1. The ACES Study, Toxic Stress, and Building Resiliency What Happens in Childhood Matters! December 4, 2015 Kelly L. Dauk, M.D. Erin R. Frazier, M.D.

2. LOUISVILLE.EDU Objectives Discuss the research on Adverse Childhood Experiences Toxic Stress Resiliency Practice changes Advocacy “It is easier to build strong children than to repair broken men” Frederick Douglass (1817-1895)

3. LOUISVILLE.EDU With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

4. LOUISVILLE.EDU Origins of the ACE Study 51 weeks later What was the core problem here? 408 132 lbs With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

5. LOUISVILLE.EDU >400 lbs. in a shorter period of time than the weight was lost. Weeks With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

6. LOUISVILLE.EDU ACE Study Design Survey Wave 1 71% response (9,508/13,454) n=13,000 Survey Wave II n=13,000 All medical evaluations abstracted Present Health Status Mortality National Death Index Morbidity Hospitalization Doctor Office Visits Emergency Room Visits Pharmacy Utilization All medical evaluations abstracted vs. 17,337 adults With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

7. LOUISVILLE.EDU Source: http://www.rwjf.org/e n/about- rwjf/newsroom/newsr oom- content/2013/05/Info graphic-The-Truth- About- ACEs.html?cid=xsh_rw jf_tw

8. LOUISVILLE.EDU Prevalence of Adverse Childhood Experiences Abuse, by Category Psychological (by parents)11% Physical (by parents)28% Sexual (anyone)22% Neglect, by Category Emotional15% Physical10% Household Dysfunction, by Category Alcoholism or drug use in home27% Loss of biological parent < age 18 23% Depression or mental illness in home17% Mother treated violently13% Imprisoned household member 5% Prevalence (%) With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

9. LOUISVILLE.EDU Childhood Experiences Underlie Chronic Depression Well-being With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

10. LOUISVILLE.EDU With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN. Adverse Childhood Experiences Score Number of categories (not events) is summed… ACE Score Prevalence 033% 125% 215% 3 10% 4 6% 5 or more 11%* Two out of three experienced at least one category of ACE. If any one ACE is present, there is an 87% chance at least one other category of ACE is present, and 50% chance of 3 or >. * Women are 50% more likely than men to have a Score >5.

11. LOUISVILLE.EDU Childhood Experiences Underlie Suicide Attempts 1 2 0 3 4+ Well-being With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

12. LOUISVILLE.EDU ACE Score and Rates of Anti- Depressant Medication Prescriptions ACE Score ACE Score Prescription rate per 100 person-years 0 1 2 3 4 5 or more Costs approximately 50 years later ACE Score With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

13. LOUISVILLE.EDU Adverse Childhood Experiences vs. Smoking as an Adult % p<.001 Health Risks With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

14. LOUISVILLE.EDU Childhood Experiences vs. Adult Alcoholism 0 1 2 3 4+ Health Risks With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

15. LOUISVILLE.EDU ACE Score vs Injection Drug Use p<0.001 Health risks With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

16. LOUISVILLE.EDU ACE Score and Teen Sexual Behavior Looking for love Intercourse by Age 15 Teen PregnancyTeen Paternity Social function With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

17. LOUISVILLE.EDU ACE Score and the Risk of Perpetrating Domestic Violence ACE Score and the Risk of Perpetrating Domestic Violence __________________________________ Risk of Perpetration (%) 0 5 10 15 Women Men 0 1 2 3 4 >5 ACE Score Social function: With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

18. LOUISVILLE.EDU Social function: ACE Score and Indicators of Impaired Worker Performance 0 5 10 15 20 25 01234 or more ACE Score Absenteeism (>2 days/month) Serious Financial Problems Serious Problems Prevalence of Impaired Performance (%) Performing job With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

19. LOUISVILLE.EDU { Childhood Sexual Abuse and the Number of Unexplained Symptoms 0 1 2 3 4 5 6 7 8 With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

20. LOUISVILLE.EDU ACE Score vs. COPD Biomedical Disease 0 1 2 3 4 With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

21. LOUISVILLE.EDU { ACEs Increase Likelihood of Heart Disease* Emotional abuse1.7x Physical abuse1.5x Sexual abuse1.4x Domestic violence1.4x Mental illness1.4x Substance abuse1.3x Household criminal 1.7x Emotional neglect1.3x Physical neglect1.4x * After correction for age, race, education, and conventional risk factors like smoking and diabetes.Circulation, Sept 2004. Biomedical disease

22. LOUISVILLE.EDU Effect of ACEs on Death Rate (Null hypothesis) Age Group >=6 ACE shortens lifespan by 20 yrs. With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

23. LOUISVILLE.EDU { basic and long- lasting In Summary, the ACE Study indicates: Adverse childhood experiences are the most basic and long- lasting cause of health risk behaviors, mental illness, social malfunction, disease, disability, death, and healthcare costs. With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

24. LOUISVILLE.EDU With permission: Anda, RF.. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

25. LOUISVILLE.EDU ADVERSE CHILDHOOD EXPERIENCES SURVEY SOURCE: http://www.childhealthdata.org/brows e/rankings/maps?s=108

26. LOUISVILLE.EDU 30% of KY children with ACE>=2 (22.6% nationally) 1:5 KY children experience >=2 ACES by age 5 (1:8 nationally) KY children with ACE scores >=3, one of the highest rates in the country ACES and KENTUCKY’s CHILDREN 2011-2012 National Survey of Children’s Health Source: 2014 KY Kids Count Data Book

27. LOUISVILLE.EDU KY’s Most Common ACES Sources: http://www.rwjf.org/e n/about- rwjf/newsroom/newsr oom- content/2013/05/Info graphic-The-Truth- About- ACEs.html?cid=xsh_rw jf_tw; 2014 KY Kids Count Data Book http://www.rwjf.org/e n/about- rwjf/newsroom/newsr oom- content/2013/05/Info graphic-The-Truth- About- ACEs.html?cid=xsh_rw jf_tw 30% Economic hardship 29% 14% 13%

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29. What is their ACE score?

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31. A public health perspective What are conventionally viewed as Public Health problems are often personal solutions to long-concealed adverse childhood experiences.

32. LOUISVILLE.EDU Types of stress

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34. Toxic Stress “In my beginning is my end” T.S. Eliott

35. LOUISVILLE.EDU Toxic Stress

36. LOUISVILLE.EDU Toxic Stress

37. LOUISVILLE.EDU - Transient activation of the stress response is necessary for survival -Additionally inflammatory cytokines are released and parasympathetics activated Physiology of Stress

38. LOUISVILLE.EDU -The stress response is overstimulated and is not able to regulate normally -Disrupts normal brain wiring and architecture in important areas such as the amygdala, hippocampus, and prefrontal cortex -Long periods of exposure to high cortisol levels especially before age 2 leads to negative consequences on physical and mental health -Damage to the hippocampus worsens reaction to stress in the future What does toxic stress do?

39. LOUISVILLE.EDU - The plasticity of the young infant/child’s brain makes it particularly vulnerable to increases in stress hormones - Negative consequence on physical and mental health and increase stress responses in the future Bottom line

40. LOUISVILLE.EDU CHRONIC STRESS Hypothalmus Proinflammatory cytokines Effects on Developing Brain Effects on Biomedical Disease With permission: Felitti, VJ. The ACE Study Powerpoint, Academy of Violence and Trauma. April, 2011. Minneapolis, MN.

41. LOUISVILLE.EDU When positive experiences outweigh negative one- a child’s “scale” tips toward positive outcomes

42. LOUISVILLE.EDU “Its not where you begin its about where you end up” Reverend Darrell Armstrong Shiloh Baptist Church Trenton, New Jersey RESILIENCY

43. LOUISVILLE.EDU What is resiliency? - How we deal with the problems or set backs in our life -Resiliency comes naturally to some but it can also be learned -Using your skills and strengths to turn negatives into positives -Protective factors reduce the effects of adverse experiences It can be improved at any age!!

44. LOUISVILLE.EDU Building Resiliency “If we are to prepare children to become the healthy, productive, contributing adults that will repair our world and lead us into the future, we must set our vision for the long term goal” Dr. Kenneth R. Ginsberg Building Resilience in Children and Teens: Giving Kids Roots and Wings

45. LOUISVILLE.EDU -Adaptive responses to adversity -Dynamic interaction between internal predisposition and external experiences -Managing “positive stress”

46. LOUISVILLE.EDU Resiliency and the 7cs Competence Confidence Connection Character Contribution Coping Control

47. LOUISVILLE.EDU Wealth of resources on the American Academy of Pediatrics website aap.org/theresilienceproject

48. LOUISVILLE.EDU Asking the Questions - Does your child have any behavior changes seemingly without cause (trouble sleeping or changes in school performance)? -Has anyone come or gone from the household lately? -Has the child had stomach pains, headaches, or other somatic complaints? -Has your child ever witnessed anyone being harmed in the home or in the community? -We talk more about violence and its effect on children’s health…….

49. LOUISVILLE.EDU Types of violence - Bullying or cyberbullying -Community violence -Child abuse and neglect -Domestic and intimate partner violence -Sexual abuse -Teen dating violence

50. LOUISVILLE.EDU - Frame the question -Actions to take -Tools -Vignettes and webinars

51. LOUISVILLE.EDU YOU can foster resiliency

52. LOUISVILLE.EDU “the practice of supporting someone to make their voice heard” - Target the preventable triggers of toxic stress (poverty, crime, mental illness, substance abuse, discrimination, and community violence) and help families and parents create resiliency Advocacy

53. LOUISVILLE.EDU Advocacy -CHIP-Children’s Health Insurance Program -Home health visitation programs -SNAP-Supplemental Nutrition Assistance Program

54. LOUISVILLE.EDU -Foster and kinship care -Increase access to mental health resources -Head start programs -Rethink Child Protective Services -HANDS -Medical homes -Medical-legal partnership -Promote early literacy

55. LOUISVILLE.EDU Find your legislator http://lrc.ky.gov http://www.lrc.ky.gov/

56. LOUISVILLE.EDU Call to action 1. Begin to assess patients and their families in the context of what their ACES score may be 2. Ask the hard questions-obesity, abdominal pain, somatic complaints, headaches “Talking to you about what has happened in your life helps me take better care of your health” 3. Understand that children under toxic stress have differences in the hard wiring of their brains and this will manifest in their behavior and school performance 4. Foster resiliency in your patients and all children 5. Praise foster parents and kinship care providers 6. Become an active child advocate

57. LOUISVILLE.EDU Resources: 1.Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-58. 2.Felitti, VJ. The ACE Study Powerpoint. Academy of Violence and Trauma. April, 2011. Minneapolis, MN. 3.http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/05/Infographic-The-Truth- About-ACEs.html?cid=xsh_rwjf_tw. Accessed May 2015.http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/05/Infographic-The-Truth- About-ACEs.html?cid=xsh_rwjf_tw 4.Anda, RF.. The ACE Study Powerpoint. Academy of Violence and Trauma. April, 2011. Minneapolis, MN. 5.http://www.childhealthdata.org/browse/rankings/maps?s=108. Accessed May 2015.http://www.childhealthdata.org/browse/rankings/maps?s=108 6.2014 Kentucky Kids Count County Data Book. KY Youth Advocates. p. 9-17.