Holistic Approach to Addressing Adverse Childhood Events: Meeting Individual Needs

1. Addressing the Needs of Individuals who have Experienced Adverse Childhood Events: Holistic Approach Mary Balle, PMHCNS-BC, RN

2. “Adverse childhood experiences are the single greatest unaddressed public health threat facing our nation today.” - Dr. Robert Block, the former President of the American Academy of Pediatrics

3. Adverse Childhood Experiences (ACEs) • 1995-1997 CDC-Kaiser Permanente study on Adverse Childhood Experiences prevalence and relationship to long term health outcomes. (Dr Felitti, Dr Anda) • > 17,000 Health Maintenance Organization adult members from Southern California • Physical exams along with confidential surveys about childhood experiences, current health status and behaviors. • Adverse Childhood Experiences (ACEs) • Indicators of abuse, neglect, and other family challenges • Occur in the home under the age of 18. • http://www.ajpmonline.org/article/S0749-3797(98)00017-8/abstract • https://vetoviolence.cdc.gov/apps/phl/resource_center_infographic.html

4. https://vetoviolence.cdc.gov/apps/phl/resource_center_infographic.htmlhttps://vetoviolence.cdc.gov/apps/phl/resource_center_infographic.html

5. Ten Categories of ACEs • Physical Neglect • Emotional neglect • Physical Abuse • Verbal Abuse • Sexual abuse • Parental abandonment through separation • Divorce in home • Parent with a mental illness • Parent with substance abuse problem • Family member in jail • *Later ACE studies have included experiences such as racism and living in a violent neighborhood.

6. Adverse Childhood Experiences

7. Abuse, by Category Psychological (by parents) 11% Physical (by parents) 28% Sexual (anyone) 22% Forms of Neglect and Household Dysfunction Emotional 15% Physical 10% Alcoholism or drug use in home 27% Loss of biological parent <18 23% Depression or mental illness in home 17% Mother treated violently 13% Imprisoned household member 5% Prevalence of ACEs Prevalence (%)

8. How Common Are ACEs

9. ACE Study Findings ACEScore RISK Graded dose-response

11. Scope of the issue • ACEs are common and can cross all socioeconomic, racial and ethnic boundaries. The majority of those who have an adverse childhood experience have had more than one. • Children with disabilities 1.7 Xs more likely to be maltreated

13. The Childhood Roots of Health Disparities: How Adversity is Built Into the Body Middle Childhood Early Childhood Adolescence Conception Adulthood Biological Embedding during Sensitive Periods Physiological Disruption • Neurodevelopmental • Immune • Metabolic • Neuroendocrine • Cardiovascular Disease/Disorder Health-Threatening Behavior Low Educational Achievement Toxic Stress Environmental Exposures Malnutrition Early Adversity Early Death Cumulative Burden over Time

14. Toxic stress From ACEs Impacts: Brain Architecture Biology and Physiology Gene Expression and Epigenetics

15. Toxic Stress Derails Development

18. Hypothalamic-Pituitary-Adrenal Axis Eyes/ Ears to brainstem (locus coeruleus alerts amygdala in the limbic brain) Stimulates hypothalamus/ shuts off prefrontal cortex Chemical signals are sent to the adrenal glands (endocrine glands atop the kidneys) to push adrenaline to heart, lung, and large muscles and then pituitary gland (in brain to communicate to produce cortisol) Cortisol continue to build up and is longer lasting than adrenaline. It signals to calm the body if there is no further threat. If extreme threat- may freeze (both parts of nervous system in effect) After, the amygdala sends a message to the hippocampus to record this into memory. Any similar event can trigger this memory, which will in turn set off a new red alert. Also, living in a continual state of activation resets a person’s fear response at a higher level than normal.

20. Long term stress increases allostatic load Persistent adrenaline and cortisol- high blood pressure high weakens the heart and circulatory system. Glucose levels high leading to type 2 diabetes. Increase cholesterol. Increased cortisol- osteoporosis, arthritis, gastrointestinal disease, depression, anorexia nervosa, Cushing’s syndrome, hyperthyroidism and the shrinkage of lymph nodes. Can cause inappropriate inflammation response. Adrenal glands give out and can’t produce enough cortisol to keep up with the demand potentially leading to immune system attacking parts of the body (lupus, multiple sclerosis, rheumatoid arthritis, and fibromyalgia) If someone is chronically stressed and experiences more traumatic events their body will have trouble returning to a normal state.

21. Dendrites, the branches of neurons that receive signals from other neurons, are shifted into less functional patterns upon chronic exposure to glucocorticoids. This has been documented in key brain regions associated with mood, short-term memory, and behavioral flexibility (Krugers 2010). Glucocorticoids cause receptors for the mood-regulating neurotransmitter serotonin to become less sensitive to activation (van Riel 2003; Karten 1999). Neuronal damage and impaired neurogenesis, the process by which new neurons are “born” (Krugers 2010).

23. Neurological reasons people exposed to ACEs engage in high risk behaviors • Changes Nucleus accumbens= pleasure/ reward center activated in substance dependence • Inhibits Prefrontal cortex- impulse control, executive function- critical for learning • Measurable difference in amygdala (fear center)- studies with MRI scans

24. Experience Alters Brain DevelopmentNormal vs. Neglected Brain

26. Toxic Stress Changes Gene Expression Intergenerational Transmission of Stress Response in Male Rats

27. The Tale of Two Mice

28. Adults who Committed Suicide • Brains of adults with childhood trauma who had committed suicide vs. brains of adults without childhood trauma who had committed suicide. • In the brains of those who had experienced childhood trauma, the genes that regulated removing cortisol were 40 percent less functional—meaning that those individuals were less able to regulate stress.

29. In Utero • Infants who were exposed to prenatal maternal depressions, have changes in the methylation of the glucocorticoid receptor genes. • [Oberlander, et al, 2008. Epigenetics 3-97-106]

30. The Body Remembers even if the Mind doesn’t

31. How do we fare?

32. Vulnerable Populations http://www.iowaaces360.org/uploads/1/0/9/2/10925571/epigenetics_whitepaper.pdf

34. Silence = Compliance • Actual Norms vs. Perceived Norms • Screen patients • Be vulnerable • Create connection

35. Addressing ACEs impact requires: • •Assessing prevention needs and gathering data • •Effective and sustainable prevention approaches guided by applying the Strategic Prevention Framework (SPF) • •Prevention efforts aligned with the widespread occurrence of ACEs • •Building relationships with appropriate community partners through strong collaboration

36. Resiliency Trumps ACEs • Conversations that cross disciplines • Multidisciplinary treatment teams • Medicine, mental health, social service, juvenile justice, education, nutrition, CAM • Health policy experts to grass-roots organizers • Common terms • Home- based services • More aggressive treatment for medical conditions that may be related like asthma

37. Safe, Stable, Nurturing Relationships and Environments • In Environments: • Preventing early adverse experiences before they occur • Protecting against poor outcomes for children who have already experienced ACEs. • Creating a context and atmosphere that allows families to share quality time together, to discuss and resolve conflicts, and to provide emotional support to one another • With relationships with parents and other adults in children’s lives: • Strong protective factor against ACEs • Networks of support for parents are essential • . https://www.cdc.gov/violenceprevention/childmaltreatment/essentials.html

38. Potential issues with Antipsychotics to treat individuals with ACEs • Prefrontal connectivity reductions: There is evidence derived from resting fMRI studies suggesting that connections in the prefrontal region of the brain are reduced as a result of antipsychotic treatment. A reduced number of connections may translate to reductions in complex thinking, planning, attention, emotional regulation, and memory. • Global brain volume loss: Reductions in global brain volume means that nearly every aspect of brain functioning has potential to become impaired with long term use. • Grey matter volume loss: Grey matter is known to include various regions of the brain responsible for sensory perception, emotions, self-control, speech, decision making, and muscle control. • White matter volume loss: White matter is tissue that allows your brain to communicate with the central nervous system. http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2013.13030413

39. Barriers locally

40. Ways To Overcome • Long term savings to society • http://www.iowaaces360.org/professionals.html#health care • http://communityresiliencecookbook.org/

41. Studies and literature related to ACEs https://www.cdc.gov/violenceprevention/acestudy/journal.html https://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/adverse-childhood-experience http://www.acesconnection.com/g/resource-center/blog/resource-list-ace-studies