Kentucky Bullying Prevention Task Force February 11, 2015

The Public Health Approach to Bullying Prevention

Part IIKentucky Bullying Prevention Task Force

February 11, 2015

2

The Public Health Approach“The public heath perspective asks foundational questions:

Where does the problem begin?How could we prevent it from occurring in

the first place?Public Health uses a systematic, scientific approach for understanding and preventing violence.” (CDC, 2014)

3

Optimal Outcome

Poor Outcome

Lu and Halfon, 2003

Life Course Development of Health and Well-being

Neural Circuits are Wired in a Bottom-Up Sequence

(700 synapses formed per second in the early years)

Source: C.A. Nelson (2000)

FIRST FIVE YEARS

1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Months Years

Sensory Pathways(Vision, Hearing)

LanguageHigher Cognitive Function

Structural Brain Changes due to Early Experiences

5“The Two Year Window”

Healthy Brain Deprivation

Life Course Health Development Critical Period of Brain Development

• Social-Emotional development is based on secure attachment and becomes the foundation for cognitive development and sense of self-identity.

• Attachment comes from a nurturing relationship with a caregiver that is consistent and caring.

Birth – 2 years; critical window for hardwiring the brain for social-emotional development.

AttachmentSocial-Emotional Hardwiring

Self- Identity

Security

Cognitive Skills

ExecutiveFunctioning

Resilience

Recognition

Routines

Responsiveness

Relationship

Problem solvingPerseverance

Planning

Learning, focus

Delayed gratificationCuriosity

ConfidenceSelf-control

EmpathyConnectedness

Social-emotional Hardwiring forms the Foundation for Learning and Executive Function

How Risk Reduction and Health Promotion Strategies

influence Health Development

FIGURE 4: This figure illustrates how risk reduction strategies can mitigate the influence of risk factors on the developmental trajectory, and how health promotion strategies can simultaneously support and optimize the developmental trajectory. In the absence of effective risk reduction and health promotion, the developmental trajectory will be sub-optimal (dotted curve). From: Halfon, N., M. Inkelas, and M. Hochstein. 2000. The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3):447-497.

Trajectory Without RR and HP Strategies

0 20

Healt

h

Deve

lopm

en

t

40 60 80Age (Years)

HP

RR Risk Reduction Strategies

Health Promotion Strategies

Optimal Trajectory

Protective Factors

HP HPHP

RR

RR

RR

Risk Factors

8

9

Social Determinants of Health

Kaplan, et al. (2000). A Multilevel Framework for Health in :Promoting Health. Washington, DC: National Academy Press

Life Course Health Development - Environmental interaction and Disparate Outcomes

Poor NutritionStressAbuseTobacco, Alcohol, DrugsPovertyLack of Access to Health CareExposure to Toxins

Poor Birth Outcome

0 5 Puberty PregnancyAge

SAFER · HEALTHIER · PEOPLE

The Adverse Childhood ExperiencesWhen you were growing up, during your first 18 years of life, did you experience:

• Physical abuse

• Emotional abuse

• Sexual abuse

• Domestic violence

• Substance abuse in home

• Mental illness in parent

• Lost parent due to separation or divorce

• Household member in jail

• 2/3 of people had at least one ACE

• Almost 40% had 2 or more

“Did you live with anyone who was depressed, mentally ill, or suicidal?”

● Reduce Kentucky’s rate of uninsured individuals to less than 5%. ● Reduce Kentucky’s smoking rate by 10%. ● Reduce the rate of obesity among Kentuckians by 10%. ● Reduce Kentucky cancer deaths by 10%. ● Reduce cardiovascular deaths by 10%. ● Reduce the percentage of children with untreated dental decay by

25% and increase adult dental visits by 10%. ● Reduce deaths from drug overdose by 25% and reduce by 25% the

average number of poor mental health days of Kentuckians.

http://governor.ky.gov/healthierky/kyhealthnow

kyhealthnow 2019 Goals

ACE Score and Indicators of Impaired Worker Performance

Absenteeism (>2 days/month

Serious Financial Poblems

Serious Job Problems

0

5

10

15

20

25

0 1 2 3 4 or more

ACE Score

Pre

vale

nce

of

Im

pai

red

P

erfo

rman

ce (

%)

The higher their ACE score (the more they were abused or traumatized as children) the more absenteeism, serious financial problems and on the job problems they have.

0

5

10

15

20

25

0 1 2 3 4 >= 5

Regular smoking by age 14

ACE Score

Pe

rce

nt

(%)

Kyhealthnow goal: Reduce Kentucky’s Smoking rate

by 10%

Anda et al., 1999, JAMA

The higher the ACE score, the more likely a person will become a smoker by age 14.

90% of current adult smokers started smoking as a teenager.

ACEs, Smoking, and Lung Disease

Slide from Dr. Robert Anda


AOR = 1.9 (1.6-2.2)

Prevalence (% with BMI >35)

•Adapted from Anda RF et al., 2006. Eur Arch Psychiatry Clin Neurosci 256: 174-186.

•12 •10

•6 •4 •2 •0

•8

0 1 2 3 4 or

ACE Score

more

kyhealthnow goal: Reduce the rate of Obesity among Kentuckians by 10%

with 4 or more ACE’s, the risk of Obesity doubles

Adverse Childhood Experiences are associated with the Risk of Lung Cancer: A prospective cohort. Brown DW, Anda RF, Feletti VJ, et al

BMC Public Health 2010;10:20-32

• Prospective data showed graded relationships between the ACE score and the risk of Lung Cancer.

• Relationships between a high ACE score and lung cancer were particularly strong for those who died from lung cancer at younger ages.

• The increased risk of lung cancer was only partly due to relationships between ACE’s and an intermediate causal factor, smoking.

• The occurrence of ACE-related lung cancer not attributable to conventional risk factors suggests other mechanisms by which childhood traumatic stressors negatively affect health.

Kyhealthnow goal: Reduce cancer deaths in Kentucky by 10%

Compared childhood trauma and mortality

Identified 1,539 deaths within the cohort between 1995 and 2006

People with 6 or more ACE’s died nearly 20 years earlier than those without ACE’s-60.6 yrs versus 79.1

ACE Study---Early Death

Risk Factors for Adult Heart Disease are Embedded in Adverse Childhood Experiences

ACEs Source: Dong et al, 2004

Od

ds R

ati

o

0 1 2 3 4 5,6 7,8

0.5

1

1.5

2

2.5

3

3.5

Kyhealthnow goal: Reduce cardiovascular deaths by 10%

● Reduce Kentucky’s rate of uninsured individuals to less than 5%. ● Reduce Kentucky’s smoking rate by 10%. ● Reduce the rate of obesity among Kentuckians by 10%. ● Reduce Kentucky cancer deaths by 10%. ● Reduce cardiovascular deaths by 10%. ● Reduce the percentage of children with untreated dental decay by

25% and increase adult dental visits by 10%.

●Reduce deaths from drug overdose by 25%● and reduce by 25% the average number of poor mental health

days of Kentuckians.

http://governor.ky.gov/healthierky/kyhealthnow

kyhealthnow Goals


0

2

4

6

8

10

12

14

1615–18 Years

Relationship Between Number of ACEs and the Age at Initiation of Illicit Drugs

0 1 2 3 4 > 5

ACE Score

Pe

rce

nt

(%)

Dube et al., 2003, Pediatrics

ACE Score and Intravenous Drug Use

0

0.5

1

1.5

2

2.5

3

3.5

% H

ave I

nje

cte

d D

rug

s

0 1 2 3 4 or more

ACE Score

N = 8,022 p<0.001

A male child with an ACE score of 6 has a 4,600% increase in the likelihood that he will become an IV drug user later in life

78% of drug injection by women can be attributed to their experience of cumulative kinds of trauma in childhood. (ACES)

Adverse Childhood Experiences And Chronic Depression as an

Adult

0

10

20

30

40

50

60

70

80

% W

ith

a Li

feti

me

His

tory

of

Dep

ress

ion

0 1 2 3 >=4

ACE Score

WomenMen


0

5

10

15

20

25

30

35

40

0 1 2 3 4 5 6 >=7

ACE Score

Per

cen

t (%

)

Relationship Between the ACE Score and the Risk of Ever Attempting Suicide

Dube et al., JAMA, 2001


0

2

4

6

8

10

12

14

16

0 1 2 3 4 5 6 >=7

Attempted suicide < = 18 years

ACE Score

Pe

rce

nt

(%)

Relationship Between the ACE Score and Attempting Suicide During Adolescence

Dube et al., JAMA, 2001

ADVERSE CHILDHOOD EXPERIENCESAND ADULT DISEASE:

54% of depression58% of suicide attempts39% of ever smoking26% of current smoking65% of alcoholism50% of drug abuse78% of IV drug abuse48% of promiscuity (>50

partners) are attributable to ACE’s.Dr. V. Felitti. 2011

Seeking to Cope The risk factors/behaviors underlying

these adult diseases are actually effective coping devices.

What is viewed as a problem by the health care provider is actually a solution to bad experiences for the patient.

Dismissing these coping devices as “bad habits” or “self destructive behavior” misses their source of origin.

To lessen the burden of these adult diseases, we must reduce the toxic stress and heal the trauma of the adverse childhood experiences that underlie these diseases

The ACE Study is evidence that….

ADVERSE CHILDHOOD EXPERIENCES are the most basic and long lasting cause of : health risk behaviors,

mental illness, social malfunction, disease, disability, death, and healthcare costsDr. V. Felitti. 2011

Experiences in Childhood Matter for a Lifetime

Science Tells Us that Early Life Experiences Are Built Into Our Bodies

Research on the biology of stress illustrates how threat raises heart rate, blood pressure, and stress hormone levels, which can impair brain architecture, immune status, metabolic systems, and cardiovascular function.

ToxicProlonged activation of stress response systems

in the absence of protective relationships.

Three Levels of Stress

TolerableSerious, temporary stress responses, buffered by supportive relationships.

PositiveBrief increases in heart rate,

mild elevations in stress hormone levels.

Stress and Brain DevelopmentFIGHT OR FLIGHT RESPONSE

•Hypothalamus •VS •Danger

Cortisol Epinephrine Norepinephrine

Elevated Heart RateRapid breathing

RUN!!!

Allostasis: Maintain Stability through Change

McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

Allostastic Load

McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

Poor Children Experience Elevated Stress

Cortisol Epinephrine Norepinephrine

.035

.03

.025

.02

.015

.01

.005

0

6

5

4

3

2

1

0

33

32.5

32

31.5

31

30.5

30

29.5

Middle Poverty Middle Poverty Middle Poverty Income Income Income

Overnight levels in rural 9-year-old white children

•Source: Evans, GW and English, K. (2002)

Stress & Programming of the Brain

• Physiologic reaction to stress – Hippocampus

• Site of learning & memory formation, contextual learning• Stress down-regulates glucocorticoid receptors• Loss of negative feedback; overactive HPA axis

– Amygdala

• Site of anxiety and fear• Stress up-regulates glucocorticoid receptors• Accentuated positive feedback; overactive HPA axis

Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain.J Neuroendocrinol 2001;13:113-28.

Fear Response

Active “fight-or-flight” or hyper-arousal response

Passive response, known as the surrender response, which involves varying degrees of dissociation – “disengaging from stimuli in the external world and attending to an ‘internal’ world” (Perry et al, 1995).

Each of these are of adaptive benefit to the organism and promote human survival.

Fight, Flight, Freeze

Fight, Flight, Freeze

Toxic Stress

TOXIC STRESS can result from strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive, adult relationship.

• This growing scientific understanding into causal mechanisms that link early adversity into later impairments in learning, behavior, and both physical and mental well-being are potentially TRANSFORMATIONAL.

• Toxic stress in children can lead to less outwardly visible yet permanent changes in brain structure and function.

• Persistently elevated levels of stress hormones can disrupt the developing architecture of the brain. Exposure to stressful experiences has been shown to alter the size and neuronal architecture of the amygdala, hippocampus, and pre-frontal cortex.

• Thus the developing architecture of the brain can be impaired in numerous ways that create a weak foundation for later learning, behavior, and executive function.

The New Science the New Paradigm

• American Academy of Pediatrics: The Lifelong Effects of Early Childhood Adversity and Toxic Stress PEDIATRICS 2012 129(1):E232-E246

Acute Response To Trauma

Terror

Fear

Alarm

Vigilance

Calm

Traumatic Event

Vulnerable “with supports”

Normalwith

supports

Dissociationor

Resilient

Vulnerablefew

supports

Slide from Dr. David Willis, 2010

Multiple Traumatic Events

Event #1

Event #2

Event #3

Terror

Fear

Alarm

Vigilance

Calm

Slide from Dr. David Willis

The Brain Architecture of Anxiety and Fear

Cognitive, Emotional, and Social Capacities Are Inextricably Intertwined Within the

Architecture of the Brain

The Brain Architecture of Memory and Learning

Life Course Trajectory: A Balance of Risk and Protective Factors

Risk FactorsChild

FamilyCommunity

School

Protective FactorsChild

FamilyCommunity

School

Outcome

Negative vulnerability

Positiveresilience

Child Abuse

School Readiness

Family Skills and Support -+


Poor RelationshipsSecure Relationships• Poor coping & problem solving

skills• Failure to thrive > Chronic illness• Learning delays / Devel. delay• Behavior problems• Speech/Language delays• Alienation, Inability to form

relationships• Lack of trust, compassion,

remorse• Aggression, Violence, Anti-social

behavior• Eating disorders • Misdiagnosed as bipolar / severe

depression

HARDWIRING OF THE BRAIN for Social-emotional fxn

• Strong social-emotional pathways

• Cognition, problem solving• Trusting relationships with

caring adults• Ability to explore their

environment without fear; curiosity

• Tolerate disappointments• Stay on task, persevere• Able to form close

friendships, networks of support

ATTACHMENT


“Amydgala Hijack”Executive Function

Responses to chronic/ toxic stress

• Impaired memory, esp. “working” and contextual memory

• Inability to concentrate

• Harder to follow directions

• Hard to sit still• Constantly on edge• Easily provoked• Impulsive

• Ability to problem solve

• Self-control• Self confidence• Able to calm self• Follows directions• Persists on task• Able to manage

their tempers when provoked

• Able to delay gratification

• Able to plan


4 ACE’sHigh risk for:

0-3 ACE’sMore likely:

ACE

• Tobacco Use• Drug abuse• Obesity• Promiscuity, teen

pregnancy• Pathologic Gambling• Risk taking behaviors• Lack of social networks• High risk for school failure• Gang membership• Unemployment• Incarceration

• Good mental health• Normal growth and

development• Less chronic disease• Less tobacco use• Less drug abuse• School readiness &

success• Employment

Substance Exposed Infants/Drug Endangered Children

Emotional Problems:- Attachment Disorders- Anxiety- Depression- Complex emotions

Cognitive Problems- Difficulty talking and listening- Difficulty Paying Attention- Difficulty Remembering- Trouble reading- Do not learn from mistakes or

experiences- Do not pick up on social cues

Behavioral Problems:- Interpersonal Problems- Inappropriate sexual behaviors- Impulsive, low threshold for stimulation- Eating disorders

“Children who experience child abuse and neglect are 59% more likely to be arrested as a juvenile, 28% more likely to be arrested as an adult, and 30% more likely to commit violent crime.” SOURCE: childhelp.org

Moriarty L, 2014 National Conference on Drug Endangered Children

Trauma-Sensitive Schools- Trauma-informed classrooms (Compassionate Schools)

• “It all boils down to this: Kids who are experiencing the toxic stress of severe and chronic trauma just can’t learn...

It’s physiologically impossible.”• In trauma-sensitive schools, teachers don’t punish

a kid for “bad” behavior– they don’t want to traumatize an already traumatized child. They did deeper to help a child feel safe. Once a child feels safe, she or he can move out of stress mode, and learn again.

Datasource:

National Survey of Children’s Health

Maternal and Child Health Bureau of HHSConducted 2011-2012Representative sample of children age 0-17Approximately 1800 per stateParent report

www.childhealthdata.org

National and Kentucky Prevalence of Adverse Childhood Experiences Among Children Age 0-17

Adverse Child or Family ExperiencesKentucky

PrevalenceNational

PrevalenceState Range

Child had ≥ 1 Adverse Child/Family Experience 55.3% 47.9% 40.6% (CT) – 57.5% (AZ)

Child had ≥ 2 Adverse Child/Family Experiences 30.0% 22.6% 16.3% (NJ) – 32.9% (OK)

Extreme economic hardship 29.6% 25.7% 20.1% (MD) – 34.3% (AZ)

Family discord leading to divorce or separation 28.9% 20.1% 15.2% (DC) – 29.5% (OK)

Having lived with someone who had an alcohol or drug problem 14.4% 10.7% 6.4% (NY) – 18.5% (MT)

Having been a victim or witness of neighborhood violence 9.3% 8.6% 5.2% (NJ) – 16.6% (DC)

Having lived with someone who was mentally ill or suicidal 11.1% 8.6% 5.4% (CA) – 14.1% (MT)

Witnessing domestic violence in the home 9.7% 7.3% 5.0% (CT) – 11.1% (OK)

Parent served time in jail 13.2% 6.9% 3.2% (NJ) – 13.2% (KY)

Treated or judged unfairly due to race/ethnicity 3.7% 4.1% 1.8% (VT) – 6.5% (AZ)

Death of parent 4.2% 3.1% 1.4% (CT) – 7.1% (DC)

Source: 2011/2012 National Survey of Children’s HealthAvailable at http://www.childhealthdata.org/home

Percentage of High School Students Who Were Bullied on School Property in Kentucky and U.S., 2009-2013

2009 2011 20130.0%

5.0%

10.0%

15.0%

20.0%

25.0%

20.8% 18.9%21.4%

13.0%

20.3%21.2%

KYUS

Source: Youth Risk Behavior Survey, 2009, 2013

Percentage of Children 6-17 Years Who Have Repeated One or More Grades Since Kindergarten

KY is 44th Among 50 States and District of Columbia

Repeated Grades0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%14.2%

9.1%KYUS

Source: 2011/2012 National Survey of Children’s HealthAvailable at http://www.childhealthdata.org/browse/survey/results?q=2515&r=1&r2=19

58

The Public Health ApproachThe public heath perspective asks foundational questions:

Where does the problem begin?How could we prevent it from occurring in

the first place?

Public Health recommends a systematic, scientific approach for understanding and preventing violence. (CDC, 2014)

Life Course of Health Development

Optimal Outcome

Poor Outcome

Lu and Halfon, 2003

Social Determinants of Health

Kaplan, et al. (2000). A Multilevel Framework for Health in :Promoting Health. Washington, DC: National Academy Press

New Protective Interventions Significant Adversity

Healthy Developmental Trajectory

Parenting Education, Sound Nutrition, Stimulating Experiences, and Health-Promoting Environments

Counseling and Education

Individual Interventions

Population based and Long-lasting Protective

interventions

Changing the ContextTo make individual’s default decisions healthier

Socio-economic Factors

Smallest impact

LARGEST IMPACT

Frieden TR. A framework for public health impact: The health impact pyramid. AJPH 2009

Public Health: Interventions by Impact

The CDC Impact Pyramid

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Percentage of Adverse Child and Family Experiences among Kentucky Children (0-17 Years)

44.7%

25.3%

30.0%

No adverse family ex-periences

One adverse family experience

Two or more adverse family experiences

55% of Kentucky children have had at least one adverse

childhood experience

Source: 2011/2012 National Survey of Children’s HealthAvailable at http://www.childhealthdata.org

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“School wide prevention program lowers teen suicide risk” The Lancet Jan 8, 2015

168 high schools in 10 European countriesThree programs with different approaches:

Training teachers to recognize children at riskTargeted all students with lectures, role-play, and educationReferrals to professionals for at-risk pupils

No Changes in three months, significant changes by 1 year Largest effect from targeting all students

Improving supervision of

students

; engage parents and families; mentoring programs; behavio

r management in classrooms; reporting

and consequences for bullying

Univers

al programs to

teach

skills

(self-

control, problem

solving, conflict resolution, teamwork)

; Trauma-

informe

d Schools

Socio-

economic Factors:

Address

violence in neighborhoods; form com

munity

coalitions; enhance com

munity

connectedness, com

munity

pride and

belonging; enga

ge teens/peer

s in creati

ng culture of

acceptance

; provi

de supports for

families

Smallest impact

LARGEST IMPACT

Adapted from Frieden TR. A framework for public health impact: The health impact pyramid. AJPH 2009

Interventions for Anti-BullyingCan be applied at multiple levels:• Individual• Family• School • Neighborhood• Community• Region/District• State

Documents

Kentucky Bullying Prevention Task Force February 11, 2015