10/2/2017

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Vivian Lasley-Bibbs, MPH Acting Branch Manager and Epidemiologist

Office of Health Equity Kentucky Dept. for Public Health

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Presentation Objectives Overview

Current Data

Translation and dissemination of data

Resilience and Protective Factors

Next Steps: Kentucky moving forward

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Defined as: potentially traumatic events that can have negative, lasting effects on health and well-being including early death¹. These experiences range from physical, emotional, or sexual abuse to parental divorce or the incarceration of a parent or guardian.

Source: Child Trends; Research Brief; Adverse Childhood Experiences; Year 2014

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Critical Periods Birth – 2 years; critical window

for hardwiring the brain for social-emotional development.

• Social-Emotional development is based on secure attachment and becomes the foundation for cognitive development and sense of self-identity.

• Attachment comes from a nurturing relationship with a caregiver that is consistent and caring.

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Critical Periods

The Two Year window – results of extreme deprivation of stimulation

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Allostasis, Allostatic Load Allostasis refers to the way the brain and body

respond to challenges or stresses: by reacting, adapting and then recovering. That accumulated wear-and-tear, called allostatic load, can cause chemical imbalances, accelerate certain diseases, and even alter brain structures.

Genetics, early brain development, the social and physical environment, diet and other behaviors can all influence a person’s allostatic load.

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Epigenetics Epigenetics is the study of how the social and

physical environment change the expression of our genes. Even our genes respond to what happens to us, through chemical reactions that turn certain parts of the genome on or off in response to stress, diet, behavior, toxins and other factors.

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How did we get here- The ACEs Study

● In 1995, the Kaiser Permanente conducted the first ACEs study, to assess the long-term health impact of childhood abuse

● Over 17,000 individuals were included in the study

● Over 50% of respondents had at least one ACE

● People with 6 or more ACE’s died nearly 20 years earlier than those without ACE’s ● 60.6 years old versus 79.1years old

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How did we get here – The ACEs Study

• This study laid the foundation for numerous follow-up studies and initiatives aimed at better understanding the impact of childhood trauma on adult wellbeing

• Researchers are now further exploring the role of

ACEs in many physical and mental health outcomes.

• Findings also helped drive the discussion of

trauma-informed care as a strategy to address the impact of ACEs

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On-going Research • The importance of neighborhood context in youth trauma

among delinquent youth

• The Role of ACE’s and the use of Non-medical Prescription drugs among U.S. Adolescents

• Race/Ethnic difference in exposure to traumatic events and the development of PTSD and treatment seeking for PTSD in the U.S.

• Poly-Victimization and Risk of Posttraumatic, Depressive,

and Substance Use Disorders and the involvement of delinquency in a National Sample of Adolescents

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What the Research says: Researchers have also found links between ACEs and these health and social outcomes:

• Asthma • Depression • Drug abuse • Fetal death • Frequent headaches • Hallucinations • Health-related quality of life • Insufficient sleep

• Intimate partner violence • Liver disease • Sexual assault • Teen pregnancy • Low yearly

income • Medicaid participation • Home ownership • Separation and divorce

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Toxic Prolonged activation of stress response systems

in the absence of protective relationships.

Three Levels of Stress

Tolerable Serious, temporary stress responses, buffered by supportive relationships.

Positive Brief increases in heart rate,

mild elevations in stress hormone levels.

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Toxic Stress Toxic Stress

When young children feel safe and nurtured, they

are calm. This frees their brains, at a neurological

level, to develop these more advanced skills.

Children who experience early trauma — toxic

stress — are often in a chronic state of crisis. They

feel unsafe or threatened, their brains spend more

time in basic, survival-oriented stages of

development.

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Trauma/Toxic Stress Effects in Children ● Altered Neurodevelopment

● Altered cardiovascular regulation ● Behavioral impulsivity ● Increased anxiety ● Increased startle response ● Sleep abnormalities

● Effects on Relationship ● Difficulty forming positive relationships ● Poor sense of self ● Lowered self esteem ● Expectation of being treated poorly ● Loss of secure base ● Loss of sense of trust

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Trauma-Informed, Trauma-Sensitive Health care systems, schools, child protection

agencies and other such organizations can develop approaches that recognize the role of trauma in their clients’ and staff members’ lives.

They can work to build trust, provide supportive relationships and work with clients as partners in healing.

A trauma-informed or trauma-sensitive agency asks: “What happened to you?” rather than “What’s wrong with you?”

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Kentucky Behavioral Risk Factor Survey (KyBRFS)

Eleven questions about adverse childhood

experiences (ACE) were added in the 2015

Kentucky Behavioral Risk Factor Survey

(KyBRFS).

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ACE MODULE - BRFSS Comprised of 11 questions that assess the following eight categories of ACE: Childhood Abuse

1. Physical abuse 2. Sexual Abuse 3. Emotional Abuse

Household Dysfunction 4. Presence of a mentally ill household member 5. Alcohol or drug abuse in the household 6. Incarcerated household member 7. Violence between adults in the household 8. Parental divorce or separation

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ACE Rate in Nine States

KY

KS

AK

CA

AR

LO

NM

TN

WA

Year 2015 2014 2013 2013 2009

Abuse Emotional 24.4% 26.0% 31.0% 34.9% 24.3% 21.1% 28.1% 19.2% 34.9%

Physical 15.3% 15.4% 19.1% 19.9% 14.1% 10.5% 19.5% 12.9% 18.1% Sexual 15.6% 11.3% 14.8% 11.4% 10.9% 9.9% 12.9% 12.7% 13.5%

Household Dysfunction Mental

Illness 19.1% 16.0% 21.9% 15.0% 17.0% 16.6% 19.4% 17.1% 24.3%

Prison 10.9% 6.7% 11.5% 6.6% 5.5% 7.2% 7.1% 8.6% 6.6%

Substance

Abuse 29.9% 25.3% 33.8% 26.1% 25.5% 26.6% 29.9% 28.3% 32.7%

Divorce 33.6% 26.5% 31.7% 26.7% 23.3% 27.1% 24.4% 29.1% 26.0%

Violence 18.7% 15.0% 18.7% 17.5% 15.1% 14.5% 18.9% 17.1% 16.6%

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2015 KyBRFS results

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Prevalence of selected health risk factors among

Kentucky adults aged 18 years and older by ACE score

group, KyBRFS 2015

17.6

9.9

34.4

24.7

14.1

35.9 37.0

18.1

38.7

0

5

10

15

20

25

30

35

40

45

Current Smoking Binge Drinking Obesity

We

igh

ted

%

0 (No ACE) 1-2 (Low ACE) 3+ (High ACE)

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Prevalence of Adverse Childhood Experiences (ACE) among

Kentucky adults ages 18 and older by ACE Score, KyBRFS 2015

40.7

21.3

12.2

8.4 6.2

3.9 3.0 2.3 1.5 0.5 0

5

10

15

20

25

30

35

40

45

0 1 2 3 4 5 6 7 8 9

We

igh

ted

%

Number of Adverse Childhood Experiences Reported (ACE Score)

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ACEs and Kentucky Children 2011-2012 National Survey of Children’s Health 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

2014 KY Kids Count Data Book

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ACEs and High School Sophomores and Seniors

Population

Average

Washington State determined that 13 out of every 30 students will have toxic stress from 3 or more traumatic experiences

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Odds for Academic and Health Problems with Increasing ACEs in Spokane Children

Academic Failure

Severe Attendance Problems

Severe School Behavior Concerns

Frequent Reported Poor Health

Three of more ACEs N=248

3

5

6

4

Two ACEs N=213

2.5

2.5

4

2.5

One ACE N=476

1.5 2

2.5

2.0

No Known ACEs N=1,164

1

1

1

1

Copyright Washington State 2012

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ACE Score and Teen Sexual Behaviors

0

5

10

15

20

25

30

35

40

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Intercourse by 15 Teen Pregnancy Teen Paternity

Pe

rce

nt

wit

h H

eal

th P

rob

lem

(%)

0 1 2 3 4 or more

Ace Score

Hillis S et al, 2001

Percentage of High School Students Who Do Not Have an Adult in Their Life That They Trust and Can Talk to About Serious Problems, by Sex,*

Grade, and Race/Ethnicity, 2015

*F > M (Based on t-test analysis, p < 0.05.) All Hispanic students are included in the Hispanic category. All other races are non-Hispanic. Note: This graph contains weighted results.

Kentucky - YRBS, 2015 - QN99

13.9 11.1

16.5 14.1 15.5 15.0

10.7

15.4 16.7 13.3

0

20

40

60

80

100

Total Male Female 9th 10th 11th 12th Black Hispanic White

Pe

rce

nt

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ACE Score and Attempting Suicide During Adolescence

Dube et al., JAMA, 2001

0

2

4

6

8

10

12

14

16

0 1 2 3 4 5 6 >=7

Pe

rce

nt

(%)

ACE Score

Attempted suicide < = 18 years

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ACES RESEARCH MOVING FORWARD Advocates, policymakers and practitioners are asking how

other childhood experiences (such as economic hardship, neighborhood violence and exposure to racism) are linked to toxic stress and in turn shape child development and lifelong health.

The National Center for Children in Poverty (NCCP) has identified other risk factors: Poverty Low parental education Residential mobility Single parent Teen mother Non-employed parent(s).

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The Center Study of Social Policy: (CSSP) Strengthening Families- A Protective Factors Framework Five protective factors: 1. Parental Resilience: Managing stress and functioning well when faced

with challenges, adversity and trauma

2. Social Connections: Having a sense of connectedness with constructive, supportive people and institutions

3. Knowledge of Parenting and Child Development: Understanding parenting best practices and developmentally appropriate child skills and behaviors

4. Concrete Support in Times of Need: Identifying, accessing and receiving needed adult, child and family services

5. Social and Emotional Competence of Children: Forming secure adult and peer relationships; experiencing, regulating and expressing emotions

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Centers for Disease Control and Prevention. (1999). An ounce of prevention … What are the returns? 2nd edition. Washington, DC: United States Department of Health and Human Services. Miller, T., Romano, E., & Spicer, R. (2000). The cost of childhood unintentional injuries and the value of prevention. The Future of Children, 1(10), 137-162. Nemours Health and Prevention Services & The California Endowment. (2008). Helping parents raise healthy, happy, productive children. In Big Ideas for Children: Investing in Our Nation’s Future (pp. 146-158). Washington, DC: First Focus. Schor, E.L., Abrams, M., & Shea, K. (2007). Medicaid: Health promotion and disease prevention for school readiness. Health Affairs, 26, 420-429.

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Protective Factors Think of these as the opposite of ACEs—the factors or circumstances in a child’s life that buffer her/him from harm and promote stability and resilience. Research has shown that supportive family and social relationships, exercise, adequate sleep, proper nutrition, spending time in nature, listening to music, and meditation are key protective factors for individuals.

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Protective Community Factors includes adequate housing, access to health care, support in times of need and caring adults outside the family who serve as mentors and role models.

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Resilience Resilience is the ability to overcome serious hardship

The foundation of resilience is the combination of

Supportive relationships

Adaptive skill building

Positive experiences that re-inforce self-efficacy, perceived control, and belonging

Resilience requires relationships

The capabilities that underlie resilience can be strengthened at any age

Harvard Center for the Developing Child. Key Concepts

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The Science of Resilience

https://www.youtube.com/watch?v=xSf7pRpOgu8

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How Resilience is Built

https://www.youtube.com/watch?v=1r8hj72bfGo

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Building Community Resilience

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Building Human Resilience Building Blocks

Physical and psychological health of the population; Social and economic well-being Individual, family and community knowledge and

attitudes regarding self-reliance and self-help; Effective risk communication Level of social integration of government and

nongovernmental organizations Skillsets

Active stakeholder engagement Social networks Health Promotion opportunities At risk people’s needs Strengthen/rebuild health and social system

What do Families need to Thrive? • Job opportunities • Fair Wages, scheduling, paid leave • Transportation options • The quality and affordability of housing and neighborhoods • Affordable, healthy food supply • Access to affordable, quality health care • Quality of child care, public schools and opportunities for higher education • Freedom from racism and discrimination • Civic engagement and inclusion • Availability of networks of social support • Family Support

Perspective

If you always do what you have always done, you will always get what you already got.

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What can we do? • Data Sharing • Identify opportunities to incorporate protective factors into

existing programs • Raise awareness and education through community

engagement • Adopt evidence based strategies to address ACES and

resilience • Encourage and support policy that will support building

strong families and strong communities • Commitment from Leadership to recognized the impact of

ACES on the mission and vision of your organization • Reduce structural and institutional barriers that may

prevent families and communities from thriving • Continue to LISTEN to our Youth and our Youth Advocates

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Every child is one caring adult away from

a success story

What do Families need to Thrive? • Job opportunities

• Fair Wages, scheduling, paid leave

• Transportation options

• The quality and affordability of housing and neighborhoods

• Affordable, healthy food supply

• Access to affordable, quality health care

• Quality of child care, public schools and opportunities for higher

education

• Freedom from racism and discrimination

• Civic engagement and inclusion

• Availability of networks of social support

• Family Support

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Take Home Messages Exposure to violence/trauma is the single most

prevalent risk factor for children today.

Adversity is necessary for life and learning; toxic stress disrupts life and learning

Relationships are necessary for resilience.

The lifelong toll of unaddressed Adverse Childhood Experiences is a [perhaps THE] major cause of death and disability in adults

Knowing what we know, we can do better in preventing, mitigating, and treating toxic stress.

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Resources • Adverse childhood experiences reported by adults---five

states, 2009. - https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm

• The Prevalence of Adverse Childhood Experiences (ACE) in the Lives of Juvenile Offenders

file:///C:/Users/Phillip/Downloads/2014.ACEs_Juvenile_Offenders%20(2).pdf

• Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study - http://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext?refuid=S0266-6138(11)00071-4&refissn=0266-6138

• Adverse childhood experiences: national and state-level prevalence. - https://www.childtrends.org/publications/adverse-childhood-experiences-national-and-state-level-prevalence/

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Resources

Kentucky Strengthening Families - http://chfs.ky.gov/dph/mch/ecd/Kentucky+Strengthening+Families.htm ACEs in Foster Care - http://www.acesconnection.com/g/foster-children-parents-support-network BOUNCE: Building Resilient Children and Families - https://louisvilleky.gov/government/safe-healthy-neighborhoods/bounce

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Resources • Predicting Adverse Childhood Experiences: The Importance of

Neighborhood Context in Youth Trauma Among Delinquent Youth

https://www.researchgate.net/publication/273352473

• The Racial and Gender Differences in the Impact of Adverse Childhood Experiences on Juvenile Residential Placement

https://www.researchgate.net/publication/314652289

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Questions

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Thank You!

Vivian Lasley-Bibbs, MPH

Kentucky Department for Public Health

Office of Health Equity

502-564-3970 ext. 4074

Vivian.lasley-bibbs@ky.gov

Ariel Arthur

Kentucky Department for Public Health

Office of Health Equity

502-564-3970 ext. 4075 or 4141

Ariel.Arthur@ky.gov