Adverse Childhood Experiencesand the effect on long-term functioning

LCDR Brian Lees USPHS

• “…variations in the amount of licking and grooming received during infancy had a direct effect on how stress hormones…were expressed in adulthood. The more licking as babies, the lower the stress hormones as grown-ups.”

Hurley, D. (2015) Grandma’s experiences leave a mark on your genes. Discover. Retrieved from http://discovermagazine.com/2013/may/13-grandmas-experiences-leave-epigenetic-mark-on-your-genes

• Why is this the case?• How is it relevant to us?

The original ACE study

• “…the most important public health study you never heard of.” http://www.huffingtonpost.com/jane-ellen-stevens/the-adverse-childhood-exp_1_b_1943647.html

• In the mid-1990’s, 17,337 participants (Kaiser-Permanente HMO recipients) were given questionnaires about childhood experiences and current health problems.

• Based on observations that many obese patients were reporting abuse histories.

Childhood Adversity Narrative

http://www.canarratives.org/

Also see Center for Disease Control website http://www.cdc.gov/violenceprevention/acestudy/index.html

ACES questionnaire

• The original ten ACE items that had the most significant impact on adult health

• More have been added from other studies – History of being bullied– Growing up in low socioeconomic status– Growing up with neighborhood violence

• Each ACE adds to risk of health or behavior problem in a “step-wise” manner

A PERSON WITH 4 OR MORE ACES IS:

• 12.2 times as likely to attempt suicide • 10.3 times as likely to use injection drugs • 7.4 times as likely to be an alcoholic

• 2.2 times as likely to have ischemic heart disease • 2.4 times as likely to have a stroke • 1.9 times as likely to have cancer • 1.6 times as likely to have diabetes

• Basic findings from original study have been independently replicated by many different studies http://acestoohigh.com/research/

Effect of prenatal stressAnimal experiments have shown that prenatal stress can cause all the following effects on the offspring:• More anxiety• Reduced attention• Learning deficits• Less difference in function between the left and right sides of

the brain• Effects different on male and female offspring• Altered sexual behaviour – males show homosexual behaviour

and females are less nurturing mothers.– http://www.beginbeforebirth.org/

So should the patient blame his parents?

Understand epigenetics (past trauma lives in our genes)• “According to the new insights of behavioral epigenetics,

traumatic experiences in our past, or in our recent ancestors’ past, leave molecular scars adhering to our DNA. Jews whose great-grandparents were chased from their Russian shtetls; Chinese whose grandparents lived through the ravages of the Cultural Revolution; young immigrants from Africa whose parents survived massacres; adults of every ethnicity who grew up with alcoholic or abusive parents — all carry with them more than just memories. ”

• Hurley, D. (2015) Grandma’s experiences leave a mark on your genes. Discover. Retrieved from http://discovermagazine.com/2013/may/13-grandmas-experiences-leave-epigenetic-mark-on-your-genes

Implications for us

Implications for us“People who served in the military tend to have experienced more traumatic childhood events, such as being abused or living with an alcohol-dependent parent, than people who are not veterans... Men who volunteered for the military were more than twice as likely as men without military experience to report at least one adverse event in childhood, which supports a theory that people may use the military to escape from dysfunctional home lives, the researchers write in JAMA Psychiatry.”

– http://www.reuters.com/article/us-military-childhood-study-idUSKBN0FT2NN20140724

Implications for us

Understand that the care we provide, will not only help the patient, but may also help the patient’s child, effecting our society’s future.

Implications for us

• ACE score as part of intake screening?• Those with higher ACEs will likely require

longer, more comprehensive treatment • Address ACEs and connect to current

difficulties functioning/interpersonal stress.

Implications for providers

• If Antwone Fisher didn’t improve, should he have been medically or administratively separated? Does he have PTSD or Adjustment Disorder?

• When trauma/neglect occurs before service, does that get reported during medical screening such as at MEPS. Did he/she report depression/anxiety on 2807-1, if not should it be an erroneous/fraudulent enlistment?

Questions?