Julie Miller-Cribbs, MSW, PhD Professor & Director Anne & Henry Zarrow School of Social Work

1. Early Adversity & Impacts on Health and Well Being: Examples from our ClinicsSummer Institute 2014 Julie Miller-Cribbs, MSW, PhD Professor & Director Anne & Henry Zarrow School of Social Work Martina Jelley, MD, MSPH Interim Chair, Department of Internal Medicine School of Community Medicine

2. Overview • Why do we care about ACEs? In Oklahoma? • Brief overview of ACE study • Oklahoma clinic examples: ACE data • Connecting: ACE & Brain Science • ACE informed interventions

3. Bringing Up Baby

4. Setting the Stage: Why do we care?  Most of us in public or social services have experienced folks with high ACEs

5. Why does an internist care about childhood issues??

6. The journey starts here…

7. And continued here…

8. And continued here…

10. Behavior Change Counseling • Classic brief intervention in primary care • Motivational interviewing • But as with many primary care interventions, there were disappointments….

11. Just one of our clinic’s patient • Female, age 34 • Morbidly obese, BMI 60 • Smoker • Oxygen-dependent COPD (emphysema) • Poorly controlled diabetes

12. Just one of our clinic’s patient • Female, age 34 • Morbidly obese, BMI 60 • Smoker • Oxygen-dependent COPD (emphysema) • Poorly controlled diabetes

13. Social history (taken directly from her chart) • Married, 3 children ages 8, 13, 15. • Molested at 8, raped at 13. Grew up in home with alcoholism, instability and physical abuse.

14. The rest of the story • Last year this patient was found dead at home, age 36 • Death thought to be due to heart attack or respiratory failure

16. Why do we care? • It’s expensive • Many of our systems and services are not responsive to the needs of this population • Re-traumatize, do more damage • Impact is likely to be intergenerational without intervention • We have increasingly better science, research and knowledge that can help us pinpoint and design effective interventions

17. Consequences of care for violence

18. Consequences of care for ACEs/Violence Using the number of children abused in the US in 2008 Total lifetime economic burden resulting from their maltreatment: $124 billion

19. Consequences of care for ACEs/Violence The lifetime cost for one child who was a victim of maltreatment is $210,012 (2010 dollars) $32,648 in childhood health care costs $10,530 in adult medical costs $144,360 in productivity losses $7,728 in child welfare costs $6,747 in criminal justice costs $7,999 in special education costs http://www.cdc.gov/injury/

20. Adverse Childhood Experiences • Recurrent physical abuse • Recurrent emotional abuse • Contact sexual abuse • An alcohol and/or drug abuser in the household • An incarcerated household member • Someone who is chronically depressed, mentally ill, institutionalized, or suicidal • Mother is treated violently • One or no parents • Emotional or physical neglect http://www.cdc.gov/ace/

21. ACE Epidemiology More than a third of women in addiction treatment have been physically forced to have sex Patients in substance abuse facilities more likely to have experienced abuse as children In 2004, Oklahoma imprisoned 129 of every 100,000 female residents. High percentages of women in treatment for mental illness have sexual abuse histories

22. Summary of Major Findings • Adverse Childhood Experiences (ACEs) are very common • ACEs are strong predictors of later health risks and disease • This combination makes ACEs the leading determinant of the health and social well-being of our nation

23. http://www.thenationalcouncil.org/wp-content/uploads/2012/11/Childrens-Resilience-Initiative-9-19-12.pdfhttp://www.thenationalcouncil.org/wp-content/uploads/2012/11/Childrens-Resilience-Initiative-9-19-12.pdf

24. ACE Score vs. Smoking and COPD

25. ACEs & Adult Alcoholism 4+ 3 2 1 0

26. Childhood Experiences Underlie Chronic Depression

27. ACEs & Suicide 4+ 3 2 1 0

28. ACEs & Risk Behaviors *Adjusted Odds Ratio

29. ACEs & Risk Behaviors *Adjusted Odds Ratio

30. Risk for these health problems increases in a strong and graded fashion: • COPD • Lung cancer • Ischemic heart disease • Liver disease • Stroke • Obesity

31. Bringing it Home: Oklahoma Examples • OU-Tulsa studies (a very brief overview) • Clinic sample • Educare • Homeless youth • Public housing

32. Data

33. Study Investigators

34. OU Clinic Patients: ACEs Verbal abuse 42% Physical abuse 32% Sexual abuse 27% Familial ties 34% Basic needs unmet 20% Witness IPV 25% Sep/Divorce 41% Alcohol/drugs 37% Mental illness 27% Prison 18%

35. Educare Parents: ACEs Verbal abuse 20% Physical abuse 14% Sexual abuse 11% Familial ties 22% Basic Needs Unmet 9% Witness IPV 11% Sep/Divorce 47% Alcohol/drugs 21% Mental illness 10% Prison 17%

36. Clinic Sample: ACEs and health ACE score

37. Educare Survey: Health Problems by ACE score

38. Clinic Sample: Depression and PTSD by ACE score Depression & PTSD (z-scores) by ACE score ACE score

39. Clinic Sample: Health Care Barriers • 23% currently uninsured • 50% needed HC, no insurance • 36% experienced time without insurance, last 12 months • 37% reported someone in the HH went without needed HC • 54% needed care, no money • 54% needed care, no insurance • 52% used ER, no regular doctor • 58% report medical debt • 7% used payday lender for medical debt

40. Combined Data: Health Condition, ACE Mean Score * Statistically significant difference

41. Combined Data: ACE & Depression Mean ACE Score

42. Combined Data: Access to Health Care * Statistically significant difference

43. Combined Data: Health Care Barrier Items

44. Homeless Youth & Public Housing Sample: ACEs & Medical Trust • High ACE scores • ACE related to lower trust in medical providers

45. Quick Summary of Oklahoma Findings • High levels of ACEs in clinic, early childhood, homeless youth and public housing samples • ACEs related to health, mental health and health risk behaviors • ACEs related to access to health care, barriers to health care • ACEs related to trust of medical providers and the medical professions

46. Findings continued…. • Those adults with high ACE scores much less likely to have gone to the dentist or doctor regularly as child, likely setting the stage for the lower access to health care as adults • A very clear and significant pattern in the data emerges: the higher the ACE, the more barriers to health care, the less trust of medical professionals http://acestoohigh.com/?s=dr+jeffrey+brenner

47. Tying it all Together: From ACE to Adulthood

48. Core Concepts in Science of Early Childhood Development* • Child development is a critical foundation for community development and economic development • Experiences shape brain architecture by over production of connections ‘neural proliferation’, pruning is normal & healthy part of brain development • Brains build from the bottom up – skills by skill, simple to more complex. • Genes and experiences together build brains – the importance of serve and return relationships • Cognitive, emotional and social development are intertwined – and learning, behavior, and physical and mental health are related throughout life • Toxic stress damages brain architecture • For many functions, the brain’s capacity for change decreases over time – but not all functions are impacted equally Center on the Developing Child: Core Concepts in the Science of Early Childhood Development www.developingchild.harvard.edu

49. Experiences Shape Brain Architecture Brain growth fastest in first 3 years, 700 new synapses (neural connections) are formed every second Pruning= synapses are reduced to make brain circuits more efficient

50. Use it or lose it: Early experiences impact the nature and quality of brain architecture by determining with circuits are reinforced and which are pruned