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State of Alaska

Health Indicator Report of Adverse Childhood Experiences: Total ACEs Count

Childhood trauma is far more common than previously realized. 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. The ACE Study findings suggest that certain experiences are major risk factors for the leading causes of illness and death as well as poor quality of life in the United States. The higher the total ACEs count, the more likely the respondent experienced poor health - both self-reported and clinically measured.^1^ A more representative study was conducted using the Behavioral Risk Factor Surveillance System (BRFSS) in 2010 from the District of Columbia (DC) and 10 states (Hawaii, Maine, Nebraska, Nevada, Ohio, Pennsylvania, Utah, Vermont, Washington, and Wisconsin).^2^ The study found a linear dose-response relationship between the number of ACEs experienced and 8 health conditions (fair or poor health, frequent mental distress, diabetes, myocardial infarction, coronary heart disease, stroke, asthma, and disability) consistent with a dose-response relationship, after controlling for demographic variables (all p lt 0.01). 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.^3^ 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.^3^ Realizing these connections is likely to improve efforts towards prevention and recovery.[[br]] [[br]] ---- {{class .SmallerFont 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. 2. Gilbert LK, Breiding MJ, Merrick MT, Thompson WW, et al. Childhood adversity and adult chronic disease: an update from ten states and the District of Columbia, 2010. Am J Prev Med 2015;48(3):345-9. 3. Sidmore P. Alaska Department of Health and Social Services. Alaska Mental Health Board and the Advisory Board on Alcoholism and Drug Abuse. Economic costs of adverse childhood experiences in Alaska. [http://dhss.alaska.gov/abada/aceak/Documents/ACEsEconomicCosts-AK.pdf]. Accessed April 26, 2016. }}

Data Source

Alaska Data: [http://dhss.alaska.gov/dph/Chronic/Pages/brfss/default.aspx Behavioral Risk Factor Surveillance System], Alaska Department of Health and Social Services, DPH, Section of Chronic Disease Prevention and Health Promotion

Data Interpretation Issues

Eight domains of Adverse Childhood Experiences (ACEs) encompassing abuse and dysfunctional households were asked in 2013. Two questions on physical and emotional neglect were added in 2014. Refer to the individual ACEs domains in the Relative Indicators under Risk Factors for criteria for exposure. Scores are based upon respondents who answered all 11 questions in the 2013 ACEs module and the original 11 questions related to the 8 domains in the 2014 version. The 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^

Definition

Percentage of adults 18 years of age and older who were exposed to 0, 1, 2-3, or 4+ Adverse Childhood Experiences (ACEs) before age 18 based upon the ACEs domain questions on the [http://dhss.alaska.gov/dph/Chronic/Pages/brfss/default.aspx Behavioral Risk Factor Surveillance System (BRFSS)]. Responses are assigned a score of 1 for exposure and 0 for lack of exposure to each domain, which are summed as the total ACEs count. There are 10 domains of ACEs organized into abuse (i.e., verbal, physical, and sexual), dysfunctional households (i.e., substance abuse, mental illness, domestic violence, separation/divorce, and incarceration among household members), and neglect (i.e., physical and emotional). The total ACEs count is the sum of the ACEs domains respondents reported to have experienced.

Numerator

Weighted number of adults (18+) with scores of total ACEs exposures who responded to all ACEs questions on the BRFSS.

Denominator

Weighted number of adults (18+) who responded to all ACEs questions on the BRFSS, excluding those with missing or "Refused" responses. Those who responded "Don't know/Not sure" are defined as a negative response for that ACEs category.

How Are We Doing?

In 2013-2015 combined, no exposure to ACEs prior to age 18 was reported by 34.3% of Alaska adults. Only 26.0% of Alaska Native adults had not experienced any ACEs. Nearly one-fifth (19.5%) of Alaska adults reported experiencing 4 or more ACEs. In comparison, 28.4% of Alaska Native adults reported experiencing 4 or more ACEs during childhood. Those who were unemployed or unable to work reported more ACEs compared to employed Alaskans. Over one-quarter (26.1%) of unemployed Alaska adults and 33.2% of adults unable to work reported 4 or more ACEs compared to 19.5% of employed Alaska adults. The number of ACEs 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. The number of ACEs 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 ACE scores available; however, in 2009 the CDC released a study comparing ACE data from 5 states (i.e., Arkansas, Louisiana, Tennessee, New Mexico, Washington) that used the BRFSS ACE module. Generally, Alaska had higher ACE scores. The 5 states had an average of 40.6% of residents with an ACE score of 0, while Alaska reported a 35.6% mean. The rates reported by Alaska adults for every category of adverse experiences were higher than the 5-state study's average rates. In all but 2 of the categories, these higher rates were statistically significant.^4^ The 3 categories of adverse experiences with significantly higher rates among adults in Alaska --- incarcerated family member, household substance abuse, and separation and divorce --- were also found to be significantly higher in a sample of Alaska children when compared with the national rate.^5^ In the most comprehensive study to date encompassing 10 states and DC with a sample of 53,998, 40.6% of adults nationally had no exposure to ACEs compared to 33.7% for Alaska adults. The pattern of higher exposure to ACEs in Alaska adults continues for other demographic characteristics such as sex in which the study showed 41.3% of males and 40.0% of females with no exposure compared to the Alaska rates of 35.7% and 31.5%, respectively.^2^[[br]] [[br]] ---- {{class .SmallerFont 2. Gilbert LK, Breiding MJ, Merrick MT, Thompson WW, et al. Childhood adversity and adult chronic disease: an update from ten states and the District of Columbia, 2010. Am J Prev Med 2015;48(3):345-9. 4. 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. 5. Alaska Department of Health and Social Services. Alaska Mental Health Board and the Advisory Board on Alcoholism and Drug Abuse. Adverse childhood experiences - overcoming ACEs in Alaska. [http://dhss.alaska.gov/abada/aceak/Documents/ACEsReportAlaska.pdf]. Published January 2015. Accessed April 26, 2016. }}

What Is Being Done?

The [http://hss.state.ak.us/ha2020/ Healthy Alaskans 2020] initiative developed strategies by content experts to reduce child maltreatment. Public health partners around the state are aligning work around these approaches adapted by Alaska's unique needs. Alaska strategies include: 1. Promote screening and monitoring for child abuse in primary care offices and public health clinics. 2. Use the [http://www.cssp.org/reform/strengtheningfamilies Strengthening Families Protective Factors] framework in family programs. 3. Expand home visiting programs. 4. Expand and strengthen quality early childhood programs. 5. Train providers and the public on brain development, adverse childhood experiences (ACEs), and resiliency.^6^ Alaska has many groups working on preventing childhood trauma and easing the effects of damage already done.^5^ Here are a few examples (as of early 2015): Statewide, teachers and public health nurses provide teens with information on healthy relationships and life skills. They have partnered with the Alaska departments of Health and Social Services and Education and Early Development, the [http://www.dps.alaska.gov/cdvsa/ Council on Domestic Violence and Sexual Assault], and the [http://www.andvsa.org/ Alaska Network on Domestic Violence and Sexual Assault] on an evidenced-based curriculum for the 7th-9th grade called [https://education.alaska.gov/tls/schoolhealth/fourth.html "the Fourth R for Healthy Relationships."] The Division of Public Health partnered with the Alaska Native Tribal Health Consortium and the [http://dhss.alaska.gov/dph/chronic/pages/injuryprevention/akfvpp/default.aspx 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.^7^ The Division of Behavioral Health has promoted trauma-informed care for several years. Efforts include development of "Trauma 101" and "Trauma 201" curriculum for behavioral health providers, used around the state. [http://tundrapeace.org/programs/taav/ Teens Acting Against Violence (TAAV)] is a violence-prevention and youth empowerment program at the [http://tundrapeace.org/ Tundra Women's Coalition] for teenagers living in Bethel. Participation is voluntary and open for any interested teens age 12-18.^8^ 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.^3,5^ The Boards have focused since 2008 on community wellness and personal resilience.[[br]] [[br]] ---- {{class .SmallerFont 3. Sidmore P. Alaska Department of Health and Social Services. Alaska Mental Health Board and the Advisory Board on Alcoholism and Drug Abuse. Economic costs of adverse childhood experiences in Alaska. [http://dhss.alaska.gov/abada/aceak/Documents/ACEsEconomicCosts-AK.pdf]. Accessed April 26, 2016. 5. Alaska Department of Health and Social Services. Alaska Mental Health Board and the Advisory Board on Alcoholism and Drug Abuse. Adverse childhood experiences - overcoming ACEs in Alaska. [http://dhss.alaska.gov/abada/aceak/Documents/ACEsReportAlaska.pdf]. Published January 2015. Accessed April 26, 2016. 6. Alaska Department of Health and Social Services. Healthy Alaskans 2020. [http://hss.state.ak.us/ha2020/]. Accessed April 26, 2016. 7. Alaska Native Tribal Health Consortium. Getting together - teen relationship safety card. [http://www.anthctoday.org/epicenter/healthyfamilies/teenCard_111014.pdf]. Accessed April 26, 2016. 8. Teens Acting Against Violence. Tundra Women's Coalition - Crisis Line - 1-800-478-7799 or 907-543-3456 website. [http://tundrapeace.org/programs/taav/]. Accessed April 26, 2016. }}

Evidence-based Practices

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.^9^ 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 Alaska's schools. 4. Maintain and expand prevention efforts that have been proven to be effective.^10^ The [http://www.cssp.org/ Center for the Study of Social Policy] spent two years researching and identifying five protective factors that prevent child abuse and neglect. These are: parental resilience, social connections, concrete support in times of need, knowledge of parenting and child development, and social and emotional competence of children. Research studies support the common-sense notion that when these protective factors are well established in a family, the likelihood of child abuse and neglect diminishes. Research shows that these protective factors are also "promotive" factors that build family strengths and a family environment that promotes optimal child and youth development.^11^[[br]] [[br]] ---- {{class .SmallerFont 9. Child Welfare Information Gateway. Trauma-focused cognitive behavioral therapy for children affected by sexual abuse or trauma. https://www.childwelfare.gov/pubPDFs/trauma.pdf. Accessed April 26, 2016. 10. Alaska Department of Health and Social Services. Alaska Mental Health Board and the Advisory Board on Alcoholism and Drug Abuse. Investing in prevention: working together in early childhood for healthy Alaskan children, families, and communities 2015. [http://dhss.alaska.gov/abada/ace-k/Documents/State_Interagency_Prevention_2015.pdf]. Accessed April 26, 2016. 11. Alaska Department of Health and Social Services. Office of Children's Services. Strengthening families. [http://dhss.alaska.gov/ocs/Pages/families/default.aspx]. Accessed April 26, 2016. }}
Page Content Updated On 10/31/2017, Published on 10/31/2017
The information provided above is from the Alaska Department of Health and Social Services' Center for Health Data and Statistics, Alaska Indicator-Based Information System for Public Health (Ak-IBIS) web site (http://ibis.dhss.alaska.gov). The information published on this website may be reproduced without permission. Please use the following citation: " Retrieved Sun, 15 July 2018 from Alaska Department of Health and Social Services, Center for Health Data and Statistics, Alaska Indicator-Based Information System for Public Health web site: http://ibis.dhss.alaska.gov ".

Content updated: Tue, 31 Oct 2017 10:27:54 AKDT
The information provided above is from the Alaska Department of Health and Social Services' Center for Health Data and Statistics AK-IBIS web site (http://ibis.dhss.alaska.gov/). The information published on this website may be reproduced without permission. Please use the following citation: " Retrieved Sun, 15 July 2018 13:22:29 from Alaska Department of Health and Social Services, Center for Health Data and Statistics, Indicator-Based Information System for Public Health Web site: http://ibis.dhss.alaska.gov/ ".

Content updated: Tue, 31 Oct 2017 10:27:54 AKDT