Adverse childhood experiences and the life course. Dr Helen Lowey, Consultant in Public Health Blackburn with Darwen Borough Council

Transcription

1 Adverse childhood experiences and the life course Dr Helen Lowey, Consultant in Public Health Blackburn with Darwen Borough Council

2 Adverse Childhood Experiences and the Life Course Dr Helen L Lowey Consultant in Public Health

3 Adverse Childhood Experience Definition A complex set of related childhood experiences: include direct abuse i.e. directly affects a child AND indirect, i.e. household dysfunction environment in which they live The ACE Study Large study that describes long-term relationships between childhood maltreatment & later-life health and wellbeing ACE Outcomes Substantial body of evidence leading to poor health and social outcomes ACEs have created a Chronic Public Health Disaster Dr Robert Anda

4 Adverse Childhood Experiences Five Direct 1. Sexual abuse by parent / caregiver 2. Emotional abuse by parent / caregiver 3. Physical abuse by parent / caregiver 4. Emotional neglect by parent / caregiver 5. Physical neglect by parent / caregiver Five Indirect 1. Parent / Caregiver addicted to alcohol / other drugs 2. Witnessed abuse in the household 3. Family member in prison 4. Family member with a mental illness 5. Parent / Caregiver disappeared through abandoning family / divorce

5 Early Life Experience and The Brain Critical Years First 2 years - baby s brain grows from 25% to 80% of adult size Development continues in childhood learning empathy, trust, community Health At Rest Threat Fight or Run Away Exhausted Recovery ACEs Fixed Allostatic load At Rest Chronic Stress from ACEs Violence - over-develop life-preserving brain NEUTRAL CUES LOOK THREATENING School anxious, disengaged, poor learner Bellis 2016 Tau et al, 2010; Mercy, Butchart, Bellis et al, 2014

6 Adverse Childhood Experiences ACEs - The Life Course Bellis 2016 Life Course Bellis Developed from Felitti et al Death Early Death Non Communicable Disease, Disability, Social Problems, Low Productivity Adopt Health Harming Behaviours and Crime Social, Emotional and Learning Problems Disrupted Nervous, Hormonal and Immune Development Birth ACEs Adverse Childhood Experiences

7 How many people suffered ACEs 0-18 years old? European Survey of students years old (n=10,696) ACE are: England Europe Physical abuse Sexual abuse Domestic violence Parental separation Emotional neglect Emotional abuse 18.6% 15% 7.5% 6% 14.6% 13% 14.1% 24% 11.8% 8.0% Latvia 16.2% Lithuania 12.9% Russian Federation 12.8% Physical Abuse 18.6% Average Household member: Depressed/suicidal 10.0% 12% Romania 23.4% Alcoholic Incarcerated Street drug user 16.4% 10% 5.3% 4% 2.6% 4% Montenegro 6.9% Albania 41.0% FYR Macedonia 19.6% Turkey 14.6% Bellis et al, Bull World Health Organ 2014;92: B; Paunovic, Markovic et al Bellis et al, 2014

8 Compared with no ACEs, those with 4+ ACEs were: 3x more likely to be a current smoker 3x more likely to have had sex under 16 years 6x more likely to have used drugs 10x more likely to be problem drinkers 49x more likely to have ever attempted suicide INDEPENDENT OF POVERTY If they had no ACEs problems could be reduced by: Bellis 2016 Smoking 22% Early Sex 21% Drug Use 36% Aged years Problem Drinking 51% Suicide 83% Bellis et al. 2014, n=10,696 individuals

9 UK: Compared with no ACEs, those with 4+ ACEs were: 2x more likely to binge drink 3x more likely to be current smoker 5x more likely to have had sex under 16 years 7x more likely to be involved in recent violence 11x more likely to have used heroin or crack 11x more likely to have been incarcerated INDEPENDENT OF POVERTY If they had no ACEs problems could be reduced by: Bellis 2016 Smoking 16% Early Sex 33% Heroin/Crack 59% Aged years Binge Drinking 15% Violence 60% Bellis et al. 2014, n=3885

10 Blackburn with Darwen (2012) Adverse Childhood Experience (ACE) & Adult Health Outcomes Increased risk (adjusted odds ratio) having health behaviours and conditions in adulthood for individuals experiencing four or more ACEs in childhood. Pregnant or got someone accidently pregnant Under 18 x 4.5 Stayed overnight hospital in last 12 months x 1.5 Liver or digestive disease x 2.3 Morbidly Obese x 1.82 Heroin or Crack user x 9.7 Regular Heavy drinker x 3.7 Had a sexually transmitted infection x 30.6 Current Smoker x 3.9 Been hit in last 12 month x 5.2 Hit someone last 12 months x 7.9 Been in prison or cells x 8.8

11 Cumulative percentage never diagnosed with Major Illness Individuals Never Diagnosed with a Major Disease by Age (%) Major Diseases Cancer Stroke Type II Diabetes Cardio Vascular Disease Digestive/Liver Disease Respiratory Disease Differences remain after adjusting for Deprivation Age (years) 0 ACEs 4+ ACEs 50% Disease Free 20% Disease Free Bellis 2016 Aged 18 to 69 years; (n = 3,885) Bellis et al, Journal of Public Health, 2014

12 ACE Intelligence Surprisingly common; Co-occur; Associated with health outcomes but typically unrecognised Intergenerational USA: 9%; UK: 9%; BwD 12% Those in contact with substance misuse services 64% had 4+ ACE Those employed within social care 16% had 4+ ACE Those who are homeless Over 50% had 4+ ACE

13 Hughes, Lowey et al., 2016

14 ACEs are part of Inequalities Death 3x more people suffered 4 ACEs in most deprived versus wealthiest 5 th of people (UK) Deprived or Affluent areas Depression Deprivation More ACEs = More smoking, alcohol misuse, early sexual activity, mental illness, mental wellbeing & premature ill health across the life course Global Inequalities Bellis et al. 2014, n=3885

15 Girls 4+ ACES vs. 0 ACEs Mother 18 years when born The ACEs Life Cycle Children having Children 4+ ACES vs. 0 ACEs Pregnant under 18 years 4+ ACES vs. 0 ACEs First child born under 18 years Boys 3x 4+ ACES vs. 0 ACEs Mother 18 years when born 5x 4+ ACES vs. 0 ACEs Got a girl pregnant when under 18 years 4x 4+ ACES vs. 0 ACEs First child born under 18 years Bellis x 10 x 4x

16 Early Adolescence and Concurrent ACEs (Age years) Somatic complaints e.g. digestive problems, nausea, vomiting, migraine, skin disorders Frequent and recurrent Often no medical explanation Stress or emotional factors ACEs >3 vs. 0 >3x Somatic Complaints 4x Poor Health Bellis 2016 Egger et al 1999, Flaherty et al, 2013.

17 ACEs ACEs in Challenging High Schools Example from Washington State Family Policy Council 1/3 of class had 4+ ACEs Best predictor of health, attendance, behaviour Educational success related more to ACEs than income Change Public Health and others inform staff on ACEs Move away from automatic punishment Good schooling Bellis 2016 Enquiry Why Attachment Competency Resiliency and developmental skills Care-giver relationships Self-Regulation Control/Share emotional experience Graduation rates / communityresiliencecookbook.org/tastes-of-success/

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19 ACE Study: BwD [The questionnaire covered] highly relevant questions Enjoyed completing the questionnaire I found the survey very interesting. It made me think about some bad things and some good things. I know my parents had a hard life but I understand why you need to ask the questions I only hope this study helps children or vulnerable adults to not go through what I did whilst growing up Thank you very much for understanding

20 Causes of Homelessness / HMO Links to MEAM & Transforming Lives INTERIOR SUBJECTIVE Interior Individual ACE impact on developing self Overwhelming emotions Derailed psychological development Cognitive deficits Poor self-esteem Interior Collective: Lack of supports Inter-subjective stories of failure Victim blaming in larger culture INDIVIDUAL Exterior Individual Substance abuse Disruptive behaviors Inability to hold a job Poor Health/ illness/ injury Exterior Collective Family relational system/aces Lack of jobs Lack of affordable housing Inadequate access - treatment COLLECTIVE Poverty, social violence Heather Larkin, Ph.D. University at Albany, SUNY.. Studies show that ACEs are strong predictors of homelessness (Burt, 2001) EXTERIOR OBJECTIVE

21 Making Every Adult Matter - MEAM People living in Houses of Multiple Occupancy (HMO) Poor quality accommodation, housing management & support (519 bed spaces across 41 places) Residents vulnerable to exploitation; Difficulty engaging in services Increasing pressure: Health, A&E; Police; Council services; Objectives: Work with most chaotic adults living in HMOs Consult with service providers/users to re-design and support interventions; improve longer term population health approaches Align to the strategic principles and developments of Transforming Lives; Strengthening Communities

22 Opportunity to change our approach Many Chronic Diseases & lifestyle behaviours in adults Determined decades earlier, in childhood Risk factors underlying adult disease & lifestyle behaviours Effective coping devices Conventionally viewed as problem Actually solution to an unrecognised prior adversity

23 Opportunity to change our approach Bring in resilience, hope & belief Trauma-Sensitive Schools what happened? Raise awareness of ACEs own organisations Be ACE Aware change our thinking; our approach and our solutions Bring local intelligence; brain development innovative solutions Foster resilience; Embed principles across the community

24 Percentage Building Resilience - Helping people cope with ACES Avoid damaging behavioural and physiological changes in response to chronic stress Feel you can overcome hardship and guide your destiny Equipped to manage your behaviour and emotions Grounded in cultural traditions Connected One or more stable, caring child-adult relationship Children suffering 4+ ACES As a child, there was adult you trusted and could talk to about your problems? Problem Drinkers Used Cocaine or Heroin Been Incarcerated Outcome Never Always Bellis 2016 Based on Strengthening the Foundations of Resilience, Harvard, 2015; Wales ACE Survey, 2015, n=2030, unpublished data

25 Opportunity to change our approach New findings: we are ready for new approaches to address early childhood trauma & stress To do that in a big way, we need more than science we need a movement Dr Nadine Burke Harris

26 ACEs - A life course approach to Adult ill health Photo Attribution: hellocoolworld Underlying reasons for accessing health care? Multiple studies in progress Self-completed ACE survey pre-examination (Felitti) At examination, How have these [ACEs] has affected you in later life? Following year attendances (Preliminary Results, n=14,000) General Practice 35%; Emergency Department 11% Routine enquiry increases visibility not trauma? European Research Agenda and Routine Enquiry The Long Reach of Childhood Trauma, Arielle Levin Becke, 2015

27 Adverse Childhood Experiences ACEs - The Life Course Mend Broken Adults Health & Social, Educational and Criminal Justice Investment in Early Life Build Stronger Children Bellis 2016 Early Death Non Communicable Disease, Disability, Social Problems, Low Productivity Adopt Health Harming Behaviours and Crime Social, Emotional and Learning Problems Disrupted Nervous, Hormonal and Immune Development ACEs Adverse Childhood Experiences Pre-conception and Fetal Epigenetic effects

28 Bellis 2016 Summary: Adverse Childhood Experiences Internationally ACEs are a Major Cause of Non-Communicable Disease Health, Social, Education and Criminal Justice sectors benefit from starting people on the best life trajectory Benefits obvious in partnership ACEs reveal a measurable Health and Economic value of good parenting Childhood Adversity should be a consideration across the life course (Prevention, Resilience, Enquiry) Environmental Factors such as poorly controlled alcohol marketing cause ACEs and are increasing globally Tackling ACEs helps reduce inequalities in health and well-being Emerging Unified Research Agenda What works, how and when (Neurology, Epigenetics, Public Health and more) Fix once and potentially gain long-lasting inter-generational benefits Better informed parents will make better life-course decisions

29 Thank In order to change your future, you have to realise that your past has created your present With Special Thanks To - Professor Mark A Bellis Director, Policy, Research & International Development, Public Health Wales WHO UK Focal Point for Violence and Injury Prevention Professor of Public Health, Bangor University