DefinitionPercentage of adults 18 years of age and older who responded "Yes" on the [http://dhss.alaska.gov/dph/Chronic/Pages/brfss/default.aspx Behavioral Risk Factor Surveillance System (BRFSS)] to at least one of the following questions: "Did you live with anyone who was a problem drinker or alcoholic?" or "Did you live with anyone who used illegal street drugs or who abused prescription medications?"
NumeratorWeighted number of adults (18+) who responded "Yes" on the BRFSS to at least one of the following questions: "Did you live with anyone who was a problem drinker or alcoholic?" or "Did you live with anyone who used illegal street drugs or who abused prescription medications?"
DenominatorWeighted number of adults (18+) who responded to the household substance abuse questions on the BRFSS, excluding those with missing or "Refused" responses. Those who responded "Don't know/Not sure" are defined as a negative responses.
Data Interpretation IssuesThe preamble to each of the Adverse Childhood Experiences (ACEs) question was: "I'd like to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life, and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer. All questions refer to the time period before you were 18 years of age. Now, looking back before you were 18 years of age ---"
While the individual adverse childhood experience (ACE) an Alaska adult may have experienced is important, the strength of the research lies in the often multiple ACEs an individual has during childhood: "The ACE score, a total sum of the different categories of ACEs reported by participants, is used to assess cumulative childhood stress. Study findings repeatedly reveal a graded dose-response relationship between ACEs and negative health and well-being outcomes across the life course...Dose response describes the changes in an outcome (e.g., alcoholism) associated with differing levels of exposure (or doses) to a stressor (e.g., ACEs). A graded dose-response means that as the dose of the stressor increases the intensity of the outcome also increases."^1^
ACEs questions on substance abuse in the household were asked in 2013 through 2015.[[br]]
1. U.S. Centers for Disease Control and Prevention (CDC). Adverse Childhood Experiences (ACE) Study. [http://www.cdc.gov/violenceprevention/acestudy/index.html]. Updated April 1, 2016. Accessed April 26, 2016.}}
Why Is This Important?Alaska has one of the highest per capita alcohol consumption rates in the nation, and the prevalence of alcohol dependence and alcohol abuse is twice the national average.^2^ Alaska adults and youth have higher rates of per capita substance abuse.^3^ A survey of Alaskans for the [http://hss.state.ak.us/ha2020/ Healthy Alaskans 2020] Initiative identified alcohol use and abuse and other substance abuse as two of the top ten health issues in Alaska.^4^ Household substance abuse and dependence have a negative impact on the physical and emotional well-being of children and can cause home environments to become chaotic and unpredictable, leading to child maltreatment. Household substance abuse disrupts childhood development, including a disruption of the bonding process, and contributes to emotional, academic, and developmental problems; lack of supervision; social stigma; and adolescent substance use and delinquency. Compared to children of parents who do not abuse alcohol or drugs, children of parents who do are more likely to experience physical, intellectual, social, and emotional problems.^5^ As a child experiences living with a household member with substance abuse, the impacts of overwhelming stress on the brain continue into adulthood and can have generational impacts. As Alaska children are exposed to household substance abuse, they may find negative ways to cope with their damaged stress responses. When as adults they start families of their own, these behaviors can become ACEs for another generation.^3^ In fact, alcoholism runs in families, and children of alcoholics are four times more likely than other children to become alcoholics.^2^
The Adverse Childhood Experiences (ACE) Study, a collaborative between the Centers for Disease Control and Prevention and Kaiser Permanente's Health Appraisal Clinic in San Diego, assessed associations between childhood maltreatment and later-life health and well-being.^1^ It is critical to understand how some of the worst health and social problems can arise as a consequence of adverse childhood experiences. Sixteen of the [http://hss.state.ak.us/ha2020/ Healthy Alaskans 2020] measures have been shown through peer-reviewed journal articles to be negatively impacted by adverse childhood experiences. Alaska takes on the burden of approximately $82 million in costs (e.g., health care costs, welfare costs, special education costs) each year due to nonfatal child maltreatment. Realizing these connections is likely to improve efforts towards prevention and recovery.^6^[[br]]
See "References and Resources" section for references.
How Are We Doing?In 2013-2015 combined, 29.7% of Alaska adults reported having experienced living with a household member who was a problem drinker, used illegal street drugs, and/or abused prescription medications. Alaska Native adults reported significantly higher prevalence at 41.1%. Females reported significantly higher prevalence exposure to substance abuse in the household at 32.8% compared to males at 27.0%. Those adults who were college graduates reported a significantly lower prevalence of exposure at 25.0% than those who had less than a high school education at 41.2%. Overall, there were few significant differences in rates among geographic public health regions in Alaska.
Rates of exposure to substance abuse during childhood from the BRFSS are initially presented for all Alaskans and Alaska Native people for the combined 3-year period from 2013-2015. Subsequent analyses were conducted for demographic subpopulations (i.e., sex, age, race/ethnicity, ethnicity, marital status, education, employment status, income, and poverty status).
Crosstabulations were also conducted for 3-year averages by body mass index, current smoking, sexual orientation, and disability. Significant differences were evident in all 4 contrasts.
Rates of exposure to substance abuse during childhood by regions of Alaska are presented for all Alaskans and Alaska Native people for the 3-year average of surveys conducted between 2013-2015: 1) 7 Alaska Public Health Regions, 2) 5 Metropolitan and Micropolitan Statistics Areas and rural remainder, 3) 10 behavioral health assessment regions based upon aggregations of 20,000 population, 4) 29 boroughs and census areas, and 5) 12 tribal health organization regions.
How Do We Compare With the U.S.?There are no national statistics on ACEs available. However in 2009, the CDC released a study comparing ACEs data from five states (Arkansas, Louisiana, Tennessee, New Mexico, Washington) that used the BRFSS ACEs module. When compared to the five states, Alaska reported the highest rate of adults who had experienced living with someone with substance abuse.^7^
Compared to data from adults from the 10 states (i.e., Hawaii, Maine, Nebraska, Nevada, Ohio, Pennsylvania, Utah, Vermont, Washington, and Wisconsin) that implemented the ACEs module in 2010, Alaska had higher rates of adults reporting they had experienced living with a household member with substance abuse.^1^[[br]]
1. U.S. Centers for Disease Control and Prevention (CDC). Adverse Childhood Experiences (ACE) Study.
[http://www.cdc.gov/violenceprevention/acestudy/index.html]. Updated April 1, 2016. Accessed April 26, 2016.
7. U.S. Centers for Disease Control and Prevention (CDC). Adverse childhood experiences reported by adults - five states, 2009. MMWR 2010;59(49):1609-13. [https://www.cdc.gov/mmwr/pdf/wk/mm5949.pdf] Accessed October 31, 2017.
What Is Being Done?Currently the Alaska Department of Health and Social Services, through the divisions of Behavioral Health, Juvenile Justice, and the Office of Children's Services, issue grants to a diverse array of community-based organizations with the goal of developing creative programs focused on prevention of youth substance abuse; strengthening individual, family, school, and community approaches to prevention; and increasing community readiness to decrease substance abuse among youth. State agencies work in partnership to fund communities in a collaborative manner so that services are implemented without duplication or competition.^2^
The two primary objectives chosen by the Alaska Strategic Prevention Framework State Incentive Grant (SPF SIG) Advisory Committee of the Alaska Department of Health and Social Services were to reduce youth alcohol use (e.g., lifetime, current, heavy, and binge drinking) and adult alcohol abuse (e.g., heavy and binge drinking). The SPF SIG used a five-step Strategic Prevention Framework developed by the [http://www.samhsa.gov/ Substance Abuse and Mental Health Services Administration (SAMHSA)] to identify and develop data-driven prevention strategies. They identified four key strategies: enhance the Alaska Prevention workforce; develop regional/community capacity to promote prevention principles and strategies; increase the understanding and use of community coalitions and environmental strategies to accomplish sustainable community change; and increase regional/community understanding and use of data to drive decision-making, implementation, evaluation, and continuous quality improvement of strategies and interventions.^8^
The [http://hss.state.ak.us/ha2020/ Healthy Alaskans 2020] initiative developed strategies by content experts to reduce youth and adult alcohol binge drinking and alcohol-induced deaths. Public health partners around the state are aligning work around these approaches adapted by Alaska's unique needs. Alaska strategies include:
1. Ensuring access to a seamless system of care throughout Alaska for assessment, treatment, and aftercare for people with both mental health and substance use disorders.
2. Promote environmental strategies that change community conditions to reduce alcohol consumption.
3. Provide electronic screening and brief intervention (SBIRT) in certain healthcare settings throughout Alaska. SBIRT is an approach to identify and intervene early for substance misuse.
4. Expand therapeutic courts that provide treatment programs in place of incarceration for certain alcohol-related offenses throughout Alaska.
5. Fund Strategic Prevention Framework Grants that address local needs and reduce substance abuse problems.
6. Provide the Prime for Life curriculum for alternative high school students, Job Corps participants, and youth caught with alcohol or any illegal substance.
7. Conduct a positive community media campaign to promote attitude and behavior change around alcohol use among youth.
8. Increase children's social and emotional learning through adopting formal standards and curricula for schools in Alaska.^4^
The Alaska Mental Health Board and Advisory Board on Alcoholism and Drug Abuse have coordinated the efforts of many organizations to gather Alaska-specific ACE data.^6^ The Boards have focused since 2008 on community wellness and personal resilience.
The Division of Public Health partnered with the Alaska Native Tribal Health Consortium and the Alaska Family Violence Prevention Project to develop a teen safety card, a gender-neutral resource developed for Alaska teens with guidance from Alaska teens. The card provides information about healthy and unhealthy relationship characteristics, what consent looks and sounds like, and where to get help, if needed. Another safety card was designed specifically for women.^9^[[br]]
See "References and Resources" section for references.
Evidence-based PracticesThe Healthy Alaskans 2020 initiative developed strategies by content experts to reduce youth and adult alcohol binge drinking and alcohol-induced deaths in Alaska. Their strategies were based on evidence based practices including:
1. Substance Abuse and Mental Health Services Administration (SAMHSA) recommends a modern addictions and mental health service system that includes prevention, treatment and recovery supports. This continuum of care comprises nine domains: Health Homes, Prevention and Wellness Services, Engagement Services, Outpatient and Medication Assisted Treatment, Community Supports and Recovery Services, Intensive Support Services, Other Living Supports, Out of Home Residential Services, and Acute Intensive Services.
2. There is substantial evidence that environmental strategies are effective in preventing and reducing substance abuse. Increasing fines for underage drinking, not selling cold, single-serving containers of beer in convenience stores, and increasing access to treatment services by providing counselors who speak the local language are all examples of environmental strategies.
3. SBIRT is a model listed in the SAMHSA'S National Registry of Evidence-based Programs and Practices that focuses on delivering early intervention and treatment services for people with substance use disorders, or those at-risk for developing substance use disorders.
4. SAMHSA's has a five-step planning process to guide the work of states and communities in their prevention activities. The framework allows communities to identify and select evidence-based interventions that address local needs to reduce substance abuse problems. The framework is to be used in a comprehensive strategic plan.
5. The Prime for Life curriculum was developed by the Prevention Research Institute and has been widely tested throughout the US and in Sweden. Providing practical and useful information, this research-based program leads the student through a process of self-evaluation and reflection upon his or her own personal decisions around alcohol and other drug use.^4^
Recovering from trauma is a challenging process. Building resiliency and having a supportive adult in your life can help with recovery. Positive experiences - such as exposure to environments rich in a range of developmentally appropriate opportunities for social play and exploration - can compensate for and even reverse the negative consequences of stress. Efforts during childhood are essential because over time, some stress-induced detriments are increasingly resistant to reversal.
Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based treatment approach shown to help children, adolescents, and their caregivers overcome trauma-related difficulties. It is designed to reduce negative emotional and behavioral responses following traumatic events. The treatment - based on learning and cognitive theories - addresses distorted beliefs and attributions related to the abuse and provides a supportive environment in which children are encouraged to talk about their traumatic experience. TF-CBT also helps parents who were not abusive to cope effectively with their own emotional distress and develop skills that support their children.^10^
ACEs are best addressed through a coordinated effort to implement prevention programs across multiple settings and populations. Research indicates the majority of health and social challenges are interconnected and often share the same root causes. The following steps need to be taken to address these root causes:
1. Support quality early childhood programs.
2. Ensure access to health care including behavioral health care.
3. Strengthen capacity for social emotional learning throughout Alaskas schools.
4. Maintain and expand prevention efforts that have proven to be effective.^5^[[br]]
See "References and Resources" section for references.