1. The Impact of Adversity on the Health of Minnesota Youth How are our children? Naomi N. Duke MD, MPH, FAAP Department of Pediatrics, University of Minnesota

2. Disclosure Information Hot Topics in Pediatrics Conference American Academy of Pediatrics, Minnesota May 1, 2015 Naomi N. Duke I have no financial relationships to disclose. I will not discuss off label use and/or investigational use of any product/device in my presentation.

3. Objectives Describe types of social and economic adversities experienced by MN youth. Discuss the health status of MN youth and the health consequences of adverse childhood experiences. Identify provider opportunities to address adversity and to promote healing and resilience among youth and families.

5. Defining Adversity Social, institutional architecture Individual perception Individual physiology Physiologic translation helps define adversity and stress as:  Positive: normal, essential to healthy development  Tolerable: more severe, limited in duration  Toxic: severe, frequent and/or prolonged

6. Adverse Childhood Experiences (ACE) Abuse  Emotional  Physical  Sexual Neglect  Emotional  Physical Felitti et al., 1998 Household Dysfunction  Parent/caregiver treated violently  Household substance abuse  Household mental illness  Parent/caregiver separation or divorce  Incarcerated household member

7. Adverse Childhood Experiences (ACE) Relationship between poverty and ACE  Inability to meet basic needs (e.g. food, shelter, clothing)  Limited sense of safety, security, connection, purpose Historical trauma and intergenerational transmission  Internalized oppression  Limited vision for the future

8. Adverse Childhood Experiences (ACE) System events & Institutional experiences  Child protection investigation  Out-of-home placement  Harsh school disciplinary practices  Juvenile justice involvement Interpersonal experiences  Bullying  Violence involvement

9. Adverse Childhood Experiences (ACE) Global experiences of developed and developing nations  Forced marriage  Witness of criminal and collective community violence  Early conscription  Refugee status and resettlement

13. ACE by Federal Poverty Level FPL% Youth with ≥ 1 ACE < 100%66.6% 100-199%59.0% 200-399%45.1% ≥ 400%27.2% *FPL (Federal Poverty Level) $22,350 for family of 4 in 2011 Maternal & Child Health Bureau, 2011

14. Children in Poverty (KIDS COUNT)

15. Children Living in Concentrated Areas of Poverty (KIDS COUNT)

16. Children in Concentrated Poverty by Race-Ethnicity (KIDS COUNT, 2013)

18. Parents Lack Secure Employment (KIDS COUNT)

19. Household Food Insecure, Part of Year (KIDS COUNT)

20. Children in Foster Care, 0-17 years (per 1,000; KIDS COUNT)

21. Youth in Detention, Correctional, Residential Facilities (per 100,000; KIDS COUNT)

22. Victims of Maltreatment (per 1,000; KIDS COUNT)

24. Translation of ACE into Toxic Stress Physiologic stress response that is not turned off Absent, inadequate social, emotional buffers Potential permanent impact via alteration in:  Gene expression  Brain development, architecture  Immune status  Cardiovascular function  Metabolic function  Behavior

25. Allostatic Load

28. ACE and the Life Course Alcohol abuse Chronic obstructive pulmonary disease Depression Early initiation of tobacco use, smoking Illicit drug use Ischemic heart disease Liver disease Sexual risk: early initiation of sex, multiple partners, sexually transmitted infection, unintended pregnancy Suicide attempt Risk for intimate partner violence Early mortality

31. Child Population by Gender (KIDS COUNT, 2013)

32. Child Population by Age Group (KIDS COUNT, 2013)

33. Child Population by Race-Ethnicity (KIDS COUNT, 2013)

34. Children in Immigrant Families (KIDS COUNT)

35. Children Uninsured (KIDS COUNT)

36. Children Uninsured by Poverty Level (KIDS COUNT, 2011)

37. Infant Mortality Rate (per 1,000; KIDS COUNT)

38. Infant Mortality Rate by Race-Ethnicity (per 1,000; KIDS COUNT, 2011)

39. Low Birth Weight (KIDS COUNT)

40. Low Birth Weight by Race-Ethnicity (KIDS COUNT, 2012)

41. Teen Birth Rate by Race-Ethnicity (per 1,000; KIDS COUNT) United StatesMinnesota

42. Children with Asthma (KIDS COUNT)

43. Asthma by Race-Ethnicity (MDH Asthma Program, 2013)

44. No Regular Exercise (KIDS COUNT)

45. Overweight or Obese by Gender (KIDS COUNT) United StatesMinnesota

46. Emotional, Developmental, Behavioral Diagnosis (KIDS COUNT)

47. Children with Special Health Care Needs (KIDS COUNT)

48. Missed ≥ 11 Days of School Due to Illness, Injury (KIDS COUNT) United StatesMinnesota

49. What do we know about experiences and health? Community environment and social context drive health and health outcomes Adverse childhood experiences are common and interrelated Dose response relationship between adverse child experiences and child and adult health outcomes

50. American Academy of Pediatrics Reports, Policy Statements The Lifelong Effects of Early Childhood Adversity and Toxic Stress (Shonkoff et al., 2012) Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health (Committee on Psychosocial Aspects of Child and Family Health et al., 2012) The Pediatrician’s Role in Family Support and Family Support Programs (Committee on Early Childhood, Adoption and Dependent Care, 2011) The Pediatrician’s Role in Child Maltreatment Prevention (Flaherty et al., 2010)

51. Addressing ACE in the Primary Care Setting Work collaboratively with parents, family, and community Routine screening, surveillance Reminder, tracking system for follow-up Assessments to include patient and family strengths and assets Identify partners, resources in the community for referral Develop list of parent, family stress management, coping, behavioral management, mindfulness tools (Addressing Adverse Childhood Experiences and Other Types of Trauma in the Primary Care Setting, AAP, 2014)

52. ACE Score as Guideline Link to questions available for screen: www.acestoohigh.com www.acestoohigh.com Series of 10 questions with “yes/no” responses Scoring: 1 point for every “yes” answer Exposure context: prior to 18 th birthday

53. ACE Score as Guideline Abuse  Emotional  Physical  Sexual Neglect  Emotional  Physical Anda and Felitti, 1998 Household Dysfunction  Parent/caregiver treated violently  Household substance abuse  Household mental illness  Parent/caregiver separation or divorce  Incarcerated household member

54. Resilience Questionnaire Link to questions available for screen: www.acestoohigh.com www.acestoohigh.com Series of 14 statements referencing protective factors (Rains, McClinn, et al., 2006; 2013) Response options  Definitely true  Probably true  Not sure  Probably not true  Definitely not true

55. Resilience Questionnaire Example Contents  Feelings of love from parents  Engagement with parents and other adults  Parents had help in providing care  Felt support from teachers, coaches, ministers, other community members  Household had rules with expectations  Had trusted person to talk to  Had experiences of independence and achievement  Felt people noticed my capabilities  Family, neighbors, friends talked about making life better

56. Resilience Questionnaire Evaluation  For how many of the 14 statements was the answer “definitely true” or “probably true”?  Of the statements where the answer was “definitely true” or “probably true”, how many are still true?

57. Clinical Model: Recognize ACE and Treat Toxic Stress Center for Youth Wellness  Routine screening of all youth  Multidisciplinary care team for youth who screen positive Home visits and care coordination Mindfulness skill-building Nutrition Mental health care: trauma-informed, culturally relevant www.centerforyouthwellness.org

58. Clinical Model: Recognize ACE and Treat Toxic Stress Center for Youth Wellness  Educating parents about impact of ACE  Tailoring care More aggressive treatment reflecting recognition of impact of stress hormones on clinical status (e.g. asthma)  Coordinating referrals with institutional partners who work via an ACE-informed lens www.centerforyouthwellness.org

59. Clinical Model: Recognize ACE and Treat Toxic Stress The Resilience Project  Web-based resource for pediatric providers and medical home teams  Goal: more effectively identify and care for children and adolescents exposed to violence www.aap.org

60. Building Resilience in the Clinical Setting The Resilience Project  Types of violence addressed Bullying Child abuse and neglect Community violence Domestic violence and intimate partner violence Sexual abuse Teen dating violence www.aap.org

61. Building Resilience in the Clinical Setting The Resilience Project  Educational opportunities: webinars and presentations addressing treatment of violence, positive parenting, practice approaches  Quality improvement for medical home: evidence for successful strategies to identify and care for children and adolescents exposed to violence www.aap.org

62. Building Resilience in the Clinical Setting The Resilience Project  Clinical vignettes: consideration of exposure to violence as part of the differential diagnosis  Training toolkit: understanding effects of violence and how to approach the issue in medical home setting  Tools and resources: screening tools to identify children exposed to violence; support tools for practices; state-based resources www.aap.org

63. Parting Thoughts Advances across multiple disciplines have increased our understanding of the connection between ACE and health outcomes. In addition to more traditional markers of abuse, neglect, and household dysfunction, poverty and experiences of deficit are associated with significant youth and family adversity with links to poor health across the life course.

64. Parting Thoughts Acknowledgement of the impact of ACE across the life course produces a shift in how we view differences in health status across populations and strategies for closing gaps. New knowledge brings growing interest in the role of health care providers, particularly pediatric providers, in identifying ACE and fostering resilience in patients and families.