The Impact of Adversity on the Health

of Minnesota Youth

How are our children?

Naomi N. Duke MD, MPH, FAAPDepartment of Pediatrics, University of Minnesota

Disclosure Information

Hot Topics in Pediatrics ConferenceAmerican Academy of Pediatrics, Minnesota

May 1, 2015Naomi 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.

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.

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

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

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 oppressionLimited vision for the future

Adverse Childhood Experiences (ACE)

System events & Institutional experiencesChild protection investigationOut-of-home placementHarsh school disciplinary practicesJuvenile justice involvement

Interpersonal experiencesBullyingViolence involvement

Adverse Childhood Experiences (ACE)

Global experiences of developed and developing nationsForced marriageWitness of criminal and collective community

violenceEarly conscriptionRefugee status and resettlement

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

Children in Poverty (KIDS COUNT)

Children Living in Concentrated Areas of Poverty (KIDS COUNT)

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

Parents Lack Secure Employment (KIDS COUNT)

Household Food Insecure,Part of Year (KIDS COUNT)

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

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

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

Translation of ACE intoToxic 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

Allostatic Load

SES

Education

Occupation

Income

Subjective SES

SES Inequality

Race

Gender

Environmental Resources &

Constraints

Neighborhood Factors

Social Capital

Work Situation

Family Environment

Social Support

Discrimination

Psychological Influences

Resilience/Reserve Capacity

Negative Affect

anxiety, depression, hostility )(

Lack of Control

Negative Expectations

Perceived Discrimination

Reactive Responding

Access to Medical

Care

Exposure to

Carcinogens &

Pathogens

Health Related

Behaviors

CNS & Endocrine

Response

Allostatic Load

Health

Cognitive

Physical

Disease

Disease Trajectories

Recovery

Relapse

Secondary Events

Mortality

Health Outcomes

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

Child Population by Gender (KIDS COUNT, 2013)

Child Population by Age Group (KIDS COUNT, 2013)

Child Population byRace-Ethnicity (KIDS COUNT, 2013)

Children in Immigrant Families (KIDS COUNT)

Children Uninsured (KIDS COUNT)

Children Uninsured by Poverty Level (KIDS COUNT, 2011)

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

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

Low Birth Weight (KIDS COUNT)

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

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

United States Minnesota

Children with Asthma (KIDS COUNT)

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

No Regular Exercise (KIDS COUNT)

Overweight or Obese by Gender (KIDS COUNT)

United States Minnesota

Emotional, Developmental, Behavioral Diagnosis (KIDS COUNT)

Children with Special Health Care Needs (KIDS COUNT)

Missed ≥ 11 Days of School Due to Illness, Injury (KIDS COUNT)

United States Minnesota

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

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)

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)

ACE Score as Guideline

Link to questions available for screen: www.acestoohigh.com

Series of 10 questions with “yes/no” responses

Scoring: 1 point for every “yes” answer Exposure context: prior to 18th birthday

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

Resilience Questionnaire

Link to questions available for screen: 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

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

Resilience Questionnaire

EvaluationFor 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?

Clinical Model: Recognize ACE and Treat Toxic Stress

Center for Youth WellnessRoutine screening of all youthMultidisciplinary 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

Clinical Model: Recognize ACE and Treat Toxic Stress

Center for Youth WellnessEducating parents about impact of ACETailoring 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

Clinical Model: Recognize ACE and Treat Toxic Stress

The Resilience ProjectWeb-based resource for pediatric providers

and medical home teamsGoal: more effectively identify and care for

children and adolescents exposed to violencewww.aap.org

Building Resilience in the Clinical Setting

The Resilience ProjectTypes of violence addressed

Bullying Child abuse and neglect Community violence Domestic violence and intimate partner violence Sexual abuse Teen dating violence

www.aap.org

Building Resilience in the Clinical Setting

The Resilience ProjectEducational 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

Building Resilience in the Clinical Setting

The Resilience ProjectClinical vignettes: consideration of exposure

to violence as part of the differential diagnosisTraining 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

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.

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.