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Polyvictimization and the Biology of Toxic Stress: Andrew Garner, M.D., Ph.D., F.A.A.P. University Hospitals Medical Practices, and Associate Clinical.

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Presentation on theme: "Polyvictimization and the Biology of Toxic Stress: Andrew Garner, M.D., Ph.D., F.A.A.P. University Hospitals Medical Practices, and Associate Clinical."— Presentation transcript:

1 Polyvictimization and the Biology of Toxic Stress: Andrew Garner, M.D., Ph.D., F.A.A.P. University Hospitals Medical Practices, and Associate Clinical Professor of Pediatrics, Case Western Reserve School of Medicine, and Chair, AAP Leadership Workgroup on Early Brain and Child Development Translating Developmental Science into Healthier Lives

2 Disclaimer This presentation was produced by the American Academy of Pediatrics under award #2012-VF-GX-K011, awarded by the Office for Victims of Crime, Office of Justice Programs, US Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this brochure are those of the contributors and do not necessarily represent the official position nor policies of the US Department of Justice.

3 My 3 Objectives For Today Provide a very general overview of advances in developmental scienceProvide a very general overview of advances in developmental science Present an organizing, integrated, ecobiodevelopmental frameworkPresent an organizing, integrated, ecobiodevelopmental framework Discuss a public health approach towards the prevention of toxic stress lifelongDiscuss a public health approach towards the prevention of toxic stress and its lifelong consequences

4 Critical Concept #1 Childhood Adversity has Lifelong Consequences. Significant adversity in childhood is strongly associated with unhealthy lifestyles and poor health decades later.

5 ACE Categories WomenMenTotal Abuse(n=9,367)(n=7,970)(17,337) – –Emotional13.1%7.6%10.6% – –Physical27.0%29.9%28.3% – –Sexual24.7%16.0%20.7% Household Dysfunction – –Mother Treated Violently13.7%11.5%12.7% – –Household Substance Abuse29.5%23.8%26.9% – –Household Mental Illness23.3%14.8%19.4% – –Parental Separation or Divorce24.5%21.8%23.3% – –Incarcerated Household Member 5.2% 4.1% 4.7% Neglect* – –Emotional16.7%12.4%14.8% – –Physical 9.2%10.7% 9.9% * Wave 2 data only (n=8,667) Data from 1:4!

6 ACE Scores Number of categories of adverse childhood experiences are summed … ACE score Prevalence 036% 126% 216% 3 9.5% 4 or more 12.5% More than half (almost 2/3) have at least one ACE 1 in 8 have 4 or more ACEs Average pediatrician will see 2-4 children with an ACE score of 4 or more each day Adapted from Anda RF et al., Eur Arch Psychiatry Clin Neurosci 256:

7 ACEs and Obesity Prevalence (% with BMI >35) ACE Score Adapted from Anda RF et al., Eur Arch Psychiatry Clin Neurosci 256: AOR = 1.9 ( )

8 ACEs and Current Smoking % Slide modified from V. J. Felitti AOR = 1.8 ( ) 4 or more Also earlier onset!!

9 ACEs and Alcoholism Slide modified from V. J. Felitti AOR = 7.2 ( ) Also earlier onset!!

10 ACEs and Illicit Drug Use Adapted from Anda RF et al., Eur Arch Psychiatry Clin Neurosci 256: ACE Score % AOR = 4.5 ( )

11 ACEs and IV Drug Use Adapted from Anda RF et al., Eur Arch Psychiatry Clin Neurosci 256: ACE Score % AOR = 11.1 ( )

12 ACEs and Promiscuity (> 30) Adapted from Anda RF et al., Eur Arch Psychiatry Clin Neurosci 256: ACE Score % AOR = 3.6 ( ) Also earlier onset!!

13 ACEs Skeletal Fractures Relationship Problems Smoking General Health and Social Functioning Prevalent Diseases Sexual Health Risk Factors for Common Diseases Hallucinations Mental Health ACEs Impact Multiple Outcomes Difficulty in job performance Married to an Alcoholic High perceived stress Alcoholism Promiscuity Illicit Drugs Obesity Multiple Somatic Symptoms IV Drugs High Perceived Risk of HIV Poor Perceived Health Ischemic Heart Disease Sexually Transmitted Diseases CancerLiver Disease Chronic Lung Disease Early Age of First Intercourse Sexual Dissatisfaction Unintended Pregnancy Teen Pregnancy Teen PaternityFetal Death Depression Anxiety Panic Reactions Sleep Disturbances Memory Disturbances Poor Anger Control Poor Self- Rated Health

14 Mechanisms By Which Adverse Childhood Experiences Influence Adult Health Status Adverse Childhood Experiences Social, Emotional, and Cognitive Impairment Adoption of Health-Risk Behaviors Disease & Disability Early Death DeathBirth The True Nature of Preventive Medicine Slide modified from V. J. Felitti ??

15 Developing a Model of Human Health and Disease Ecology The social and physical environment Development Learning, Behavior And Health Life Course Science Early childhood ecology strongly associates with lifelong developmental lifelong developmental outcomes mechanisms What are the mechanisms underlying these well-established associations? measure How do you begin to define or measure the ecology?

16 AdversityStress Defining Adversity or Stress measureHow do you define/measure adversity? individual variabilityHuge individual variability –Perception –Perception of adversity or stress (subjective) –Reaction –Reaction to adversity or stress (objective) National Scientific Council on the Developing Child (Dr. Jack Shonkoff and colleagues) –Positive –Positive Stress –Tolerable –Tolerable Stress –Toxic –Toxic Stress REACTION Based on the REACTION (objective physiologic responses)

17 PositivePositive Stress – –Brief, infrequent, mild to moderate intensity – –Most normative childhood stress Inability of the 15 month old to express their desires The 2 year old who stumbles while running Beginning school or daycare The big project in middle school –Social-emotional buffersbaseline –Social-emotional buffers allow a return to baseline (responding to non-verbal clues, consolation, reassurance, assistance in planning) –Builds motivation and resiliency –Positive Stress is NOT the ABSENCE of stress AdversityStress Defining Adversity or Stress

18 ToxicToxic Stress – –Long lasting, frequent, or strong intensity –ACEs –More extreme precipitants of childhood stress (ACEs) Physical, sexual, emotional abuse Physical, emotional neglect Household dysfunction –Insufficient social-emotional buffering (Deficient levels of emotion coaching, re-processing, reassurance and support) – –Potentially permanent changes and long-term effects Epigenetics ONOFFEpigenetics (there are life long / intergenerational changes in how the genetic program is turned ON or OFF) Brain architecture connectivity)Brain architecture (the mediators of stress impact upon the mechanisms of brain development / connectivity) AdversityStress Defining Adversity or Stress

19 Critical Concept #2 Epigenetics: Which genes are turned on/off, when, and whereWhich genes are turned on/off, when, and where Ecology (environment/experience) influences how the genetic blueprint is read and utilizedEcology (environment/experience) influences how the genetic blueprint is read and utilized Ecological effects at the molecular levelEcological effects at the molecular level Stress-induced changes in gene expressionStress-induced changes in gene expression “Genes may load the gun, but the environment pulls the trigger”

20 Biology Physiologic Adaptations and Disruptions Ecology The social and physical environment Development Learning, Behavior And Health Life Course Science Epigenetics Through epigenetic mechanisms, ecology the early childhood ecology becomes biologically embedded biologically embedded, influencing how/which genes are used Developing a Model of Human Health and Disease

21 Critical Concept #3 Developmental Neuroscience: Brain Architecture is experience dependent (individual connections or “synapses” and complex circuits of connections or “pathways” are both dependent upon activity)Brain Architecture is experience dependent (individual connections or “synapses” and complex circuits of connections or “pathways” are both dependent upon activity) Ecology (environment/experience) influences how brain architecture is formed and remodeled (plasticity)Ecology (environment/experience) influences how brain architecture is formed and remodeled (plasticity) Diminishing cellular plasticity limits remediationDiminishing cellular plasticity limits remediation Early childhood adversity -> vicious cycle of stressEarly childhood adversity -> vicious cycle of stress Potentially permanent alterations in brain architecture and functioningPotentially permanent alterations in brain architecture and functioning

22 Two Types of Plasticity Synaptic Plasticity – Synaptic Plasticity – STRENGTH – Variation in the STRENGTH of individual connections – “from a whisper to a shout” – Lifelong (how old dogs learn new tricks) Cellular Plasticity – Cellular Plasticity – NUMBER (or COUNT) – Variations in the NUMBER (or COUNT) of connections – “ from one person shouting to a stadium shouting” waning by age 5 – Declines dramatically with age (waning by age 5)

23 Brain Stem & Cranial Nerves: Vital functions Swallowing Cerebellum: Smooth movements Coordination Occipital Lobe: Visual processing Parietal Lobe: Integration of sensory data and movement Temporal lobe (outside): Processing sound and language Limbic System (inside): Emotions and impulsivity Frontal lobes: Abstract thought, reasoning, judgment, planning, impulse and affect regulation, consequences Differential Brain Maturation + The Gas Pedal + Amygdala - The Brake – PFC (with some hippocampal help)

24 Out of Balance? Prefrontal CortexAmygdala Prefrontal Cortex Amygdala Cold Cognition Hot Cognition Judgmental Emotional Reflective Reactive Calculating Impulsive Think about it Just do it Biological maturity by 24 Biological maturity by 18 Adapted from Ken Winters, Ph.D.

25 Impact of Early Stress TOXIC STRESS Chronic “fight or flight;” cortisol / norepinephrine Changes in Brain Architecture Hyper-responsive stress response; calm/coping CHILDHOOD STRESS

26 Biology Physiologic Adaptations and Disruptions Ecology The social and physical environment Development Learning, Behavior And Health Life Course Science Neuroscience Epigenetics Declining plasticity in the developing brain results in potentially permanent alterations in brain functioning and development Developing a Model of Human Health and Disease

27 Eco-Bio-Developmental Model of Human Health and Disease Biology Physiologic Adaptations and Disruptions Ecology The social and physical environment Development Learning, Behavior And Health Life Course Science Neuroscience Epigenetics The Basic Science of Pediatrics Ecology Becomes biology, And together they development And together they drive development across the lifespan

28 Critical Concept #4 The Science of Early Brain and Child Development EpigeneticsPhysiology of StressNeuroscience EducationHealthEconomics One Science – Many Implications translate The critical challenge now is to translate developmental science game-changing advances in developmental science policies practices into effective policies and practices for families w/ children educationhealthlifelong productivity to improve education, health and lifelong productivity

29 EBD Advantages of an EBD Framework developmental science simplicity support for translation biologicallyThough grounded in developmental science, the simplicity of the EBD framework may promote understanding as well as support for translation ( early investments are the right thing to do biologically ) ecologybiological developmentPsychosocial stressors and other salient features of the ecology are every bit as biological as nutrition or lead ( no distinction between mental and physical health, just healthy vs. unhealthy development ) timeon- going, cumulativeEmphasizes the dimension of time – to reflect the on- going, cumulative nature of benefits and threats to health and wellness EBD Advantages of an EBD Framework

30 Development results from an on- going, re-iterative, and cumulative dance between nurture and nature Brain Development Alterations in Brain Structure and Function Experience Protective and Personal (versus Insecure and Impersonal) Epigenetic Changes Alterations in the Way the Genetic Program is Read Behavior Adaptive or Healthy Coping Skills (vs. Maladaptive or Unhealthy Coping Skills)

31 ecologyUnderscores the need to improve the early childhood ecology in order to: –biological disparities –Mitigate the biological underpinnings for educational, health and economic disparities –developmental –Improve developmental/life-course trajectories Changing the early childhood ecology will require a PUBLIC HEALTH approach!! toxic stressHighlights the pivotal role of toxic stress –step on the gas –Not just “step on the gas” or enrichment –take off the brake –But “take off the brake” by treating, mitigating or immunizing against toxic stress EBD Advantages of an EBD Framework

32 Models Maslow ’ s Hierarchy of NeedsAmerica ’ s Promise AllianceASCD ’ s Whole Child Education (Theoretical )(Evidence-based)(Implementation) Needs Self-ActualizationNeed to know, explore An effective education Each student is actively and understandengaged in learning EsteemNeed to achieve andOpportunities to contribute Each student has numerous opportunities be recognizedto demonstrate achievement Love/BelongingNeed for friendsCaring adultsEach student has access to and familyqualified, caring adults Safety/SecurityNeed to feel secure and Safe places Each student learns in a physically safe from dangerand emotionally safe environment PhysiologicalNeed to satisfy hunger, A healthy startEach student enters school thirst, sleephealthy Reinventing the Wheel - All over again? STRESS Unmet needs are potential sources of STRESS!!

33 Childhood AdversityPoor Adult Outcomes Toxic Stress Epigenetic Modifications Disruptions in Brain Architecture Behavioral Allostasis Linking Childhood Experiences and Adult Outcomes

34 BIG The BIG Questions are… TOXIC STRESSACE exposurepoor adult outcomes If TOXIC STRESS is the missing link between ACE exposure and poor adult outcomes, it raises the following BIG questions: Are there ways to: –treat, –mitigate, –mitigate, and/or –immunize against –immunize against the effects of toxic stress? If so, is there a mismatch between: –KNOW –what we KNOW … and … –DO –what we actually DO? (If there is time!)

35 Toxic Addressing Toxic Stress TreatmentTreatment of the consequences –TF-CBTPCIT –TF-CBT and PCIT are evidence-based –Reactive –Reactive – some “damage” already done! – –Efficacy linked to age and chronicity brain plasticityDeclining brain plasticity? –costly –Can be costly –numberaccess –Insufficient number of / access to providers Limited reimbursements; carve-outs –Parity –Mental Health Parity? –STIGMA –Persistent STIGMA “Character Flaws”“Biological Mal-adaptations”“Character Flaws” vs “Biological Mal-adaptations”

36 Secondary / Targeted PreventionsSecondary / Targeted Preventions – “at high risk” –Focused, targeted interventions for those deemed to be “at high risk” – –Visiting Nurse Programs (Nurse Family Partner.) – –Parenting Programs (Triple-P, Nurturing Parent.) – –More likely to be effective; minimize “damage” –screening –Requires screening –stigmanumbersaccess –Still issues with stigma, numbers of/access to providers Toxic Addressing Toxic Stress

37 Primary / Universal PreventionPrimary / Universal Prevention – positive –Proactive, universal interventions to make stress positive, or tolerable instead of toxic – impossibleundesirable –Acknowledges that preventing all childhood adversity is impossible and even undesirable –Actively building resiliency –Actively building resiliency (“immunizing” through positive parenting, 7C’s, promoting optimism, formalized social-emotional learning) –SE Buffers –SE Buffers allow the physiologic stress response to return to baseline Parenting/CaregivingParenting/Caregiving skills for younger children SELwww.casel.orgSEL skills for older children (www.casel.org) Toxic Addressing Toxic Stress

38 Social-Emotional Skills Can Be Taught / Learned

39 Critical Concept #5 SOCIAL-EMOTIONAL SKILLS… (a.k.a – Affect Regulation, Non-Cognitive Skills, Mindfulness) … Are learned (they can be modeled, nurtured, taught, practiced, and reinforced) … Effectively buffer against toxic stress (by helping to turn off the physiologic stress response) … Increase test scores (an average of 11 points by meta-analysis!)

40 Parenting Skills Promoting Parenting Skills in the first 1000 days NERVOUS! – Parenting is personal – makes pediatricians NERVOUS! – “Positive/Nurturing/Supportive” Parenting – A Poor investment? teachable Are parenting skills “teachable?” ceiling effect Is there a “ceiling effect” on returns? Gold Standard? – Or the “Gold Standard?” Shouldn’t this be THE reference point (NOT routine, general, or control populations) Recent article from Luby et al., PNAS – Maternal supportChild depression severity – Maternal support and Child depression severity at ages 3-5 “Waiting Test” assessed the dyad (Bright Gift + Parental Surveys) – Hippocampal volumes – Hippocampal volumes at school age (7-13) Primary Parenting as Primary Prevention What is “OK?” YES!!

41 Luby et al., Available at: a positive influence onEarly maternal support exerts a positive influence on hippocampal development The positive effect of maternal support on hippocampal greater in nondepressed children volumes was greater in nondepressed children

42 Critical Concept #6 For young children, parent/caregiver support is critical : Turns off physiologic stress response by addressing physiologic and safety needs (PROTECT = Maslow levels 1+2)Turns off physiologic stress response by addressing physiologic and safety needs (PROTECT = Maslow levels 1+2) Turns off the physiologic stress response by promoting healthy relationships and attachment (RELATE = Maslow level 3)Turns off the physiologic stress response by promoting healthy relationships and attachment (RELATE = Maslow level 3) Notes and encourages foundational coping skills as they emerge (NURTURE = Maslow levels 4+5)Notes and encourages foundational coping skills as they emerge (NURTURE = Maslow levels 4+5) Early Childhood Professionals are ideally placed to: Promote this sort of “Purposeful” ParentingPromote this sort of “Purposeful” Parenting Advocate / participate public health approach to address TSAdvocate / participate public health approach to address TS

43 Universal Primary Preventions Anticipatory guidance Consistent messaging ( CTC ) No identification No stigma Ceiling effects = Limited evidence base Targeted Interventions (for those “at risk”) Nursing home visits ( NFP ) Parenting programs ( PPP ) Early Intervention Less ceiling=More evidence Requires screening Issues with stigma Evidence-Based Treatments (for the symptomatic) PCIT; TB-CBT; Pharmacotx Treatment works! Screening / stigma / access Social-Emotional Safety Nets A Public Health Approach to “Toxic Stress”

44 Universal Primary Preventions Bright Futures Connected Kids / HS - NCH Circle of Security / VIP Relationships as a “vital” sign Decrease Stress/Build Skills Targeted Interventions Screening for risks Assess the ecology ( SEEK/cACE ) Refer to/advocate for EBI Collaborating/Developing EBI ID Risks/Provide EBI Evidence-Based Treatments Screening for diagnoses Common factors approach Refer for/advocate for EBT Collaborating/Developing EBT ID Symptoms/Provide EBT WHAT are we DOING?!

45 Public Health Public Health Implications childhood antecedents adult disease.ACE data provide a working model for understanding and addressing the childhood antecedents of adult disease. we doIs there a gap between what we do we know and what we know? DOWhat we DO: – treatmentNOT prevention –95% of the trillions of dollars that we spend on health is on treatment and NOT prevention

46 Public Health Public Health Implications KNOWWhat we KNOW: –70% of early deaths are preventable –That 70% of early deaths are preventable, with… – majority (40% overall) behavioral patterns chronic disease. –The majority (40% overall) due to behavioral patterns that lead to chronic disease. –Behavioral Allostasis –Behavioral Allostasis due to toxic stress? McGinnis, Williams-Russo and Knickman, 2002

47 Proximal Chronic Disease Proximal Causes of Death: Chronic Disease Acute causes of death are the exception, not the rule

48 Distal Unhealthy Lifestyles Distal Causes of Death: Unhealthy Lifestyles FUNDAMENTALTOXIC STRESS If these unhealthy lifestyles are manifestations of behavioral allostasis, a FUNDAMENTAL cause of death is TOXIC STRESS!

49 90% Non- Communicable Diseases By 2030, 90% of the morbidity in high income countries will be due to Non- Communicable Diseases unhealthy behaviors NCDs are related to unhealthy behaviors (overeating, smoking, alcohol, promiscuity, and illicit drugs)

50 How do those automatic processes form in the first place!?

51 Public Health A Public Health Dilemma: disease Do we continue to treat disease, unhealthy lifestyles the unhealthy lifestyles that lead to disease, TOXIC STRESS or the TOXIC STRESS that leads to the adoption of unhealthy lifestyles??

52 Public Health A Public Health Parable: drowningMan by the river hears someone drowning rescuesBeing a good swimmer, he rescues the person another anotheranotherBefore catching his breath, he hears another in need, and another and another… walk awayThe man, exhausted, begins to walk away Asked where he’s going, he responds…

53 A Public Health Parable: upstream “I’m going upstream to prevent others from falling in!!”

54 What is Toxic Stress?What is Toxic Stress? –A physiologic stress response that is excessive or prolonged –A physiologic stress response that is excessive or prolonged (reflects an inability to “turn it off”) –Results in potentially permanent changes in: Gene expressionGene expression (epigenetics) Brain developmentBrain development (neuroscience) BehaviorBehavior (allostasis)SUMMARY

55 Why should I care?Why should I care? –Toxic stress is a MEDIATOR between early childhood adversity and less than optimal outcomes in learning, behavior and health –Understanding the BIOLOGY underlying these well established associations opens up new opportunities for primary prevention and early intervention SUMMARY

56 Childhood AdversityPoor Adult Outcomes Linking Childhood Experiences and Adult Outcomes

57 Childhood AdversityPoor Adult Outcomes Linking Childhood Experiences and Adult Outcomes Toxic Stress Epigenetic Modifications Disruptions in Brain Architecture Behavioral Allostasis Maladaptive behaviors Non-communicable Diseases Improve caregiver/community capacity to prevent or minimize toxic stress (e.g. – efforts to promote the safe, stable and nurturing relationships that turn off the physiologic stress response) Improve caregiver/community capacity to promote healthy, adaptive coping skills (e.g. - efforts to encourage rudimentary but foundational SE, language, and cognitive skills )

58 What can I do?What can I do? –Understand ecobiodevelopmental framework –Understand the ecobiodevelopmental framework (advocate for a public health approach to address toxic stress) –Help how to turn off –Help children figure out how to turn off their stress response (in a healthy way!) –Intervene early unable to turn off –Intervene early for those children who are at high risk or appear unable to turn off their stress responseSUMMARY

59 CONCLUSION: build strong children repair broken men It is easier to build strong children than to repair broken men. Frederick Douglass


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