1. Teresa Everson, M.D. Clark County Public Health Oregon Health & Science University Preventive Medicine April 21, 2016 Addressing ACEs (Adverse Childhood Experiences): A Population Health Perspective

2. DISCLOSURES: (none) No one in control of content has indicated a relevant financial relationship with an ACCME-defined commercial interest. The activity was planned and all presentations will be evidence-based and unbiased. CME: This presentation is approved for 1 hour of AMA category 1 CME credit EVALUATION: Please complete! Logistics & Details

3. GOALS Review of ACE Study and Findings Review ACEs prevalence in Washington Review endocrinology and epigenetics of ACEs Review epidemiologic and financial impact of ACEs Discuss population health approaches to ACEs Discuss potential primary care approaches to ACEs

4. The ACE Study Adverse Childhood Experiences

5. The ACE Study Adverse Childhood Experiences Lead Authors: Dr.s Vincent Felitti and Robert Anda. Initial publication May 1998 in AJPM Ongoing study examining the health and social effects of ACEs throughout the lifespan among 17,421 members of the Kaiser Health Plan in San Diego County Identified an association between amount of childhood trauma, behavioral risk factors, increased chronic disease morbidity, and early death.

6. ACE study factors ABUSE Physical Emotional Sexual NEGLECT Physical Emotional FAMILY DYSFUNCTION Mental illness, depression, suicidality/attempt Substance abuse/addiction Parental discord – divorce, separation, abandonment Observing domestic violence Incarceration of any family member Poverty, Homelessness, Racism (“ACE Score” = Number of the original 10 categories to which a person reports significant exposure)

7. ACE Study Findings Adverse Childhood Experiences are common. o Household dysfunction : Substance abuse (including EtOH)27% Parental separation/divorce 23% Mental illness or suicidality17% Domestic violence against mother 13% Incarceration of household member 6% o Abuse: Physical 28% Sexual 21% Psychological 11% o Neglect: Emotional 15% Physical 10%

8. ACE Study Findings Adverse Childhood Experiences are common. Looking at seven primary types of ACEs reported in 1998 study : (three categories of abuse: physical, sexual, and psychological; and four categories of household dysfunction: substance abuse, mental illness, domestic violence, and incarceration) -Almost 2/3 (63.9%) of patients have at least one ACE -More than 1/5 (22%) have 3+ ACEs

9. ACE Study Findings Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Fetal death Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy There is a DOSE RESPONSE with ACEs: the more a person experiences, the greater their odds of the following health behaviors and chronic diseases:

10. Zero ACEs 1 in 16 smokes 1 in 69 is alcoholic 1 in 480 uses IV drugs 1 in 14 has heart disease 1 in 96 attempts suicide With Three ACEs 1 in 9 smokes 1 in 9 is alcoholic 1 in 49 uses IV drugs 1 in 7 has heart disease 1 in 10 attempts suicide With Seven or More ACEs 1 in 6 smokes 1 in 6 is alcoholic 1 in 30 uses IV drugs 1 in 6 has heart disease 1 in 5 attempts suicide 0 37+ As ACEs scores increase…

11. (Odds ratios adjusted for: age, sex, race, educational attainment)

12. ACE Score & Risk for Chronic Disease Dong M Dong M 1, Giles WH, Felitti VJ, Dube SR, Williams JE, Chapman DP, Anda RF. “Insights into causal pathways for ischemic heart disease: adverse childhood experiences study.” Circulation. 2004 Sep 28;110(13):1761-6.Giles WHFelitti VJDube SRWilliams JEChapman DPAnda RFCirculation.

13. ACEs in Washington In 2009, 2010, and 2011 Washington state was one of 5 to voluntarily include questions about ACEs in their annual BRFSS (Behavioral Risk Factor Surveillance System) telephone surveys. RESULTS:

14. ACEs in Washington -Almost 2/3 of respondents (65.4%) had at least 1 ACE -More than 1/4 (28%) had three or more ACEs *Bynum, L, Griffin, T, Riding, DL, Wynkoop, KS, Anda, RF, Edwards, VJ, Strine, TW, Liu, Y, McKnight-Eily, LR, and Croft, JB in Morbidity and Mortality Weekly Report (MMWR), Dec. 17, 2010. Centers for Disease Control and Prevention.

15. ACEs in Washington Schools 12% of elementary school children have three or more ACEs 42 % of high school students have three or more ACEs In an average Washington State high school classroom of 30 students: Seven students (almost 25%) will have four to five ACEs Three students (10%) will have six or more ACEs - NW Children’s Fund, 2013 42% of Washington 10 th Graders have ≥ 3 ACEs

16. The ACE paradigm (+/-)

17. Back to Medical School Endocrinology of Stress Other proposed biochemical pathways to chronic disease Epigenetics

18. The Brain Under Stress

19. Being Chased by the Bear… Hypothalamus  CRH and Vasopressin Anterior Pituitary  ACTH Adrenal  cortisol and epinephrine Result of all of this? You’re ready for fight or flight. Increased available glucose, increased respiratory rate and heart rate, and nonessential systems are shut down (GI, immune systems) Your Neocortex? Switched OFF

20. All good if you are in the forest, being chased by a bear…

21. But, what if the bear lives in your home? With significant threats to safety and well-being in childhood our brain development is different, especially when these threats occur between 3-6y/o. We are subsequently quicker to activate the HPA. This may manifest as withdrawn OR hyper-aroused children. Increased activation of the HPA leads to decreased ability to absorb new information, not just in schools, but in our clinic patients. This ingrained response from childhood also changes a person’s inherent ability to regulate behaviors in stressful situations when what they instinctually crave is stability and safety.

22. Other biochemical impacts of ACEs High ACE scores may impact long-term expression of norepinephrine, serotonin, dopamine and subsequent regulation of mood, behavior and sleep. High ACE scores may also lead to upregulation of inflammatory markers (interleukins, C-reactive protein)

23. The impact of childhood trauma is inheritable (epigenetics) Methylation Model of Heritability: As a consequence of maternal environmental and health factors, methyl groups attach differently to DNA and can cause future DNA expression to be repressed or augmented Histone Modification Model: As a consequence of environmental factors, DNA is wound differently around histones, causing future repressed or augmented expression.

24. The impact of childhood trauma is inheritable Telomere Shortening Model: Adults with high ACE scores have been found to have shortened telomeres compared to those with an ACE score of zero.* Additional studies have found increased telomerase activity in patients with high ACE scores and depression. Telomere shortening is causally associated with premature aging processes. *Andrews NP, Fujii H, Goronzy JJ, Weyand CM. Telomeres and immunological diseases of aging. Gerontology. 2009;56(4):390–403

25. Economic consequence of ACEs “Approximately 579,000 new substantiated cases of nonfatal child maltreatment (CM) and 1,740 cases of fatal CM per year in the United States result in a total economic burden of $124 billion/year. This estimate is based on discounted lifetime costs of $210,012 per victim of nonfatal CM and $1,272,900 per victim of fatal CM. These estimates are based on an incidence-based approach, which facilitates economic analysis for public health interventions. Compared with other health problems, the burden of CM is substantial, even after conservative assumptions are used, indicating the importance of preventing and treating CM. “ Fang, X. et al. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect. 36:2 (Feb 2012); 156–165. http://www.sciencedirect.com/science/article/pii/S0145213411003140http://www.sciencedirect.com/science/article/pii/S0145213411003140

26. Economic Consequences of ACEs Annual economic costs of Adverse Childhood Experiences in Alaska - 2015 http://dhss.alaska.gov/abada/ace-ak/Pages/default.aspx Unduplicated $91,936,300/year

27. What do we do about ACEs?

28. Why are some people affected by ACE’s more than others?

29. RESILIENCE

30. Keys to Resilience CAPABILITY ATTACHMENT AND BELONGING COMMUNITY CULTURE FAITH Skills Knowledge Self-regulation Mindfulness Focus Discipline Family bonds Caring adults Relationships Inclusion Intrinsic and extrinsic value Faith Hope Meaning Traditions Network of services Belonging

31. Public Health Approach to ACEs Trauma-Informed Communities: requires cooperative efforts of Education, Law Enforcement and Health sectors as well as business owners and community members: -Training around appropriate response to trauma-fed behavior -Education about resiliency-building factors -investment in supportive youth and family services -investment in behavioral health resources to support ACEs survivors -Mind frame shift from What’s WRONG with you that makes you ACT like this?  What HAPPENED to you that makes youREACT like this?

34. Early childhood support = Excellent return on investment

35. Primary Care Approach to ACEs- PROactive Screen prenatal patients, give education about generational aspect of ACEs to encourage early engagement with visiting home nurses, early connection with parenting support groups Screen at well baby checks - screen new parents for ACEs and interest in related resources, connect families with home nurses and peer support. Screen in early adolescence. Resiliency counseling and training for ACEs already experienced has higher yield the younger we are. Screen everyone to better understand their chronic disease risks. Also to understand health behaviors, and help people understand why they respond the way they do to perceived threats to well-being. Might refer for behavioral health, or customize their chronic disease management.

36. Primary Care Approach to ACEs- REactive Identify a portion of ACE’s through existing means: social and sexual histories on intake and at well visits; substance use screening; routine prenatal screening questionnaires; behavioral health visits; WIC screening, opioid risk tools Modify health screening and care as appropriate Refer for appropriate services (BH for acute trauma, active mood disorder, or to address unresolved/toxic stress from childhood issues)

37. Problem with Reactive approach? You miss a lot. Can’t judge ACE score by someone’s appearance, substance use or mental health history, employment history, or insurance status. There is still higher risk for heart disease, cancer, early death even if you have screened patients well for behavioral risk factors. Will identify individuals who despite “success” in life still live with toxic stress and might benefit from behavioral health referral.

38. So what do we do about ACEs? Talk with your staff, QI teams, and patient advisory boards about whether/how your clinic can implement ACEs screening. Identify local resources for families and patients affected by high ACE scores. Consider trauma-informed care training for your organization. Keep ACEs in mind with challenging interactions with patients and coworkers. Be aware of the impact of your own experiences on how you deal with stressful situations. Practice self-care. Foster resilience and healthy relationships in the children in your practice, your community, and your family.

39. Raise awareness in patients and staff around ACEs and their effects. Advocate for reimbursement for time spent on ACEs screening and counseling. Advocate for funding for programs and resources supporting individuals with high ACE scores Advocate for an updated USPSTF recommendation for ACEs (childhood maltreatment) screening Advocate for policies that support families- parental leave, support for breastfeeding, flexible work hours to attend well child checks So what do we do about ACEs?

40. Aligning community efforts to promote resilience in Clark County, Washington ACEs Action Alliance Action Teams: Assessment and Evaluation Team Education and Awareness Team Trauma-Informed Organizations Team Cross-Sector Collaboration Team Interested? Please email Cyndie.Meyer@Clark.wa.gov

42. References VJ Felitti, RF Anda, D Nordenberg, DF Williamson, AM Spitz, V Edwards, MP Koss, JS Marks. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, May 1998Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study http://www.cdc.gov/violenceprevention/acestudy/about.html Documentaries: Paper Tigers (Walla Walla public school story), Raising of America (http://raisingofamerica.org/watch), Resiliencyhttp://raisingofamerica.org/watch TED Talks/YouTube: https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_life time?language=en https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_life time?language=en Saving Brains, A Grand Challenge, by Dr. Mike Evans: https://www.youtube.com/watch?v=vw0TkwjjpZU#t=102 Robert Wood Johnson Foundation http://www.rwjf.org/en/library/collections/aces.html http://www.rwjf.org/en/library/collections/aces.html American Academy of Pediatrics: The Resilience Project https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/ACEs-and-Toxic-Stress.aspx https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/ACEs-and-Toxic-Stress.aspx Washington Department of Health http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/PublicHealthSystemResourcesandServices/LocalHealthR esourcesandTools/MaternalandChildHealthBlockGrant/AdverseChildhoodExperiences http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/PublicHealthSystemResourcesandServices/LocalHealthR esourcesandTools/MaternalandChildHealthBlockGrant/AdverseChildhoodExperiences Resiliencytrumpsaces.org ACEstoohigh.org

43. eversont@ohsu.edu Teresa.Everson@clark.wa.gov QUESTIONS?