What Happens
in Childhood
Adverse
Childhood Matters!
Understanding
The ACESExperiences:
StuADSev0--dy,
Toxic Stress, and
Impact and
Promoting
Building
AResiliency
Resilience
September 12, 2016
Erin R. Frazier, M.D.
Medical Director Children’s Hospital
Foundation Office of Child Advocacy
Objectives
• Discuss the research on Adverse Childhood
Experiences
• Understand the impact of toxic stress
• How to increase resiliency
“It is easier to build strong children than to
repair broken men”
Frederick Douglass (1817-1895)
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
Origins of the ACE Study
51 weeks later
408
132 lbs
What was the core problem here?
450
>400 lbs.
in a shorter
period of time
than the weight
was lost.
400
300
250
200
150
Week
Weeks
90
80
70
60
50
40
30
20
10
100
Start
Weight in Lbs
350
ACE Study Design
Survey Wave 1
71% response (9,508/13,454)
Mortality
National Death Index
n=13,000
All medical evaluations
abstracted
Survey Wave II
vs.
Present
Health Status
17,337 adults
Morbidity
Hospitalization
Doctor Office Visits
Emergency Room Visits
Pharmacy Utilization
n=13,000
All medical evaluations
abstracted
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
Source:
http://www.rwjf.org/e
n/aboutrwjf/newsroom/newsr
oomcontent/2013/05/Info
graphic-The-TruthAboutACEs.html?cid=xsh_rw
jf_tw
Adverse Childhood Experiences Score
Number of categories (not events) is summed…
ACE Score Prevalence
0
33%
1
25%
2
15%
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.
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
Prevalence of ACES
Abuse, by Category
Psychological (by parents)
Physical (by parents)
Sexual (anyone)
Neglect, by Category
Emotional
Physical
Household Dysfunction, by Category
Alcoholism or drug use in home
Loss of biological parent < age 18
Depression or mental illness in home
Mother treated violently
Imprisoned household member
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis,
MN.
Prevalance
11%
28%
22%
15%
10%
27%
23%
17%
13%
5%
WHAT IS YOUR ACE SCORE?
• www.WhatsYourACEscore.com
1. Did a parent or other adult in household
often or very often…swear at you, insult
you, put you down, or humiliate you? Or act
in a way that made you afraid that your
might be physically hurt?
2. Did a parent or other adult in the household
often or very often.. Push, grab, slap, or
throw something at you? Or ever hit you so
hard that you had marks or were injured?
3. Did an adult or person at least 5 years older
than you ever touch or fondle you or have
you touch their body in a sexual way? Or
attempt or actually have oral, anal, or
vaginal intercourse with you?
4. Did you often or very often feel that…no
one in your family loved you or your family
didn’t look out for each, feel close or
support each other.
5. Did you often or very often feel that… you
didn’t have enough to eat, had to wear dirty
clothes, and had no one to protect you? Or
your parents were to drunk or high to take
care of you or take you to the doctor?
6. Were your parents every separated or
divorced?
7. Was your mother or stepmother: often or
very often pushed, grabbed, slapped, or had
something thrown at her or sometime,
often or very often kicked, bitten, hit with a
fist or hit with something hard or ever
repeately hit at least a few minutes or
threatened with a gun or knife?
8. Did you live with anyone who was a
problem drinker or alcoholic, or used street
drugs?
9. Was a household member depressed or
mentally ill or attempt suicide?
10. Did a household member go to prison?
% With a Lifetime History of
Depression
Well-being
Childhood Experiences Underlie Chronic Depression
80
70
60
50
40
30
20
Women
Men
10
0
0
1
2
ACE Score
3
>=4
With permission: Felitti, VJ. The ACE Study
Powerpoint,
Academy of Violence and Trauma. April, 2011.
Minneapolis, MN.
Well-being
Childhood Experiences Underlie Suicide Attempts
25
% Attempting Suicide
20
15
10
5
0
ACE Score
0
1
2
3
4+
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis,
MN.
Health Risks
Adverse Childhood Experiences vs. Smoking as an Adult
20
18
16
14
12
10
8
%
6
4
2
0
0
1
2
3
4-5
ACE Score
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
6 or more
p< .001
Health Risks
Childhood Experiences vs. Adult Alcoholism
18
16
% Alcoholic
14
4+
12
10
3
8
2
6
4
1
2
0
0
ACE Score
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
Health risks
ACE Score vs Injection Drug Use
% Have Injected Drugs
3.5
3
2.5
2
1.5
1
0.5
0
0
1
2
3
ACE Score
With permission: Felitti, VJ. The ACE Study
Powerpoint,
Academy of Violence and Trauma. April, 2011.
Minneapolis, MN.
4 or more
p<0.001
ACE Score and Teen Sexual Behavior
Social function
Looking for love
45
Percent With Health Problem (%)
40
ACE Score
0
1
2
3
4 or more
35
30
25
20
15
10
5
0
Intercourse by Age 15
Teen Pregnancy
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
Teen Paternity
Social function
ACE Score and the
Risk of Perpetrating Domestic Violence
__________________________________
15
Men
Women
10
5
0
0
1
2
3
4
>5
0
ACE Score
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
1
2
3
4
>5
Social function
ACE Score and Indicators of Impaired Worker Performance
25
ACE Score
20
0
1
2
3
4 or more
15
10
5
0
Absenteeism
(>2 days/month)
Serious
Financial
Problems
Serious
Problems
Performing Job
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis, MN
Biomedical Disease
Percent with Problem
ACE Score vs. COPD
18
16
14
12
10
8
6
4
2
0
COPD
0
1
2
3
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
4
Source: Dong el al (2004). Credit: Center on the Developing
Child.
Biomedical Disease
ACEs Increase Likelihood of Heart Disease*
•
•
•
•
•
•
•
•
•
Emotional abuse 1.7x
Physical abuse
1.5x
Sexual abuse
1.4x
Domestic violence 1.4x
Mental illness
1.4x
Substance abuse 1.3x
Household criminal 1.7x
Emotional neglect 1.3x
Physical neglect
1.4x
*After correction for age, race, education, and conventional risk factors like smoking and
.
diabetes.Circulation
, Sept 2004
Effect of ACEs on Death Rate
(Null hypothesis)
>=6 ACE
shortens
lifespan by
20 yrs.
Age
Group
Percent in Age Group
60
19-34
35-49
50-64
65=>
50
40
30
20
10
0
0
2
ACE Score
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis,
MN.
4
Odds for Academic and Health Problems
with Increasing ACEs in Spokane Children
Academic
Failure
Three of more
ACEs N=248
Severe
Attendance
Problems
Severe School
Behavior
Concerns
Frequent
Reported Poor
Health
3
5
6
4
Two Aces
N=213
2.5
2.5
4
2.5
One Aces
N=476
1.5
2
2.5
2
No Known ACEs
=1,164
1.0
1.0
1.0
1.0
Copyright Washington State 2012
Source: Barth et al (2008). Credit: Center on the
Developing Child.
Adverse Childhood Experiences Survey
SOURCE:
http://www.childhealthdata.org/browse/rankings/
maps?s=108
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
Source: 2014 KY Kids Count Data Book
KY’s Most Common ACES
13%
14%
30%
29%
Sources:
http://www.rwjf.org/en/aboutrwjf/newsroom/newsroomcontent/2013/05/Infographic-TheTruth-AboutACEs.html?cid=xsh_rwjf_tw; 2014
KY Kids Count Data Book
What is their ACE score?
A public health perspective
What are conventionally viewed
as Public Health problems are often
personal solutions to long-concealed
adverse childhood experiences.
The American Academy of Pediatrics is
now asserting the ACEs are the single
greatest unaddressed public health
threat facing our nation today.
Types of Stress
With permission: Felitti, VJ. The
ACE Study Powerpoint,
Academy of Violence and Trauma.
April, 2011. Minneapolis, MN.
July 6, 2007
Toxic Stress
“In my beginning is
my end”
T.S. Eliott
Toxic Stress
Toxic Stress
Physiology of Stress
Transient activation of the stress
-
response is necessary for survival
-Additionally inflammatory
cytokines are released
What does toxic stress do?
The stress response is overstimulated and is
not able to regulate normally
THESE CHILDREN ARE
CONSTANTLY BEING CHASED
BY THE BEAR
Percent of Children with Abnormal
Stress Hormone Levels
35%
Hormone levels
30%
25%
20%
15%
Hormone levels
10%
5%
0%
Middle Class US Toddlers
in Birth Families
Neglected/Maltreated
Toddlers from Overseas
Orphanages
Source: Gunnnar and Firsher (2006) Harvard Center
for the Developing Child
Basic Brain Anatomy
• Limbic system- emotions
• Amygdala-fight or flight
• Hippocampus-store and
files memories
• Neocortical structuresplanning and control
Balance of Brain Function
Executive function
• Able to problem solve
• Self-control
• Self-confidence
• Able to calm self
• Follow direction
• Manage temper when
provoked
• Delay gratification
• Able to plan
Adapted from Dr. Ruth Ann Shepherd
“Amydgala Hijack”-toxic stress
• Impaired memory esp.
working and contextual
• Inability to concentrate
• Hard to follow directions
• Hard to sit still
• Constantly on edge
• Easily provoked
• Impulsive
Why is this toxic stress so important to the developing
brain?
--The plasticity of the young
infant/child’s brain makes it
particularly vulnerable to
increases in stress hormones
--First 1,000 days have a
strong impact on brain
development
-
• The brain is built by connections
from the ground up like a house
A weak foundation can lead to
compromised function
Simple connections for complex circuits over time with
appropriate reinforcement
The first three years of life are the most active with 700-1,000
new connections per second
http://developingchild.harvard.edu/science/key-concepts/brainarchitecture
Serve and Return
www.harvardcenterforthedevelopingchild.com
Source: C.A. Nelson (2008) : Marshall, Fox, & the BEIP Core Group (2004)
CHRONIC
STRESS
Hypothalmus
Proinflammatory
cytokines
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
Effects on Developing
Brain
Effects on Biomedical
Disease
Epigenetics
• Science behind
nature vs nuture
• Stress/toxins/poor
nutrition can
actually cause
genes to be turned
on or off and can
be passed on
generationally
Physical Manifestations of Toxic Stress
Diarrhea/
constipation
Headaches
Nightmares
Anxiety/
Depression
Backaches
Anger
Diabetes
risk
Tantrums
Social
Isolation
Impaired
Immune system
Heart
palpitations
Abdominal
pain
High
Blood
Pressure
Difficulty
sleeping
Intergenerational Cycle of Toxic Stress
• s ACEs- family
dysfuncton/abuse
/neglect
Untreated/
unrecognized
Adult-FFF+risky
behavior+
Depression
Suicide
Victim of DV
IV drug use
Difficulty at work
Financial difficulty
Chronic diseases
Unplanned
pregnancy
Toxic Stress
Abnormal Brain Structure
and function
High stress hormones
Adolescent-FFF+
Teen smoking
Pregnancy
Drug and alcohol use
Juvenile delinquency
Gangs
Fighting
Out of control
Source: Felitti VJ. 2013 The Origins of Addiction : Evidence from the Adverse
Childhood Experiences Study
Child
Fight, Flight, Freeze
Can’t sit still
Memory problems
Speech delay
Poor relationship
Lack of empathy
Always of edge
Resiliency
When positive
experiences
outweigh
negative one- a
child’s “scale”
tips toward
positive outcomes
Paradoxically,
Trauma both occurs in the context of a
relationship and can only be healed in the
context of a relationship
Resilience Score
I believe my mother loved me when I was
little.
I believe my father loved me when I was
little.
When I was little, other people helped my
parents take care of me and they seemed to
love me.
I’ve heard that when I was an infant, someone
in my family enjoyed playing with me.
When I was a child, there were relative in my
family who helped me feel better when I was
sad or worried.
When I was a child, neighbors or my friends’
parents seemed to like me.
When I was a child, teachers, coaches, youth
leaders or minister were there for me.
Someone in my family cared about how I was
doing in school.
My family, friends, and neighbors talked about
making our lives better.
We had rules in our house and were expected
to keep them.
When I felt really bad, I could almost always
find someone I trusted to talk to.
As a youth, people noticed that I was capable
and could get things done.
I was independent and a go-getter.
I believe that life is what you make it.
There are people I can count on now in my
life.
Change the First Five
Years and You Change
Everything!
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!!
Every child is one caring adult
away from a success story
Building Resiliency as Individuals
Building resiliency is important for your patients,
your children, your family members, or your
neighbors!
Resiliency and the 7cs
•
•
•
•
•
•
•
Competence
Confidence
Connection
Character
Contribution
Coping
Control
• Competence and Confidence-praise the
effort not the end result
• Connection-slow down, form relationships,
develop empathy, larger community
• Character-right from wrong
• Contribution-developing
a sense of purpose
• Coping-role model stress reduction, eat
healthy, adequate sleep
• Control-discipline is about teaching
not about controlling or punishing
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
Improving Community Resilience
• Invest early in parents and young children
– Home visitation programs-HANDS, Healthy start
– Early Head Start, Jump Start, Head start
– Help parents assess and understand their own
trauma and how it affects their children
www.futureswithoutviolence.org
• Help schools promote positive school climates,
be trauma-sensitive, and raise achievement
– BOUNCE coalition
– Implement programs and provide resources for
mental health services in the school system
– School Resource services
– Police interaction with JCPS
• Health care providers should be trained on
trauma informed care and ACES
– Medical homes
– Breakdown barriers
– What is important to the patient? Food insecurity
– Promote positive parenting programs- normalize
– Medical-legal partnerships
– Increase access to mental health providers
– Think outside the box-medicine filled/late appts
• Prevent violence and trauma
– Domestic Violence education
– Improve community infra-structure
– Promote father programs
– Drug addiction programs
– Increase awareness of poverty and increase jobs
• Bring community members together to
promote services and problem solve
• Educate the Kentucky General Assembly
“Resilience”
• Sold out crowds at the Sundance film
festival
Wealth of resources on
the American Academy
of Pediatrics website
aap.org/theresilienceproject
Adverse Childhood Experiences Score
Number of categories (not events) is summed…
ACE Score Prevalence
0
33%
1
25%
2
15%
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.
With permission: Felitti, VJ. The ACE Study Powerpoint,
Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
Breaking the cycle
Caregiver with
high ACES
Health care
provider
Support another
family
Teacher
Trauma
informed care
(ACEs
education)
Social Worker
CASA
Resource worker
Home visitation
Early Head Start
Successful parent
and child
Drug Rehabilitation
Parenting
education
Job Training
Community
Partners
It turns from “what is wrong
with you to what happened to
you”
Take care of yourself
• Mindfulness
• Healthy Coping
• One day at a time one step forward at a time
Sources
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. Ginsburg, Kenneth M.D. Building Resilience in Children and Teens: Giving Kids Root and Wings. Elk Grove
Village, IL. American Academy of Pediatrics, 2015.
3. Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and
Dependent Care, and Section on Developmental and Behavioral Pediatrics; American Academy of Pediatrics. The
Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. 2012;129: e232-243.
4.Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and
Dependent Care, and Section on Developmental and Behavioral Pediatrics; American Academy of Pediatrics. Early
Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong
Health. Pediatrics. 2012;29: e224-231.
5. Felitti, VJ. The ACE Study Powerpoint. Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
6. http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/05/Infographic-The-Truth-AboutACEs.html?cid=xsh_rwjf_tw. Accessed May 2015.
7. Anda, RF.. The ACE Study Powerpoint. Academy of Violence and Trauma. April, 2011. Minneapolis, MN.
8. http://www.childhealthdata.org/browse/rankings/maps?s=108. Accessed May 2015.
9.
2014 Kentucky Kids Count County Data Book. KY Youth Advocates. p. 9-17.
10.
www.developingchild.harvard.edu