THE IMPACT OF CHILDHOOD TRAUMA
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1 THE IMPACT OF CHILDHOOD TRAUMA Prepared for the NCCADV Children and ACEs Pre-conference Meghan Shanahan, PhD, MPH Maternal and Child Health Department Injury Prevention Research Center May 17 th, 2016
2 OVERVIEW 1. Brain development 2. Trauma and brain development 3. ACE study 4. ACEs and North Carolina (with thanks to Anna Austin, MPH) 5. Prevention and Intervention
3 BRAIN DEVELOPMENT Child Welfare Information Gateway. Understanding the effects of maltreatment on brain development.
4 BRAIN DEVELOPMENT o Synapse formation o Pruning o Myelination o Plasticity
5 STRESS RESPONSE Fight or flight Stress can be: opositive otolerable otoxic National Scientific Council on the Developing Child (2005/2014). Excessive Stress Disrupts the Architecture of the Developing Brain: Working paper No. 3. Updated Edition. Retrieved from
6 TRAUMA AND THE BRAIN Changes to: ostructure ochemical activity oemotional and behavioral functioning
7 ADVERSE CHILDHOOD EXPERIENCES
8 CONCEPTUAL FRAMEWORK: ACE PYRAMID
9 ADVERSE CHILDHOOD EXPERIENCES (ACE) STUDY o Life course perspective o Primary care setting o 17,337 participants completed survey o Retrospective report of childhood experiences o Current health status and behaviors Centers for disease control and prevention. Adverse Childhood Experiences (ACE) Study. Data and Statistics. Prevalence of Individual Adverse Childhood Experiences. Available at: Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. Am J Prev Med 1998;14(4):
10 Centers for disease control and prevention. Adverse Childhood Experiences (ACE) Study. Data and Statistics. Prevalence of Individual Adverse Childhood Experiences. Available at: ACE STUDY: PREVALENCE Household dysfunction Substance abuse 26.9% Separation/divorce 23.3% Mental illness 19.4% IPV12.7% Incarceration 4.7% Maltreatment Physical abuse 28.3% Sexual abuse 20.7% Emotional neglect 14.8% Emotional abuse 10.6% Physical neglect 9.9%
11 ACE STUDY: PREVALENCE Number of ACEs Total or more 12.5
12 ACE STUDY: OUTCOMES ACEs associated with: o Alcoholism and alcohol abuse o COPD o Depression o Fetal death o Health-related quality of life o Illicit drug use o IHD o Liver Disease o IPV o Multiple sex partners Dose response was found o STIs o Smoking o Suicide attempts o Unintended pregnancies o Early initiation of smoking o Early initiation of sexual activity o Adolescent pregnancy Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE) Study. Data and Statistics. Prevalence of Individual Adverse Childhood Experiences. Available at:
13 DOSE RESPONSE Anda R. The health and social impact of growing up with adverse childhood experiences. The human and economic costs of the status quo. Available at:
14 NC ADVERSE CHILDHOOD EXPERIENCES o NC Behavioral Risk Factor Surveillance System (BRFSS) Yearly random telephone survey of NC residents Ages 18+ o The ACE Module Developed by CDC as standardized optional module in questions assess 8 categories of ACEs Included on N.C. BRFSS in 2012 o The ACE Score Calculated based on the 8 categories of ACEs assessed Exposure to any single category counts as one point toward score Final score ranges from 0 to 8 Measure of cumulative exposure to ACEs
15 METHODS 2012 N.C. BRFSS 10,383 (87.3%) responses to ACE Module ACE Study Groups No ACE (0 ACEs) Low ACE (1-2 ACEs) High ACE (3-8 ACEs) Outcomes Health risks Perceived poor health Chronic conditions
16 METHODS SAS SURVEY procedures Prevalence estimates (SURVEY FREQ) Multivariate logistic regression (SURVEY LOGISTIC) Adjusted ORs examining odds of outcomes for Low ACE and High ACE compared to No ACE Goodness of fit test to determine best set of independent variables Control variables: age, sex, race, education
17 Percent RESULTS % 23.7% Prevalence of Adverse Childhood Experiences among North Carolina Adults 11.9% 57.6% reported one or more ACEs 8.5% 6.0% 3.4% 2.1% 1.4% 0.5% ACE Score
18 RESULTS Prevalence of Adverse Childhood Experiences by Study Group No ACE (0) 42.4% Low ACE (1-2) 35.6% High ACE (3-8) 22.0% Percent
19 RESULTS Prevalence of Sex and Age among High ACE Group 60% 58.5% 56.6% 50% 40% 41.5% 30% 20% 10% 20.2% 14.8% 8.4% 0% Female Male
20 RESULTS
21 RESULTS Prevalence of Adverse Childhood Experiences by Category Parental Separation/Divorce Substance Abuse in Household Emotional Abuse Violence between Adults in Household Mentally Ill Household Member Physical Abuse Sexual Abuse Incarcerated Household Member 17.0% 15.5% 15.2% 10.8% 7.8% 23.7% 27.4% 26.8% Percent
22 RESULTS Prevalence Adverse Childhood Experiences (ACEs) by Study Groups Parental Separation/Divorce Substance Abuse in Household Emotional Abuse Mentally Ill Household Member Violence Between Adults in Household Physical Abuse Sexual Abuse Incarcerated Household Member 38.9% 59.6% 26.6% 76.5% 20.0% 72.3% 12.9% 48.3% 11.2% 57.0% 9.9% 50.0% 9.1% 33.6% 4.8% 27.1% High ACE (3-8) Low ACE (1-2)
23 RESULTS Increased odds for health risks for Low and High ACE groups Current smoking, binge drinking, obesity, HIV Risk Increased odds for perceived poor health for Low and High ACE groups 14+ days of poor physical health, mental health, and activity limitation in past 30 days Increased odds for chronic conditions for Low and High ACE groups COPD, history of CVD, arthritis, depressive disorder, disability
24 RESULTS Examples of Adjusted Odds Ratios for Low and High ACE Study Groups Health Indicators Low ACE (1-2) High ACE (3-8) Health risks aor 1 (95% CI) aor 2 (95% CI) Current Smoker 1.44 (1.22, 1.69) 2.50 (2.11, 2.97) HIV risk 1.98 (1.30, 3.01) 4.14 (2.80, 6.12) Perceived poor health Fair or poor general health 1.01 (0.94, 1.29) 2.34 (1.96, 2.79) 14+ days of activity limitation 1.59 (1.28, 1.98) 3.26 (2.59, 4.09) Chronic conditions COPD 1.69 (1.36, 2.11) 2.94 (2.32, 3.73) CVD 1.25 (1.04, 1.50) 1.70 (1.36, 2.12) Diabetes 1.02 (0.86, 1.22) 1.45 (1.17, 1.80) Depressive disorder 1.65 (1.39, 1.97) 4.15 (3.47, 4.97)
25 RESULTS Examples of Adjusted Odds Ratios for High ACE Study Group for Perceived Poor Health and Chronic Conditions Health Indicators Adjusted OR Model 1 (95% CI) Adjusted OR Model 2 (95% CI) Perceived poor health Fair or poor health status 2.34 (1.96, 2.79) 2.16 (1.80, 2.61) 14+ days of activity limitation 3.26 (2.59, 4.09) 2.83 (2.24, 5.89) Chronic Conditions COPD 2.94 (2.32, 3.73) 2.40 (1.86, 3.08) CVD 1.70 (1.36, 2.12) 1.57 (1.25, 1.98) Diabetes 1.45 (1.17, 1.80) 1.30 (1.03, 1.63) Depressive disorder 4.15 (3.47, 4.97) 3.61 (2.99, 4.34)
26 CONCLUSIONS AND RECOMMENDATIONS ACEs are prevalent in N.C. Do not occur in isolation Impact health and wellbeing in adulthood Life course perspective Primary, secondary, and tertiary ACE prevention Evidence-based home visiting Public policy Focus on resiliency ACE and childhood injury prevention as effective longterm strategy to improving population health Promotion of collaboration between injury, child welfare, and chronic disease initiatives among others
27 PREVENTION AND INTERVENTION o Multiple prevention models exist: Examples: Nurse Family Partnership, Triple P, Parents as Teachers o Multiple trauma-informed interventions exist: Examples: Trauma-Focused Cognitive Behavioral Therapy, Attachment and Biobehavioral Catch-up, Cognitive Behavior Intervention for Trauma in Schools
28 THANK YOU! Meghan Shanahan, PhD Phone: Office: (919)
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