Alaska has a costly substance abuse problem. The prevalence of alcohol consumption in Alaska is high (Figure 1), part of a problem costing Alaskans an estimated $1.2 billion annually in lost productivity and expenditures associated with traffic crashes, criminal justice and protective services, health care, and public assistance and social services, according to a 2012 report by the McDowell Group. In Alaska there are also elevated rates of the following Adverse Childhood Experiences (ACEs) (Table 1)—childhood abuse (verbal/emotional, physical, and sexual) and other forms of household dysfunction (mental illness or substance abuse in the home, separation or divorce, witnessing domestic violence, and having an incarcerated family member)—all of which impact individuals, communities, and the economy. One indication of the long-term effect of ACEs can be seen in a recent nationwide study by the Perryman Group which estimated that each first-time incident of child abuse in 2014 would cost $1.8 million dollars over a lifetime. The personal and economic impacts are substantial.
In this article we examine the relationship between abuse and household dysfunction in childhood and the increased likelihood of problem alcohol drinking by Alaska adults. The behavioral health of Alaskans could be improved by addressing the association between ACEs and health-risk drinking behaviors, and establishing an integrated prevention system.
Adverse Childhood Experiences Linked to Adult Outcomes
Research on Adverse Childhood Experiences (ACEs) conducted by the Centers for Disease Control and Prevention (CDC), Kaiser Permanente, and others over the last twenty years has documented links between adverse experiences in childhood and outcomes later in life. Research studies involving surveys of adults have consistently found a number of undesirable outcomes in populations reporting exposure to a larger number of adverse events in their childhood. These outcomes include: chronic disease, reproductive health and sexual behavior problems, health-risk behaviors, mental health problems, and criminal victimization and perpetration. (See “Adult Health Outcomes of Adverse Childhood Experiences (ACEs),” below.)
Researchers developed a dose response method for analyzing the impact of adverse childhood experiences on various outcomes. An ACE score is computed by totaling exposure to any of ten types of ACEs (Table 1). Experiencing a single type of the ten identified ACE types results in a score of “one ACE.” A higher ACE score results from reported exposure to multiple ACE types but not multiple exposures to one ACE type. It is important to keep in mind that ACE scores are derived from the number of types of adverse childhood experiences, not the total number of experiences. Researchers have found that for those who experienced any particular type of ACE, the likelihood of experiencing multiple types of ACEs is high.
How Adverse Experiences Impact the Developing Brain
Research about the developing brains of children has established the causal mechanisms that link adverse experiences in childhood with undesirable outcomes in adulthood. Traumatic experiences alter brain chemistry (neurotransmitter and hormone levels) and brain structure, and thereby impact brain function. The toxic stress of repeated trauma produces a dysregulated biological stress response in affected individuals who then frequently cope by self-medicating through health-risk behaviors such as alcohol and tobacco use. Stress-induced brain changes can also impact executive cognitive function and self-regulation which increase the likelihood of impulsive behaviors. Current research studies are exploring the different adverse experiences and their occurrences at critical periods in a child’s development to determine their impacts on different adolescent and adult outcomes.
The diagram in Figure 2 integrates the ACEs research with neurobiological studies to illustrate the mechanism which leads to poor outcomes in adulthood. In this article, we focus on the connection between the first or base level of the pyramid (adverse childhood experiences) and the fourth level (adoption of health-risk behaviors) using data from Alaska adults.
ACEs and Risky Drinking: Definitions and Measurement
In 2013 Alaska adults 18 years and older were surveyed about their exposure to ACEs. These questions were asked through the Behavioral Risk Factor Surveillance System (BRFSS), a statewide telephone survey which measures the prevalence of diseases and risk factors in adults (18 years of age and older). The BRFSS is conducted annually by the Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion. In 2013, the BRFSS reached approximately 4,000 Alaskans through both landlines and cell phones. Data are weighted to increase the representativeness of estimates based on the demographic makeup of the state’s population and prevalence of landlines and/or cell phones.
Alaska used an ACE Module of 11 questions developed by the CDC specifically for the BRFSS survey. These questions focused on eight out of the ten types of ACEs. Alaska became the twentieth state to use this module which allows for easy comparisons among states. The module used in Alaska differs from both the original ACE study and other studies in that it does not include questions about emotional or physical neglect. The results, therefore, allow for a maximum ACE score of eight rather than ten. The existence of substance abuse in the home was determined based on a composite of two questions (alcohol and illegal drugs) and sexual abuse was based on a composite of three questions. The other six ACEs were each determined based on a single question. Each of the questions in Table 1 was prefaced with the reminder that the individual should provide answers regarding events prior to their eighteenth birthday.
Health-risk behavior data on heavy and binge drinking also came from BRFSS. Rates of heavy and binge drinking in Alaska were based on definitions of heavy and binge drinking used by the Centers for Disease Control and Prevention (CDC). Heavy drinking is defined as anything in excess of moderate drinking. The CDC defines moderate drinking as no more than 2 drinks per day for males and no more than 1 drink per day for females. In other words, heavy drinking involves consuming on average 15 or more drinks per week for males and 8 or more drinks per week for females. Researchers for a number of years have reported heart health benefits from moderate alcohol consumption, particularly red wine. A 2010 article from the Journal of Cardiovascular Disease Research concludes that there are demonstrated cardiovascular benefits to red wine as a diet supplement. However, the CDC does not recommend initiating or increasing alcohol use for heart health benefits because those potential benefits are offset by increased health and safety risks associated with alcohol consumption. Binge drinking is defined for males as drinking 5 or more drinks on a single occasion, and as 4 or more drinks on a single occasion for females. Binge drinking was more commonly reported by younger Alaskans under 45 years of age than by older Alaskans.
Results: ACEs and Risky Drinking in Alaska
Table 2 describes the demographic characteristics of Alaska adults which were used to weight the Behavioral Risk Factor Surveillance System (BRFSS) survey data discussed above. Just under half of Alaskans were females and just over half of Alaskans were males. Roughly half of Alaskans were 18 to 44 years old and the other half were 45 years or older. A majority of Alaskans were Caucasians (70%). Nearly two-thirds of Alaskans had some college education or were college graduates. Fifty-five percent of Alaskans had an annual household income of $50,000 or more.
According to 2013 BRFSS data, 8 percent of Alaska adults are heavy drinkers and 20 percent are binge drinkers (see Figure 1). Binge drinking was more commonly reported by younger Alaskans under 45 years of age than by older Alaskans. While a quarter or more of Alaskans aged 18 to 24 years (26 percent), 25 to 34 years (29 percent) and 35 to 44 years (25 percent) reported binge drinking in the past 30 days, only 16 percent of Alaskans aged 45 to 54 years and 9 percent of Alaskans aged 55 years and older did (Table 3). No association was found between age and rates of heavy drinking. Results of the Alaska ACE study indicate that the level of adverse experiences in the state are higher than in most states that have conducted the same survey. There are no national statistics on ACEs in the U.S.; however, after the 2009 BRFSS, the CDC released the results of five states’ ACE surveys in aggregate. These states—Arkansas, Louisiana, New Mexico, Tennessee, and Washington—provide a large sample of ACEs in a population base of approximately 26 million people. This broad-based analysis provides context for the Alaska ACE results.
The relative frequency of adult Alaskans who reported experiencing one or more ACE types generally declined with each additional type of ACE, resulting in a stair-step pattern similar to the finding from the ACEs report presenting average figures for the five states (see Figure 3). ACEs are prevalent among adults in Alaska: 63 percent of adult Alaskans surveyed reported one or more types of adverse childhood experiences (Figure 4). This prevalence rate of 63 percent is slightly more than and significantly different from the five-state average in which 59 percent of surveyed adults in the five states reported at least one type of ACE. Higher prevalence rates of ACEs in Alaska relative to the five-state average may partially explain why we have more serious alcohol and substance abuse problems in Alaska—higher ACE scores are generally associated with increased risk behaviors. The Alaska ACEs data allowed us to specifically examine associations between ACEs and the health-risk behaviors of adult heavy and binge drinking.
Results of the analysis (Figure 5) show a significantly increased frequency of heavy drinking in adult Alaskans with higher ACE scores. Whereas 6 percent of adult Alaskans who reported exposure to zero ACEs reported heavy drinking, 13 percent of adult Alaskans with an ACE score of 6 or higher reported heavy drinking. Prevalence rates for heavy drinking were significantly larger for Alaskans with higher ACE scores, but on a positive note, only a small percentage of Alaskans who reported multiple types of ACEs reported heavy drinking. Logistic regression showed a pattern of increased odds of heavy drinking (adjusted for age, race, gender, education, and income) for each additional ACE type that was experienced relative to no ACEs. The odds of heavy drinking are 1.33 times higher for adult Alaskans with an ACE score of one and 1.84 times higher for adult Alaskans with an ACE score of four or five than for adult Alaskans who experienced zero ACEs. The odds of heavy drinking are 2.81 times higher for adult Alaskans exposed to between six and eight types of ACEs than for adult Alaskans who experienced zero ACEs. (See “Methodology and Odds Ratio Interpretation,” above.)
A larger percentage of adult Alaskans reported binge drinking than reported heavy drinking, and results of the cross tabulation (Figure 6) also showed a significantly increased prevalence of binge drinking associated with higher ACE scores. Whereas 16 percent of adult Alaskans who experienced zero ACEs reported binge drinking, 24 percent with an ACE score of 3 reported binge drinking, and 25 percent with an ACE score of 4 or 5 reported binge drinking. Logistic regression showed increased odds of binge drinking (adjusted for age, race, gender, education, and income) with higher ACE scores compared to experiencing no ACEs. The odds of binge drinking are 1.44 times higher for adult Alaskans with an ACE score of 1 than for adult Alaskans who experienced no ACEs. For adult Alaskans with an ACE score of 3 or a score between 6 and 8, the odds of binge drinking are 1.82 times higher than for adult Alaskans with an ACE score of 0. The odds of binge drinking are 2.02 times higher for adult Alaskans with an ACE score of 4 or 5 than for adult Alaskans who experienced no ACEs.
The prevalence rates of adverse childhood experiences among adult Alaskans are high and these traumatic experiences are associated with health-risk behaviors of heavy and binge drinking. Population attributable risk (PAR) is the percentage of a problem which can be directly attributed to a set of exposures to something or to an event. In this study, the problem is heavy drinking and the set of exposures is adverse childhood experiences. Using the Alaska ACEs data we could expect that if all ACEs were eliminated, this would lead to a population-based reduction in heavy drinking of 20.5 percent (results not shown). Researchers should continue to study other risk factors for high-risk drinking, as well as protective factors that promote resilience in the majority of people with higher ACE scores who do not report high-risk drinking. It is also recommended that researchers study other health outcomes associated with ACEs in Alaska.
Given the high social and economic cost of alcohol abuse in Alaska, a reduction in ACEs through primary prevention could have significant benefits. Considerable investments in the state have been made to respond to the poor behavioral health outcomes researchers have linked to ACEs. Besides addressing the long-term consequences of ACEs, increased attention should be directed to developing a cohesive strategy to more effectively prevent the occurrence of ACEs. There are a number of resources currently focused on efforts to prevent child abuse and family dysfunction in Alaska, but these efforts are undertaken by multiple state departments and private agencies often acting independently of each other. Existing prevention efforts could be more coordinated and less fragmented. An integrated system designed to prevent ACEs would more effectively improve the lives and health of Alaskans and would be more cost efficient.
Marny Rivera is an associate professor in the Justice Center. Patrick Sidmore is a Health and Social Services Planner with the Alaska Department of Health and Social Services, Division of Behavioral Health.
Note: The original sources of Behavioral Risk Factor Surveillance System (BRFSS) datasets for this article are the Alaska Department of Health and Social Services, Division of Public Health, and the Centers for Disease Control and Prevention.
Any analyses, interpretations, or conclusions in this article are those of the authors, and not of the Alaska Department of Health and Social Services, Division of Public Health, or the Centers for Disease Control and Prevention.