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3 Adverse Childhood Experiences (ACEs) and their Long- term Implications for Adult Health Keith S. Dobson, Ph.D. Department of Psychology University of Calgary Presented at the Public Health Ontario Rounds- Public Health Early Years Group April 12, 2018

Acknowledgements Work in adult mental health, focus on depression, cognitive behavioral therapy, and evidence-based practice more generally Working in partnership with colleagues from Alberta Health

4 Acknowledgements Work in adult mental health, focus on depression, cognitive behavioral therapy, and evidence-based practice more generally Working in partnership with colleagues from Alberta Health Services (AHS), and the Primary Care Networks within Calgary area Representatives from mental health, primary care, government, justice, AHS leadership Have a long standing patient advisory group Sponsored by Norlien (Palix) Foundation

5 Overview Discuss the long shadow of childhood adversity Adult representations of childhood adversity The potential for change in adulthood Implications for intergenerational transmission

6 Predictors of Health Problems Biological Biological propensity (e.g., genetics, epigenetics) Injury or physical illness in childhood Psychological Low self- esteem and poor self-image Learned coping behaviors (e.g. avoidance) Low resilience Social Lower socioeconomic status Limited, suspended or halted education Restricted opportunities (e.g. occupational) War, famine, disaster Adverse Childhood Experiences (ACEs)

7 ACEs as a Predictor of Health Problems The largest study of its kind, that examined the health and social effects of adverse childhood experiences over time. Involved over 17,000 participants at Kaiser Permanente in California. Study conducted in 1998.

8 Abuse Emotional: recurrent threats, humiliation (11%) Physical: beating, not spanking (28%) Contact sexual abuse (28% women; 16% men) Neglect Physical (10%) Emotional (15%) Household Dysfunction Mother treated violently (13%) Household member was drug or alcohol abuser (27%) Household member was imprisoned (6%) Household member with chronic mental illness (17%) Not raised by both biological parents (23%) What are ACEs?

9 ACE Distribution (%)- Anda & Felitti, Males Females

10 Response gets bigger The Dose-Response Relationship More ACEs = more health problems Dose gets bigger The dose-response relationship leads to inferences about cause & effect. The response in this case the occurrence of the health condition is influenced directly by the size of the dose in this case, the number of ACE categories.

11 % Abusing Alcohol ACEs and Adult Alcohol Abuse _ ACE Score (Dube et al., 2002)

12 Odds Ratio ACEs and Risk for Heart Disease ACE Score (Dong et al., 2004)

Percentage of Group Adult Health Risks by ACE Score ACEs and Other Outcomes ACE Score 0 1.

13 Percentage of Group Adult Health Risks by ACE Score ACEs and Other Outcomes ACE Score % 15% 10% 5% 0% Current Smoking Obesity Attempted Suicide Ever Injected Drugs Ever Had an STD SOURCE: Felitti, V.J., & Anda, R.F., Center for Disease Control and Prevention, 2003 SOURCE: Felitti, V.J., Kaiser Permanente; and Anda, R.F., Center for Disease Control and Prevention.

14 Same patterns have been found for: Early smoking, and COPD (Anda et al., 1999; 2008) Adolescent pregnancy (Hillis et al., 2004) Lifetime history of depression (Chapman et al., 2004) Early death (Anda, et al, 2007)

15 Developmental Responses to Stress NORMAL, TIME- LIMTED STRESS BRAIN Hormones, chemicals & cellular systems prepare for fight or flight; resolve after stress or is resolved; world viewed as neutral or benevolent INDIVIDUAL Resilient Relationshiporiented Thoughtful; coping oriented Process over power OUTCOMES Better mental and physical health; social connectedness; ability to cope with and appropriate responses to adversity BIRTH TRAUMATIC or TOXIC STRESS BRAIN Hormones, chemicals & cellular systems prepare for fight or flight on recurrent basis; less time to resolve; world viewed as hostile/ tough INDIVIDUAL Hyper-vigilant; Edgy; quick to temper Impulsive; avoidant coping Brawn over brains OUTCOMES Worse mental and physical health; social disconnectness; emotion dysregulation; avoidant/ less functional coping strategies.

16 Lifetime Effects

17 The Potential for Change in Adulthood

18 Implications of ACEs We need to do something about chronic disease, depression, addictions, and their associated costs. If ACEs are a significant predictor of these health problems, we need to do something about the long term effects of ACEs.

19 Possible approaches Screening alone isn t enough! Primary prevention (stop ACEs from happening) Home visits for families with newborns Parenting training programs; family wellness Social justice; reducing incarceration rates Social development; economic opportunity Secondary prevention (early help for people with ACEs) Screen for people at risk Offer treatment to increase resilience and reduce risk Tertiary prevention (treat the final condition that emerges) Chronic disease support groups Mental illness and substance abuse treatment

20 The ACEs-Alberta Research Program Project Purpose and Goals : To identify and treat adults with high ACE childhoods in primary care settings Four Phase Implementation Phase 1: Develop and validate an ACEs measure Phase 2: Large scale replication of the first ACEs study The hunt for moderators and modifiers Phase 3: Develop and test an intervention for people with high ACE scores in primary care Phase 4: Test the intervention in an RCT

21 Phase 1: ACEs- Alberta Program Phase 1 Purposes: Develop and validate the ACEs-A measure; pilot procedures Process: Recruit patients in primary care clinics to complete various measures of trauma and health status Conduct focus groups Examine health care usage in the past year (acute care and primary care) Study completed (N = 291)

22 Phase 2: ACEs-Alberta Purpose: Large scale replication of the ACEs study in Primary Care in Alberta Process: 4000 subjects to complete the new ACEs measure Subjects to complete life experience questionnaires Look at health care usage in the past year (acute care and primary care), as well as in the year following the completion of the questionnaires Look at resilience emotional regulation and interpersonal problems as moderating and mediating variables

23 Phase 2 Results 40 ACE Scores for Sample (%) N = 4, Females Males

24 ACEs and Gastro-Intestinal Problems ** *** *** ** *** *** Irritable Bowel Syndrome (IBS) Stomach or Intestinal Ulcers

25 ACEs and Frequent Headaches & Fatigue *** 3 2 *** *** *** *** *** *** Headaches Fatigue

26 ACEs and Substance Abuse & GAD *** 8 6 *** *** *** 4 * *** 2 *** Substance-Related Disorder Generalized Anxiety Disorder (GAD)

27 ACEs and Clinical Depression & Suicidal Ideation *** *** *** *** 3 *** 2 * *** Major Clinical Depression Suicidal Ideation

Avg. Total Health Care Costs by ACE Score 1600 1400 1200 1000 800 600 400 200 0 0 1 2 3 4+ ACE Score NOTE: An ACE history of 4+ is

28 Avg. Total Health Care Costs by ACE Score ACE Score NOTE: An ACE history of 4+ is associated with about a 25% increase in health care costs, from $1100 to $1360/ person/ year. About 20% of the population has an ACE score of 4+.

29 An Exploration of Mediators and Moderators We know that ACEs predict depression in adulthood. Depression is also associated with a range of other poor health outcomes in adulthood. Mechanisms responsible for the association between ACEs and depression will likely apply to ACEs and other poor health outcomes in adulthood.

30 Implications This research helps to establish emotion dysregulation and interpersonal problems as mechanisms by which ACEs may be associated with depression, and resilience as a buffer of the association between ACEs and depression.

31 Psychological Resilience

32 Implications This research helps to establish emotion dysregulation and interpersonal problems as mechanisms by which ACEs may be associated with depression, and resilience as a buffer of the association between ACEs and depression. Analyses with anxiety and other health conditions have revealed the same general pattern. Emotion dysregulation, interpersonal problems and resilience have been shown to be modifiable treatment targets. Treatment initiatives for ACE- related depression and other outcomes should address emotion dysregulation, interpersonal problems, and resilience as treatment targets.

33 An ACE-informed Adult Treatment Program 1. Key guiding principles in the development process 2. Specific steps in the development process 3. Elements of the treatment

34 Key Principles of the ACEs Treatment Evidence-informed treatment Literature review of treatments for trauma revealed CBT, mindfulness based, expressive writing as most effective (Korotana, Dobson, Pusch, Josephson, 2016, Clinical Psychology Review) Trauma-informed process Must be close to the point of care: Primary Care Multidisciplinary effort Layers of players provides for a more integrated model of treatment, support and care

Treatment Development Group Experienced mental health clinicians in primary care settings Training and knowledge of developmental trauma factors Experience in clinical work within primary care Met

35 Treatment Development Group Experienced mental health clinicians in primary care settings Training and knowledge of developmental trauma factors Experience in clinical work within primary care Met over the course of about a year to develop the treatment model Reviewed literature, clinical models, relevant factors Consultation with experts: Anda, Briere, Cloitre, Strosahl, Robinson Consensus and feedback! ACEs-Alberta Research Group Patient Advisory Group

36 The embrace Program Past and Future Relationships Intro to ACEs ACEs Body Thoughts Process Initial ACE screening Meeting with GP and Clinician Inclusion/ exclusion criteria Invited to join the skillsbased group Follow up at 3 &, 6 months to assess health outcomes Emotions

37 Format of Each Meeting 1. Today s topic 2. Review of homework 3. Relaxation exercise 4. Skill building, discussion, practice 5. Check out and homework

38 Development of a Self-Care Plan List of all the skills taught in the 6 sessions Participants indicate their favourite skills Participants make a plan for using those skills in the future Participants share their plan with GP and/or clinician after the end of the group

39 Self-Care Plan Select the skills that have worked best and describe how you will use the skills in the future. My Favourite Self-Care Skills My Resolution Grounding Exercise Bulls Eye Exercise Increasing Movement Sleep Hygiene SMART goals Identifying Thinking Traps Riding the Wave

40 The Child is the father of the Man --William Wordsworth, 1802 Meeting 1: Introduction

41 Meeting 1: Content Why are we here? Presentation: ACEs and You Relaxation exercise Review and practice Bull s eye exercise Introduction of self-care plan Check-out

42 Take care of your body. It s the only place you have to live. --Jim Rohn Meeting 2: Taking care of my body

43 Meeting 2: Content Goals Relaxation exercise Check-in Six key areas: Sleep Nutrition Exercise Relaxation Self-nurturing rituals Grounding strategy Check-out +

44 Meeting 3: Taking care of my thoughts We can complain because rose bushes have thorns, or rejoice because thorn bushes have roses. --Abraham Lincoln

45 Meeting 3: Content Goals Relaxation exercise Check-in Thinking traps: Identify thinking traps Create alternate thoughts/beliefs Additional strategies for changing thinking traps Check-out

Meeting 4: Taking care of my emotions If you are faced with a mountain, you have several options. You can climb it and cross to the other side. You can go around it. You can dig under it.

46 Meeting 4: Taking care of my emotions If you are faced with a mountain, you have several options. You can climb it and cross to the other side. You can go around it. You can dig under it. You can fly over it. You can blow it up. You can ignore it and pretend it s not there. You can turn around and go back the way you came. Or you can stay on the mountain and make it your home. --Vera Nazarian

47 Meeting 4: Content Goals Relaxation exercise Check-in Values and feelings Acceptance--hands as thoughts and feelings exercise Four techniques to cope with unpleasant emotions Check-out

48 Meeting 5: Taking care of my relationships You don t develop courage by being happy in our relationship every day. You develop it by surviving difficult times and challenging adversity --Epicurus

49 Meeting 5: Content Goals Relaxation exercise Check-in Potential impact of ACEs on relationships Common characteristics in nurturing and supportive relationships Boundaries in relationships Communication styles in relationships Assertiveness communication techniques Check-out

50 Meeting 6: Taking care of my past and living a valued life Owning our story and loving ourselves throughout that process is the bravest thing that we will ever do. -Brene Brown, The Gifts of Imperfection

51 Meeting 6: Content Goals Relaxation exercise Check-in Bull s eye exercise Self-compassion exercise Review of favorite self-care skills Self-care plan Check-out: What s next?

52 Preliminary Results from the Open Trial

53 embrace Study Phase 3- Open Trial Goal was to develop and provide Proof of Concept data for an ACEsinformed treatment for patients in primary care Inclusion criteria: An ACE score of 3 or more A presenting chronic health problem (mental or physical) Physician referral

54 Demographic Characteristics (n = 107) Variable Gender: - Female - Male Ethnicity: - Caucasian - Black or African American - South Asian - First Nations - Other n

55 Demographic Characteristics (n = 107) Variable Education: - High school or less - Some college or university - College or university graduation Household income: - < 20,000-20,000-39,999-40,000-79,999-80,000+ Employment status: - Not employed outside the house - Full time - Part time - Retired n

56 Changes over time- Anxiety Pre-test Post- test 3 Month 6 Month Repeated measures ANOVA, F (3/39) = 9.05, p <.001

57 Changes over time- Depression Pre-test Post- test 3 Month 6 Month Repeated measures ANOVA, F (3/40) = 13.84, p <.001

Changes over time- Emotion Dysregulation (DERS) 105 100 95 90 85 80 Pre-test

58 Changes over time- Emotion Dysregulation (DERS) Pre-test Post- test 3 Month 6 Month Repeated measures ANOVA, F (3/39) = 9.05, p <.001

59 Changes over time- Mindfulness Pre-test Post- test 3 Month 6 Month Repeated measures ANOVA, F (3/33) = 7.68, p <.001

60 Changes over time- Perceived Social Support Pre-test Post- test 3 Month 6 Month Repeated measures ANOVA, F (3/37) = 4.90, p <.01

Changes over time- Resilience 63 62 61 60 59 58 57 56 55 54 Pre-test

61 Changes over time- Resilience Pre-test Post- test 3 Month 6 Month Repeated measures ANOVA, F (3/32) = 3.89, p <.01

62 Next Steps Conduct literature review on possible biomarkers (completed Fall, 2017) Revise manuals based on feedback (April, 2018) Finalize IP and Partnership Agreements Randomized Clinical Trial Design is 2 armed: 1. The embrace Program immediate 2. Treatment as Usual; then the embrace Program delayed

63 Implications for intergenerational transmission

64 So what can we do about ACEs? CDC Best Practices Prevention- Technical-Package.pdf Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Preventing child abuse and neglect: A technical package for policy, norm, and programmatic activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

65 Preventing Child Abuse and Neglect

66 Preventing Child Abuse and Neglect Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Preventing child abuse and neglect: A technical package for policy, norm, and programmatic activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

67 Preventing Child Abuse and Neglect

68 Lifetime Effects A Self- Care Plan Cognitive, emotional and social skills Mindfulness; taking care of the body

69 What is trauma informed care? Education and Skills A paradigm shift: Understanding prevalence and effect of trauma Patient centered communication and care Empathetic listening Universal trauma precautions Giving patients more control of their environment

70 What is trauma informed care? Culture Trauma informed health care and organizations Resist stigmatization and re-traumatization Understanding and addressing our own history and reactions Screening for ACEs and trauma history Conversations: Not What s wrong with you? but What happened to you? Integrate knowledge about trauma into policies, procedures, and practices

71 Thank you Comments and Questions.

Trauma/ACEs 101. Tom Bradach IL Chapter, American Academy of Pediatrics

Trauma/ACEs 101. Tom Bradach IL Chapter, American Academy of Pediatrics Trauma/ACEs 101 Tom Bradach IL Chapter, American Academy of Pediatrics Providing pediatrician and interprofessional education, resources, and technical assistance Working on policy, advocacy, and systems