Dr. Roy Wade's Presentation from Childhood Adversity & Poverty: Creating a Collaborative Response on April 12, 2016
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Dr. Roy Wade, a pediatrician from Children’s Hospital of Philadelphia, specializes in the connection between adverse childhood experiences and urban issues such as poverty, violence and health problems. This presentation was made during our community conversation on urban ACES and trauma informed care in Milwaukee.
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Dr. Roy Wade's Presentation from Childhood Adversity & Poverty: Creating a Collaborative Response on April 12, 2016
- 1. Childhood Stress and Urban Poverty: The Impact of Adverse Childhood Experiences on Health Roy Wade, Jr. MD, PhD, MPH Instructor of Pediatrics Children’s Hospital of Philadelphia Philadelphia PA
- 2. Overview • The Adverse Childhood Experience Study • Approaches to Addressing Toxic Stress • The Philadelphia Adverse Childhood Experience Study • Developing a Youth Informed ACE Measure
- 3. Outcomes Associated with Adverse Childhood Experiences: A Life Course Perspective Childhood: Fetal Death Developmental Delay Behavioral Problems Cognitive Impairment Adolescence to Young Adulthood: Mental Health Academic Achievement Juvenile Justice Adulthood: Mental Health Physical Health Disability Early Mortality
- 4. How Does Childhood Stress Get Under the Skin?
- 5. Adverse Childhood Experience Study Childhood Exposure Subcategory Abuse Psychological Physical Sexual Household dysfunction Substance abuse Mental illness Intimate partner violence Criminal behavior Divorce Neglect Emotional Physical • Published by CDC/Kaiser in 1998 • Surveyed 17,000 policy holders • Understand relationship between childhood adversity & adult health outcomes Adapted from Felitti et al., 1998
- 6. Graded Relationship Between ACE Score and Cardiovascular Disease Association between ACE Score and Risk for Cardiovascular Disease Adapted from Dong et al., 2004 0 0.5 1 1.5 2 2.5 3 3.5 4 0 1 2 3 4 5 to 6 7 to 8 IncreasedRiskofCVD ACE Score
- 7. Graded Relationship Between ACE Score and Health Outcomes Health Risk Behaviors Mental Health Conditions Physical Health Conditions Smoking Alcohol Abuse Drug Abuse/Illicit Drug Use High Risk Sexual Behavior Depression Anxiety PTSD Hallucinations Suicide Cardiovascular Disease Diabetes Emphysema Cancer Obesity Liver Disease Headaches Autoimmune Disease Sexually Transmitted Infections Self-Reported Health Disability Fetal Death Health outcomes highlighted in red are among the top ten leading causes of death in the US
- 8. Individuals with 4 or More ACEs are at Highest Risk for Poor Outcomes • 4- to 12-fold increased risk for health risk behaviors • 1.4- to 1.6-fold increased risk for adult diseases Adapted from Felitti et al., 1998
- 9. Population Attributable Risk of ACEs Adapted from ACE Interface 2013
- 10. ACEs are Interrelated Additional ACEs (%) ACE Category 0 ≥1 ≥2 ≥3 ≥4 ≥5 ≥6 Emotional Abuse 2 98 90 77 62 42 25 Physical Abuse 17 83 64 46 32 20 12 Sexual Abuse 22 78 58 42 29 19 12 Emotional Neglect 7 93 79 63 47 32 19 Physical Neglect 11 89 75 61 50 37 24 Parental Separation or Divorce 18 82 61 43 30 19 12 Household Substance Abuse 19 81 60 41 29 18 11 Household Mental Illness 16 84 65 48 34 21 13 Domestic Violence 5 95 82 64 48 32 20 Incarcerated Care Provider 10 90 74 56 43 30 23 Adapted from Dong et al, 2004
- 11. ACEs Impact Outcomes Across Different Sectors of Society 0 0.5 1 1.5 2 2.5 0 1 2 3 4 or more Job Problems Work Absenteeism Financial Problems ACE Score IncreasingRiskofWorkand FinancialProblems Adapted from Anda et al., 2004
- 12. Economic Costs Associated with ACEs ACEs and Social Problems • Job problems • Work absenteeism • Homelessness • Exposure to violence • Juvenile & criminal justice system involvement • Poor academic achievement • Residential mobility Lifetime Economic Toll • Total - $124 billion • Productivity loss - $83.5 billion • Health care - $25 billion • Special education - $4.6 billion • Child welfare - $4.4 billion • Criminal justice - $3.9 billion Adapted from Fang et al, 2011
- 13. Transgenerational Transmission of ACEs 9.8% 23.6% 31.8% 35.2% 38.4% 15.1% 25.9% 33.8% 37.9% 29.6% 65+ 55-64 45-54 35-44 18-34 In Crisis & Persistent ThrivingLow capacity Youngest Age Cohort IncreasingPrevalenceof3ormoreACEs Adapted from Washington State Family Policy Council, 2011
- 14. ACEs are Associated Poor Pediatric Health Outcomes Common Pediatric Conditions • Fetal death • Developmental delay • Cognitive impairment • Behavioral problems • Headaches • Somatic complaints • ADHD • Adolescent pregnancy • Early initiation of sexual activity and smoking ACE Score and Risk of Fetal Demise After First Pregnancy 0 0.5 1 1.5 2 0 1 to 2 3 to 4 5 or more IncreasingRiskofFetalDemise ACE Score Adapted from Hillis et al., 2004
- 15. ACE Exposure Associated with Academic Problems 0 1 2 3 4 5 6 7 0 1 2 3 or more Academic Failure Problems with School Attendance School Behavior Concerns ACE Score RiskforAcademicProblems Adapted from C. Blodgett et. al., 2014
- 16. Overview • The Adverse Childhood Experience Study • Approaches to Addressing Toxic Stress • The Philadelphia Adverse Childhood Experience Study • Developing a Youth Informed ACE Measure
- 17. Three Levels of Stress Positive Stress: Brief increases in heart rate, mild elevations in stress hormone levels Tolerable Stress: Serious, temporary stress responses buffered by supportive relationships Toxic Stress: Prolonged activation of stress response systems in the absence of protective relationships Adapted from the Center on the Developing Child Working Paper Excessive Stress Disrupts the Architecture of the Developing Brain
- 18. Impact of Toxic Stress
- 19. Breaking the Cycle of Trauma Nurturing Supportive Relationships
- 20. Strategies to Address Toxic Stress • Parenting programs – Home Visiting programs – Parent Child Interaction Therapy • Trauma Focused Cognitive Behavior Therapy • Mindfulness training • Promoting Non-Cognitive skills
- 21. The Importance of ACEs Knowing • Trauma informed approaches – Adjusting office/provider processes to decrease patient stress – Morning huddles to anticipate patient needs – Provider mindfulness • Helping patients rewrite their narrative • Helping patients build capacity for emotional control – Learn self regulations skills – Identify triggers – Effective use of mindfulness and exercise • Collaborative care plans
- 22. The Safe Environment for Every Kid Model Adapted from Dubowitz et al., 2012
- 23. Decreased CPS Reports and Physical Assault in SEEK Intervention Group Intervention (N = 308) Control (N = 250) Odds Ratio p Families With at Least 1 CPS Report, n(%) 41 (13.3) 48 (19.2) 1.5 0.045 Physical assault severe or very severe, Mean (SD)* 0.11 (0.75) 0.33 (1.96) -- 0.04 • Health professionals endorsed increased comfort in screening and addressing risk factors for ACEs • Intervention increased clinic screening rates for risk factors for ACEs – 25% increase • Addressing patient psychosocial problems DID NOT require additional provider time • Implementation of SEEK cost approximately $5.12 per family Adapted from Dubowitz et al., 2009 * Scores from Parent-Child Conflict Tactics Scale
- 24. Overview • The Adverse Childhood Experience Study • Approaches to Addressing Toxic Stress • The Philadelphia Adverse Childhood Experience Study • Developing a Youth Informed ACE Measure
- 25. AAP Policy Statement on ACE Identifying children at high risk for toxic stress is the first step in providing targeted support for their parents and other caregivers. … Pediatric practices have been asked to consider implementing standardized measures to identify other family- or community-level factors that put children at risk for toxic stress… the AAP and others have encouraged pediatric providers to develop a screening schedule that uses age-appropriate, standardized tools to identify risk factors that are highly prevalent or relevant to their particular practice setting.
- 26. ACE Study Population is not Representative of Urban Populations Demographics ACE Study Philadelphia Mean age 56 34 Race/ethnicity 79% White 45% White 5% African American 44% African American 5% Hispanic 14% Hispanic High school graduates 94% 81% College graduates 43% 24% Percent below FPL Not measured 27%
- 27. ACE Scale Can Be Improved by Adding Additional Adversities to the Measure Original • Emotional abuse • Physical abuse • Sexual abuse • Physical neglect • Emotional neglect • Mother treated violently • Household substance abuse • Household mental illness • Incarcerated household member • Parental separation or divorce Additional Adversities • Property victimization • Peer victimization • Exposure to community violence • Socioeconomic status • Someone close had a bad accident or illness • Below-average grades • Parents always arguing • No good friends
- 28. Exposure to Community Level ACEs is Common Amongst Youth 0 10 20 30 40 50 60 70 Physical Abuse Sexual Abuse Emotional Abuse Emotional Neglect Physical Neglect Household Mental Illness Household Substance Abuse Domestic Violence Incarcerated Household Member Parental Separation or Divorce Peer Victimization Property Victimization Exposure to Community Violence Problems with Friends Problems in School Experienced Disaster Involved in Child Welfare System Prevalence (%) Family&CommunityLevelACEs Prevalence of Family & Community Level ACEs Amongst a Nationally Representative Sample of Youth (N = 2030) Blue – Family Level ACEs Red – Community Level ACEs Adapted from Finkelhor et al., Arch Pediatr Adolesc Med 2013
- 29. Childhood Exposure to Community Level ACEs Associated with Poor Health • Community level stressors associated with childhood behavior problems and mental health conditions – Childhood exposure to community violence associated with adolescent depression, anger, anxiety, and posttraumatic stress (explains ~30% of variance) - Singer et al., JAMA 1995. • Association of community level ACEs with child physical health outcomes unclear – Adolescent perceived racial discrimination associated insulin resistance among African American girls but not boys – Chambers et al., J Natl Med Assoc 2004. – Perceived neighborhood safety associated with adolescent obesity in some studies but not others – Lumeng et al., Pediatrics 2010; Romero et al., JAMA Pediatr 2001. • Few studies examining impact of childhood stressors across the life course – Adolescent exposure to community violence associated with poor health among women but not men – Olofsson et al., BMC Public Health, 2012
- 30. Childhood Exposure to Multiple Forms of Victimization is Common -1 -0.5 0 0.5 1 1.5 2 2.5 0 5 10 15 20 25 30 35 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14+ TraumaSymptomScore PercentofSample Number of Types of Victimizations Relationship Between Multiple Types of Victimization and Trauma Symptom Scores in the Past Year Adapted from Finkelhor et al., OJJDP Bulletin 2011
- 31. A collaborative, led by the Institute for Safe Families (ISF), to develop and implement research, practice, and policies in urban pediatric settings based on the Adverse Childhood Experiences (ACE) study. The Philadelphia ACE Study
- 32. Survey Methods • Survey was completed as a follow up to the Southeastern Pennsylvania Household Health Survey (SEPA HHS). – Survey of over 13,000 children and adults in Southeastern Pennsylvania – Comprehensive survey on a broad range of topics • Philadelphia ACE Survey re-contacted original SEPA HHS Philadelphia respondents who were 18 years or older • Telephone survey (landline and cell phones) • Completed by trained male and female interviewers • Interviews were conducted in English and Spanish • Interviewed 1,784 Philadelphia adults age 18 and older • Response rate 67.1%
- 33. Philadelphia ACE Study Questions Conventional ACEs Expanded ACEs Physical Abuse Emotional Abuse Sexual Abuse Emotional Neglect Physical Neglect Domestic Violence Household Substance Abuse Incarcerated Care Provider Mental Illness in the Home Witnessing Violence Living in Unsafe Neighborhoods Experiencing Racism Living in Foster Care Experiencing Bullying
- 34. Many of the Traditional ACEs are More Prevalent in an Urban Setting Philadelphia ACE Study (N = 1,784) CDC-Kaiser ACE Study (N = 17,337) Emotional abuse 33.2% 10.6% Physical abuse 35.0% 28.3% Sexual abuse 16.2% 20.7% Physical neglect 19.1% 14.8% Emotional neglect 7.7% 9.9% Substance abusing household member 34.8% 26.9% Mentally ill household member 24.1% 19.4% Witnessed domestic violence 17.9% 12.7% Household member in prison 12.9% 4.7%
- 35. Prevalence of Expanded ACEs Expanded ACE Indicators Respondents (N = 1,784) Witnessed violence 40.5% Felt discrimination 34.5% Adverse neighborhood experience 27.3% Bullied 7.9% Lived in foster care 2.5%
- 36. Distribution of Total ACE Scores 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% 0 ACEs 1 - 3 ACEs 4+ ACEs ACEPrevalence(%) ACE Score
- 37. Prevalence of Conventional ACEs CDC-Kaiser vs. Philadelphia ACE Study ACEPrevalence(%) 0 10 20 30 40 50 60 70 80 1 or more Coventional ACEs 4 or more Conventional ACEs CDC-Kaiser ACE Study Philadelphia ACE Study
- 38. Overlap Between Exposure to Conventional and Expanded ACEs 17.2% 19.6% 13.9%49.3% No ACEs > 1 Conventional ACE 1 Conventional ACE & > 1 Expanded ACE > 1 Expanded ACE
- 39. Relationship Between Philadelphia ACE Score and Smoking History 0 0.5 1 1.5 2 2.5 3 Conventional ACEs Expanded ACEs Total ACEs 0 1 to 4 4+ SmokingRisk
- 40. Relationship Between Philadelphia ACE Score and Mental Health 0 1 2 3 4 5 6 Conventional ACEs Expanded ACEs Total ACEs 0 1 to 4 4+ RiskforMentalIllness
- 41. Relationship Between Philadelphia ACE Score and Cardiovascular Disease 0 0.5 1 1.5 2 2.5 Conventional ACEs Expanded ACEs Total ACEs 0 1 to 3 4+ CardiovascularDiseaseRisk
- 42. Direct and Indirect Influences of Neighborhood ACEs on Toxic Stress Neighborhood & Community Level ACEs (Racism) Family & Household Level ACEs (Nurturing Parenting) Toxic Stress Child
- 43. Perceived Discrimination Decreases the Quality of Mother-Child Relationships Maternal perceived racial discrimination Maternal stress (life events, financial strain, job stress) Maternal psychological functioning (anxiety and depression level) Nurturing mother child relationship No No Yes Adapted from Murry et al., Journal of Marriage and Family 2001
- 44. Demographic Characteristics for Philadelphia Adults with Four or More ACEs Demographics Respondents (N = 1,784) Sex** Male 58.2% Female 41.8% Race*** Black 48.6% White 34.0% Poverty Level*** Below 150% of poverty guidelines 68.2% Above 150% of poverty guidelines 31.8% *p<0.05; **p<0.01; ***p<0.001
- 45. Total ACE Score > 4 by Zip Code Health Statistics from these 5 Zip Codes - 22% of adults unemployed - 46% of residents live in poverty - Life expectancy for males age 68 - 22% of children obese - Homicide rate 30 to 40 deaths per 100,000 Philadelphia County
- 46. Overview • The Adverse Childhood Experience Study • Approaches to Addressing Toxic Stress • The Philadelphia Adverse Childhood Experience Study • Developing a Youth Informed ACE Measure
- 47. Current Childhood Adversity Screening Tools are Insufficient Adversity Measures Constructs Assessed Childhood Trauma Questionnaire Anatomical Doll Questionnaire Checklist of Sexual Abuse and Related Stressors Abusive Sexual Exposure Scale Checklist for Child Abuse Evaluation Child Abuse & Neglect Interview Schedule Physical Abuse Emotional Abuse Sexual Abuse Neglect Children’s Exposure to Community Violence Adolescent Self Report Trauma Questionnaire My Worst Experience Scale Exposure to Violence Routine Stressors Urban Hassles Index Adolescent Perceived Events Scale* Routine Stressors Traumatic Events Screening Inventory Childhood Trust Events Survey Life Events & Coping Inventory* Lifetime Incidence of Traumatic Events Abuse/Neglect Exposure to Violence Routine Stressors * Youth Informed Measures
- 48. • Series of focus groups with young adults • Nominal Group Technique – Generate list of adverse childhood experiences – Prioritize items on list based on relative significance • Analyze ranked lists for common themes • Develop final ranked list of adverse experiences • Member checking process & discussion of context surrounding each theme A Youth Informed Approach to Assessing ACEs
- 49. Study Participant Demographics Demographics Percent of Individuals (N = 119) Sex Male 55% Race/Ethnicity Caucasian 5% Hispanic 18% Non-Hispanic Black 71% Other 6% Neighborhood Poverty Level (100% FPL) Less than 10% 5% 10 to 20% 11% 20 to 40% 51% Greater than 40% 33%
- 50. Domains of Most Stressful Experiences Domain Number of Responses Family Relationships 195 Community Stressors 119 Personal Victimization 72 Economic Hardship 67 Peer Relationships 35 Discrimination 23 School 22 Health 17 Child Welfare/Juvenile Justice 8 Media/Technology 5
- 51. Family Relationships Family Relationship Subdomains Number of Responses Family Members Abusing Alcohol & Drugs 37 Lack of Love & Support in the Family 33 Single Parent Homes 30 Death & Illness of Family Members 21 Violence in the Home 20 Poor Parenting & Lack of Guidance 20 Criminal Activity by Family Members 15 Having to Take on Adult Responsibilities 14 Violent Victimization of Family Members by Individuals Outside of the Home 4
- 52. Family Relationships Representative Quote “My mom said, ‘I ain’t teach you nothing because I want you to go through the same thing I went through…’ It’s just like heartless, like you just don’t care. My parents couldn’t show me [love]. They made me feel like I was just there for a check.”
- 53. Community Stressors Community Stressor Subdomains Number of Responses Neighborhood Crime, Violence, and Death 57 Negative/Adult Behavior in the Neighborhood 50 Neighborhood Nonviolent Crime 12
- 54. Community Stressors Representative Quote “There were shootings every night, so much so that the kids couldn’t play outside. You wake up in the morning and find that someone from your friend’s family passed away.”
- 55. Personal Victimization Personal Victimization Subdomains Number of Responses Child Abuse 33 Bullying 16 Child Neglect 9 Violent Crime (Nonsexual) 7 Nonviolent Crime 3 Rape 3 Being chased by cops 1
- 56. Personal Victimization Representative Quote “I seen my cousins getting raped by my uncles because they were addicted to drugs,… literally if you woke up in the middle of the night, you would be scared to walk down the steps because your uncles were doing whatever to your cousins.”
- 57. Economic Hardship Economic Hardship Subdomains Number of Responses Not Enough Money 35 Lack of Nonmonetary Resources (hunger, homelessness, lack of adequate housing, lack of utilities, housing instability) 31 Watching Parents Struggle to Make Ends Meet 1
- 58. Economic Hardship Representative Quote “The hardest thing for me was watching my mom struggle [financially to pay for] food, utilities, bills.”
- 59. Peer Relationships Peer Relationships Subdomains Number of Responses Peer Pressure 13 Death of Friends 11 Problems with Friends & Peers 9 Victimization of Friends (Violence) 2
- 60. Peer Relationships Representative Quote “Gossip, it always carries stress because it results into things... And the people that get brought into it that don’t have nothing to do with it. Once in my school gossip got around to one of my friends getting killed because it traveled down to a family member. Things got heated and he got shot.”
- 61. Discrimination Discrimination Subdomain Number of Responses Stereotypes, Racism, Discrimination 23
- 62. Discrimination Representative Quote “Stereotyping… it’s mostly white people, the way they look at you when you are out walking in the street, they try to downgrade [you]… I’ve seen people follow [black people] around the store. They already got a mindset about us before they even know who we are.”
- 63. Summary • ACEs are common across sociodemographic backgrounds • ACEs impact outcomes across sectors and throughout the lifecourse • Numerous strategies to address ACEs – importance of awareness • Certain populations at higher risk for ACEs • Contextual issues surrounding ACEs for certain populations
- 64. Acknowledgements • Joanne Wood • Judy Shea • David Rubin • Steve Berkowitz • Ken Ginsburg • Chris Forrest • Carole Tucker • Katherine Bevans • RWJF Clinical Scholars Program • Institute for Safe Families • Martha Davis • Joel Fein • Sandra Bloom • Lee Pachter • Megan Bair-Merritt • Peter Cronholm • Community Partners • Study Participants
Notas del editor
- The Adverse Childhood Experience study was a landmark study connecting a broad range of negative childhood exposures (toxic stressors) to poor adult health outcomes.
- Stress is defined as a state of mental or emotional strain or tension resulting from adverse or very demanding circumstances. We often then of stress as a bad thing for health, however learning to respond to stressful situations is a normative part of child development. Present here a model for describing types of stress based on the activity of systems that oversee production of stress hormones like cortisol.
- Identifying children at high risk for toxic stress is the first step in providing targeted support for their parents and other caregivers. Pediatric practices have been asked to consider implementing standardized measures to identify other family- or community-level factors that put children at risk for toxic stress the AAP and others have encouraged pediatric providers to develop a screening schedule that uses age-appropriate, standardized tools to identify risk factors that are highly prevalent or relevant to their particular practice setting.
- Partnered with 10 community based organizations to hold focus groups in economically distressed areas in Philadelphia. Inclusion criteria included individuals ages 18 to 26, who lived at least half of their life prior to age 18 in Philadelphia. Recruitment occurred through directors and staff of community organizations who directly targeted individuals who grow up in low-income settings.
- Combine categories, eliminate female, create other