Primary Children's Center for safe and healthy families and the division of child protection and family health of the Pediatrics department at the University of Utah School of Medicine in Salt Lake City presents the relationship of adverse childhood experiences to adult health status with dr. Vincent Jay politi based upon the adverse childhood experiences study a collaborative effort of dr. Vincent J phylidia of Kaiser Permanente and dr. Robert F anda of the Centers for Disease Control and Prevention from the child trauma treatment network of the Intermountain West at its September 2003 Snowbird conference [Music] thank you very much and it's really a pleasure being here I hadn't expected the weather to be snow I mean I think it's wonderful but when you come from San Diego with this that is unexpected I got into this in an unusual way some years ago 28 years ago I had the opportunity to put together a department of preventive medicine that Kaiser Permanente at San Diego and as part of that department we built a series of risk abatement programs one of which was the weight program and we were doing pretty well with that we had a powerful technology that enabled us non-surgically to take weight off people safely and reliably at the weight at the rate of about 300 pounds a year extraordinary but true and by 1985 and we were seeing about 1500 people a year in the program we're very disturbed by the high dropout rate that we had what was particularly disturbing was the people dropping out were the ones who successfully were losing weight and that really drove us nuts and ultimately in despair I started interviewing a large number of people who were dropping out in the course of successfully loosing weight and having no idea what I was looking for did basically a social worker's timeline interview what did you weigh when you were born when you were in kindergarten sixth grade of a woman when you began to menstruate that cetera et cetera and by accident I put in a question in this sequence how old were you when you first became sexually active and I misspoke myself early on and asked some woman how much she weighed when she first became sexually active and she said forty pounds and then blurted out it was with my father and started sobbing and I remember thinking to myself second incest case I've seen in 24 years of little did I know ten ten days later I ran into the same thing and fortunately had the wit to conclude that I was not likely starting with third twenty four year cycled within ten days and as I pursued the issue really became quite quite disturbed because it seemed every other person I was talking with was giving me a history of childhood sexual abuse and I remember you know strongly feeling this really can't be true people people would know someone would have told me in medical school system if this were true a hundred and eighty six patients later turned out not to be every other person who turned out to be fifty five percent and I remember still being concerned perhaps I was introducing observer bias in some way and eliciting this needlessly falsely incorrectly and so I got five other people to interview a hundred additional patients and they turned up the same information and then a few years later I was in Atlanta talking with some people at CDC and and they told me look you know no one is going to believe two hundred and eighty six cases no matter how well you've studied them what we need to do is put together an epidemiological e sound study with thousands of patients and so we did because in the department of preventive medicine we provide 258 thousand adults a year comprehensive biomedical psychological and social evaluation it's a quite remarkable place so it was fairly easy to ask twenty-six thousand consecutive people whether they would be willing to help us on condition of anonymity and the information never appearing in their medical records understand more about how what happened to people in childhood affect their health as adults and that's what I will share with you overwhelmingly what you will see is the results of what happens to people who have abusive experiences in childhood or grow up in dysfunctional households and never have access to any sort of treatment this is the largest study of its type that's ever been done to examine the health and social effects of adverse childhood experiences over the course of a lifetime essentially we're asking how do you get from here to here from a newborn infant with tobe potential to the man who is broken biomedically psychologically and socially who's got the cardboard sign on his second on his neck at the corner we looked at several categories of childhood abuse and neglect and several categories of household dysfunctions and we picked these really empirically because as we spoke with people in more and more depth than the wait program the categories that we studied kept turning up more and more frequently the study is simple in concept it has a retrospective and a prospective component we are meeting people here and asking them about what happened here on average a half century earlier the average age participant is 57 years old the population was 80% white 10% black 10% Asian 50 and 1/2 percent female 49 and one sent mail 74% had been to college 46% had graduated from college in no way could you dismiss this as a marginalized population this was really a section out of the middle class of a major American city basically it was you and me we did the first we did the retrospective portion in two waves so that we could stop halfway through and regroup and see if we needed to correct anything and then we have also a prospective portion going on which is tracking these people forward in time we now are at the five-year point and hope to go to ten matching what happened back here a half-century ago against current Pharmacy utilization ER visits doctor office visits hospitalizations and death you have the bibliography of the ACE study to date and you have in your folders information about how to track it forward over time and find out what's coming out new if anyone wants to correspond with me if we don't have a chance to talk here my email address is VJ FM d SD CA s in San Diego California at msn.com vjf MD SD CA at msn.com I'm a pretty good email correspondence so feel free to sure vjf MD SD CA as msn.com MSN doesn't Microsoft network the the economic consequences by the way we've taken a peek at this our huge I'll give you a summary of what we found and then spend the rest of the time providing you evidence for why this is true what we found is that the things that we termed adverse childhood experiences and that I will define momentarily are remarkably common what is uncommon is their recognition or their acknowledgement they are well concealed by time by shame by secrecy and by social taboo they turn out to be strong predictors of what happens later in life in terms of health risks in terms of disease and as you will see in terms of premature mortality and that combination of their high prevalence and their great power makes this statement not an overblown one makes adverse childhood experiences the leading determinant of what happens to the health and social well-being of a nation's population okay we looked at three categories of abuse if you read the original article and see the questions that we used you will realize that we are talking about the rather heavy end of things for the moment take my word for it until you look at the article and we looked at recurrent emotional abuse one in nine people this is that believe me the heavy end of things recurrent physical abuse such as by mothers beating children with the wires on the electric wires on irons or with wire coat hangers or fathers with fists belts or objects one in nine people contact sexual abuse contact sexual abuse 22 percent for women that was twenty eight percent for men with 16% 22 was the average for both in terms of household dysfunction growing up in a household where one of the members was alcoholic or a drug user could be anybody could be a mother and father your brother could be an uncle living in the house one of the household members was either alcoholic or a drug user one in four people growing up in a household where someone was mentally ill chronically depressed suicidal or institutionalized one in five people growing up in a household where mother was treated violently one in eight people growing up in a household where one of the members was imprisoned during your childhood one in 30 people here's what this looks like the eighth category that we have the second way it was growing up without both biological parents one of the things that we discovered in terms of losing a parent is that if one is going to lose a parent and as incontestably it is best to lose that parent by death and worst to lose that parent by abandonment just him on my mom divorced and when I was I'd probably say five or six the last time and he moved to a different state got remarried had more kids and just never know contact really so so after he and your mother got divorced he never came back to see um no I went to I went to a state with him two weeks when I was a senior in high school stay with him two weeks and then he left when you were five yeah and you didn't see him again did you receive my advice when I was a senior in high school did he find you or did you find him no I found him I used to call him a lot ride him a lot and he would never write back or call back or anything but you know I was majorly the one trying to you know contact him so so when you saw him years later when you're a senior in high school what what happened whose it was a good experience it made me it made me feel maybe we would be closer I have more contact it was a good experience so it's been I really had a good time and but there were no contact after that well you know I tried and but still how much did you weigh them then I weighed uh really fast me I was weighing about 240 245 or so but uh that's funny we're doing that time that two-week period of time I remember coming back Wayne to round to 10 or so I lost probably thirty pounds an afternoon of time yeah and what happened afterwards I hope gain we met oh yeah I probably by the end of my senior year I was probably around 255 the interesting example of losing weight Andres very specific condition spontaneously without intending to and then regaining more and the question is why we just keep that in mind you're looking at that man after he has lost 180 pounds of the weight program and of course the practical question is why did he get had to start with okay - to deal with the massive data that we were dealing with from 18,000 people we needed to create some sort of a simple scoring system so we created the so-called East score if you were exposed to none of the categories that I showed you before the a score was zero if you're exposed to any three it was three to any five it was five we did not count within a category so if you grew up in a home with one alcoholic that counted the same as if you grew up at home with one alcoholic and one addict if you were rate - once that counted the same as being rated three times if anything this understates the point one of the things that was surprising to us was that in this very middle-class population fewer than half of the people had an ace score of zero and one in 15 had an ace score of 4 or more from the standpoint of the physician and practice that means every day he is going to see at least one most likely two people with an ace score of four or more and the relevant question is who were they going to be they are going to be the people with chronic symptoms they are going to be the most intractable problems of the you'll see specifically shortly another thing that we learned was that if at least one eighth was present at least exposure to any one category was present then it was highly likely that there were other categories to which one was exposed and the eighth floor was likely to range given one to actually range between two point four and four I think the calculation was that if you had an a score of 1 you had an 84% likelihood of being exposed to actually more categories than them let's start on the light end of things we will talk about smoking smoking one pack a day in Southern California where there's a great deal of legitimatize abuse that is heaped on people who smoke you can't smoke and trains you can't smoke in restaurants and hotels and bars and office buildings etc I mean in an office building typically you have to go outside and stand at large things and square you know to enjoy your Camel cigarette usually painted near the garbage cans etc so so one of the things that's happened is that all of the all of the light weight smokers have gone away all the people used to smoke two three four cigarettes a day have disappeared and now you have people who are smoking and the heavy-duty range and that number has been persistent in spite of the heavy duty public health effort against it I will show you this pattern repeatedly this is a pattern from an infectious disease days is the so called dose response curve we're looking at dose not the microorganisms but dose the number of categories of adverse childhood experience to which one has been exposed and matching it against response namely the likelihood of whatever it is that we are studying and what you see here is that there is a strong graded relationship between ace score and likelihood of being a pack a day or more smoker in a place where you thought were a lot of humiliation and mistreatment as a result of doing them interesting observation because after all people say that smoking is really due to an addiction to nicotine this man is a three pack a day smoker he is also a I would describe him as a semi-pro slum fighter he earns that he earns a very good living he earns a very good living as a high voltage electrician on major construction projects I spent two hundred twenty-five years drowning out some poor childhood experiences with drugs alcohol cigarettes gotten rid of the drugs or the alcohol next thing I got to get rid of his cigarettes and I had no idea that the nicotine played such an important part in keeping that door closed the memories that I've blocked out with all these years with the alcohol and the drugs so you see what's happening to you now is related to what happened to you decades ago yep I found a way to block the emotions and the memories with drugs alcohol cigarettes most of you perhaps are aware that the most commonly used three truck in the country is methamphetamine most people are not aware that the first antidepressant medication introduced into North America by sea with pharmaceuticals in 1932 was dextroamphetamine a very close chemical relative isn't it interesting that the most commonly used pre drug in the country probably the world has potent antidepressant activity so we will now progress from the behavior of smoking to disease chronic obstructive pulmonary disease otherwise known as emphysema what you see here we've color-coded the ace score is the ace score goes up the likelihood of emphysema goes up found shift and we have now gone from psychosocial experience and childhood to behavior smoking to organic disease and here we are looking at the initiation of permanent smoking regular smoking for the age of 14 not just you know sneaking a cigarette in the bathroom with the window open but becoming a regular smoker before the age of 14 and you see that has the same rated relationship to a swarm that I've shown you before those of you with a statistical bet should know that every piece of data that I'm showing has a p-value of better than point two zero zero one this interesting woman once took herself from 420 to 280 pounds by buying the dr. Atkins diet book and following the directions in it at that point her husband made to her the common test I'll have to get me a new fat woman now but as far as being molested that's stuck with me all my life you know it's still in the back of my mind my aim in therapy I too suffer from depression yeah the most traumatic was my mother visiting my mother most definitely which had the most to do with you're putting on so much weight that's a hard question I think I started getting heavier and heavier after my father and mother divorced but then I I started really getting heavy after the molestation and I would try to take it off and then I would just gain it all back and then some gained it all back and then some once again when I asked her what she thought her husband meant by his comment guess I'll have to get me a new fat woman now she said that she thought that the fact that she was more physically natural was in some way threatening to him and the fact that she had become somewhat more outspoken that the lesser weight was also threatening him ultimately to provide the safety of a continued marriage she regained weight we looked at self defined adult alcoholism most people do not loosely defined themselves as alcoholic if you ask them so if anything the point was probably underrepresented here but when we ask people a simple question have you ever considered yourself to be an alcoholic what we saw was as the ACE score went up the likelihood of being a self-defined alcoholic went up from a little less than 3% to 16% it rise up over 500% in a stepwise graded fashion one of the things we saw in the wait program was that depression was very common the mythology of you know the Jolly fat man or the Jolly fat woman is precisely that it is a protective myth I've been looking for 18 years for that individual and I'm not met one yet so depression is something that we deal with a great deal and some people as you know say it's genetic certainly runs in families but so too does speaking the same language some people say that genetics affect depression by causing chemical imbalances certainly you're likely to hear people talk about not being depressed but having a chemical imbalance a man at Stanford named Allen barber wrote a wonderful book but she made the point that depression is not a disease it is a normal response to have normal life experiences I think that's true let me give you the evidence we looked at self to find self to find chronic depression and what we saw in red women and yellow men an interesting point that we won't go into as to why there is a difference but what you see here is that you're going from about 17 percent to bumping sixty percent and so if indeed there is a meaningful genetic component it's got some space to operate in but most of the space has been occupied already and incontestably there are chemical in but they simply illustrate the difference between mechanism and basic cause and the same sort of way the people who hope to use leptin is the explanation for obesity mistaking mechanism for basic cause if you were to tie someone in the chair just out of reach of a rabid wolf you'd have a pretty pretty pretty anxious person their adrenaline levels would be enormously high if you didn't think the situation through or were so narrowly focused that you didn't choose to look at the wolf you might say that high direct adrenaline levels were the cause of anxiety in fact they simply are the intermediary mechanism if you're dubious about self-defined product depression then we can switch to self acknowledged prior suicide attempts and if there's something that people don't talk about very much as the number of times they've previously attempted suicide so if anything I think once again is probably under represents the poignant what you see is matching a score against self acknowledged suicide attempts you have a really remarkable rise if you go out to an a score of six or more you can get up to between a 31 and 50 fold increase in attempting suicide and adolescence that is to say a 3100 to 5,000% increase and the people who are epidemiologists for a living tell me that these numbers are of a magnitude that they professionally are likely to see what's in the career the technique of population attributable risk is a fairly simple concept in other words what portion of a condition and a population can be attributed to some specific risk factor the calculation is complex but the idea is fairly simple and when we look at chronic encourage of depression we see that we could probably acknowledge safely more than half is related to adverse childhood experiences chronic depression that 40% attempted suicide close to 60% we looked at promiscuity because of its link to sexually transmitted diseases particularly AIDS we in our conservative way thought 50 lifetime sexual partners was a lot I've had a number of patients tell me that that would be an ordinary year but whatever the case and using this index you see that as the ACE score goes up the likelihood of promiscuity goes up and so too does the likelihood of sexually transmitted disease we looked at teenage pregnancy big problem most people who look at this look at the girls who become pregnant as teenagers we decided to look at the male's be they teenagers or adults who get teenage girls pregnant and we were far enough into this to wonder whether perhaps these males might have been abused themselves as kids and this was some way of acting out indeed that turned out to be the case because as you see here we looked at the age at which those males were molested as children and the younger the age at which they were molested the greater the likelihood of them later getting a teenage girl pregnant we looked at unintended pregnancy this was published in the Journal of the American Medical Association about a year and a half ago and said their reference list that you have and most people blow this office you know that unfortunate accident well as is often the case things that we conveniently describe as accidents are not accidental and what you see here is that as the a score goes up the likelihood of unintended pregnancy and its treatment elective abortion goes up so sort of a running subtotal now if you compare now we'll use a score zero days or five or more multiple sexual partners at the level we're talking about increases five point eight fold 580 percent three or more marriages three point eight fold to three hundred and eighty percent unwanted pregnancy leading to abortion goes up two hundred and ninety percent we looked at rape surprise the first surprise was how common rape was I didn't know that until I started talking with patients and the wait program and then that surprise was this the powerful relationship to adverse childhood experiences think how this is why is this what makes this happen what are the intervening links that make this operational why would adverse childhood experiences make typically a woman sometimes a man more susceptible to rape later in life it's a hard question there's an important question to think about perhaps someone will bring it up later and this we looked at the making of madness the presence of hallucinations there what you see is as the eighth score goes up the likelihood of a history of hallucinations knows though until you're at the 10% level within a score of seven or more many of these people would be defined as schizophrenic of course the practical question is why is somebody schizophrenic and for those who would point out that people with high a scores often using alcohol or drugs and perhaps that's the real issue that they are having hallucinations we corrected for that in the other color of the bar you see essentially the same thing so comparing an a score of zero to one a five for more the likelihood of being involved in intimate partner violence domestic violence spouse beating whatever you want to call it goes up over 500% the likelihood of being raped goes up almost 900 percent we did not know and looking at population attributable risk it appears that you can account for about half of all depression leading to suicide attempts you can lay that on to chop adverse childhood experiences being raped almost 2/3 being involved in domestic violence about half the back prediction for a moment I think this is a fair representation of what most people believe that addiction is something that happens because of characteristics that are intrinsic and the molecular structure of some of some chemical now it sounds good it's comforting in a way and my kids a heroin addict because this evil wretch selling heroin a well-known addicting substance moved into the neighborhood we found very much the opposite that addiction highly correlates with characteristics that are intrinsic and that individuals childhood experiences the implications of the difference are enormous if you want to do something about drug use or drug abuse drug use is really the better term actually no drug abuse takes you in a totally different direction here's the evidence we look at the extreme intravenous drug use because it's sometimes easier to see by looking at the extremes and so what we see is that when you compare a score zero with a score four or more the likelihood of becoming an intravenous drug user some point later in life goes up 12 fold or 1200 percent if you move this out to a score six or more it goes up to forty six fold four thousand six hundred percent sort of a running subtotal again a score zero compared to a score five or more self acknowledged alcoholism over fivefold intravenous drug use over nine fold but not a self acknowledged suicide attempts essentially seventeen fold and when we look at what part of the problem in populations might be attributed to the category of adverse childhood experiences about two-thirds of alcoholism about half of all drug abuse their youth and about three-fourths of intravenous drug use and so we ended up in the border where we never anticipated being I mean we started out trying to figure out why people were fleeing the wait program and destroying our reputation for being successful but in fact the things that I've been showing you are the risk factors that underlie the ten most common causes of death in the United States with an a score of zero you have a very medically uninteresting population non obese non-smoking non-alcoholic non-diabetic non hypertensive etc no no internist has a chance of making a living with that group but with an a score or four more I mean this is big medicine maybe the way they choose themselves well let's take a different approach calling this let us look at the null hypothesis let's let's say well maybe kind of overflow for this kind of thing so let us assume for a moment that there's no relationship between adverse childhood experiences and adult health status if that's true then the 58,000 people a year coming into the department should have no particular age gradient related to ASA score no it's a strange thought for logical of you think of this for a moment and when we look at people with an ace score of zero see what you'd expect the most common age quantile is the oldest over 65 the least common is the youngest under 35 no surprise young people do not see much reason to go to the doctor you get older things start going wrong include you might die someday etc this is pretty pretty expected but when we move to a score to something has caused that expected distribution pattern to reverse what had been the most common age quantile the oldest has become the least common what had been the least common has become the most common and when you move to a score for you see that the most common age quantile that in a score of zero has almost disappeared and we were very worried when we first came upon this because I was in Atlanta at the time and we we were working with over 600,000 pages of data and we lived in mortal fear that somehow we would lose control of it and when we saw this we you know really thought we had lost control of it that took us two days to point out what many patients point out in a few seconds oh you mean they died and that of course is what happened I've shown you the relationship of adverse childhood experiences to health risks like smoking to diseases like emphysema and now to the consequence of diseases someone thinking carefully about this might say well maybe they don't come through the department for some reason we looked into that possibility and we found that in any four year period 81% of all of the adults who were members in San Diego come through the department at least once and then when we looked at the medical records of those 19% who didn't have compared them with the 81% to do he could not discern any recognizable difference between the groups so I think this is not only a real thing but it's simply a logical progression of what we have been talking about putting in a different way many chronic diseases and adults are determined Akkad's earlier in childhood when I was doing infectious disease work if somebody had asked me you know how might what happens to kid affect their health a half-century later I probably would have said well we might get rheumatic fever and don't have valvular heart disease a half-century later or Ripton and Russia maybe they get diphtheria and have residual tips of ridding the right us sounds pretty smart and those things are true but but they're really dust the big action is not from organic disease in childhood they action is from an adverse childhood experiences not only that but the things that we term risk factors not only predisposed to disease but they look in the other direction are remarkably good windows of insight into earlier life events they won't tell you what they are precisely but they will identify with very high probability what's likely to be there and poets sometimes recognize that more quickly than other people and so there's that wonderful line from TS Eliot and my end is my beginning and we commonly dismissed these things as bad habits or self-destructive behavior and that totally totally misses their functionality no one smokes to get lung cancer or bladder cancer or coronary artery disease no one shoots heroin to get heart valve infections people smoke for relief because nicotine is a beneficial psychoactive ancient it has detrimental effects incontestably it is also beneficial sometimes we find it difficult to believe that posing powerful forces can go on simultaneously but one of the things that we learned on the whate program is that people typically come in on the one hand watching very much to lose weight and on the other hand often are terrified usually unconsciously and sometimes not of the changes and social sexual and physical expectations that a major weight loss will impose on them so it's important to look at the functional aspects of what we protectively dismissed as dysfunctional behavior I've been talking about medical things up to now we'll switch to social impact how you do your work most people do not go out of their way to falsely claim that they're enough to doing their work so if anything this probably understates the point once again but when we look at self acknowledged serious job problems do you have serious job do you have serious problems carrying out your work we see that is the ace score goes up you have a progressive increase in the likelihood of that and for people who are familiar with occupational medicine it turns out that much of what causes time to be lost from work is actually predetermined to kage earlier by adverse childhood experiences and may simply be triggered later by something that happens at work this is an interesting sequence because this is the real kid who once belonged to a secretary in the department here he is at seven unhappy-looking kidding but you know who thinks seriously about asking why is that kid unhappy at seven that's why kids are held it over effective response here's the same kid as a teenager solid looking kid but that's why teenagers are and he'll get over it he never gotten to this point he got to this point his mother drew me this picture about a year after he had hanged himself shortly before Christmas we're not used to thinking of suicide as a coping mechanism it is and we should think of it that way the story was that that kid had been extensively molested by his father as a child but the things that we call risk factors are effective coping devices this is an important idea because another way of saying it is many of the things termed public health problems are in fact personal solutions they are personal solutions to problems that are well hidden by time ashamed by secrecy by social taboo and perhaps that later that latter observation has a lot to do with why we are doing so poorly with trying to change the prevalence of certain public health problems the stuff is notably difficult to deal with those of you who deal with children understand that and perhaps you will have a little difficulty accepting the idea that it's even harder to deal with an adult fifty years later after patterns have been set for half a century but here's an interesting insight this is a picture that was on the cover of the Journal of the American Medical Association about ten years ago it looks through the dining-room window of a family that eats together mother be raising father sitting there solemnly with knife up raised kid cringing towards his mother and the real question of course is what is the impact of this if it happens Li day after day here's some insight into that this is a PET scan essentially an x-ray showing biochemical activity of the brains of two three-year-old children this one being an ordinary American child this would being a child who was raised in a Romanian orphanage people who study these things saying that currently Romanian orphanages are the worst institutions of their type in the world and what you see is that there are a lot of areas in this brain that do not have any biochemical activity and there is no stretch of the imagination to believe that at the time when brain is being formed that lack of normal biochemical activity may have something to do with the neuro anatomical structure that is laid down if you want to read a fascinating book about what's known about you know truly remarkable book because it's so easy to read and and the experiments that are so remarkably interesting in a genius the book is called magic trees of the mind the author uses trees metaphorically for in turn neuronal connections for synaptic connections and the offer is a woman named Marian diamund as in diamond ring she is a old-time neurobiologist at Berkeley a remarkably good book magic trees of the mind Marian diamond back to the old public health problem personal solution that's pretty heavy-handed statement I feel very comfortable banging I mean essentially this is what psycho analysts have been saying for 100 years but they have been saying it you know based on two cases 4/4 and we're saying it based on 18,000 one way of describing what we've been talking about would be this way you have this large base of individuals with adverse childhood experiences most of them are going to be impaired as a result in some way may be socially may be emotionally may be cognitively mean this is this is not the way to get a scholarship to BYU or Stanford or wherever by the time they become adolescents and have some freedom they ordinarily will try to do something to feel better and hence initiate what we term the health risk of behaviors which might equally properly be called self health behaviors those over time will produce disease and disability and many of them and the significant portion of them will die early you have a copy of this pyramid in your handout folder Alice Miller is a Swiss psychoanalyst who has written a remarkable number of interesting monographs on various aspects of this if you're not familiar with her look up her name on the Amazon website the truth about childhood has stored up in our bodies and lives in the depths of our souls our intellect can be deceived our feelings can be numbed and manipulated our perceptions can be shamed and Confused or our bodies tricked with medication but our soul never forgets and because we are one one whole soul in one body someday our body will present its bill she of course is talking present its bill metaphorically but in the prospective arm of the study we are also looking at it literally the cost of this is truly enormous another line from TS Eliot home is where one starts from as we grow older the world becomes stranger the patterns more complicated of dead and living in my end is my beginning who ever would have thought that Pediatrics is the breeding ground for internal medicine so one might sensibly ask how do you get from here where we are which is about to good to where we theoretically could be and from what we've seen there would be two essential pieces necessary to bridge that gap one is acknowledgement that these problems exist there is very little of such technology but now and two is the recognition of such cases in medical practice there is exceedingly little of that now the bigger problem is this if that if any health insurer archives our Permanente Intermountain whatever were to make a big investment in terms of improving parenting skills of people now that may or may not have a benefit next year it's a complicated issue but certainly the health-related benefit the organic disease related benefit is going to be the years or decades downstream they are not likely to be with Kaiser Permanente or Intermountain or whatever at that point you know they'll be a blue cross or health net or some other organization so to get a big company to make a serious investment in preventive measures that are beneficial but that have a long-term benefit is understandably going to be difficult in one of the handouts that you have which is subtitled turning golden to lead the article closes with an actual case that I was asked to consult on as I was finishing writing the article and I think you'll find that an interesting case because it shows two different ways of looking at something can you do this can you recognize these cases in medical practice yes no question became and because of what we've learned in the ACE study because of what we learned trying to resolve our annoyance with people fleeing the wait program and taking their success our success with them because of that we have routinely sort fought these issues now in the past 400,000 patients who have gone through the department it's a big number you know it truly can be done everybody everybody of course what everyone is afraid of is well you know my god what if that patient says yes so here's a good one-liner to remember how has that affected you later in life not as how has I've affected you later in Lyon and so you were molested as a kid by your grandfather tell me how that affected you later in life so you were the one who found your father hanging in the garage tell me how that affected you later in life people will be fearful of opening Pandora's box so to say but it doesn't happen and as I can tell you range from 20 seconds to about a minute they are concise often associated with crying the principle of things and really the deserve crying in the world and what people tell you is remarkably instructive in terms of trying to figure out what to do to be helpful now we ask these questions by questionnaire by a very well devised questionnaire that we've developed in the course of treating 1.1 million patients or evaluating 1.1 million patients in this department from the course of the past 28 years I've gotten pretty good at the question there the questionnaire well devised questionnaire is is much better at getting this information than a face to face interview because you know we're never at our best we're going to be tired one day pressed for time another day irritated it another day you're going to turn out to be the wrong sex the role on race the wrong age the wrong hair do whatever for that particular patient people attribute to a well devised questionnaire or a touchscreen computer whatever characteristics they seem to need so our ability to get this information is predicated on getting it quasi anonymously where we're the anonymous person and then of course obviously at some point it has to be dealt with in a conventional interpersonal manner but there's an important idea in there and then I think the single most important thing we do is to help a person tell the worst secret of their life to somebody who was deemed socially important and come out of that still feeling that they are an acceptable human being by being told that by shaking hands and asking them to come back talk more about those things in a couple of days or a couple of weeks or a month or whatever so here's the building in which I work we do a good bit of our work on the whole top floor of this building and in the past since 1975 we've evaluated in detail 1.1 million patients on that floor it's kind of a mind-boggling idea but it's true and we've we've ultimately built a system that is the reverse of conventional medical practice conventional medical practice depends on symptoms that basis visits that basically are symptom initiated the work is done by a physician with nursing support ok history is taken related to the symptom patients examined symptom related laboratory studies that done maybe another visit to come to a conclusion we've done the reverse of that and bypass what we're talking about is individual and population health assessment system lots of questions that are unusual down in the dumps or depressed nervousness drink more than you think is good for you use street drugs when raped or sexually molested as a child and physically abused and verbally abused etc so comprehensive history on everybody at the out that not symptom initiated that questionnaire is put into a digital scanner totally reformatted by body systems in a way that physicians are used to dealing with things a large block of measurements biochemical tests are also carried out then at the second visit review of the history review the laboratory tests full physical examination coming to some conclusion and plan and a written letter of summary roles are reversed the work is done by nurse practitioners or physician assistants the role of the physician here is in a supervisory role to provide support and advice whenever necessary and we've now carried out this version of the system with about four hundred and fifty thousand times gone since the slide was made middle class and E Hagins the work is highly accepted by physicians they're not happy to receive some of the information but they certainly don't doubt its reliability it's it's provided a major improvement on current practice it has been cost effective it's provided a major marketing advantage to Kaiser health plan in San Diego the people who sell Kaiser health plan in San Diego tell me the health appraisal is probably the major marketing tool they have in terms of speaking with potential member groups so in medical practice that is it is we have really an extraordinary technology for secondary and tertiary care and in primary care where I work we have a very primitive processes in general for information gathering for record-keeping for patient feedback and we end up working with partial information routinely and our efforts commonly are not cumulative with this system providing comprehensive biomechanical psychological and social evaluation to everyone at the outset of ongoing care by providing educational feedback by letter of summary to patients and by videotapes etc by providing a lifetime health plan by making available matching risky bateman programs by providing password-protected and Internet based medical records we've seen some interesting things in 1977 when we were doing the biomedical version of this work going through the department was associated with an 11% reduction in doctor office visits in the subsequent year I was surprised by that because we find new things we generate work but in 77 when we're doing a very conventional biomedical evaluation we had a net effect left percent reduction in doctor office visits the next year those are pleasing to me more recently an outside company did an analysis of 125,000 patients going through the department to my utter amazement there was a 35% reduction in doctor's office visits in the year subsequent to going through this process two years out that reverted to the prior baseline now it's an interesting question why for one year this kind of approach is associated with a 35% reduction in doctor office visits the cost consequences of that obviously are huge so we're not talking about a reduction in doctor office visits due to the proved health we're talking about a reduction in doctor office visits due to reduced anxiety about health because at least in adult medicine the driving force behind doctor office visits is not health it is an anxiety about health important distinction and so going through this kind of comprehensive evaluation has significant anxiety reducing the fact that lasts about a year so there's a short-term benefit in adults whether there would be in children I have no idea anyway this is what we've done and this is what we've done with it which is only a bare beginning I mean essentially the adverse childhood experience the study provides a blueprint for altering medical practice not by buying more MRI machines and so forth but by altering the initial approach the entry into the system so we have put this into scale on a very large scale we do this routinely with 58,000 adults the year it is possible to do it if you are set up properly to do it it is possible to deal with it but you may have to put together some unconventional ways of helping people because the idea of saying well yeah you know refer for psychotherapy that's the nice way of avoiding reality because the magnitude of this problem is enormous most people can't afford psychotherapy so we've devised other things fighting people things to read using theater techniques in small groups because it turns out if you can find an emotionally stable actor or actress to help you with this anything well they'll do that at a much lesser cost than will a psychiatrist or a psychologist or a social worker and also works very well if you think about it that really has been the role of theater from the beginning to help people think about things that public wise were too difficult to think about that's the role of soap operas now if you're educated you look out your nose with those but the real role of soap operas is to help people to think about life problems anyway that's where we are from trying to figure out why people were fleeing success and ruining our reputation so if you'd like to discuss any of this birthright be happy to you know not anything that I could formally formally present informally I would say that the things that we're doing and I will add some to what I mentioned are valuable acceptable effective and affordable otherwise we wouldn't be continuing them some other things we do autobiographical writing there's the psychologist at the University of Texas named James pennybaker PN NEPA keer a lot of stuff in the literature including a few books on the role in medical medical practice of therapeutic writing I often tell patients look you know how to use the computer terrific I want you to send me an autobiography of your life in five year segments this is an email attachment make sure you have the first segment in to me before you come back the record thus far is from the former Miss Pittsburgh of 1962 who taught me that if you have a daughter you would not want her to be miss anything and Miss Pittsburgh who was once a very very attractive woman before she decided that that was incompatible with any sense of safety in her life was also a very proficient typist and had one of her prizes at this and she has sent me now 264 pages of single space typing she's only up to her middle 40s when she's actually in her 60s I concluded even though I'm a pretty fast reader that whether I read it or not is the important part it's the part the important part is somebody doing it having a pass through their mind again etc and pennybaker show that while this is initially disturbing to people ultimately it's quite ameliorative and indeed has a distinct effect on doctor office business another technique that that I really became familiar with it the insistence of a woman who had very successfully been treated for some some big scale incest problems as a child is medical hypnosis now it's easy to hypnotize anybody you know I can do that to do something skillful with someone when they're in it in a trance state that's that's the rub if you can find a skillful hypnotherapist you can sometimes accomplish a great deal really and sometimes highly improbable things in relatively short periods of time I feel very lucky that I know one such person in San Diego County another one in Los Angeles County I'm sure there are more but yes given that most of us in this room do work with children and that's really kind of the purpose of our our network our organization Charlie beautifully with children who have childhood experiences I cannot answer that I can tell you that most overwhelmingly both of the people that we saw never had any treatment of any kind anecdotally I will tell you that those who did seem to be doing somewhat better than those who didn't but that's purely anecdotal weak we have not looked at that point in any formal way because so few people see you have to remember we're looking 50 years after the fact if this stuff is denied today imagine you know how much it was the night of 1950 and 1960 yes all they wanted to meet with a group of positions or a position meet with a legislature meet with an insurance company representative do you have some ideas about how people in this room who come from a seven state area could take what you know what you presented it and use that to educate people who can influence decisions about making services available for people at an earlier age well let me answer you in two stages because you're really asking you know what would you do and then the question how would you carry it out it's clear to me that to do this work with adults it's kind it's a very interesting learning experience but but if you take the magnitude of the problem in the population it's really no it's illusory you're not going to solve the population for the country you know for for a person for small number of people sure if one is going to do anything it's going to have to be with children and as early as possible and the more we think about this the more we have thought that really even better than starting with children would probably be with pregnant mothers to identify a group of high-risk women and pregnancy high-risk being women who cannot stop drinking smoking the drug incurring pregnancy women who have an acknowledged history of childhood sexual abuse or rape women who gained another pounds in pregnancy women who were married to an abusive spouse or an alcoholic that's a trait and to focus one's attention there we think we don't know we think that would really be the most effective place to direct once every another thought that has crossed our minds a number of times is the use of broadcast television to teach not didactically but by illustrative example what good parenting looks like what bad parenting looks like and how that plays out in the in 1997 the Ford Foundation posted something called the the soap summit where they put together a meeting of people who were producers and writers of soap operas basically asking them whether they would be willing to write thematic material relating to public health problems into soap opera scenarios and the answer was yes and to date no one has done anything useful with them but I believe that would have tremendous potential for reaching enormous numbers of people in very low cost now how one would do that with the legislature it would help a great deal if you knew something about the people in the legislature for instance in the state of California the Attorney General a guy named William blockier acknowledges publicly that he was molested as a child he's pretty interested in the subject that's a big help undoubtedly that'll be true when you call a South Dakota or anywhere else the question is how you would find that individual but I think that would strike me as being the the most efficient way of trying to find a helpful inside person who would work with you to get you the invitation presentation of information yes well you know you have to understand Kaiser is enormous organization we have roughly 10 million members around the country and God knows how many doctors that's at around no VOC most of the doctors don't want to go near this with a pole I presented this information to our Pediatrics department a couple of years ago and I asked at the end I mean it's really good people are about 70 of them there that took care of my kids some of them of my friends and I remember asking them maybe there's one or two of you who would like to meet with me a couple of times how we could think about how we could do something with this because really knowing so much of what we're seeing in internal medicine as a result of what wasn't seen in pediatrics even though it was there and I mean I was a man I figured a free lunch I'll pay the bill somebody a couple of people will surely put their hands up I got a big round of applause I know it's had enough so so I would say that most people shy away from this greatly you know in part out of embarrassment we are all that cultured to know the one doesn't talk about certain things it's not nice to one doesn't ask about certain things that's not nice to that leaves you really kind of in a weak position to know how to deal with these things to my knowledge know if you have any ideas how to do that I'm be certainly happy to listen okay so so what I would say is in terms of Kaiser Permanente it has radically changed the nature of one department and because of the style in which we lay leave our footprints in the unified medical record we use in San Diego it's undoubtedly affected the thinking of a number of physicians how much it's changed their behavior is hard to tell yeah from Heidi's campus for abuse and neglect and as I started doing these more and more you know I couldn't believe the amount of course you know most of this is it's probably ninety five percent of mothers I've seen great you know five percent of fathers and most of them you know good percentage has been you know either emotionally physically or sexually so basically I feel like I anecdotally see the same pattern you see just it's or like these kids had these badge these people had these many childhood and they're like just keep going on just worse than doors and sometimes well concealed by great professional success which is coupled by a disastrous personal life sure yeah good point what are you all thinking about how do you think that occurs because you know the link is for sure there and you may remember that the prevalence of pre-release of being great at least once the prevalence within a score for more was 33% one and three people funded three women so so how does that work yes I can't hear [Music] sure if you're asking that we look carefully at one category versus another yes we do and we decided not to bother publishing anything about that because it was looking at a trivia and it would be very very tempting to take the easy way out and look at trivia similarly although we clearly looked at racial differences that ethnic differences and so forth and there are some we decided not to publish that for the same reason it was going to just be distracting from the main point if you look at the eight categories of adverse childhood experiences yes if you look at different outcomes there are some minor differences between them if you don't know better you might you know think they were important but they're like 30% differences etc and here we are talking about numbers 3,000 percent and so on so we specifically decided not not to let that noise out this ain't the same thing with ethnic and you know maybe you can show that Italians are worse than Greeks or you know Jews they're worse than Mormons or whatever Allah didn't do is set up a lot of internecine warfare and accomplish nothing while missing the greater point the greater point being that this whole problem is so distressing to people that most people don't love it though anywhere near it and it's a lot more comforting if you have to to look at some crumb yes yeah no not formally but I can tell you anecdotally my experience over the past 17 years now I have interviewed and that's almost 2,000 individuals and followed many of them and you know there's no question about the power of intergenerational transfer of this you look at the people where a whole sequence of children has have been molested through through the generations you look at the propagation of alcoholism through a family you know in which of course is what makes people want to take the easy explore must be genetic you know like like all speaking the same language in the family of genetic you know might be but hardly makes the taste passionately absolutely yes so if you're asking is the questionnaire that we used available debase the study questionnaire is really a research document is in the literature it's in the first paper we published in 1998 if you want the kaiser permanente questionnaire email me I'll be happy to send you a PDF file with the copies in better see the nice thing about the general medical questionnaire that we have developed is that we've buried these things in with other questions including we've come to rican sexualize the nature of certain questions but we had in there the question we have an area question about multiple fractures and I assumed when I put that question in years ago that I was asking the orthopedic question but then but then a brief period of time I was the startup medical director of psychiatric hospital that we own and I put in the medical intake machinery and that question was there I was startled to find the 70% of the people in that hospital had a history of three or more lifetime fractures not to be published and I'm trying to think whether we have a question about household income and I'm afraid like I can't bring that to mind right now I know we discussed the innumerable times however it is one word you know if you wanted to to discuss the point I would probably choose to take the view that one walk to look at poverty is an outcome rather than the causal factor lest one end up trying to figure out how come Christ and Gandhi and mother Teresa did not have a bad influence on the people around them when they were poor so so I you know I've come to see that this is a good way to get poor yes louder please they're not knowing and your point is very well taken because although we have not studied the point formally again anecdotally and been talking with about 2,000 people it's pretty clear that that teaching children about sex and the households of the people who might see as patients is not something that occurs now if it's learned from classmates etc has learned on the street not in any organized kind of way either in schools for a family I still can't hear you bellow yeah well then they take the easy part of your question you know my other insurance companies use this technically to put people at higher risk at or conceivably I've not seen anything in particular to you know to suggest that that operationally is likely to happen in fact most insurance companies understand that taking individuals and is very high-risk because individuals lives with their teeth taking groups and there's far more satisfactory it's a lot less expensive administrative Lea to bring in a thousand members you know at a time than then one member of time a thousand times and although you will have some pretty sick people in the group you will have some you know a lot of healthy people hopefully to offset that so so what you're saying is commonly raised I don't I don't see it as a big operational issue vjf MD SD CAS in San Diego California at MSN and s my croissant network.com okay one minute yes is that someone's hand we're a long ways from there any suggestions on how the mental health community can promote driving I think however it's realistic to try to change the expectations of patients if you can do that successfully basically by showing them you know a different way of what might be available etc then you've created a potent market force to change what's applied particularly at a time when there are large organizations responsive to market forces so you know my own efforts currently are designed towards trying to take out into the community a nonprofit organization to demonstrate this to patients to make it available to people that low-cost and large number and thereby change patient expectations and thereby change market forces thank you for inviting me [Applause] for further information and updates about dr. Vincent politi and dr. Robert andas adverse childhood experiences study please visit the study's website at WWE study org [Music]
Vince Felitti accidentally asked one of his patients how much they weighed when they had their first sexual experience instead of how old they were, and this led to a study which linked "adverse childhood experiences" to adult health for the first time. In this lecture he describes how ACEs are linked to eg obesity, heavy smoking and drinking.
Great talk