10/28/2019

Learning Objectives:

1. Articulate the key findings, and limitations, of the ACEs study

ACEs as a Social Determinant of Health: focusing specifically on the burden on individual and public health.
The Latest in Research and Practice 2. Critically review the best available evidence regarding current
interventions and strategies to address ACEs.

3. Identify promising approaches and initiatives in North Carolina

October 30th, 2019
Winston-Salem Clinical Lecture Series
to address ACEs in policy and clinical practice
Paul Lanier, PhD, MSW
Associate Professor
Kuralt Early Career Distinguished Scholar
UNC School of Social Work

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Outline Outline
1. What are the key findings, and limitations, of the 1. What are the key findings, and limitations, of the
ACEs study focusing specifically on the burden on ACEs study focusing specifically on the burden on
individual and public health? individual and public health?

2. What is the best available evidence regarding 2. What is the best available evidence regarding
current interventions and strategies to address current interventions and strategies to address
ACEs? ACEs?

3. Identify promising approaches and initiatives in 3. Identify promising approaches and initiatives in
North Carolina to address ACEs in policy and clinical North Carolina to address ACEs in policy and clinical
practice? practice?

3 4

Clarifying Concepts Clarifying Concepts - SDoH

1. Social Determinants of Health (SDoH) 1. Social Determinant of Health (SDoH)

2. Adverse Childhood Experiences (ACEs) • “Conditions in the places where people are born, live, learn, work, play, worship, and age
3. ACEs + SDoH that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

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Clarifying Concepts - SDoH Clarifying Concepts - SDoH

1. Social Determinant of Health (SDoH)’s conceptual roots: 1. Social Determinant of Health (SDoH)
1. Kannel (Framingham Heart study, 1973) • Featured in NC Medicaid Transformation, including:
2. Breslow (Alameda County study, 1983) • Statewide SDoH map
3. Marmot (Whitehall Study, 1991) • Screening questions
4. McGinnis (2002), Schroeder (2007) • NCCARE360
• Healthy Opportunities Pilot

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Clarifying Concepts - SDoH Clarifying Concepts

1. Social Determinants of Health (SDoH)

2. Adverse Childhood Experiences (ACEs)
• Adversity vs. trauma
3. ACES + SDoH

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Total ACEs Publications (1994-present; Web of Science)

The CDC-Kaiser ACE Study

591
Publications!!!

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ACEs Literature by Discipline (Web of Science) Clarifying Concepts

1. Social Determinants of Health (SDoH)

2. Adverse Childhood Experiences (ACEs)
3. ACEs + SDoH

Why is this a thing now?

Thank you science!

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Clarifying Concepts Clarifying Concepts

• Hans Selye (1936) letter to Nature

• “General Adaptation Syndrome”

• Alarm, Resistance, Exhaustion
• Produced by “noxious agents” (toxic
stress?)

• “symptoms are independent of the nature

of the damaging agent”

• Preferred “strain” later “One of the most important characteristics of polymers is their inherent toughness and
resistance to fracture (crack propagation). It is not coincidence that the name plastic, is
• The closest Chinese word to signify “stress” similar to the word plasticity which is the propensity of a solid to undergo permanent
is two characters meaning “danger” and deformation under stress.”
“opportunity”
https://polymerdatabase.com/polymer%20physics/Stress-Strain%20Behavior.html

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Adversity and Health

Historical/Evolutionary
Lens

Developmental
Traumatology

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Clarifying Concepts - ACEs

Perry, BD and Pollard, D. Altered brain

development following global neglect in early
childhood. Society For Neuroscience:
Proceedings from Annual Meeting, New
Orleans, 1997

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10% reduction in ACEs =

Lanoix, D., & Plusquellec, P. (2013). Adverse effects of pollution on mental savings of $105,000,000,000/year
health: the stress hypothesis. OA Evidence-Based Medicine, 1(1), 1-9.

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BRFSS NSCH
Survey Largest continuously conducted Nationally representative survey of
Current Data Source for ACEs Design and
Sample
health survey system in the world children’s health and well-being

in North Carolina Size 2014 n = 506,000

NC = 7,000
ACE module = 2,913
2016-2017 n = 71,811
NC = 1,400
ACE Module = 1,325

1. BRFSS (Behavioral Risk Factor Surveillance System, Target Adults 18+ All non-institutionalized children ages
Population 0 – 18 years
2014)
Reporter Self Parent

ACE Prompt I’d like to ask you some questions The next questions are about events
about events that happened during that may have happened during this
your childhood... child’s life….

2. NSCH (National Survey of Children’s Health, 2016- ACE Items 0-8 items: Mental Health, Alcohol,
Drug Use, Incarceration, Divorce,
2017) Witness Domestic Violence, Physical
Abuse (not spanking), Verbal Abuse,
Sexual Abuse,
0-8 items: Mental Health, Alcohol or
Drugs, Incarceration, Divorce, Parent
Died, Witness Domestic Violence,
Witness Neighborhood Violence,
Race/Ethnic Discrimination, Poverty

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No ACE (1-2) ACEs (3-8) ACEs

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Current Data Source for ACEs in North 40

Carolina 30

1. BRFSS (Behavioral Risk Factor Surveillance System, 20

2014)
10

0
Non-Hispanic White Non-Hispanic Black Hispanic

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Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in Did you live with anyone who was a problem drinker or alcoholic?
any way?
Did you live with anyone who used illegal street drugs or who abused prescription
Did your parents or adults in your home ever slap, hit, kick, punch or beat each medications?
other up? Did you live with anyone who was depressed, mentally ill, or suicidal?
Did a parent or adult in your home ever swear at you, insult you, or put you
down? 35
Experienced Sexual Abuse
30
35
25
30

25 20

20 15
15
10
10
5
5
14.4 15.5 30.6 11.3 8.3 19.2 21 12.2 25.7 23.4 30.5 10 25.6 11.8 18.2 16.9 10.6 7.5 26.9 8.1 11
0 0
Non-Hispanic White Non-Hispanic Black Hispanic Non-Hispanic White Non-Hispanic Black Hispanic

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Did you live with anyone who served time or was sentenced to serve time in a
prison, jail, or other correctional facility?
Were your parents separated or divorced?
40

Current Data Source for ACEs in North

35

30

25
Carolina
20

15
2. NSCH (National Survey of Children’s Health, 2016-
10 2017)
5
5.7 28.2 13.4 36.6 4.2 36.3
0
Non-Hispanic White Non-Hispanic Black Hispanic

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NSCH: Total # of ACEs

No adverse childhood experiences
One adverse childhood experience
Two or more adverse childhood experiences Black Age 1 = 45%
70

60
55.5
59.7 Proportion of Children with any ACE by
Race and Age
White Age 10 = 43%
50

40
34.6 36
29.5
30

21.4 23.2 22.8

20 17.5

10

Hispanic White, non-Hispanic Black, non-Hispanic

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Hard to get by on family income Divorce Witness Domestic Violence Witness Neighborhood Violence
12

Parent Died Incarceration

40 10

35
8
30

25
6

20

4
15

10
2

0 0

Hispanic White, non-Hispanic Black, non-Hispanic Hispanic White, non-Hispanic Black, non-Hispanic

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Summary of Race/Ethnic Differences in North Carolina ACEs

Mental Health Alcohol or Drugs Race/Ethnic Discrimination
ACE BRFSS NSCH
16
Mental Health White > Black White > Black
Alcohol, Drug Use Alcohol: White > Black ND
14 Drug: No difference
Incarceration Black > White Black > White
12
Divorce ND Black > White
Witness Domestic ND ND
10 Violence
Physical Abuse White > Black -
8 (not spanking) Hispanic > White/Black
Verbal Abuse White > Black -
6 Sexual Abuse ND -
Parent Died - ND
4 Neighborhood Violence - Black > White

Race/Ethnic - Black > White

2
Discrimination Black > Hispanic
Poverty - Black > White
0
Total ACE Score (>0) 1-2 ACEs: Black > White 1 ACE: No difference
Hispanic White, non-Hispanic Black, non-Hispanic 3-8 ACEs: No difference 2-8 ACEs: Black > White

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Outline
1. What are the key findings, and limitations, of the
ACEs study focusing specifically on the burden on
individual and public health?
But, wait…..What about resilience?
2. What is the best available evidence regarding
current interventions and strategies to address
ACEs? Shouldn’t we also consider protective
3. Identify promising approaches and initiatives in factors!?
North Carolina to address ACEs in policy and clinical
practice?

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Interplay of Risk & protection

National Scientific Council on the Developing Child, Center on the Developing Child at
Leadbeater et al., 2004 Harvard University, 2015

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When your family faces problems...

NSCH Family Resilience talk together about what to do?
All of the time Most of the time Some or none of the time
A composite measure based on responses to the following 4 survey items: 60

“When your family faces problems, how often are you likely to do each of the 54.1
following?” 50

42.7
40
1. Talk together about what to do. 40

30

2. Work together to solve our problems.

20

3. Know we have strengths to draw on. 10

4. Stay hopeful even in difficult times.

0

Hispanic White, non-Hispanic Black, non-Hispanic

41 42

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When your family faces problems.... When your family faces problems....
work together to solve our problems? know we have strengths to draw on?
All of the time Most of the time Some or none of the time All of the time Most of the time Some or none of the time
60 70

52.9
60
58.4
50
45.1
41.5 49.8 49.7
50
40

40

30

30

20
20

10
10

0 0

Hispanic White, non-Hispanic Black, non-Hispanic Hispanic White, non-Hispanic Black, non-Hispanic

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When your family faces problems... White Overall Black Overall

stay hopeful even in difficult times? 100%
All of the time Most of the time Some or none of the time
70 95%
63.3
% Excellent/Good Health

60 56.8 90%

50 47 85%

40
80%

30
75%

70%
20

65%
10

60%
0

Hispanic White, non-Hispanic Black, non-Hispanic Low Family Resilience High Family Resilience

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White 0 ACEs White 2+ ACEs Does Family Resilience Buffer the Effects of Discrimination on Child Health for
Black 0 ACEs Black 2+ ACEs Black Children?
100%
Yes Discrimination No Discrimination
95% 100%
% Excellent/Good Health

95%
% Excellent /Very Good Health

90%
90%
85% 85%
80%
80%
75%
75% 70%
65%
70%
60%
65% 55%
50%
60% Low High
Low Family Resilience High Family Resilience Family Resilience Indicator

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Does Family Resilience Buffer the Effects of Discrimination on Child Health for Black Children? Outline
Yes Discrimination No Discrimination 1. What are the key findings, and limitations, of the
100% ACEs study focusing specifically on the burden on
95% individual and public health?
% Excellent /Very Good Health

90%
1% Gap
85% 2. What is the best available evidence regarding
80% current interventions and strategies to address
75% ACEs?
70%
12% Gap
65% 3. Identify promising approaches and initiatives in
60% North Carolina to address ACEs in policy and clinical
55% practice?
50%
Low High
Family Resilience Indicator

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1. Uncovered high prevalence of ACEs

1. Uncovered high prevalence of ACEs in the general population.
in the general population. Confirmed highest exposure to ACEs
Confirmed highest exposure to ACEs in vulnerable populations.
in vulnerable populations.
What have we What have we
2. Supported causal link between
clearly observed clearly observed ACEs and poor health (supported by
about ACEs about ACEs clear dose-response).

through clinical through clinical

translational corollary:
and community- and community- preventing/buffering ACEs will a)
based studies? based studies? promote individual and public
health, and b) reduce health
disparities.

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1. Promote general awareness of

ACEs research.
How has the field
2. Advocate for evidence-based
translated the policies and programs that
observation prevent/buffer ACEs.

(prevent/buffer ACEs to 3. Encourage awareness of

improve health) into individual “ACE score” in service-
delivery settings.
interventions?

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The vital sign monitor of the future? The lab test results of the future?

ACEs 5 High 0-10

5 ACE Score
55 56

Ongoing ACEs-Related Initiatives in North Carolina

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References

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Braveman, P. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports, 129, 5-8.
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planier@unc.edu
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