Kalpana Miriyala MD Zero to Three Fellow Assoc Professor Child and Adolescent Psychiatry Marshall University Huntington WV 25701 Objectives Describe ACEs Describe the ACEs pyramid Describe protective factors ID: 809336
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Slide1
Understanding the Impact of ACEs
Kalpana Miriyala, MD
Zero to Three Fellow,
Assoc. Professor Child and Adolescent Psychiatry
Marshall University, Huntington, WV 25701
Slide2Objectives
Describe ACEs
Describe the ACEs pyramid
Describe protective factors
Discuss ways to address ACEs in a pediatric practice
Slide3Childhood Trauma
Oprah Winfrey
Slide4Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes
of Death in Adults
Vincent
J
Felitti
, Robert F
Anda
, Dale
Nordenberg
, David F
Williamson
, Alison M Spitz, Valerie Edwards, Mary P Koss, James
S
Marks
American Journal of Preventive Medicine
Volume 14, Issue 4, Pages 245-258 (May 1998)
DOI: 10.1016/S0749-3797(98)00017-8
Slide5www.cdc.gov
Slide6www.cdc.gov
Slide7Slide8www.cdc.gov
Slide9ACEs in current children in WV
Atleast
one ACE – WV: 52.4%; USA: 46.3
2 or more ACEs – WV: 26%; USA : 21.7
- Analysis conducted by Child and Adolescent Health Measurement Initiative on 2016 National Survey of Children’s Health.
Slide10Slide11Slide12Slide13Brains are built over time
Use it or
Lose it
Experience-Expectant and Experience-Dependent
Slide14Dopamine
Endorphins
Oxytocin
Cortisol
Slide15Slide16Stress Axis
Prenatally affected by maternal HPA axis; at birth- Hypothalamus is fully developed.
Cortisol at high doses: neurotoxic, inhibits neural connections.
Cortisol at lower levels: induces neuronal development and growth
Oxytocin and social interaction decrease cortisol levels
Hippocampus- matures around 3 months, spatial and emotional memory –recognizes, remembers mother. Glucocorticoid receptors – significant sensitivity to stress.
Stress is neurotoxic to hippocampus, HC cannot give feedback inhibition to HPA, resulting in more neurotoxic cortisol.
Slide17Toxic Stress Derails Healthy Development
Maternal HPA axis trains Infant HPA
Excess cortisol: neurotoxic
Lower levels of cortisol: Induce
neurons
Slide18Slide19Social, Emotional and Cognitive Impairment
Self Control
Working Memory
Mental Flexibility
Slide20Slide21Is it ADHD or Trauma?
(NCTSN: Is it ADHD or trauma – A guide for clinicians Aug 2016)
Children ages 3-5 with
>
2 ACEs: more likely to have trouble calming themselves, be easily distracted, have a hard time making and keeping friends.
More than ¾ of those who are expelled from preschool have
>
2 ACEs.
(Finding from CAHMI data analysis)
Slide22Slide23Mechanisms of translation
Attachment early on can be very powerful and non discriminatory – hence a child exposed even a traumatic sensory experience during the sensitive time period, will seek out those traumatic experiences repetitively.
Early neglect and abuse can interfere with the switch from novelty seeking reward to familiarity seeking reward - leading to a greater likelihood substance abuse problems as the reward of comforting relationships does not protect against the reward of novelty thru substances.
Slide24Health-Risk Behaviors
Health Problem
No. of Categories
Prevalence (%)
Adjusted Odds Ratio
WV Ranking
(BRFSS
rpt
16)
% WV adults
(BRFSS
ACE ‘14)
No
leisure-time physical activity
0
>
4
18.4
26.6
1.0
1.3
11
Severe Obesity (BMI
>
35)
0
>
4
5.4
12.0
1.0
1.6
1
33.1
40.9
Current
Smoker
0
>
4
6.8
16.5
1.0
2.2
2
17.8
44.2
Ever had
Sexually transmitted disease
0
>
4
5.6
16.7
1.0
2.5
Had
50 or more intercourse partners
0
>
4
3.0
6.8
1.0
3.2
Slide25Health-Risk Behaviors
Health Problem
No. of Categories
Prevalence (%)
Adjusted Odds Ratio
WV Ranking
%
WV Adults
(BRFSS ACE ‘14)
Two or more weeks of depressed mood in the past year
0
>
4
14.2
50.7
1.0
4.6
2
14.3
46.9
Ever
used illicit drugs
0
>
4
6.4
28.4
1.0
4.7
Considers
self an alcoholic
0
>
4
2.9
16.1
1.0
7.4
54
(Heavy)2.5/6.5(Binge)
3.3/13.3
Ever
injected drugs
0
>
4
0.3
3.4
1.0
10.3
Ever attempted suicide
0
>
4
1.2
18.3
1.0
12.2
Slide26ACEs and the Opioid Epidemic
2016 study found that individuals who reported 5 or more ACEs were 3X more likely to misuse prescription pain meds and 5X more likely to engage in injection drug use. (6)
Another study has found that over 80% of the patients seeking treatment for opioid addiction had
atleast
one form of childhood trauma and almost 2/3
rd
report having witnessed violence in childhood.(7)
Sexual abuse and parental separation for women, physical and emotional abuse for men appear highly correlated with opioid abuse.
Male children with 6 or more ACEs are 46 times more likely to become IVDUs as adults than boys with zero ACEs.
Slide27Slide28Slide29Chronic Medical Problems
Disease
Condition
No. of Categories
Prevalence (%)
Adjusted Odds Ratio
WV Ranking
% WV Adults
Ischemic
Heart Disease
0
>
4
3.7
5.6
1.0
2.2
1
Heart
attack -7.5
IHD -
8
Any
Cancer
0
>
4
1.9
1.9
1.0
1.9
3
14
Stroke
0
>
4
2.6
4.1
1.0
2.4
Chronic
bronchitis/emphysema
0
>
4
2.8
8.7
1.0
3.9
Diabetes
0
>
4
4.3
5.8
1.0
1.6
2
15
Slide30Chronic Medical Problems
Disease
Condition
No. of Categories
Prevalence (%)
Adjusted Odds Ratio
WV
Ranking
% of WV adults
Ever
had a skeletal fracture
0
>
4
3.6
4.8
1.0
1.6
Ever
had hepatitis or jaundice
0
>
4
5.3
10.7
1.0
2.4
Fair
or poor self-rated health
0
>
4
16.3
28.7
1.0
2.2
1
26.3
Slide31Slide32Slide33Slide34Parental Adverse Childhood Experiences (P-ACES)/ Intergenerational Trauma/ Epigenetics
Slide35Parental ACEs
Women with h/o child abuse have lower oxytocin in general and during post partum period.
Women with insecure attachment have a lower response in the ventral striatum reward area when shown pictures of happy smiling face of their infant.
Intrusive mothers the left amygdala was active and showed a disorganized response with the PFC, while OT levels did not co-relate with
neurocircuitry
response.
Epigenetics: Early environment affects gene expression – through methylation causing a difference in the gene expression pattern of the DNA. Can be reversible or permanent and are heritable.
Slide36Conceptual Framework
Slide37Slide38Protective factors
Slide39Slide40Slide41Slide42Slide43SSNRE: Stable Supportive Nurturing Relationships and Environments
Slide44Protective Factors
Parental Resilience
Social connections
Knowledge of parenting and child development
Concrete support in times of need
Social and emotional competence of the children
Slide45Slide46Slide47Slide48Incorporating Information into the Practice
Pre-requisites
A champion who recognizes the importance of the issue and is able and willing to move it forward
A
significant number of staff, including other clinicians and front office and back office staff, who are willing and ready to change
A practice environment that supports open, honest questions, dialogue, feedback, and confidentiality
Opportunities to educate and train staff prior
to and
during implementation
An
established goal or vision: what do you
want to
accomplish?
Financial
resources available to
support practice
change
Slide49The Process
Why are we looking at this issue?
What are we looking for? – Who should be assessed, when, how often, parents?
How do we find it? – How will questions be asked, questionnaire/interview, documentation, follow up.
What do we do once we have found it? Resource list, possible care
co-ordinator
, ask parents.
Slide50Trauma informed care is
Quality Improvement
Set the tone.
Use other modalities to open the topic : Posters, Did you know
Encourage developmental promotion.
Create a parent advisory group.
Shift of attitude – the family is the patient.
Slide51Trauma informed care is Quality Improvement
Review and evaluate the process of asking questions.
Understand that listening can be therapeutic – “don’t just do something, stand there”
Encourage parents to come up with their own solutions.
Self-care is so important. Reflective supervision is helpful.
Find community partners.
Slide52Balancing Adversity with HOPE
Understanding the importance of positive environments on social emotional well-being.
Support children and families through positive relationships.
Develop resilience through learning skills needed to manage stress and nurture children.
Recognize and address disparities that exist through inclusion.
Connect families with resources that allow them to meet their basic needs.
Slide53Responding to Adversity with HOPE (Health Outcomes from Positive Experiences)
Being in nurturing, supportive
relationships.
Living, developing, playing, and learning in safe, stable, protective, and equitable environments
Having opportunities for constructive social engagement and to develop a sense of connectedness
Learning social and emotional
competencies
Slide54“You are not alone,
it is not your fault and
we will help”
Slide55Resources
https
://
www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/journal.html
WV
Department of Health and Human Resources, Health Statistics Center. (2018). West Virginia Behavioral Risk Factor Surveillance System Report,
2016
https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Trauma-Guide.aspx
WV Infant
T
oddler mental health association
Healthysteps.org
Attachment and
Biobehavioral
Catchup
Child parent Psychotherapy
Slide56-
Nurse
Family Partnership
-
Healthy
Families America
-
www.wvaces.org
-
https
://teamwv.org
/
-
http
://healthygrandfamilies.com/
-
Stumbling blocks or stepping stones- Findings on ACEs in WV January 2018
www.strengtheningfamilies.net Center for Study of Social Policy
www.zerotothree.org
-
Center on the Developing Child At Harvard University
-
Responding to ACEs With HOPE: Health Outcomes From Positive Experiences
Sege
, Robert D. et
al. Academic
Pediatrics , Volume 17 , Issue 7 , S79 - S85
Slide57Maternal adverse childhood experiences, mental health, and child behavior at age 3: The all our families community cohort study
S.W.McDonald
ab
S.Madigan
c
N.Racine
c
K.Benzies
d
L.Tomfohr
c
S.Tough
ab
Preventive Medicine Volume 118, January 2019, Pages 286-29
https://doi.org/10.1016/j.ypmed.2018.11.013
Intergenerational Transmission of Maternal Childhood Maltreatment Exposure: Implications for Fetal Brain development. Buss et al. JAACAP 2017; 56(5): 373-382