Data to Inform Action

Create the Context for Safe, Stable,

Nurturing Relationships & Environments

• Funding Initiative: 5 State Health Departments

– California

– Colorado

– Massachusetts

– North Carolina

– Washington

• Over 30 self-supported states participating in

Essentials for Childhood initiative

GOAL 1: RAISE AWARENESS

AND COMMITMENT

The Raising of America

• Raising explores how a

strong start for all our kids

can lead to a healthier,

stronger, and more equitable

America

• Components:

– Six-part documentary series

– National public engagement

campaign

– Companion website

GOAL 2: USE DATA TO

INFORM SOLUTIONS

30+ States Have Included the ACE Module on

Their BRFSS

Source: ACE Executive Summary - Minnesota Department of Health

• Wisconsin

– Examining ACE “Hotspots”

– Added Poverty and Neglect Items to BRFSS

– Oversampled AI/AN Population

• Washington

– Legislators changed the definition of work

participation for TANF recipients

– Juvenile offenders needed additional support to

mitigate future adverse outcomes

Using Data to Inform Solutions:

State Examples

GOAL 3: CREATE THE CONTEXT FOR

HEALTHY CHILDREN & FAMILIES

THROUGH NORMS CHANGE

Essentials for

Parenting

Essentials for Parenting

Toddlers and Preschoolers

• On-line interactive resource

developed for parents with

toddlers and preschoolers

• Based upon best available

science

• Includes a variety of

content, including:

– Written content, videos, and

interactive activities

www.cdc.gov/parents/essentials

38

CDC Resource for Employers

Provides Opportunities for Action for Small and Large Business

• Model safe, stable, nurturing relationships and environments in your organization

• Create a family-friendly workplace

• Take a comprehensive approach to employee wellness

• Provide parenting resources for employees

• Consider the role of state and local policy in improving employees’ and their children’s access to safe, stable, nurturing relationships and environments

GOAL 4: CREATE THE CONTEXT FOR

HEALTHY CHILDREN AND FAMILIES

THROUGH POLICIES

Policies with impacts on risk factors for child

abuse & neglect

Increased minimum wage

Earned Income Tax Credit

Child Tax Credit

Housing vouchers

Head Start

Bans on corporal punishment

Family-friendly work

Technical Packages

A core set of strategies based

on the best available evidence

to help communities and

states sharpen their focus on

prevention activities with the

greatest potential to have

impact on a specific health

outcome.

Technical Package for

Preventing Child Abuse & Neglect

Strategy – preventive direction or actions to achieve

goal of preventing child abuse and neglect

• Approaches – ways to advance the strategy

- Example programs, policies, or practices

Supports Goals 3 & 4 of Essentials for Childhood

• Goal 3: Create the context for healthy children and

families through norms change and programs

• Goal 4: Create the context for healthy children and

families through policies

Technical Package Development

Review of literature

Identification of strategies

& approaches

Written draft

Review by partners

Editing and

formatting of final product

Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Preventing child abuse and neglect: A technical package for policy, norm, and

programmatic activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

44

Child Abuse and Neglect Prevention

Technical Package

Strengthen Economic Supports to Families

Change Social Norms to Support Parents and Positive Parenting

Provide Quality Care and Education Early in Life

Enhance Parenting Skills to Promote Healthy Child Development

Intervene to Lessen Harms and Prevent Future Risk

45

Sector Involvement

Public health

Education

Government (local, state, federal)

Social services

Health services

Business/labor

Justice

Housing

Media

Other non-governmental organizations

Change in Mind Initiative

46

• Alliance for Strong Families and Communities, The Palix Foundation (formerly The Norlien Foundation) & The Robert Wood Johnson Foundation.

• Two country cohort involving 5 non-governmental organizations based in Alberta and 10 U.S. based private, nonprofit human serving organizations.

• Contracting with FrameWorks Institute on framing and strategic communications.

• Contracting with Community Science on the developmental evaluation.

Change in Mind Cohort Sites

47

United StatesChildren & Families First, Wilmington, DE

Children’s Home Society of Washington, Seattle, WA

Children’s Hospital of Wisconsin, Milwaukee, WI

East End House, Cambridge, MA

Family Service Association of San Antonio, San Antonio, TX

KVC Health Systems, Olathe, KS

LaSalle School, Albany, NY

Martha O’Bryan Center, Nashville, TN

The Family Partnership, Minneapolis, MN

Wellspring Family Services, Seattle, WA

Change in Mind Cohort Sites

48

Alberta, CanadaBig Brothers, Big Sisters of Calgary, Calgary

Boyle McCauley Health Centre, Edmonton

CASA Child, Adolescent, & Family Mental Health, Edmonton

CUPS Health, Education, Housing, Calgary

Sheldon Kennedy Child Advocacy Centre, Calgary

Mobilizing Action for Resilient Communities

• Coordinated by the Health Federation of Philadelphia with:– Funding from the Robert Wood Johnson Foundation and The California

Endowment

– Guidance from the MARC Advisory Committee

• Learning collaborative comprising 14 communities:

AlaskaAlbany/Capital Region, NY

Boston, MABuncombe County, NC

Columbia Gorge Region, ORIllinois

Kansas City, MO

MontanaPhiladelphia, PASan Diego County, CASonoma County, CATarpon Springs, FLWashingtonWisconsin

Child Abuse & Neglect (CAN)

Opportunities and Future Directions

• Integrate violence prevention into the

extraordinary and fast growing movement

in the U.S. to invest in healthy child

development

– Disseminating the CAN technical package

and developing implementation guidance

– Launching new ACE website in April 2016

due to high demand for information

51

What it means for our work?

Vision: move in this direction

in a more deliberate way

over next 5 years

Attending to the “dots” and the

“lines”

Goal: maximize impact of

our prevention efforts

IPV

EA

YV

SVCAN

Suicidal

Behavior

TDV

Thank you!

Questions?

53

Thank you!

Melissa T. Merrick, PhD

mmerrick@cdc.gov

www.cdc.gov/violenceprevention/acestudy

The findings and conclusions in this presentation are those of

the author(s) and do not necessarily represent the official

position of the Centers for Disease Control and Prevention.

Policies, Programs, Practices:

Considerations for Inclusion

Examples chosen based on the best available evidence

• Meta-analyses, systematic reviews or rigorous evaluation studies showing impacts on perpetration or victimization behaviors or established risk/protective factors for child abuse & neglect.

• Empirical support or a strong theoretical rationale for changing one or more forms of violence or the conditions that give rise to violence.

• Likelihood of achieving beneficial effects on multiple forms of violence.

Policies, Programs, Practices:

Considerations for Inclusion (continued)

Examples chosen based on the best available

evidence

• Likelihood of similar outcomes with different

populations and/or in different settings.

• No evidence of harmful effects on specific outcomes or

with particular subgroups.

• Feasibility in a U.S. context if the program or policy has

been evaluated in another country

Progress to Date

SME Technical Package Team

• Beverly Fortson (lead); Melissa Merrick (co-lead);

Sandra Alexander; Leah Gilbert; Joanne Klevens

Input received from DVP’s Child Maltreatment Workgroup; branch chiefs; division; center, and agency leadership; external partners

Hot off the press

Draft Narrative of the Technical Package

Describes the strategies, corresponding approaches,

and examples of programs, policies, and practices

with evidence of impact

• Implemented directly by health departments or

collaboration between public health and other sectors

• Implemented by other sectors

Includes a section on monitoring and evaluation

58

Preventing Child Abuse and Neglect

CDC’s Technical Package

Strategies:

● Strengthen economic supports

to families

● Change social norms to support

parents and positive parenting

● Provide quality care and

education early in life

● Enhance parenting skills to

promote healthy child

development

● Intervene to lessen harms and

prevent future risk

Helping states and communities take

advantage of the best available

evidence

59

Strategy 1: Strengthen Economic Supports to Families

Strengthen household financial security

Use of policies to reduce child abuse and neglect by improving

parents’ ability to satisfy children’s basic needs (e.g., food,

shelter, medical care), provide developmentally appropriate

child care, and reduce parental stress and depression.

Support family-friendly work policies

Use of policies to change the context for families by improving

the balance between work and family, ensuring economic

security, and making positive parenting an easier and more

realistic “choice”.

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Strategy 2: Change Social Norms to Support Parents and Positive Parenting

Public engagement and education campaigns

Attempt to reframe the way people think and talk about child

abuse and neglect and who is responsible for preventing it.

Legislative approaches to reduce corporal

punishment

Help establish norms around safe, more effective discipline

strategies to reduce the harms of harsh physical

punishment.

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Strategy 3: Provide Quality Care and Education Early in Life

Preschool enrichment with family engagement

Provide high quality early education and care to

economically disadvantaged children to build a strong

foundation for future learning and healthy development.

Provide support and educational opportunities for parents.

Improved quality of child care through licensing and

accreditation

Ensure quality, positive, and supportive daily experiences

for children

62

Strategy 4: Enhance Parenting Skills to Promote Healthy Child Development

Early childhood home visiting programs

Provide information, caregiver support, and training about child

health, development, and care to families in their homes.

Parenting skill and family relationship approaches

Provide support and teach behavior management and positive

parenting skills to build strong and safe families that protect

children from violence and its long-term consequences.

63

Strategy 5: Intervene to Lessen Harms and Prevent Future Risk

Enhanced primary care

Used to identify and address psychosocial problems in the family

that serve as risk factors for child abuse and neglect.

Behavioral parent training programs

Reduce the recurrence of child abuse and neglect while teaching

parents specific skills to build a safe, stable, nurturing relationship

with their children.

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Strategy 5: Intervene to Lessen Harms and Prevent Future Risk (continued)

Treatment for children and families to lessen the

harms of exposure to abuse and neglect

Mitigates the health consequences of abuse and neglect

exposure and decreases the risk for other types of violence

later in life.

Treatment for children and families to prevent

problem behavior and later involvement in violence

Addresses the behavioral consequences of experiencing

child abuse and neglect.

6565

Preventing Child Abuse and Neglect

CDC’s Technical Package

Fortson, BL, Merrick MT, Klevens J, Gilbert L, Alexander S. Preventing child abuse & neglect: A technical package for policy, norm, and programmatic activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (forthcoming April, 2016).

Strategy Approach

Strengthen economic supports to families • Strengthen household financial security

• Family friendly work policies

Change social norms to support parents and positive

parenting

• Public engagement and education campaigns

• Legislative approaches to reduce corporal

punishment

Provide quality care and education early in life • Preschool enrichment with family engagement

• Improved quality of child care through licensing &

accreditation

Enhance parenting skills to promote healthy child

development

• Early childhood home visitation

• Parenting skill and family relationship approaches

Intervene to lessen harms and prevent future risk • Enhanced primary care

• Behavioral parent training programs

• Treatment to lessen harms of abuse and neglect

exposure

• Treatment to prevent problem behavior and later

involvement in violence