2/2/2018

1

Adverse Childhood Experiences and Toxic Stress:

Moving from Theory into Practice

R.J. Gillespie, MD, MHPE, FAAP

The Children’s Clinic – Portland, OR

St. Luke’s Children’s Hospital Grand Rounds

May 17, 2017

Disclosures

I have no personal financial relationships in any commercial interest related to this CME.

I do not plan to reference off label/unapproved uses of drugs or devices.

2/2/2018

2

Objectives

• Define Adverse Childhood Experiences and Toxic Stress.• Brief overview of current theories in the physiologic mechanisms

connecting environmental stresses to health risks.

• Discuss the role of the primary care provider in addressing toxic stress in practice.• Review a few potential screening and surveillance options.

• Provide a practice example of incorporating ACE assessments in practice.

BackgroundWhat are Adverse Childhood Experiences and Toxic Stress?

2/2/2018

3

Adverse Childhood Experiences

Felitti, et al. Am J Prev Med 1998;14:245–258

“We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.”

Source: Centers for Disease Control and Prevention

Credit: Robert Wood Johnson Foundation

ACEs are Common

• About 2/3 report at least one ACE

• 40% reported 2 or more ACEs

• 12.5% reported 4 or more ACEs

• If a patient has disclosed one ACE, there is approximately an 87% chance that they have experienced another.

• Felitti, et al.

2/2/2018

4

2/2/2018

5

2/2/2018

6

Premature Morbidity & Mortality with ACEs

• 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

• Autoimmune diseases

• ER Visits

• Medical Office Visits

• Fractures

• Psychotropic Medications Prescribed

• Early Death from MI

ACE Pyramid

2/2/2018

7

National Survey of Children’s Health 2016

• ACEs are a factor in a lot of the common problems that we see on a daily basis.

• 69% of kids with behavioral problems have ACEs

• 45.7% of kids at risk for development have ACEs

• About two-thirds of children ages 6-17 who bully, pick on, or exclude other children—or are themselves bullied, picked on, or excluded—have ACEs.

More NSCH Facts…

• ACEs impact a child’s social emotional development and chances of school success.

• Children ages 3-5 who have had two or more ACEs are over four times more likely to have three out of six social and emotional challenges, for example, have trouble calming themselves down, be easily distracted, and have a hard time making and keeping friends.

• More than three out of four children ages 3-5 who have been expelled from preschool also had ACEs.

• Children ages 6-17 who have had two or more ACEs are twice as likely to be disengaged from school than are peers who have had no ACEs.

2/2/2018

8

Beyond ACEs…Stress and Toxic Stress

• Normal stress: Everyday pressure that pushes us to perform. Usually temporary and has an activating effect.

• Tolerable stress: Negative events (usually temporary or one-time) that are well-buffered by coping strategies and support of those around us.

• Toxic stress: Chronic, repeated stresses – often committed by those who are supposed to support us – and which overwhelm our capacity for coping.

Cumulative Burden of Recurrent or PersistentExposure to Trauma

• Alterations in brain architecture (decreased gray matter, smaller hippocampus, decreased prefrontal activity, hypertrophy of amygdala)

• Changes in gene expression • Endocrine and immune imbalance• Decreased executive function and affect regulation• Interference with relational health• Behavioral allostasis• Chronic illness, health disparities, decreased quality and

length of life

2/2/2018

9

Eco-Bio-Developmental (EBD) model of human health and disease

BiologyPhysiologic Adaptations

and Disruptions

Life Course Science

The Basic

Science ofPediatrics

EcologyBecomes biology,

And together they drive development across the lifespan

• Underscores the need to improve the early childhood ecology in order to:• Mitigate the biological underpinnings for educational, health and

economic disparities

• Improve developmental/life-course trajectories

• Highlights the pivotal role of toxic stress• Not just “step on the gas” or enrichment

• But “take off the brake” by treating, mitigating or immunizing against toxic stress

Advantages of an EBD Framework

2/2/2018

10

The BIG Questions

If TOXIC STRESS is the missing link between ACE exposure and the unhealthy lifestyles and poor outcomes seen as adults, it raises the following BIG questions:

1) Are there ways to treat, mitigate, and/or immunize against the effects of toxic stress?

2) What are the long term costs due to toxic stress versus the up-front costs to treat, mitigate or immunize?

“We are the only living species that regularly and predictably maims and destroys its own young.”

Sandra L. Bloom

Creating Sanctuary

2/2/2018

11

A Word from the American Academy of Pediatrics…• Pediatric medical homes should:

1. strengthen their provision of anticipatory guidance to support children’s emerging social-emotional-linguistic skills and to encourage the adoption of positive parenting techniques;

2. actively screen for precipitants of toxic stress that are common in their particular practices;

3. develop, help secure funding, and participate in innovative service-delivery adaptations that expand the ability of the medical home to support children at risk; and

4. identify (or advocate for the development of) local resources that address those risks for toxic stress that are prevalent in their communities.

Smoking Prevention

2/2/2018

12

Drug Abuse Prevention

Alcohol abuse prevention

2/2/2018

13

Teen pregnancy prevention

Prevention of Early Death From Heart Attacks

2/2/2018

14

Kindergarten Readiness

The Role of the Primary Care ProviderSome tips for getting started

2/2/2018

15

Considering Children who have been Exposed to Trauma as CYSHN

• Medical home model originally developed for CYSHN

• CEV meet the definition of CYSHN as they…• Are at risk for poor health outcomes

• Should be connected to additional services compared to other children

• Deserve tracking and follow up

• “CEV need developmental promotion times ten.”

Basic Medical Home Workflow

• Identify the population through screening or surveillance, and track them

• Assess the family and patient strengths / assets, and needs for specific services

• Make referrals

• Provide self-management tools (developmental promotion)

• Follow up on referrals / close communication loops

2/2/2018

16

Four Starting Questions:

1. Why am I looking?

2. What am I looking for?

3. How do I find it?

4. What do I do once I’ve found it?

4. What Do I Do Once I’ve Found It?

• Ethical question: why screen if you don’t know what you’re going to do with the information?

2/2/2018

17

1. Why am I Looking?

• Is there a particular need in my community or patient population that needs to be addressed?

• Is there a specific interest amongst my providers to address a particular practice gap?• Is there a clinical problem that I’m trying to get a handle on?

• Is there an outcome that I’m trying to improve?

2. What am I Looking For?

•Different approaches depending on practice readiness and goals of screening / surveillance.• Am I looking for a specific trauma or

toxic stress / ACEs in general?

•Who am I screening?• Universal?

• Targeted for specific problems: somatic complaints, mental health concerns, school failure?

• Patients or families / parents?

2/2/2018

18

Types of Childhood Violence Exposure

•Abuse – physical, emotional, sexual

•Domestic Violence

•Bullying

•Dating Violence

•Community violence / gang activity

•Sexual exploitation / trafficking

Endemic

•School violence

•Natural disasters

•Terrorism

•War / Genocide

Episodic

The Role of Surveillance

• Not all cases will be identified via routine interview• Remember that certain symptoms may be a manifestation

of stressful experiences or exposure to violence:• Under two: dysregulated eating, sleeping patterns;

developmental regression; irritability, sadness, anger; poor appetite, low weight; increased separation anxiety, clinginess

• 3-6 years: Increased aggression; somatic symptoms; sleep difficulties/nightmares; increased separation anxiety; new fears; increased distractibility/high activity level; increased withdrawal/apathy; developmental regression; repetitive talk/play about the event; intrusive thoughts, memories, worries

NCTSN.org/earlychildhoodtrauma

2/2/2018

19

How do Children Exposed to Toxic Stress Present in the Classroom?• Aggression

• Anxiety

• Problems with focus / attention (vs. “hypervigilence”)

• Withdrawal / apathy

• Others?

3. How do I Find It?

• What techniques fit into my practice style and context?• Paper-based screening tools or surveillance questions?

• Some types of screening are more amenable to paper-based tools.

• How will I maintain respect, privacy and trust?

2/2/2018

20

How do I find it? Deciding on an Office Workflow

• At which visits will I do my assessments?

• How will I ask the questions? Pre-visit questionnaire versus direct interview?

• If a questionnaire, who will distribute, explain to patients, and get it to the provider? How do I ensure patient privacy as they answer the questions?

• If direct interview, what decision supports will help me remember the questions?

• How do I document the results?

Setting the Stage: Introductory Questions

• “I have begun to ask all of the women / parents / caregivers in my practice about their family life as it affects their health and safety, and that of their children. May I ask you a few questions?”

• “Violence is an issue that unfortunately effects everyone today and thus I have begun to ask all families in my practice about exposure to violence. May I ask you a few questions?”

Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health. From www.futureswithoutviolence.org.

2/2/2018

21

How Do I Find it? Surveillance Tips

• Universal surveillance question:

“Since the last time I saw your child, has anything really scary or upsetting happened to your child or anyone in your family?”

(Cohen, Kelleher, & Mannarino, 2008)

“The New Mexico Three”

• Some providers feel that a one-sided focus is unbalanced:

• Since the last time I saw you have there been any issues that have caused you or your child great stress?

• Are there any of these issues that still bother you?• In spite of this, can you tell me something good that has

happened?

Courtesy of Javier Aceves, MD – University of New Mexico

2/2/2018

22

Other Surveillance Options

• Consider other formats and opportunities for surveillance.• Are there specific trauma types that you want to do surveillance for (see

the AAP Resilience Project website for specific question suggestions)?• At specific visit types (somatic or mental health concerns)

• Do you have a systematic way for assessing a history of trauma in these types of visits?

• What decision support / documentation prompts might help with this?

• Other screening / questionnaire opportunities• Adolescent Well Visit Questionnaires – opportunity to assess dating violence,

bullying, family conflicts.• General mental health screeners: Pediatric Symptom Checklist• Specific mental health screeners: PHQ2 or PHQ9, CRAFFT, SCARED, Vanderbilt –

does your follow up history questions and plan include a “trauma lens”?

Screening tools

Always work hard on something

uncomfortably exciting.

Larry Page

2/2/2018

23

Social Determinants of Health

“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”

World Health Organization

2/2/2018

24

Sample Screening Map

Visit and recommended screening tools

2 week

New patient forms, demographics, family history paperwork

2 month

Post partum depression

4 month

6 month

Post partum depression

9 month

Developmental Screening tool

12 month

Lead assessmentTB risk assessment

15 month 18 month

Developmental Screening toolAutism Screening tool

24 month

Lead assessmentAutism Screening tool

Postpartum Depression

• Current AAP guidelines recommend screening at every well visit in the first six months after birth.

• As this is a social determinant (and an important source of toxic stress for the child)…consider screening for this if you aren’t already.

• Edinburgh is most commonly used.

• Be prepared to refer to (a) the mother’s PCP or OB, (b) community resources, including emergent mental health support, or (c) both, if needed.

2/2/2018

25

Special Considerations for IPV Screening

• Studies indicate that women prefer self-administered assessments when asking about IPV

• Family Violence Prevention Fund has published guidelines for managing IPV, including tips for ensuring safety / developing a safety plan

• Remember that exposure to IPV is associated with a higher risk of child abuse – some states have specific reporting requirements

• AAP Clinical Report – Intimate Partner Violence: The Role of the Pediatrician. Pediatrics 2010; 125: 1094-1100.

Domestic Violence Screen for Pediatric Settings

1. Are you in a relationship now or have you ever been in a relationship in which you have been harmed or felt afraid of your partner?

2. Has your partner ever hurt any of your children?

3. Are you afraid of your current partner?

4. Do you have any pets in the house?

5. Has your partner or child ever threatened or hurt any of the pets?

6. Are there any guns in your house?Siegel RM, Hill TD, Henderson VA, Ernst HM, Boat BW (1999). Screening for domestic violence in the community pediatric

setting. Pediatrics 104, 874-77.

2/2/2018

26

The Adverse Childhood Experiences Survey

• The original ten ACE questions devised by Felitti & Anda in their original study.

• Many sites are using this as a clinical tool to assess for trauma.

• Finkelhor et al. described an “enhanced ACE screen” to include additional traumas such as community violence, bullying, racism / prejudice.

• Some centers are using an “aggregate” format rather than individual response format to allow for greater privacy.

Caveats

• The tool was not specifically developed or validated as a clinical tool (epidemiologic use).

• Item-level responses may be difficult for people to feel comfortable disclosing.

• Items on the ACE questions may be reportable if using in children.

• Discussed past traumas and not present stresses…• Food or housing insecurity, extreme poverty, current domestic violence

are not assessed.

• Other past and present traumas (immigration / refugee status, for example) are also not included.

2/2/2018

27

The Safe Environment for Every Kid (SEEK)

• Developed by the University of Maryland and the Maryland Department of Human Resources with funding from the CDC.

• Looks for common risk factors for child maltreatment, including:• Maternal depression• Alcohol and substance abuse• Intimate partner violence• Harsh parenting styles• Major parental stress• Food insecurity

• Recommended to be used at multiple visits, such as the 2, 9 and 15-month, and the 2, 3, 4, and 5-year visits.

2/2/2018

28

Caveats

• Must spend time mapping questions to your proposed clinical response, including local resources / referrals.

• Low sensitivity but high specificity.

• Considered ideal to have a behavioral health / social worker available to help with positive responses.

• Found to reduce the risk of child maltreatment in low risk populations in randomized controlled trials.

The Survey of Well-being in Young Children (SWYC)• Developed at Tufts University.

• Survey designed to assess developmental milestones, infant and toddler behavior, and family risk factors.

• Questionnaires developed for ages 2 months through 5 years.

• Can be downloaded for free at https://www.floatinghospital.org/The-Survey-of-Wellbeing-of-Young-Children/Overview.aspx

2/2/2018

29

Caveats

• Are there specific tools that are approved by Medicaid for 96110 (for example, in my state, the SWYC is not…)? Also would need to verify billing for 96127 (social-emotional screening tool).

• Again need to map out resources, responses to each segment of the tool.

• Some practices have opted to do just the family risk questions rather than the entire tool (thus supplementing other developmental screening tools that they’ve already implemented).

2/2/2018

30

So what’s better? Surveillance or Screening?• Consider that “success” in conversations around trauma and toxic

stress is often relational.

• Consider how screening tools and questionnaires are treated in your office.• Not the type of survey to put aside to review later…

• Screening tools should be, at their core, educational in some way…

• So what message are you giving with how your tools are handled?

• That said, what is the provider’s and patient’s comfort with surveillance and direct interviews versus screening tools?

• My answer? Depends on the situation…

Surveillance or Screening?

• Screening – often a more comfortable way to introduce a subject.• Universal approach rather than an assumption of a problem

• Can be used to create an atmosphere of safety.

• Surveillance – better flow when in the middle of a visit.• Surveillance questions are often inserted into the natural flow of a

conversation.

• Trigger questions to elicit more information than just a yes / no that a screening tool implies.

2/2/2018

31

4. What do I do Once I’ve Found It?

• Assessment of child and family safety

• Assets, resources and resiliencies in the family

• Follow up tools for assessing mental health in patients as needed• PSC, Emotional Distress Screening, PTSD Reaction

Index

• Connecting with appropriate resources

A Brief Example…How my clinic has addressed ACEs and Toxic Stress

2/2/2018

32

Stories from the literature – why parent trauma matters….

Correlations exist between parent ACE scores and child’s ACE score…the more ACEs a parent experiences, the more ACEs the child is likely to experience.

Parenting styles are at least in part inherited: if a parent experienced harsh parenting, they are more likely to engage in harsh parenting styles themselves.

Parents have new brain growth in the first six months after their child’s birth – in both the amygdala (emotional center) and frontal cortex (logical center) UNLESS they are experiencing stress, which impairs frontal cortex development.

Children who have experienced three or more ACEs before entering Kindergarten have lower readiness scores: literacy, language and math skills are lower – and rates of behavioral problems are higher.

1

2

3

4

The assumption

If…• we can identify parents who are at greatest risk• bring their trauma histories out of the closet• agree to support them when they feel most challenged in a

non-judgmental way

…we will be able to create a new cycle of healthier parenting.

2/2/2018

33

The Theory…

• Certain moments in the life of an infant or toddler will be stressful• Tantrums, colic, toilet training, hitting / biting, sleep

problems are examples

• What happens to a parent who has experienced trauma? Will their response be:• Fight?• Flight?• Freeze?• Can it be something else?

• How can we better prepare at-risk parents for these inevitable moments?

And thinking further…

• If a parent experienced trauma, do they have appropriate skills / ideas for:• Taking care of themselves?• Identifying when they need help?• Modeling appropriate conflict resolution?• Discipline that is developmentally

appropriate?• Playing with their child?

• In other words, can we teach parents and children to be more resilient?

2/2/2018

34

Case Study: The Children’s Clinic

• 30 providers in three practice sites• Strong interest in early childhood development / developmental

promotion• Since 2008 have implemented multiple standardized universal screening

protocols• Developmental delay• Autism• Maternal Depression• Adolescent Depression• Adolescent Substance Abuse

• Adolescent questionnaire has always included questions about dating violence; many providers ask about bullying in their history for school aged children.

Our Logic Model

Standard Anticipatory Guidance

“Enhanced” Anticipatory Guidance

2/2/2018

35

How do I Find it? Our First Step

• Eight providers piloted screening

• At the four month visit, parents are given the ACE screener, along with a questionnaire about resilience and a list of potential resources.

• Cover letter explaining the rationale for the screening tool, and what we plan to do with the information

• Created a confidential field in the EMR that does not print into notes, but perpetuates into visits to document results while minimizing risk to families.

What do I do Once I’ve Found It? Meaningful Conversations and Follow Up

• Selected Connected Kids resources stocked in exam rooms. Offered Zero to Three resources to providers to use selectively.

• Used guidance from Connected Kids to supplement conversation during subsequent exams.

• Care Coordinator tracked down community resources (parenting classes, resources for home visitation, support groups, etc.).

2/2/2018

36

Initiating the Conversation to Help Families Understand their own Experiences

• Thank parents for opening up about their experiences, validate the importance of the conversation.

• Are there any of these experiences that still bother you now?

• Of those that no longer bother you, how did you get to the point that they don’t bother you?

• How do you think these experiences affect your parenting now?

Teach Parents What Resilience Means

• Defining Resilience: the ability to resist, recover from, and grow from adversities.

• If parents understand resilience factors, they can identify where they need to strengthen their own systems.• Include the message of hope…ACEs are not our destiny – resilience gives us the chance to

shape our future.

• Once parents have understood and worked on resiliency, they can model that for their children.

• Remember that what we’re doing is also what we are asking parents to do.

2/2/2018

37

Key Findings

• We get better response rates from parents if we use an aggregate format compared to asking individual questions (11.2% vs. 8.1% endorse an ACE score of 4 or higher).

• Parents are willing to talk about this…and providers have found it so valuable that they say they’ll continue this indefinitely.

• Average conversations take 3-5 minutes, and are tailored to the parents’ needs at the time of the visit.

• Unfortunately, it doesn’t take a lot of parental ACEs to negatively impact the child’s developmental screening scores.

2/2/2018

38

Adjusted risk for suspected developmental delayRelative Risk (95% CI)

aMaternal (n=311) bPaternal (n=122)

cACE

≥ 1 1.25 (0.77, 2.00) 2.47 (1.09, 5.57)**

< 1 (Ref) - -

≥ 2 1.78 (1.11, 2.91)** 3.96 (1.45, 10.83)***

< 2 (Ref) - -

≥ 3 2.23 (1.37, 3.63)*** 0.82 (0.12, 5.72)

< 3 (Ref) - -

Payer source

Public 1.67 (1.05, 2.67)** 0.87 (0.37, 2.03)

Private (Ref) - -

Gestational age at birth

< 37 weeks 1.70 (0.89, 3.24) 7.76 (3.12, 19.33)***

≥ 37 weeks (Ref) - -

* = p <0.1, ** = p <0.05, *** = p <0.01

Domain-specific developmental risk by Maternal ACE exposure

Maternal ACEsRelative Risk (95% CI)

≥ 1 (n=149) <1 (n=162)

Communication, n (%) 24 (16.3) 18 (11.1) 1.47 (0.83, 2.60)

Gross Motor, n (%) 20 (13.5) 17 (10.6) 1.28 (0.70, 2.35)

Fine Motor, n (%) 18 (12.1) 16 (9.9) 1.22 (0.65, 2.31)

Problem Solving, n (%) 17 (11.6) 8 (5.0) 2.31 (1.03, 5.20)**

Personal-Social, n (%) 19 (12.9) 17 (10.6) 1.22 (0.66, 2.26)

≥ 2 (n=60) <2 (n=251)

Communication, n (%) 12 (20.3) 30 (12.0) 1.69 (0.92, 3.11)*

Gross Motor, n (%) 12 (20.0) 25 (10.0) 1.99 (1.06, 3.73)**

Fine Motor, n (%) 9 (15.0) 25 (10.0) 1.51 (0.74, 3.06)

Problem Solving, n (%) 11 (18.3) 14 (5.7) 3.23 (1.55, 6.76)***

Personal-Social, n (%) 9 (15.0) 27 (10.9) 1.38 (0.68, 2.77)

≥ 3 (n=39) <3 (n=272)

Communication, n (%) 10 (26.3) 32 (11.8) 2.23 (1.19, 4.16)**

Gross Motor, n (%) 9 (23.1) 28 (10.4) 2.23 (1.14, 4.36)**

Fine Motor, n (%) 8 (20.5) 26 (9.6) 2.15 (1.05, 4.40)**

Problem Solving, n (%) 6 (15.4) 19 (7.1) 2.17 (0.92, 5.10)*

Personal-Social, n (%) 8 (20.5) 28 (10.4) 1.97 (0.97, 4.01)*

* = p <0.1, ** = p <0.05, *** = p <0.01

2/2/2018

39

Dose response relationship between Maternal ACE and risk for suspected developmental delay

Hypothesis #1

• Assessing parental ACEs is feasible in primary care…that is, parents will accept it, providers will do it, and it won’t disrupt our flow too much.

2/2/2018

40

Hypothesis #2

• Screening for parental ACEs will make a difference.

• Our next steps: understanding interventions that work, building relationships in the community, studying more outcomes of kids whose parents had high ACEs, getting more feedback from parents about their experiences.

Why I think this works…And what you need to make this work.

2/2/2018

41

Listening is Therapeutic…But Who the Listener is Matters

• For a person who has experienced trauma, authority figures (including parents / caregivers, schools, health care systems, mental health institutions, etc.) were often those inflicting the trauma.

• When an authority figure becomes the listener, that authority becomes a positive, strategic force for healing.• Can the adults around us tolerate the conversation?• The message of silence or ignoring: history is not important or speaker is

not safe.

Validating the Experiences

• When survivors said that they had been listened to with compassion they were 2.9 times more likely to report being mostly or completely healed.

• When survivors believed that people understood the impact of trauma on their lives they were 2.2 times more likely to report being mostly or completely healed.

• When survivors believed that people knew how to help them heal they were 2.3 times more likely to report being mostly or completely healed

From: Survivor Voices Study, 2009 & 2011, Trauma Healing Project, Eugene, OR

2/2/2018

42

Redefining Our Role & Goal: Understanding the “Righting Reflex”

• “Success” in our conversations about ACEs and trauma is relational.• Is the door open to further conversation?

• Conversation should be validating, safe and non-threatening.

• If we’re leaning on our training to “fix everything” we may not be present to hear the stories.

• Parents’ behaviors make more sense if you understand their story.• Instead of “what’s wrong with this person?”, think “what happened to this

person?”

What I think you need to make this work…

• A provider champion

• A clear idea of what you’re looking for and why

• A trauma-informed office / support staff

• A willingness to get your hands dirty

• A lot of self-care

• An understanding of community resources and partnerships available to you

2/2/2018

43

Back to the AAP Statement…

• Pediatric medical homes should:1. strengthen their provision of anticipatory guidance to support

children’s emerging social-emotional-linguistic skills and to encourage the adoption of positive parenting techniques

• How to ensure that providers can effectively and efficiently add to their anticipatory guidance:

• Strong developmental promotion• Positive parenting• Resilience skills

•Ultimate goal (for me and my practice): prevent failed developmental screens

“One does not need to be a therapist to be therapeutic.”

J. Ford, C. Wilson

2/2/2018

44

Acknowledgments

• The AAP’s Medical Home for Children Exposed to Violence Project Advisory Committee / Resilience Project

• Elaine Walters, Trauma Healing Project, Eugene, OR

• Teri Pettersen, MD, Oregon Pediatric Society

References• Bethell, CD, Davis, MB, Gombojav, N, Stumbo, S, Powers, K. Issue Brief: A national and across state profile on adverse childhood experiences among

children and possibilities to heal and thrive. Johns Hopkins Bloomberg School of Public Health, October 2017. http://www.cahmi.org/projects/adverse-childhood-experiences-aces/

• Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M., Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine, 14(4), 245-258. doi:10.1016/s0749-3797(98)00017-8

• Garner AS, Shonkoff JP, et al. Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption and Dependent Care, and Section on Developmental and Behavioral Pediatrics. Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health. (2012). Pediatrics 129 (1) e224.

• Gershoff ET, Grogan-Kaylor A. (2016). Spanking and Child Outcomes: Old Controversies and New Meta-Analyses. Journal of Family Psychology, 30(4), 453-69.

• Gillespie, R.J., Folger A.T. Feasibility of Assessing Parental ACEs in Pediatric Primary Care: Implications for Practice-Based Implementation. (2017) Journ Child Adol Trauma. DOI 10.1007/s40653-017-0138-z.

• Ginsburg, K. Building Resilience in Children and Teens. 2014, American Academy of Pediatrics Press.

• Jimenez, M. E., Wade, R., Lin, Y., Morrow, L. M., & Reichman, N. E. (2016). Adverse Experiences in Early Childhood and Kindergarten Outcomes. Pediatrics, 137(2). doi:10.1542/peds.2015-1839

• Kim, P. LCRN (Life Course Research Network) Webinar Series: 04/01/16 Title: "The Parental Brain: How Parenthood Shapes the Adult Brain“ http://www.lcrn.net/the-parental-brain-how-parenthood-shapes-the-adult-brain/

• Kim P., Capistrano C, Congleton C. (2016). Socioeconomic disadvantages and neural sensitivity to infant cry: role of maternal distress. Social Cognitive and Affective Neuroscience. Vol 0(0) 1-11.

• Lomanowska, A., Boivin, M., Hertzman, C., & Fleming, A. (2015). Parenting begets parenting: A neurobiological perspective on early adversity and the transmission of parenting styles across generations. Neuroscience. doi:10.1016/j.neuroscience.2015.09.029

• Randell, K. A., O’Malley, D., & Dowd, M. D. (2015). Association of Parental Adverse Childhood Experiences and Current Child Adversity. JAMA Pediatrics JAMA Pediatr, 169(8), 786. doi:10.1001/jamapediatrics.2015.0269