1. VERMONT DATA ON ACE RISK AND RESILIENCE: THE CALL FOR MIND/BODY INTERVENTIONS IMPROVING CLINICAL OUTCOMES FOR COMPLEX PATIENTS CONFERENCE OCTOBER 25-26, 2013 STOWE, VERMONT CHRISTINA BETHELL, PHD, MPH, MBA PROFESSOR, OHSU SCHOOL OF MEDICINE DIRECTOR, THE CHILD & ADOLESCENT HEALTH MEASUREMENT INITIATIVE “It is easier to build strong children than to repair broken men.” Frederick Douglass (1817–1895)

2. Healing is Upon Us! Where Science, Policy and Experience Meet The Science of Linked Lives and Life Course Health: Safety, Connection, Attachment, Stress and Health Christina Bethell, PhD, MPH. VT ACES 2 10/25/2013

3. Healing is Upon Us! (and within and between us!) Where Science, Policy and Experience Meet Christina Bethell, PhD, MPH. VT ACES 3 10/25/13

4. Healing is Economic! Where Science, Policy and Experience Meet Many of our social problems, such as crime, are traced to an absence of the social and emotional skills, such as perseverance and self-control, that can be fostered by early learning. Crime costs taxpayers an estimated $1 trillion per year. --James Heckman, Nobel Prize Winning Economist IMAGE SOURCE: Heckman & LaFontaine (2007) The Economists Are Listening 10/25/13 Christina Bethell, PhD, MPH. VT ACES 4

5. And Now We Have National and State Data on Adverse Childhood Experiences and Resilience FOR CHILDREN (2011-12 NSCH (HRSA/MCHB/CDC) State Variation In Prevalence of 2+ (of 9) ACES 16.3% (UT) – 32.9% (OK) across states. 10/25/13 Christina Bethell, PhD, MPH. VT ACES 5

6. Query for children in your state at www.childhealthdata.orgwww.childhealthdata.org 6

7. 7 Adverse Child Experiences Included Adverse Childhood Experiences Vermont Prevalence National Prevalence State Range Child had one or more Adverse Child or Family Experiences 50.6%47.9% 40.6% (CT) - 57.5% (AZ) Child had two or more Adverse Child or Family Experiences 23.3%22.6% 16.3% (NJ) - 32.9% (OK) Socioeconomic hardship 24.9%25.7% 20.1% MD – 34.3% (AZ) Divorce/separation of parent 26.2%20.1% 15.2% (DC) – 29.5 (OK) Death of parent 14.5%3.1% 1.4% (CT) – 7.1% (DC) Parent served time in jail 7.9%6.9% 3.2% (NJ) – 13.2% (KY) Witness to domestic violence 10.9%7.3% 5.0% (CT) – 11.1% (OK) Victim or witness of neighborhood violence 5.7%8.6% 5.2% (NJ) – 16.6% (DC) Lived with someone who was mentally ill or suicidal 5.9%8.6% 5.4% (CA) – 14.1% (MT) Lived with someone with alcohol/drug problem 1.8%10.7% 6.4% (NY) – 18.5% (MT) Treated or judged unfairly due to race/ethnicity 3.0%4.1% 1.8% (VT) – 6.5% (AZ) IMPORTANT NOTE: Questions about child abuse and neglect were not directly asked about in the survey—though are unlikely to lead to substantially different overall rates since ACES are so commonly co-occurring. Christina Bethell, PhD, MPH. VT ACES 10/25/13

8. Christina Bethell, PhD, MPH. VT ACES 8

9. Protective Effect of Resilience

10. Compounded Risks ACES and the Health and Stress of Parents 10/25/13 Christina Bethell, PhD, MPH. VT ACES 10

11. Compounded Risks: Proportion of VT children with and without ACES and Home, School, Community indicators 10/25/13 Christina Bethell, PhD, MPH. VT ACES 11

12. 12 Access to healthcare and ACEs in Vermont

13. 10/25/13Christina Bethell, PhD, MPH. VT ACES 13 Likelihood of Medical Home with 1+ ACEs Nationally, compared to children without ACEs, children with 1 or more ACEs are less likely to receive care in a Medical Home (*AOR 0.77 (95% CI: 0.71-0.82). In Vermont, children with 1 or more ACEs have half the odds of receiving care in a Medical Home (*AOR: 0.50 (95% CI: 0.37- 0.67) Geographic Location Adjusted Odds Ratio 95% Confidence Interval US0.770.71-0.82 Vermont0.500.37-0.67 *After adjusting for age, sex, race, poverty level, insurance type, and CSHCN status.

14. 10/25/13 14 Effect of having a Medical Home on Positive Health Indicators by ACE subgroup, Vermont Met Protective Home Environment IndexMet School Success Index

15. 10/25/13 15 Effect of having a Medical Home on Positive Health Indicators by ACE subgroup, Vermont Mother’s health is excellent/very goodFamily eats 4 or more meals together a week

16. Positive Health Indicator Adjusted Odds Ratio 95% Confidence Interval Protective Home Environment Index 1.281.13-1.43 School Success Index 1.351.21-1.50 Mother’s health excellent or very good 1.501.36-1.65 Family eats 4 or more meals together a week 1.191.07-1.33 16 Likelihood of Positive Health Indicators by presence of Medical Home among children with 1 or more ACEs Nationally, among children with 1 or more ACEs, having a medical home has a positive effect on positive health outcomes (from about 20% increase to 50% increase in odds compared to children without a medical home). In Vermont, estimates were similar but did not reach significance likely due to small sample size *After adjusting for age, sex, race, poverty level, insurance type, and CSHCN status.

17. “CSHCN are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally” Current CSHCN –existing condition resulting in above routine need or type of health care and related services (5 item screener) At risk (examples) diagnosis, but no above routine need or use unclear chronicity, above routine need or use meets criteria for being “at risk” of developmental problems born premature or low birth weight but not yet CSHCN psychosocial risks strongly associated with health (e.g. Adverse Childhood Experiences, etc.) Who Are Children With Special Health Care Needs (CSHCN)

18. Overall Prevalence of CSHCN in Children age 0-17 10/25/13 Christina Bethell, PhD, MPH. VT ACES 18

19. Prevalence of CSHCN in Vermont Across Age Groups: by Public Insurance and 1 or more ACEs by Public Insurance and 1 or more ACEs 19

20. Prevalence of Children with and without special health care needs in Vermont by 1+ ACEs and Age Group 20 Data source: 2011/12 NSCH

21. 10/25/13 Christina Bethell, PhD, MPH. VT ACES 21

22. 22 36.4% of VT children with EMB have parents who report usually or always feeling aggravated with their child

23. Expanding Our Reach: Importance of a Broad View DATA SOURCE: 2011/12 National Survey of Children’s Health (2011/12 NSCH). *Number of conditions is based upon the list of 18 conditions included in the 2011/12 National Survey of Children’s Health, including ADD/ADHD, anxiety problems, asthma, autism/ASD, behavioral problems, brain injury or concussion, depression, developmental delay, diabetes, hearing problems, intellectual disability, bone/joint/muscle problems, learning disability, epilepsy or seizure disorder, Tourette Syndrome, vision problems. **Almost half of children (47.9%) nationally have 1 or more Adverse Child/Family Experiences, with 50.6% of children in Vermont. Nine Adverse Child/Family Experiences were included in the survey: (1) socioeconomic hardship, (2) divorce/separation of parent, (3) death of parent, (4) parent served time in jail, (5) witness to domestic violence, (6) victim of neighborhood violence, (7) lived with someone who was mentally ill or suicidal, (8) lived with someone with alcohol/drug problem, (9) treated or judged unfairly due to race/ethnicity. Non-CSHCN; No named conditions Non-CSHCN; 1+ conditions CSHCN; 1+ conditions Overall Health Status Excellent/Very Good 82.3%73.2%53.1% 11+ Missed School Days (6-17) 2.2%9.7%22.5% High levels of parenting aggravation with child 11.5%16.3%32.2% NationVermont Children with Special Health Care Needs (CSHCN) 19.8%21.8% Non-CSHCN with the following risk factors: Chronic Conditions (1+ of 18 conditions assessed) -but not CSHCN10.0%11.6% Met 1+ CSHCN Consequences (but not condition/duration CSHC criteria)12.9%12.2% Risk of Developmental Delay: Moderate or Severe (PEDS) (< age 6)22.9%17.0% Adverse Child and Family Experiences (2+ of 9 assessed)19.3%17.7% Born Premature10.1%8.6% Overweight/Obese: (age 10-17)30.0%21.0% Non-CSHCN: 1+ risk factors 48.6% 43.4% CSHCN + Non-CSHCN With 1+ Risk Factors 58.8%55.8%

25. Query for children in your state at www.childhealthdata.orgwww.childhealthdata.org 25

26. Healing is Upon Us! (and within and between us!) 10/25/13Christina Bethell, PhD, MPH. VT ACES 26

27. Contact Information  E-mail: bethellc@ohsu.edu  Connect with the DRC to Join the Conversation! Like us on Facebook: Facebook.com/childhealthdata Facebook.com/childhealthdata Follow us on Twitter: @childhealthdata 10/25/13Christina Bethell, PhD, MPH. VT ACES 27

28. 28 Additional Resource Slides “You can’t go to good places with your mind if you can’t go to good places with your body. “ Stephen Porges, PhD Professor Emeritus, University of Illinois at Chicago. Director, Brain Body Center in the Department of Psychiatry. Author: The Polyvagal Theory “It is always a good thing to help a person rejoin the human race.” Ronald Siegel, MD, Harvard Medical School 10/25/13Christina Bethell, PhD, MPH. VT ACES

29. 29 NSCH Measurement Domains Child Health & Well-Being Community and School Activities Family Health and Activities Neighborhood Safety and Support Health Care Access and Quality Physical and Oral Health Mental and Emotional Health Health Insurance

30. 30 Within State Disparities New Jersey, the state with the lowest rate of Adverse Child/Family Experiences (2+), had the greatest variation by household income level. NJ= 16.3 Within State Disparities Kentucky, the state with the third highest rate of Adverse Child/Family Experiences (2+), had the greatest variation by insurance type. KY= 30.0 10/25/13Christina Bethell, PhD, MPH. VT ACES

31. Empowering Parents To Improve Psychosocial Screening and Referral During Well Visits (www.wellvisitplanner.org) 31 10/25/13Christina Bethell, PhD, MPH. VT ACES

32. Making the “CAACE” for Mindfulness  C ross-Cutting  A ccessible  A daptable  C onnecting  E nabling “Without mindfulness, there is no therapy. Mindfulness is a necessary state to be in to live your life. All growth occurs because you are in a state of mindfulness. Without mindfulness, there is no growth.” Bessel van der Kolk Professor of Psychiatry, Boston University. Author : Treating Traumatic Stress in Children and Adolescents 5/13/13Christina Bethell, PhD, MPH. ACES Summit 32

33. Coping with Stress and the Body The Essential Role of Mindfulness 33 10/25/13 “You can go good places with your mind if you can’t go good places with your body. “ Stephen Porges, PhD Professor Emeritus, University of Illinois at Chicago. Director, Brain Body Center in the Department of Psychiatry. Author: The Polyvagal Theory

34. Healthy Attachment and Parental Well-Being The Importance of ACEs Healing for Parents The best predictor of a child’s security of attachment is not what happened to his parents as children, but rather how his parents made sense of those childhood experiences. Daniel Siegel, Mindsight Population Attachment Profile: 59% secure, 25% avoidant, and 11% anxious

35. Making sense of yourself is a source of strength and resilience for your child! Making sense means being able to put your story into words and convey it to another person. Your story includes: how your mind has shaped your memories of the past to explain who you are in the present. the way you feel about the past your understanding of why people behaved as they did the impact of those events on your development into adulthood 10/25/13 Christina Bethell, PhD, MPH. VT ACES 35

36. Conventional Care Use Among Children With Emotional, Behavioral and Developmental Problems (EMB) Missed opportunities for improving efficiency? Among children with EMB conditions/problems* (2-17 years): EMB conditions/problems: anxiety/stress, depression, ADD/ADHD, phobia/fears, insomnia/trouble sleeping, incontinence including bedwetting $5813 for CSHCN with EMB (9%; 40% of CSHCN vs. <$900 for non-CSHCN) 10/25/13Christina Bethell, PhD, MPH. VT ACES 36

37. Thinking about the types of medical, traditional and alternative treatments that you are happy with, does a medical person Usually/Always show respect for these treatments? Mind-Body Therapy Users non-Users 70.5% 90.4% Bias Patient’s Face All children Among CSHCN 54.3% 90.8% 10/25/13Christina Bethell, PhD, MPH. VT ACES 37