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.
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