The Impact of Adversity on the Health of Minnesota Youth

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The Impact of Adversity on the Health of
Minnesota Youth

• How are our children?
• Naomi N. Duke MD, MPH, FAAP
• Department of Pediatrics, University of Minnesota

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Disclosure Information

• Hot Topics in Pediatrics Conference
• American Academy of Pediatrics, Minnesota
• May 1, 2015
• Naomi 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.

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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.

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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

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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

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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 oppression
• Limited vision for the future

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Adverse Childhood Experiences (ACE)

• System events Institutional experiences
• Child protection investigation
• Out-of-home placement
• Harsh school disciplinary practices
• Juvenile justice involvement
• Interpersonal experiences
• Bullying
• Violence involvement

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Adverse Childhood Experiences (ACE)

• Global experiences of developed and developing
  nations
• Forced marriage
• Witness of criminal and collective community
  violence
• Early conscription
• Refugee status and resettlement

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ACE by Federal Poverty Level

• FPL Youth with 1 ACE
• lt 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

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Children in Poverty (KIDS COUNT)
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Children Living in Concentrated Areas of Poverty
(KIDS COUNT)
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Children in Concentrated Poverty by
Race-Ethnicity (KIDS COUNT, 2013)
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Parents Lack Secure Employment (KIDS COUNT)
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Household Food Insecure,Part of Year (KIDS COUNT)
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Children in Foster Care, 0-17 years (per 1,000
KIDS COUNT)
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Youth in Detention, Correctional, Residential
Facilities (per 100,000 KIDS COUNT)
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Victims of Maltreatment (per 1,000 KIDS COUNT)
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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

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Allostatic Load
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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

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Child Population by Gender (KIDS COUNT, 2013)
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Child Population by Age Group (KIDS COUNT, 2013)
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Child Population byRace-Ethnicity (KIDS COUNT,
2013)
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Children in Immigrant Families (KIDS COUNT)
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Children Uninsured (KIDS COUNT)
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Children Uninsured by Poverty Level (KIDS
COUNT, 2011)
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Infant Mortality Rate (per 1,000 KIDS COUNT)
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Infant Mortality Rate by Race-Ethnicity (per
1,000 KIDS COUNT, 2011)
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Low Birth Weight (KIDS COUNT)
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Low Birth Weight by Race-Ethnicity (KIDS COUNT,
2012)
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Teen Birth Rate by Race-Ethnicity (per 1,000
KIDS COUNT)

• United States

• Minnesota

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Children with Asthma (KIDS COUNT)
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Asthma by Race-Ethnicity (MDH Asthma Program,
2013)
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No Regular Exercise (KIDS COUNT)
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Overweight or Obese by Gender (KIDS COUNT)

• United States

• Minnesota

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Emotional, Developmental, Behavioral Diagnosis
(KIDS COUNT)
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Children with Special Health Care Needs (KIDS
COUNT)
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Missed 11 Days of School Due to Illness, Injury
(KIDS COUNT)

• United States

• Minnesota

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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

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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 Pediatricians Role in Family Support and
  Family Support Programs (Committee on Early
  Childhood, Adoption and Dependent Care, 2011)
• The Pediatricians Role in Child Maltreatment
  Prevention (Flaherty et al., 2010)

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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)

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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

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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

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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

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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

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Resilience Questionnaire

• Evaluation
• For 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?

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Clinical Model Recognize ACE and Treat Toxic
Stress

• Center for Youth Wellness
• Routine screening of all youth
• Multidisciplinary 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

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Clinical Model Recognize ACE and Treat Toxic
Stress

• Center for Youth Wellness
• Educating parents about impact of ACE
• Tailoring 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

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Clinical Model Recognize ACE and Treat Toxic
Stress

• The Resilience Project
• Web-based resource for pediatric providers and
  medical home teams
• Goal more effectively identify and care for
  children and adolescents exposed to violence
• www.aap.org

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Building Resilience in the Clinical Setting

• The Resilience Project
• Types of violence addressed
• Bullying
• Child abuse and neglect
• Community violence
• Domestic violence and intimate partner violence
• Sexual abuse
• Teen dating violence
• www.aap.org

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Building Resilience in the Clinical Setting

• The Resilience Project
• Educational 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

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Building Resilience in the Clinical Setting

• The Resilience Project
• Clinical vignettes consideration of exposure to
  violence as part of the differential diagnosis
• Training 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

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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.

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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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