The Science and Economics of Early Life Toxic Stress

“It is easier to build strong children than to repair broken men.”-Frederick Douglas

To produce a well-educated and healthy adult population that is sufficiently skilled to participate in a global economy and to become responsible stakeholders in a productive society.

American Academy of Pediatrics Technical Report “The Lifelong Effects of Early Childhood Adversity and Toxic Stress”

Goal of a Nation

Use sound science, which shows:◦ That we need to invest

in clinical practice that addresses complex social, economic, environmental, and developmental issues that influence population-based health disparities

Sound investments in interventions that reduce adversity in early childhood years◦ Many adult diseases

originate in early childhood (ACEs)

◦ Changes the system to a “well-care” model rather than “sick-care”

How Do We Do That

Development is not nature vs. nurture, but it’s nature and nurture working with each other over time◦ Thus, adversity early in childhood can permanently

impair learning, behavior, and health (mental and physical)

A New Framework

Critical Concepts in Early Brain Development

• Proportional brain growth• Neural plasticity• Critical periods• Sequential development• Role of experience

Role of Experience

The human brain has the ability to be shaped by experience

Experience, in turn, leads to neural changes in the brain

◦ birth: 50 trillion synapses

◦ 1 year: 1,000 trillion

◦ 20 years: 500 trillion

The remolded brain reflects new experiences and efficiencies learned over time

Impact of Neglect

Stress without the buffering response of a strong adult relationship causes prolonged secretion of stress hormones◦ Cortisol, norepinephrine, epinephrine, etc. ◦ Potentially permanent changes in gene regulation

Both of these responses are beneficial in the short term with good adult support, but can be damaging to health if they occur over long periods of time◦ Constant wear and tear

Physiologic Response to Stress in Kids

Compelling new science showing how nurture can affect nature◦ Molecular biological methods to change gene expression

without changing the gene itself◦ Done by changing the chemical composition of

regulatory segments of the gene DNA methylation Modification of histones

The Mechanism of ChangeEpigenetics

Rat mothers who groom and lick their pups during the first week of life have pups that have a less vigorous response to stress as adults than mothers who don’t groom well◦ Appears to be caused by DNA methylation and histone changes

in stress-related genes

Stressed rat mothers with bad nurturing behavior have pups with poor cognitive skills as adults and persistent changes in stress-related gene expression

Epigenetics in Rats

Fetal exposure to maternal stress influences future stress responses in a negative way◦ Moms who are stressed (stressful event, increased

anxiety, depression) during pregnancy are more likely to have kids with: Preterm birth Poor emotional coping skills Decreased cognitive abilities Increased fear response to stimuli Increased anxiety

◦ These effects are mediated by histone modification and DNA methylation

Epigenetics Passed from Moms to Children

Kids raised in institutional environments (Romanian orphanages) ◦ Epigenetic changes in regions of brain development

Childhood Epigentic Changes

Structural brain changes: Smaller hippocampus (memory), smaller corpus callosum (connections between the hemispheres of the brain), smaller prefrontal cortex (reasoning, emotional control), larger amygdala (anxiety and release of stress hormones from the pituitary)

Inflammation/immunological changes: C-reactive protein levels elevated in adults with history of early adversities

Endocrine changes: Dysregulation of stress hormones, decreased oxytocin

How Do These Epigenetic Changes Affect Them as Adults

Telomeres & ACEs

• Telomeres appear to be impacted by

exposure to violence• In a longitudinal study

of twins, researchers found the twin exposed to violence had shorter telomeres than the twin

who was not.• Telomeres in

individuals removed from a violent

environment by age 5 showed improvement

by age 10.

Public Investment in Children by Age

Econometrics of Early Intervention & Prevention

Funding early interventions should provide the largest possible return on investment.

Doyle et al. (2009) Investing in Early Human Development. In: Economics and Human Biology

v7:pp1-6

Costs of Child Abuse: USA

$104 billion spent annually for the direct costs of child abuse

An additional $69.5 billion spent for indirect costs including special education, mental and physical health care and juvenile delinquency

Cost per maltreated child ~$182,000

C Wang and J Holton (2007) Economic Impact Study funded by Pew Charitable Trusts, and S. Fromm (2001) Total estimated costs of child abuse and neglect in the United States: Statistical evidence, http://member.preventchildabuse.org/site/

Over $124 billion in costs/year (Fang et al., 2012)

Lifetime cost per victim of nonfatal child maltreatment is $210,012:-$144,360 productivity losses-$6,747 criminal justice costs

-$32,648 childhood health care costs -$10,530 adult medical costs-$7,999 special education costs

-$7,728 child welfare costs

Costs of Child Abuse: USA

10 Adverse Childhood Experiences ACEs

1. Physical abuse 2. Sexual abuse 3. Emotional abuse 4. Emotional neglect 5. Physical neglect

---------6. Witness domestic violence 7. Mental illness in home 8. Family member incarcerated9. Alcohol/drug problems10. Parental separation or divorce

ACE: Prevalence data

Key finding:◦ About 2/3rd of those surveyed reported at least one ACE.◦ The 1/3 of participants with no reported ACEs were

consistently healthier across all measures.

ACE Score

ACE score = total number of ACEs experienced.◦ Examples:

Childhood history of exposure to domestic violence only ACE score = 1

Childhood history of parental alcoholism and physical abuse ACE score = 2.

Childhood history of physical neglect, sexual abuse, and parental divorce ACE score = 3.

Up to a maximum score of 10.

Key finding: higher ACE score = greater risk for health problems.

Health Measures Now Linked to Adverse Childhood Experiences Score

Stepwise increased risk for:◦ Heart disease

◦ Asthma

◦ Diabetes

◦ Cancer

◦ COPD

◦ Skeletal fractures

◦ Sexually transmitted diseases

◦ Liver disease

◦ Autoimmune disorders

◦ Osteoarthritis

◦ Smoking

◦ Alcohol abuse

◦ Over eating and obesity

◦ Illicit drug use

◦ Promiscuity

◦ IV drug use

◦ Clinical depression

◦ Bullying

And◦ Autobiographical memory disturbance

◦ Poor anger control

◦ Relationship problems

◦ Employment problems

◦ Early age at first intercourse

◦ Teen pregnancy

◦ Unintended pregnancy

◦ Teen paternity

◦ Fetal death

◦ Suicide

◦ Domestic violence

◦ Anxiety disorders

◦ Hallucinations

◦ Sleep disturbances

◦ Chronic pain

◦ Headaches

◦ Early death

2013 Alaska BRFSS  ACE SCORE 0 1 2 3 4 5+

All Alaskan Adults 35.6% 22.3% 14.7% 10.1% 6.5% 10.8%

Age Group 

18-24 34.0% 26.0% 15.9% 8.2% 5.8% 10.0%

25-34 33.3% 19.8% 15.5% 10.9% 8.4% 12.1%

35-44 30.4% 26.8% 10.5% 10.7% 6.2% 15.3%

45-54 33.8% 20.5% 13.6% 12.8% 6.3% 13.0%

55+ 41.7% 20.6% 16.7% 8.6% 5.9% 6.5%

Gender

Male 38.9% 22.5% 16.1% 8.5% 5.6%% 8.5%

Female 32.0% 22.2% 16.1% 11.9% 7.5%% 13.2%

*Percentages in red are the highest of the states compared.Source: Alaska data from the 2013 Alaska Behavioral Risk Factor Surveillance System, Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion Source: Five States Study data from the Centers for Disease Control and Prevention, Adverse Childhood Experiences Reported by Adults --- Five States, 2009, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm

Adverse Childhood

Experience*

Alaska

Arkansas

Louisiana

New Mexico

Tennessee

Washington

Abuse % % % % % %

Emotional 31.0 24.3 21.1 28.1 19.2 34.9

Physical 19.1 14.1 10.5 19.5 12.9 18.1

Sexual 14.8 10.9 9.9 12.9 12.7 13.5

*Percentages in red are the highest of the states compared.Source: Alaska data from the 2013 Alaska Behavioral Risk Factor Surveillance System, Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion Source: Five States Study data from the Centers for Disease Control and Prevention, Adverse Childhood Experiences Reported by Adults --- Five States, 2009, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm

Adverse Childhood

Experience*

Alaska

Arkansas

Louisiana

New Mexico

Tennessee

Washington

Household Dysfunction % % % % % %

Mental Illness in the Home 21.9 17.0 16.6 19.4 17.1 24.3

Incarcerated Family Member 11.5 5.5 7.2 7.1 8.6 6.6

Substance Abuse in Home 33.8 25.5 26.6 29.9 28.3 32.7

Separation or Divorce 31.7 23.3 27.1 24.4 29.1 26.0

Witnessed Domestic Violence 18.7 15.1 14.5 18.9 17.1 16.6

But These Effects Can Be Reversed

Example: A prevention program that reduces ACEs in a given population would result in:◦ Reduction in suicide attempts ◦ Risk for alcohol dependence cut in half for next

generation◦ And so on for all health measures studied to this point

CostsAlaskan adults who report four or more Adverse Childhood Experiences compared to Alaskan adults who report zero Adverse Childhood Experiences.

– 49% more likely to be unemployed– 274% more likely to be unable to work– 92% more likely to earn less than $20,000

annually Source: 2013 Alaska Behavioral Risk Factor Surveillance System, Analysis by Alaska Mental Health Board/Advisory Board on Alcoholism and Drug Abuse Staff

Population Attributable Risks in Alaska

Source: Alaska data from the 2013 Alaska Behavioral Risk Factor Surveillance System, Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion, Graphic: AMHB/ABADA

So What Do We Do as People Who

Interact with Families?The Ecological Model

This means we ask the question, “What’s happened to you in the past?” rather than “What’s wrong with you?”◦ This fundamentally changes the way we interact with people◦ Changes an office visit from “I must fix you” to “I must listen to you”

What We’re Really Talking About: Trauma-Informed Care

Ages: 0-2◦ Dysregulated eating,sleeping

patterns◦ Developmental regression◦ Irritability, sadness, anger◦ Poor appetite, low weight gain◦ Increased separation anxiety,

clinginess

NCTSN.org/earlychildhoodtrauma

Ages 3-6◦ Increased aggression◦ Somatic symptoms◦ Sleep difficulties/nightmares◦ Increased separation anxiety◦ New fears◦ Increased distractibility/high

activity level◦ Increased withdrawal/apathy◦ Developmental regression◦ Repetitive talk/play about the

event◦ Intrusive thoughts, memories◦ Absenteeism

Behaviors Associated with Early Childhood Trauma

Primary Prevention:◦ Raising national awareness

Secondary Prevention:◦ Routine screening allows for early detection and

intervention Tertiary Prevention:

◦ Current best practices including home visiting, mental health, social work, two generation interventions

The Ecological Model for Addressing ACEs

Awareness Is Increasing

When Is the Best Time to Screen Families?

One-page questionnaire, completed by the parent

Targets risk factors that jeopardize children’s health, development and safety

Administered at selected well-child visits

Free, available in 4 languages

http://theinstitute.umaryland.edu/seek/

Parent Screening Questionaire

Comprehensive screening instrument for children under 5. Forms available for each recommended well-child visit recommended by the AAP.

Targets developmental milestones, social-emotional development, and family risk factors.

Free; available in 3 languages—theswyc.org

Survey of Well-Being of Young Children

Not a validated screening tool (they’re working on it), but available for young kids and teens

Center for Youth WellnessACE-Q

Has anything really stressful happened to your child since the last time I saw you?

How has that affected your child’s behavior?◦ Corollary question: How has this event and any changes

in your child’s behavior affected you? What have you done that’s really fun with your

child since the last time I saw you?

Three Questions—Gets Almost Everything

Assess for child and family safety Provide developmental guidance about trauma

response Provide education/guidance about behavior

management, routines and daily living activities to promote recovery and sense of safety

Refer to social work, child protection, domestic violence team or for mental health intervention, if needed

Provide close follow-up and ongoing monitoring

If a Traumatic Stressor Is Identified:

Chronic vs. single incident trauma When the symptoms persist for more than one

month When the parents are unable to ensure safety, be

supportive or attuned to the needs of the child When the parent has also been traumatized and is

symptomatic When the trauma involves the sudden or violent

loss of a caregiver or family member

When to Refer for Mental Health Treatment

Child-Parent Psychotherapy (CPP) (ages 0-5) Parent-Child Interaction Therapy (PCIT) (ages 2-

7) Pre-School PTSD Treatment (PPT) (ages 3-6) Trauma Focused Cognitive-Behavioral Therapy—

(TF-CBT) (ages 3-18)

Treatments for Traumatic Stress in Young Children

Parent is actively involved!!!! Provide education about trauma symptoms Enhance emotional regulation/ anxiety

management skills Address children and families' traumatic stress

reactions and experiences Provide an opportunity for the child to review, talk

about what happened (the trauma narrative) in the safety of a therapeutic setting

Core Components of Effective Treatment

How do we support schools, provider offices, day cares, etc. with appropriate screening tools to identify families at risk?◦ Can we reimburse for screening?

How do we increase services and programs so families can be referred to quality programs to get help?

Also….

Triple P—Positive Parenting Program◦ Gives parents practical strategies to:

Build healthy family relationships Manage their children’s behavior Prevent developmental problems

◦ Delivered in the Primary Care setting to target specific problem issue or behavior

◦ WSIPP benefit to cost ratio = $8.74◦ www.triplep.net

Triple P

Triple P System

Level 5

Level 4

Level 3

Level 2

Level 1

Intensive family Intervention………................

Broad focused parenting skills training………...

Narrow focus parenting skills training………….

Brief parenting advice……………………………

Media and communication strategy…………….

Breadth of reach

Intensity of intervention

Connects at-risk children with the services they need◦ Training for primary care offices to provide effective

developmental screening to facilitate early detection◦ Builds collaboration across sectors to improve access◦ Identifies gaps and barriers to access systems◦ Four Core Components

Child health care provider outreach to support screening Community outreach to identify resources Centralized telephone access point Collection of data, including service gap analysis

◦ www.helpmegrownational.org

HelpMeGrow

• Assessment of needs & referrals to services

• Education on development, behavior management and programs

• Ongoing developmental monitoring

• Advocacy and follow up

Care Coordinators provide

All of This Leads to a New Way of Thinking About Problems in Alaska

Sleep-Related Mortality Review

A group reviewed all sleep-related infant deaths from 2012-14 to see if there were trends◦ 195 total infant deaths◦ 66 occurred in a sleep environment◦ Alaska Epi Bulletin describes results

http://www.epi.alaska.gov/bulletins/docs/b2015_13.pdf

Alaska Maternal Infant Mortality Review (MIMR)

Sleep-Related Mortality Is NOT Just Back-to-Sleep

Source: Alaska data from the 2013 Alaska Behavioral Risk Factor Surveillance System, Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion

Zero One Two-Three Four Plus0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

5.7% 7.4%11.8% 14.7%

Percentage of Alaskan Adults who Report Not Finishing High School or

getting a GED by ACE Score

Sleep-Related Mortality Is NOT Just Back-to-Sleep

“In the brain, as in the economy, getting it right the first time is ultimately more effective and less costly than trying to fix it later. “

James HeckmanNobel Laureate Economist

National Scientific Councilon the Developing Child, Perspectives: The Cradle of Prosperity. (2006). http://www.developingchild.net

Thank you