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The Science and Economics of Early Life Toxic Stress
“It is easier to build strong children than to repair broken men.”-Frederick Douglas
To produce a well-educated and healthy adult population that is sufficiently skilled to participate in a global economy and to become responsible stakeholders in a productive society.
American Academy of Pediatrics Technical Report “The Lifelong Effects of Early Childhood Adversity and Toxic Stress”
Goal of a Nation
Use sound science, which shows:◦ That we need to invest
in clinical practice that addresses complex social, economic, environmental, and developmental issues that influence population-based health disparities
Sound investments in interventions that reduce adversity in early childhood years◦ Many adult diseases
originate in early childhood (ACEs)
◦ Changes the system to a “well-care” model rather than “sick-care”
How Do We Do That
Development is not nature vs. nurture, but it’s nature and nurture working with each other over time◦ Thus, adversity early in childhood can permanently
impair learning, behavior, and health (mental and physical)
A New Framework
Critical Concepts in Early Brain Development
• Proportional brain growth• Neural plasticity• Critical periods• Sequential development• Role of experience
Role of Experience
The human brain has the ability to be shaped by experience
Experience, in turn, leads to neural changes in the brain
◦ birth: 50 trillion synapses
◦ 1 year: 1,000 trillion
◦ 20 years: 500 trillion
The remolded brain reflects new experiences and efficiencies learned over time
Impact of Neglect
Stress without the buffering response of a strong adult relationship causes prolonged secretion of stress hormones◦ Cortisol, norepinephrine, epinephrine, etc. ◦ Potentially permanent changes in gene regulation
Both of these responses are beneficial in the short term with good adult support, but can be damaging to health if they occur over long periods of time◦ Constant wear and tear
Physiologic Response to Stress in Kids
Compelling new science showing how nurture can affect nature◦ Molecular biological methods to change gene expression
without changing the gene itself◦ Done by changing the chemical composition of
regulatory segments of the gene DNA methylation Modification of histones
The Mechanism of ChangeEpigenetics
Rat mothers who groom and lick their pups during the first week of life have pups that have a less vigorous response to stress as adults than mothers who don’t groom well◦ Appears to be caused by DNA methylation and histone changes
in stress-related genes
Stressed rat mothers with bad nurturing behavior have pups with poor cognitive skills as adults and persistent changes in stress-related gene expression
Epigenetics in Rats
Fetal exposure to maternal stress influences future stress responses in a negative way◦ Moms who are stressed (stressful event, increased
anxiety, depression) during pregnancy are more likely to have kids with: Preterm birth Poor emotional coping skills Decreased cognitive abilities Increased fear response to stimuli Increased anxiety
◦ These effects are mediated by histone modification and DNA methylation
Epigenetics Passed from Moms to Children
Kids raised in institutional environments (Romanian orphanages) ◦ Epigenetic changes in regions of brain development
Childhood Epigentic Changes
Structural brain changes: Smaller hippocampus (memory), smaller corpus callosum (connections between the hemispheres of the brain), smaller prefrontal cortex (reasoning, emotional control), larger amygdala (anxiety and release of stress hormones from the pituitary)
Inflammation/immunological changes: C-reactive protein levels elevated in adults with history of early adversities
Endocrine changes: Dysregulation of stress hormones, decreased oxytocin
How Do These Epigenetic Changes Affect Them as Adults
Telomeres & ACEs
• Telomeres appear to be impacted by
exposure to violence• In a longitudinal study
of twins, researchers found the twin exposed to violence had shorter telomeres than the twin
who was not.• Telomeres in
individuals removed from a violent
environment by age 5 showed improvement
by age 10.
Public Investment in Children by Age
Econometrics of Early Intervention & Prevention
Funding early interventions should provide the largest possible return on investment.
Doyle et al. (2009) Investing in Early Human Development. In: Economics and Human Biology
v7:pp1-6
Costs of Child Abuse: USA
$104 billion spent annually for the direct costs of child abuse
An additional $69.5 billion spent for indirect costs including special education, mental and physical health care and juvenile delinquency
Cost per maltreated child ~$182,000
C Wang and J Holton (2007) Economic Impact Study funded by Pew Charitable Trusts, and S. Fromm (2001) Total estimated costs of child abuse and neglect in the United States: Statistical evidence, http://member.preventchildabuse.org/site/
Over $124 billion in costs/year (Fang et al., 2012)
Lifetime cost per victim of nonfatal child maltreatment is $210,012:-$144,360 productivity losses-$6,747 criminal justice costs
-$32,648 childhood health care costs -$10,530 adult medical costs-$7,999 special education costs
-$7,728 child welfare costs
Costs of Child Abuse: USA
10 Adverse Childhood Experiences ACEs
1. Physical abuse 2. Sexual abuse 3. Emotional abuse 4. Emotional neglect 5. Physical neglect
---------6. Witness domestic violence 7. Mental illness in home 8. Family member incarcerated9. Alcohol/drug problems10. Parental separation or divorce
ACE: Prevalence data
Key finding:◦ About 2/3rd of those surveyed reported at least one ACE.◦ The 1/3 of participants with no reported ACEs were
consistently healthier across all measures.
ACE Score
ACE score = total number of ACEs experienced.◦ Examples:
Childhood history of exposure to domestic violence only ACE score = 1
Childhood history of parental alcoholism and physical abuse ACE score = 2.
Childhood history of physical neglect, sexual abuse, and parental divorce ACE score = 3.
Up to a maximum score of 10.
Key finding: higher ACE score = greater risk for health problems.
Health Measures Now Linked to Adverse Childhood Experiences Score
Stepwise increased risk for:◦ Heart disease
◦ Asthma
◦ Diabetes
◦ Cancer
◦ COPD
◦ Skeletal fractures
◦ Sexually transmitted diseases
◦ Liver disease
◦ Autoimmune disorders
◦ Osteoarthritis
◦ Smoking
◦ Alcohol abuse
◦ Over eating and obesity
◦ Illicit drug use
◦ Promiscuity
◦ IV drug use
◦ Clinical depression
◦ Bullying
And◦ Autobiographical memory disturbance
◦ Poor anger control
◦ Relationship problems
◦ Employment problems
◦ Early age at first intercourse
◦ Teen pregnancy
◦ Unintended pregnancy
◦ Teen paternity
◦ Fetal death
◦ Suicide
◦ Domestic violence
◦ Anxiety disorders
◦ Hallucinations
◦ Sleep disturbances
◦ Chronic pain
◦ Headaches
◦ Early death
2013 Alaska BRFSS ACE SCORE 0 1 2 3 4 5+
All Alaskan Adults 35.6% 22.3% 14.7% 10.1% 6.5% 10.8%
Age Group
18-24 34.0% 26.0% 15.9% 8.2% 5.8% 10.0%
25-34 33.3% 19.8% 15.5% 10.9% 8.4% 12.1%
35-44 30.4% 26.8% 10.5% 10.7% 6.2% 15.3%
45-54 33.8% 20.5% 13.6% 12.8% 6.3% 13.0%
55+ 41.7% 20.6% 16.7% 8.6% 5.9% 6.5%
Gender
Male 38.9% 22.5% 16.1% 8.5% 5.6%% 8.5%
Female 32.0% 22.2% 16.1% 11.9% 7.5%% 13.2%
*Percentages in red are the highest of the states compared.Source: Alaska data from the 2013 Alaska Behavioral Risk Factor Surveillance System, Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion Source: Five States Study data from the Centers for Disease Control and Prevention, Adverse Childhood Experiences Reported by Adults --- Five States, 2009, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm
Adverse Childhood
Experience*
Alaska
Arkansas
Louisiana
New Mexico
Tennessee
Washington
Abuse % % % % % %
Emotional 31.0 24.3 21.1 28.1 19.2 34.9
Physical 19.1 14.1 10.5 19.5 12.9 18.1
Sexual 14.8 10.9 9.9 12.9 12.7 13.5
*Percentages in red are the highest of the states compared.Source: Alaska data from the 2013 Alaska Behavioral Risk Factor Surveillance System, Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion Source: Five States Study data from the Centers for Disease Control and Prevention, Adverse Childhood Experiences Reported by Adults --- Five States, 2009, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm
Adverse Childhood
Experience*
Alaska
Arkansas
Louisiana
New Mexico
Tennessee
Washington
Household Dysfunction % % % % % %
Mental Illness in the Home 21.9 17.0 16.6 19.4 17.1 24.3
Incarcerated Family Member 11.5 5.5 7.2 7.1 8.6 6.6
Substance Abuse in Home 33.8 25.5 26.6 29.9 28.3 32.7
Separation or Divorce 31.7 23.3 27.1 24.4 29.1 26.0
Witnessed Domestic Violence 18.7 15.1 14.5 18.9 17.1 16.6
But These Effects Can Be Reversed
Example: A prevention program that reduces ACEs in a given population would result in:◦ Reduction in suicide attempts ◦ Risk for alcohol dependence cut in half for next
generation◦ And so on for all health measures studied to this point
CostsAlaskan adults who report four or more Adverse Childhood Experiences compared to Alaskan adults who report zero Adverse Childhood Experiences.
– 49% more likely to be unemployed– 274% more likely to be unable to work– 92% more likely to earn less than $20,000
annually Source: 2013 Alaska Behavioral Risk Factor Surveillance System, Analysis by Alaska Mental Health Board/Advisory Board on Alcoholism and Drug Abuse Staff
Population Attributable Risks in Alaska
Source: Alaska data from the 2013 Alaska Behavioral Risk Factor Surveillance System, Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Graphic: AMHB/ABADA
So What Do We Do as People Who
Interact with Families?The Ecological Model
This means we ask the question, “What’s happened to you in the past?” rather than “What’s wrong with you?”◦ This fundamentally changes the way we interact with people◦ Changes an office visit from “I must fix you” to “I must listen to you”
What We’re Really Talking About: Trauma-Informed Care
Ages: 0-2◦ Dysregulated eating,sleeping
patterns◦ Developmental regression◦ Irritability, sadness, anger◦ Poor appetite, low weight gain◦ Increased separation anxiety,
clinginess
NCTSN.org/earlychildhoodtrauma
Ages 3-6◦ Increased aggression◦ Somatic symptoms◦ Sleep difficulties/nightmares◦ Increased separation anxiety◦ New fears◦ Increased distractibility/high
activity level◦ Increased withdrawal/apathy◦ Developmental regression◦ Repetitive talk/play about the
event◦ Intrusive thoughts, memories◦ Absenteeism
Behaviors Associated with Early Childhood Trauma
Primary Prevention:◦ Raising national awareness
Secondary Prevention:◦ Routine screening allows for early detection and
intervention Tertiary Prevention:
◦ Current best practices including home visiting, mental health, social work, two generation interventions
The Ecological Model for Addressing ACEs
Awareness Is Increasing
When Is the Best Time to Screen Families?
One-page questionnaire, completed by the parent
Targets risk factors that jeopardize children’s health, development and safety
Administered at selected well-child visits
Free, available in 4 languages
http://theinstitute.umaryland.edu/seek/
Parent Screening Questionaire
Comprehensive screening instrument for children under 5. Forms available for each recommended well-child visit recommended by the AAP.
Targets developmental milestones, social-emotional development, and family risk factors.
Free; available in 3 languages—theswyc.org
Survey of Well-Being of Young Children
Not a validated screening tool (they’re working on it), but available for young kids and teens
Center for Youth WellnessACE-Q
Has anything really stressful happened to your child since the last time I saw you?
How has that affected your child’s behavior?◦ Corollary question: How has this event and any changes
in your child’s behavior affected you? What have you done that’s really fun with your
child since the last time I saw you?
Three Questions—Gets Almost Everything
Assess for child and family safety Provide developmental guidance about trauma
response Provide education/guidance about behavior
management, routines and daily living activities to promote recovery and sense of safety
Refer to social work, child protection, domestic violence team or for mental health intervention, if needed
Provide close follow-up and ongoing monitoring
If a Traumatic Stressor Is Identified:
Chronic vs. single incident trauma When the symptoms persist for more than one
month When the parents are unable to ensure safety, be
supportive or attuned to the needs of the child When the parent has also been traumatized and is
symptomatic When the trauma involves the sudden or violent
loss of a caregiver or family member
When to Refer for Mental Health Treatment
Child-Parent Psychotherapy (CPP) (ages 0-5) Parent-Child Interaction Therapy (PCIT) (ages 2-
7) Pre-School PTSD Treatment (PPT) (ages 3-6) Trauma Focused Cognitive-Behavioral Therapy—
(TF-CBT) (ages 3-18)
Treatments for Traumatic Stress in Young Children
Parent is actively involved!!!! Provide education about trauma symptoms Enhance emotional regulation/ anxiety
management skills Address children and families' traumatic stress
reactions and experiences Provide an opportunity for the child to review, talk
about what happened (the trauma narrative) in the safety of a therapeutic setting
Core Components of Effective Treatment
How do we support schools, provider offices, day cares, etc. with appropriate screening tools to identify families at risk?◦ Can we reimburse for screening?
How do we increase services and programs so families can be referred to quality programs to get help?
Also….
Triple P—Positive Parenting Program◦ Gives parents practical strategies to:
Build healthy family relationships Manage their children’s behavior Prevent developmental problems
◦ Delivered in the Primary Care setting to target specific problem issue or behavior
◦ WSIPP benefit to cost ratio = $8.74◦ www.triplep.net
Triple P
Triple P System
Level 5
Level 4
Level 3
Level 2
Level 1
Intensive family Intervention………................
Broad focused parenting skills training………...
Narrow focus parenting skills training………….
Brief parenting advice……………………………
Media and communication strategy…………….
Breadth of reach
Intensity of intervention
Connects at-risk children with the services they need◦ Training for primary care offices to provide effective
developmental screening to facilitate early detection◦ Builds collaboration across sectors to improve access◦ Identifies gaps and barriers to access systems◦ Four Core Components
Child health care provider outreach to support screening Community outreach to identify resources Centralized telephone access point Collection of data, including service gap analysis
◦ www.helpmegrownational.org
HelpMeGrow
• Assessment of needs & referrals to services
• Education on development, behavior management and programs
• Ongoing developmental monitoring
• Advocacy and follow up
Care Coordinators provide
All of This Leads to a New Way of Thinking About Problems in Alaska
Sleep-Related Mortality Review
A group reviewed all sleep-related infant deaths from 2012-14 to see if there were trends◦ 195 total infant deaths◦ 66 occurred in a sleep environment◦ Alaska Epi Bulletin describes results
http://www.epi.alaska.gov/bulletins/docs/b2015_13.pdf
Alaska Maternal Infant Mortality Review (MIMR)
Sleep-Related Mortality Is NOT Just Back-to-Sleep
Source: Alaska data from the 2013 Alaska Behavioral Risk Factor Surveillance System, Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion
Zero One Two-Three Four Plus0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
5.7% 7.4%11.8% 14.7%
Percentage of Alaskan Adults who Report Not Finishing High School or
getting a GED by ACE Score
Sleep-Related Mortality Is NOT Just Back-to-Sleep
“In the brain, as in the economy, getting it right the first time is ultimately more effective and less costly than trying to fix it later. “
James HeckmanNobel Laureate Economist
National Scientific Councilon the Developing Child, Perspectives: The Cradle of Prosperity. (2006). http://www.developingchild.net
Thank you
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