Early Adversity & Impacts on Health and Well Being: Examples from our Clinics - PowerPoint Presentation

1. Early Adversity & Impacts on Health and Well Being: Examples from our ClinicsSummer Institute 2014Julie Miller-Cribbs, MSW, PhDProfessor & DirectorAnne & Henry Zarrow School of Social WorkMartina Jelley, MD, MSPHInterim Chair, Department of Internal MedicineSchool of Community Medicine

2. OverviewWhy do we care about ACEs? In Oklahoma? Brief overview of ACE studyOklahoma clinic examples: ACE dataConnecting: ACE & Brain ScienceACE informed interventions

3. Bringing Up Baby

4. Setting the Stage: Why do we care?  Most of us in public or social services have experienced folks with high ACEs

5. Why does an internist care about childhood issues??

6. The journey starts here…

7. And continued here…

8. And continued here…

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10. Behavior Change CounselingClassic brief intervention in primary careMotivational interviewingBut as with many primary care interventions, there were disappointments….

11. Just one of our clinic’s patientFemale, age 34Morbidly obese, BMI 60SmokerOxygen-dependent COPD (emphysema)Poorly controlled diabetes

12. Just one of our clinic’s patientFemale, age 34Morbidly obese, BMI 60SmokerOxygen-dependent COPD (emphysema)Poorly controlled diabetes

13. Social history (taken directly from her chart)Married, 3 children ages 8, 13, 15.Molested at 8, raped at 13. Grew up in home with alcoholism, instability and physical abuse.

14. The rest of the storyLast year this patient was found dead at home, age 36Death thought to be due to heart attack or respiratory failure

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16. Why do we care?It’s expensiveMany of our systems and services are not responsive to the needs of this populationRe-traumatize, do more damageImpact is likely to be intergenerational without interventionWe have increasingly better science, research and knowledge that can help us pinpoint and design effective interventions

17. Consequences of care for violence

18. Consequences of care for ACEs/ViolenceUsing the number of children abused in the US in 2008Total lifetime economic burden resulting from their maltreatment:$124 billion

19. Consequences of care for ACEs/ViolenceThe lifetime cost for one child who was a victim of maltreatment is $210,012 (2010 dollars)$32,648 in childhood health care costs$10,530 in adult medical costs$144,360 in productivity losses$7,728 in child welfare costs$6,747 in criminal justice costs$7,999 in special education costshttp://www.cdc.gov/injury/

20. Adverse Childhood ExperiencesRecurrent physical abuseRecurrent emotional abuseContact sexual abuseAn alcohol and/or drug abuser in the householdAn incarcerated household memberSomeone who is chronically depressed, mentally ill, institutionalized, or suicidalMother is treated violentlyOne or no parentsEmotional or physical neglecthttp://www.cdc.gov/ace/

21. ACE EpidemiologyAbuse Type% ExperiencedPsychological11%Physical11%Sexual22%Household DysfunctionSubstance abuse26%Mental illness19%Domestic violence12%HH member imprisoned3%Ace ScorePrevalence048%125%213%37%4 or more7%More than a third of women in addiction treatment have been physically forced to have sexPatients in substance abuse facilities more likely to have experienced abuse as childrenHigh percentages of women in treatment for mental illness have sexual abuse historiesIn 2004, Oklahoma imprisoned 129 of every 100,000 female residents.

22. Summary of Major FindingsAdverse Childhood Experiences (ACEs) are very common ACEs are strong predictors of later health risks and diseaseThis combination makes ACEs the leading determinant of the health and social well-being of our nation

23. http://www.thenationalcouncil.org/wp-content/uploads/2012/11/Childrens-Resilience-Initiative-9-19-12.pdf

24. ACE Score vs. Smoking and COPD

25. ACEs & Adult Alcoholism01234+

26. Childhood Experiences Underlie Chronic Depression

27. ACEs & Suicide 12034+

28. ACEs & Risk Behaviors*Adjusted Odds Ratio

29. *Adjusted Odds RatioACEs & Risk Behaviors

30. Risk for these health problems increases in a strong and graded fashion:COPD Lung cancerIschemic heart diseaseLiver diseaseStrokeObesity

31. Bringing it Home: Oklahoma ExamplesOU-Tulsa studies (a very brief overview)Clinic sampleEducareHomeless youthPublic housing

32. DataStudyNSampleLinked toOU-Tulsa, School of Community Medicine Clinic Survey 354Clinic patients, adultsElectronic Medical Record data: health conditions, medications, historyEducare Survey: Family Life and Stress 338Parents of children enrolled in Tulsa EducareEducare data:Parent interviewsTeacher observationsANDCortisol sample from childrenHomeless Youth (title)95Homeless youth, YST & clinicNAResidents in public housing64Residents in public housingCommanche Park

33. Study InvestigatorsStudyOU-Tulsa, School of Community Medicine Clinic Survey Marty Jelley, MD; Frances Wen, PhD; Kim Coon, Ed, Julie Miller-Cribbs, PhD; Jennifer Hays-Grudo, PhDEducare Survey: Family Life and Stress Jennifer Hays-Grudo, PhD; Diane Horm, PhD; Kent Teague, PhD; Julie Miller-Cribbs, PhDHomeless Youth & trust of medical providersMunoz, R.T., Brahm, N.C.  & Fox, M.D. (2014) Homeless Adolescents: The Impact of Adverse Childhood Experiences on Trust in the Medical Profession Across Attachment Styles.Residents in public housing , community healthRic Munoz, MSW & Mark Fox, MD

34. OU Clinic Patients: ACEsVerbal abuse 42%Physical abuse 32%Sexual abuse 27%Familial ties 34%Basic needs unmet 20%Witness IPV 25%Sep/Divorce 41%Alcohol/drugs 37%Mental illness 27%Prison 18%

35. Educare Parents: ACEsVerbal abuse 20%Physical abuse 14%Sexual abuse 11%Familial ties 22%Basic Needs Unmet 9%Witness IPV 11%Sep/Divorce 47%Alcohol/drugs 21%Mental illness 10%Prison 17%

36. Clinic Sample: ACEs and healthACE score

37. Educare Survey: Health Problems by ACE score

38. Clinic Sample: Depression and PTSD by ACE scoreDepression & PTSD (z-scores) by ACE scoreACE score

39. Clinic Sample: Health Care Barriers23% currently uninsured50% needed HC, no insurance36% experienced time without insurance, last 12 months37% reported someone in the HH went without needed HC54% needed care, no money54% needed care, no insurance52% used ER, no regular doctor58% report medical debt7% used payday lender for medical debt

40. Combined Data: Health Condition, ACE Mean ScoreHealth ConditionACE MeanArthritis*No2.3806Yes2.9362Depression*No1.6225Yes2.1805Substance Abuse*No2.1591Yes3.6312Hypertension*No2.2321Yes3.0457Diabetes*No2.3801Yes3.1646* Statistically significant difference

41. Combined Data: ACE & DepressionMean ACE Score

42. Combined Data: Access to Health Care# of ACEsNHealth Care Barriers, Mean (SD)0-13192.29 (1.59)*2-42173.22 (1.57)*4 or above1403.84 (1.65)*Doctor Regularly as a Child?*NACE Mean (SD)No2342.95Yes4192.25Dentist Regularly as a child?*NACE Mean (SD)No2893.07Yes3632.02* Statistically significant difference

43. Health Care BarriersNMean Ace ScoreDid you need health care but not get it because you did not have money?*No3601.84Yes3043.21Did you use the ER because you did not have a regular doctor?*No3661.96Yes3003.10Do you have medical debt?*No3121.84Yes3593.00Did you use a payday lender to help cover medical costs?*No6152.36Yes543.69Needed health care but no health insurance?*No4041.92Yes2623.33Combined Data: Health Care Barrier Items

44. Homeless Youth & Public Housing Sample: ACEs & Medical TrustHigh ACE scoresACE related to lower trust in medical providersTable 1: Percentage of ACEs by category among homeless youth compared to a national sample26Number of Adverse Childhood Experiences (ACE Score)Homeless adolescent sample (N = 95)National Sample(N=17,337)05.336.115.326.0211.615.935.39.54 or more72.612.5

45. Quick Summary of Oklahoma FindingsHigh levels of ACEs in clinic, early childhood, homeless youth and public housing samplesACEs related to health, mental health and health risk behaviorsACEs related to access to health care, barriers to health careACEs related to trust of medical providers and the medical professions

46. Findings continued….Those adults with high ACE scores much less likely to have gone to the dentist or doctor regularly as child, likely setting the stage for the lower access to health care as adultsA very clear and significant pattern in the data emerges: the higher the ACE, the more barriers to health care, the less trust of medical professionalshttp://acestoohigh.com/?s=dr+jeffrey+brenner

47. Tying it all Together: From ACE to Adulthood

48. Core Concepts in Science of Early Childhood Development*Child development is a critical foundation for community development and economic developmentExperiences shape brain architecture by over production of connections ‘neural proliferation’, pruning is normal & healthy part of brain development Brains build from the bottom up – skills by skill, simple to more complex.Genes and experiences together build brains – the importance of serve and return relationshipsCognitive, emotional and social development are intertwined – and learning, behavior, and physical and mental health are related throughout lifeToxic stress damages brain architectureFor many functions, the brain’s capacity for change decreases over time – but not all functions are impacted equallyCenter on the Developing Child: Core Concepts in the Science of Early Childhood Development www.developingchild.harvard.edu

49. Experiences Shape Brain ArchitectureBrain growth fastest in first 3 years, 700 new synapses (neural connections) are formed every secondPruning= synapses are reduced to make brain circuits more efficient

50. Use it or lose it: Early experiences impact the nature and quality of brain architecture by determining with circuits are reinforced and which are pruned

51. Connections continue and prune in order: the brain is not a blank slate

52. Serve and Return: Developing CompetenceBrains are not sponges –The main way they developAnd grow is through experiences –Competence is developed through SERVE and RETURN, or the interactive relationship of genes and enviornment

53. Development of social, emotional and cognitive skills are connectedEmotional well being AND social competence provide foundation for cognitive abilitiesExecutive functions (cognitive control)Management of cognitive processWorking memoryReasoningFlexibilityProblem solving

54. Toxic StressDamages brain architectureLong lasting impacts

55. ACEs: compromised brain development￬￬ stimulation (language and learning)￪￪ stimulation (stress)

56. Inadequate stimulation, Inadequate developmentAverage # Words a Child Hears by Age 3Average # of Words a Child would say @ Age 3Low SES10.000.000500Middle SES20,000,000700High SES30,000,0001100Children from low SES backgrounds hear 1 million words less during their first 5 years of life due to the difference in socioeconomic statusChildren of middle class parents experience 1,000 more hours of being read to than lower SES

57. Underdeveloped neural connections= weaker brain architecture

58. Stress Response & Allostatic LoadSeminars in Medicine of the Beth Israel Deaconess Medical Center: Protective and Damaging Effects of Stress Mediators.McEwen, Bruce. New England Journal of Medicine. 338(3):171-179, January 15, 1998.

59. Positive & Tolerable Stress

60. Allostatic Load: Wear and tear from chronic stress

61. “Pay Now” or “Pay more Later”: Change gets harder & more expensive

62. Stress can shorten your telomeresChildhood Trauma Shortens TelomeresShalev I et al. Mol Psychiatry 2013 May.

63. How do we help?Promising PracticesEvolving EvidenceWhat works?

64. National Child Traumatic Stress NetworkA trauma-informed child- and family-service system is one in which all parties involved recognize and respond to the impact of traumatic stress on those who have contact with the system including children, caregivers, and service providers. Programs and agencies within such a system infuse and sustain trauma awareness, knowledge, and skills into their organizational cultures, practices, and policies. They act in collaboration with all those who are involved with the child, using the best available science, to facilitate and support the recovery and resiliency of the child and family.

65. National Child Traumatic Stress NetworkA service system with a trauma-informed perspective is one in which programs, agencies, and service providersroutinely screen for trauma exposure and related symptoms; use culturally appropriate evidence-based assessment and treatment for traumatic stress and associated mental health symptomsmake resources available to children, families, and providers on trauma exposure, its impact, and treatmentengage in efforts to strengthen the resilience and protective factors of children and families impacted by and vulnerable to traumaaddress parent and caregiver trauma and its impact on the family system;emphasize continuity of care and collaboration across child-service systemsmaintain an environment of care for staff that addresses, minimizes, and treats secondary traumatic stress, and that increases staff resilience

66. Public Campaigns & EducationCDC http://vetoviolence.cdc.gov/childmaltreatment/phl/resource_center_infographic.html Aces too High http://acestoohigh.com/ (see “got your ACE score?”Aces Connections http://acesconnection.com/  Impact: reducing stigma, sensitize to ACE impact, reduce isolation, heighten awareness, common language & understanding

67. Screen, Measure & CountState wide surveys/studiesScreening ACEs statewide in adults (Arkansas, California, Louisiana, New Mexico, Tennessee and Washington)  - use 2009 ACE module of the Behavioral Risk Factor Surveillance System (BRFSS) State wide initatives and programsWashington State and WisconsinIowa  Iowasaces360http://www.iowaaces360.org/state-aces-work.html Screening (Vermont)

68. Front Line WorkersReception, ER, triage, clinic staff, Intake workers (TANF/SNAP/Sooner Care), day care, paraprofessionals, ‘aides’Compassionate expectationsReassurance and acceptanceConflict management, support & interpersonal skills for handling difficult situationsFirst responders/screeners – can make the difference between someone leaving and staying for servicesSelf-care and EAP awareness Impact: train staff, sensitize to ACE impact, reduce isolation, heighten awareness

69. Early Childhood ProgramsProven results – many examplesAbecedarian projectHigh Scope/Perry preschoolEarly childhood programs +Economic development for parentsParent supportHome visisting

70. Classic ACE Triangle

71. Expand the Focus of InterventionsTraditional interventionsPreparatory interventions Most programs address observable behaviors and conditions stemming from ACEs

72. Expand the Focus of InterventionTraditional interventionsPreparatory interventions Most programs address observable behaviors and conditions stemming from ACEsStressed adults, who have experienced trauma in past and current life, may not respond well to educational or behavioral interventionsThese interventions are needed, but they come late (not primary prevention) and stressed adults may not be ready to participate & also have little impact on generational change

73. Expand the Focus of InterventionsTraditional interventionsPreparatory interventions Most programs address observable behaviors and conditions stemming from ACEsInterventions target what we know re: stress research, ACE studies, animal models:Biological imbedding of toxic stress, elevated cortisol levels, changes in brain structure & function

74. Examples of Promising PracticesMeditationExecutive functioningAttachment-based interventions (PCIT)Modified health behavior interventions (mindfulness based CBT, mindfulness based stress reduction)Interestingly, many of these have wide application for both trauma and non-trauma affected folks. Reduces stigma, positive for all

75. NIH, AMA, AHA, JAMA, APA StudiesTranscendental MeditationRestful alertnessPromotions balance – integration between mind and bodyReduces cortisol, blood pressure, heart attack, anxiety, learning and memory problemsMindfulness MeditationReducing anxiety, pain, rumination, PTSDThese practices target the underlying stress, anxiety, imbalance. Promotes alertness, integration, calm.Helps prepare alone, but also people along side other interventions: education, therapy, health behavior change

76. Health Behavior InterventionsIf you go to the doctor and have high blood pressure? What is your doctor likely to tell you?ExerciseEat rightGet good sleepQuick smokingLose weight(I don’t know about you, but that is stressful enough when I think about it from a low/no ACE low score)

77. Now, think about it from a high ACE score perspectiveWhat do we know?Emotional avoidanceDistress intoleranceAnxiety sensitivityFocus attentionLack of problem solving skills You want me to what?? I am either going to argue, ask for drugs, or nod and agree and leave and not change my behaviorInterventions that prepare me for treatment as usual will be more successful

78. Thank you!Acknowledgements & CollaboratorsDr. Kim CoonDr. Frances WenDr. Martina JelleyDr. Diane HormDr. Jennifer Hays-GrudoRic MunozDr. Mark Fox