ACEs, Toxic Stress, and Resilience: What do We Need to Know? MiPCT Pediatric Care Management Summit Tuesday, September 20, 2016 Tina Marie Hahn, MD (drtinahahn@gmail.com)

Objectives Learn that Childhood Adversity and Toxic Stress are common in the lives of children and parents in our practices. Childhood Adversity Affects Brain Structure and Function, Gene Expression, and Ultimately the Adults we Become. ACEs are forms of Toxic Stress. Toxic Stress also includes housing insecurity, food insecurity, financial stressors. Realize Childhood Adversity and Toxic Stress Effects how Kids Develop and Adults Function – Helping families understand ACEs and learning and building on their strengths and capabilities promotes resiliency.

The Origins of the ACE Study The ACE Study had its origins in an obesity clinic. People who were 300 pounds overweight lost 100 pounds and then dropped out. Why? “How much did you weigh when you were first sexually active?’ The patient answered, ‘Forty pounds,’” and burst into tears, “It was when I was only four, with my father.” A woman who had been raped at age 23, in the year after the attack, told Felitti, she gained 105 pounds. “As she was thanking me for asking the question, she looks down at the carpet, and mutters, ‘Overweight is overlooked, and that’s the way I need to be.’” 17500 Individuals from Kaiser Permanente Health Plan living in San Diego California Middle Aged, Employed and Primarily White Most with at least some college education

What is “My” ACE Score? First, what is an ACE Score? A score from 0 to 10 based on the number of “Yes” answers you have to 10 questions. Each “Yes” Answer is Scored as One Point, Even if it Occurred Multiple Times Prior to Age 18. Add Up all the “Yes” Answers to the 10 questions and that is Your ACE Score.

The study measured ten types of childhood trauma. Abuse and neglect The study measured ten types of childhood trauma. Abuse and neglect. And five household dysfunctions -- witnessing a mother being abused. Living with a household member who's an alcoholic or addicted to some other drug. A family member in jail or diagnosed with a mental illness. Losing a parent to separation or divorce. Of course, there are other types of trauma -- bullying, witnessing violence outside the home, racism, involvement with the foster care system , poverty– and there are organizations that are including these other types of childhood adversity in ACE surveys.

ACE Score and % Lifetime Depression and Antidepressant Scripts What if depression was a normal response to adverse childhood experiences as this slide would suggest. One of the most rapidly rising set of prescribed drugs in the US are antidepressants. As the ACE score approaches 4 or more the percent of people prescribed antidepressant drugs is over 90 percent and at 5 or more it is almost 100 percent.

Childhood Experiences Underlie Suicide At an ACE of 6 the increased likelihood of attempting suicide is 3000-5000 % compared to an ACE score of Zero this represents a 30 – 50 fold increased Risk. This link is closely associated with all types of abuse and neglect but is especially associated with child sexual abuse (as is cutting and borderline personality disorder)

Percentage of Children in an Urban Pediatric Community Clinic with Learning or Behavioral Problems Based on ACE Score At an Adversity Score of 4 or more over 50 percent of the children have a learning or behavioral problem as opposed to only about 3 percent of comparable children with an ACE score of Zero. In children with behavioral problems or learning disorders consider Overwhelming Adversity and Toxic Stress. N. Burke et al, Child Abuse and Neglect 35(2011) 408-413 This gives an Odd Ratio of 32 for an ACE score of 4 or more versus an ACE of 0

ACEs and Population Attributable Risks Adverse Childhood Experiences (ACES) are very common. ACES are strong predictors of adult DEATH, health risks, social functioning, well-being, and health care costs. ACES are the major cause of much of adult medicine and many major public health and social problems. This combination makes Adverse Childhood Experiences the prime determinant of the health, social, and economic well being of the nation.

Childhood Experiences are Powerful Predictors of the Adults We Become!!!! WHY??

SIMPLE Because ACES and Toxic Stress Drastically Alter a Child’s Developing Brain, Immune System and Gene Expression. Lets Explain.

Types of Stress Center for the Developing Child at Harvard University Excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection of a stable and responsive relation (Center on the Developing Child at Harvard University, 2007). Center for the Developing Child at Harvard University

What do we know about stress? A little stress: A lot of stress: enhances kids learning activates our brain can still think helps build coping skills kids can return to a stable emotional state Kids can use their frontal lobes (thinking) brain to respond appropriately cortisol release primitive parts of the brain react fight or flight response is activated decreases coping skills is toxic and damaging to brain, genetics and body not teachable moments

Resilience A critical factor that determines if an individual can recover from Toxic Stress. Various protective factors (parental reassurance, social supports, internal strengths) allow an individual to return to baseline physiological state after experiencing Toxic Stress. Protective factors prevent Toxic Stress which Improves Physical and Social Outcomes allowing children to grow into healthy adults. The Strengthening Families Approach of Increasing protective factors fosters Resilience.

Resilience – Strengthening Families Components Parental Resilience Knowledge of Parenting and Child Development. Developing positive Social Connections. Providing Concrete Supports in Times of Need. Building Children’s Social and Emotional Competence.

Pediatricians help Strengthen Families? Be prepared. Know community resources like *211, public health department, great start collaborative. Help parents understand the link between taking care of themselves and their child. A great resource is Zero to Three. Encourage families to make positive social connections – for example local parenting groups. Have information in the waiting room on trauma and toxic stress. Know contacts for domestic violence shelters, food pantries, housing assistance. Look for signs like developmental regression, behavioral changes, somatic complaints and address these

Resources Vincent Felitti, MD and Robert Anda, MD (CDC/Kaiser Adverse Childhood Experiences Study) Center for Youth Wellness Strengthening Families Bruce Perry, MD (Child Trauma Academy) AcestooHigh.com Center for the Developing Child at Harvard