Transcript of CDC Telebriefing: At least 5 of the top 10 leading causes of death are associated with Adverse Childhood Experiences (ACEs)

OPERATOR: Thank you so much for standing by.  Please continue to hold.  Conference will begin in just a few minutes.  Again, thank you.  Please stand by.  We will start momentarily.  You’ll hear music until we begin.

OPERATOR: Welcome.  Thank you very much for standing by.  Participants are in a listen-only mode until a question-and-answer session.  At that time you may press star-one on your touch tone phone to ask a question.  Today’s event is being recorded.  If you have any objections, you may disconnect.  I now would like to turn the conference over to your host, Miss Amy Heldman.  Thank you, ma’am.  You may begin.

HELDMAN: Thank you, Fran.  I am Amy Heldman from CDC’s public affairs office.  I’ll be moderating the telebriefing today. I’d like to thank you for joining us for the release ofs a new CDC “vital signs.”  We’re joined today by Dr. Anne Schuchat, the principal deputy director as well as Dr. Jim Mercy, m-e-r-c-y, director of CDC’s division of violence prevention.  Dr. Schuchat and mercy will be available for the Q&A portion of the briefing.  Without further ado, I’ll like to turn it over to Dr. Schuchat.

SCHUCHAT: Good afternoon and thank you so much for joining us today. CDC works 24/7 to protect Americans against health threats.  Each month in the CDC’s “Vital Signs” report, we focus on one of these threats and what can be done about it. Today we’re talking about adverse childhood experiences or A.C.E.s. We’re reporting CDC’s first-ever comprehensive estimates of how much A.C.E.s affect adults’ long-term health and social situations. And the substantial benefits that preventing A.C.E.S could have on the nation’s health. There are proven ways to prevent A.C.E.s and to lessen their impact when they occur in childhood. Some examples of A.C.E.s are experiencing abuse, witnessing violence, and growing up in a family with mental health or substance misuse problems. The accumulation of A.C.E.s can lead to health and social problems throughout childhood and into adulthood. Multiple different types of A.C.E.s together can produce toxic stress which is a chronic activation of the stress response system that results in negative effects on brain development, behavior, and well being. A.C.E.s are linked to many problems in adulthood.  At least five of the top ten leading causes of death, heart disease, cancer, respiratory diseases, diabetes, and suicide are all associated with A.C.E.s. A.C.E.s are linked to problems across the life span.  In addition to chronic health problems like diabetes and heart disease, A.C.E.s are also linked to health conditions like depression and substance misuse.  Our report found that more than half of adults have experienced at least one type of adverse childhood experience or A.C.E., and one in six people have experienced four or more types of A.C.E.s. The effects of A.C.E.s add up. That means that the more types of A.C.E.s a person has, the higher their risk for negative outcomes which can limit their opportunities their whole lives.  Families and communities are working hard to create safe, stable, and nurturing relationships and environments for all children. It’s important to note that while it might not be possible to avoid every A.C.E., there are many opportunities to prevent A.C.E.s from happening in the first place and to help those who have experienced A.C.E.s. Today’s “Vital Signs” provides the first-ever U.S. estimates of how much preventing adverse childhood experiences could reduce future chronic diseases, risky healthy behaviors, and socio-economic challenges like unemployment and having less than a high school education. We analyzed behavior, the behavior risk factor surveillance system – or BRFSS – data that came from 25 states that included A.C.E. questions for the years 2015 to 2017. We had data for over 144,000 adults. The survey respondents were adults who answered questions by phone about their childhood experiences. We found that women, American Indian or Alaska Native, and African-americans had a higher risk of experiencing four or more types of A.C.E.s. The analysis suggested that preventing A.C.E.s could potentially reduce the number of people with coronary heart disease, the leading cause of death in the united states, by up to 13 percent. If we applied the same results to national disease estimates in 2017, preventing A.C.E.s would have potentially resulted in up to 1.9 million avoided cases of coronary heart disease, 2.5 million avoided cases of overweight or obesity, and 21 million cases of avoided depression. Behind their impact on health, A.C.E.s also negatively affect life opportunities like completing high school or future employment. For example, using the same 2017 national estimates, preventing A.C.E.s could have kept up to 1.5 million students from dropping out of school. Preventing A.C.E.s can help children and adults thrive and have the potential to substantially lower the risk for conditions like asthma, cancer, depressive disorder, and diabetes. Preventing A.C.E.s could reduce health risk behaviors like smoking, heavy drinking, and substance misuse, and improve education and job potential.  While A.C.E.s are strongly associated with a host of negative outcomes, not everyone who experiences A.C.E.s will go on to have poor outcomes. Children’s positive experiences, relationships, or other protective factors and interventions can strengthen resilience and reduce behavioral and health consequences even after A.C.E.s have occurred. It will take all of us working together to change environments and behaviors to stop A.C.E.s from happening in the first place and to lessen the harms for those who have experienced A.C.E.s. There’s a role for everyone: parents, families, neighborhoods, schools, spiritual communities, businesses, and government. CDC has recently released a new resource called preventing adverse childhood experiences: leveraging the best available evidence. The report describes six strategies for prevention:  intervening to lessen harms of A.C.E.s with treatment, services and support; connecting youth to caring adults and activities through mentoring and after-school programs;  improving youth and parent skills like communication and problem-solving to manage stress and everyday challenges;  providing high-quality, affordable childcare and early education to assure a strong start; promoting social norms that protect against violence and adversity; and strengthening families’ economic stability to reduce family stress and conflict. This new resource for states and communities describes each strategy and provides specific approaches with examples of programs, practices, and policies. The resource also provides a brief summary of the evidence base for preventing A.C.E.s or the associated risk factors for A.C.E.s. Some prevention approaches like enrichment programs that provide expanded services to children and their families have had long-term studies. For example, evaluation of child-parent centers found not only substantially lower levels of child abuse and neglect, but also sustained benefits on a range of outcomes into young adulthood for children who participated. Long-term benefits included better academic success, lower arrest rates, lower levels of depression, and lower rates of disabilities.  Preventing A.C.E.s is a priority for us at the CDC. While we are still building the evidence base related to programs that work to prevent A.C.E.s, we also know some strategies to prevent A.C.E.s that can be used now by various sectors to stop A.C.E.s before they occur and mitigate the immediate and long-term harms of A.C.E.s. States and communities can help parents and youth grow their skills to manage stress, reduce violence, and tackle everyday challenges by using relationship skill-building programs as well as parenting skills and family relationship approaches.  Employers can adopt and support family-friendly policies such as paid family leave and flexible work schedules. Health care providers can recognize current risks in children and A.C.E.s history in adults and refer patients to effective family services and support.  States and communities can use effective social and economic policies to address financial hardships and other conditions that put families at risk for A.C.E.s. Everyone can participate in A.C.E.s prevention by recognizing the challenges that families face and offering support and encouragement to reduce stress. Bottom line is this: adverse childhood experiences produce toxic stress that can impact people all their lives. A.C.E.s are potentially preventable by creating safe, stable, nurturing relationships and environments for all children, families, and communities.

HELDMAN: All right, thank you, Dr. Schuchat.  Fran, we are now ready for questions, please.

OPERATOR: Thank you very much for that. We’ll begin the question-and-answer session now. Please press star, then one if you would like to ask a question. If you did mute your own phone, please take a moment to unmute your line and record your name clearly when prompted.  Your name is needed to introduce your question. To withdraw a request, press star-two, but again, to ask a question now, please press star then one, and record your name. One moment, please. One moment, please. Thank you. Our first is from Mike Stobbe, the “associated press.”  your line is open.

STOBBE: Hi.  Thank you for taking my call.  A couple of questions if i may.  First, just to clarify, Dr. Schuchat, you said, you framed it by saying preventing A.C.E.s could have reduced, for example, the number of adults who are overweight or obese by as much as 2 percent. Is a way to rephrase that is that as many as 2 percent of overweight and obese cases can be associated with A.C.E.s or multiple A.C.E.s?  Is that a correct rephrase?

SCHUCHAT: Actually, the analysis is a little more complicated than that. It’s looking at how strong the linkage is between the higher level of A.C.E. exposure and the particular outcomes and doing something called a population attributable fraction. So essentially the math is saying if we took away the high level of A.C.E.s from that individual, what would be the chances of them developing the outcome, obesity and overweight? If you took it out and kept everything else the same, it would be about a 2 percent reduction in the overweight occurrences. So it’s not — I think the way you said it, maybe mine is too long, but it’s essentially population attributable fraction for that factor. So it’s not really the one-to-one, you know, how many of the people who have obesity had A.C.E.s. It’s really the impact that A.C.E.s were having in the probability of developing obesity.

STOBBE: Okay. Thank you. Wait. I’m sorry.

HELDMAN: He had a couple more.

STOBBE: Sorry.

STOBBE: Thanks. Yeah, I was wondering, you mentioned that A.C.E.s are associated with outcomes on other leading causes of death including diabetes. I think you said suicide, cancer.  Are there also estimates of how many cases of cancer, diabetes, suicide would be prevented by addressing A.C.E.? Also, are there certain A.C.E.s that are worse than others? I see divorce is in the mix and also child abuse. Is the likelihood of coronary heart disease or other problems more closely linked to child abuse than your parents getting divorced? Can you distinguish the relative threat from different A.C.E.s? Thank you.

SCHUCHAT: Thanks, Mike. Let me begin the answers and then let Dr. Mercy expand.  In terms of other estimates, we estimated that up to 1.9 million cases of heart disease could be prevented if the A.C.E.s were prevented. And that preventing A.C.E.s could prevent up to 21 million cases of depression. We have percents of reduction for the different conditions, but I don’t believe we’ve estimated what that translates to numbers for all of them. Now in terms of are all A.C.E.s alike, I just want to say some general comments and then let Dr. Mercy talk a little bit more. We think that multiple types of A.C.E.s increases the risk or the impact. So you know, witnessing abuse and experiencing loss of a parent, two things might be worse than just one. And we know prolonged exposure is worse than sort of a single kind of exposure. And every individual is different in terms of how a particular adverse experience impacts them. I don’t think we have a rating of, you know, this is the worst down to the least, because each of these exposures could be very bad in an individual instance.  Dr. Mercy can expand.

MERCY: Yes. That’s exactly right, Dr. Schuchat. This is an area for future research. We really do want to understand which A.C.E.s have the greatest impact, and also get into issues like how frequently do they occur. I think one of the really important issues is that when these A.C.E.s occur in the absence of adult support, their impact can be even greater. And that really gets to the issue of prevention and the need to promote safe, stable, nurturing relationships for all children and environments for all children.

HELDMAN: Okay. Thank you. Next question, please.

OPERATOR: Thank you, ma’am, Rhitu Chatterjee with NPR, your line is open.

CHATTERJEE: Thank you.  So Dr. Schuchat, you mentioned positive experiences that strengthen resilience and the different role of different people and groups and the government.  So my question is two parts.  One, if you can elaborate a little bit on what we know about what kind of positive experiences actually strengthen resilience.  What does the evidence say on that?  And then in terms of the role for different people, different groups.  Again, if you can, say, for example, just give a couple of examples of how as a society we can help prevent A.C.E.s.

SCHUCHAT: Yes, thank you. You know, being in a stable, safe, structured, nurturing relationship can be very helpful in the face of A.C.E.s. It might be a parent, it might be a teacher, it might be a neighbor. But having a stable, reliable person in your life can help you at that individual level with resilience. We think there are similar activities that the community can do in terms of safe spaces or group settings, you know, the early childcare and so forth.  And so the evidence on that stability and nurturing role helps you when you have a stress or a difficult problem, have an outlet and have a reliable way to process it and also to seek help if you need it. Let me let Dr. Mercy talk a little bit more about the societal opportunity.

MERCY: Yeah. I think one great example is of an intervention that is evidence-based that can impact A.C.E.s is mentoring programs. Programs where we can put children in connection with adults, caring adults, who can help support them through difficulties in their lives, either at home or in school or other settings. But that gives an example of the kind of adult support we’re trying to create and we think can be effective in reducing exposure to adversity and mitigating the effects of adversity if children are experiencing that.

HELDMAN: Thank you. Next question, please.

OPERATOR: Thank you. Our next is from Lee Hawkins with the “Wall Street Journal.” Your line is open, sir.

HAWKINS: Thank you.  Yes.  Is there a linkage between experiencing a.c.e.s and the chances one could be a victim of homicide?  And are there any estimates for how violent crime could be reduced by addressing A.C.E.s?

SCHUCHAT: Yes. Let me first just refer to CDC has a nice technical package on prevention of youth violence that really reviews the evidence base about what factors could be addressed to reduce youth violence. And we do think that risks of experiencing violence can be reduced with attention to A.C.E.s. Dr. Mercy?

MERCY: Yes. There’s a strong literature that links exposure to adverse childhood experiences and violence — both perpetration and victimization by violence later in life. So yes, the prevention of A.C.E.s could also impact the expression of violent behavior. And that’s another reason why it’s important to prevent these things early. Get it right the first time.

HELDMAN: Great. Thank you. Next question.

OPERATOR: Our next is from Allison Aycoff with AAP news at the American Academy of Pediatrics. Ma’am, your line is now open.

WYCOFF: Thank you. This question is for Dr. Schuchat. Could you please comment on — do you have any particular message for pediatricians who have the opportunity to screen children for A.C.E.s but may not have the time or may not be inclined to screen their parents, as well?

SCHUCHAT: Yes, thank you. You know, clinicians are busy and may or may not incorporate A.C.E.s into their practice, but we think it’s very important they do. Both pediatricians in terms of evaluating the children and screening the parents, as well, because we know that this is one of those issues that can pass generations. That adults who experience A.C.E.s may have challenges with their parenting experience. So we hope that clinicians will take the time to screen and refer.  We also think that incorporating principles of trauma-informed care into that clinical encounter can be very helpful at the time of the event and then going forward.  Dr. Mercy?

MERCY: Yes, and there are various programs that are — that can be used in primary care offices for pediatricians. The seek [safe environment for every kid] program, for example, is one that’s been found to be effective in reducing child maltreatment and one of the adverse childhood experiences. And so these provide ways that these offices can organize their efforts around identifying and intervening around child maltreatment and other adversity.

HELDMAN: Great. Thank you. All right. Thank you, Fran. That will conclude our Q&A portion of the telebriefing, and thank you, Dr. Schuchat and dr.  Mercy, for joining us today, as well as the reporters who are on the phone.  If you have followup questions, you can call the CDC press office at 404-639-3286, or you can e-mail us at media@cdc.gov.  We’ll also be posting the audio and transcript on the CDC newsroom, that’s at cdc.gov/media later today.  Thank you for your time.

OPERATOR: Today’s event is now concluded. Again, thank you for your participation.  Please go ahead and disconnect at this time. Thank you so much.

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