1. ACE S AND F AMILY P LANNING Building Bridges over Barriers Caitlin Suginaka, MPH 2014

2. O VERVIEW 1. Review ACEs and their impact on individuals, family systems and communities 2. Discuss the value of ACE prevention and promotion of resilience 3. Connect ACEs, prevention and resilience to outcomes

3. R EVIEW ACE S and their impact on individuals, family systems and communities

4. T ITLE 1. Emotional abuse 2. Physical abuse 3. Psychological abuse 4. Sexual abuse 5. Neglect 6. Witnessing domestic violence 7. Household member with mental illness 8. Household member with substance abuse 9. Incarcerated parent 10. Loss of parent ACE S A dverse C hildhood E xperiences (or ACEs) are stressful or traumatic experiences that occur prior to the age of 18. To assess the presence of ACEs in the initial study, adults were asked about the following:

5. T ITLE Trau·ma ˈ troum ə, noun 1. A deeply distressing or disturbing experience. 2. Emotional shock following a stressful event or a physical injury which may be associated with physical shock or disruption to a person’s social, emotional or spiritual well-being. ACE S The original ACE Study started in the 90’s Collaboration between the CDC and Kaiser in San Diego 17,337 Kaiser patients In addition to ACEs, the survey asked about current behaviors, health habits and experiences ACEs Today Many states, including Iowa, are collecting responses to a BRFSS survey based on the original research The ACE score: number of “YES” responses to questions about each of the ACE categories “YES” responses are added up to get a total score between 0-10 Scores are NOT the number of incidents

6. T ITLE ACE S ACEs are common ACEs occur in a cluster ACEs have a cumulative effect 1. Common: 26% of participants reported substance abuse, 22% reported sexual abuse. 1. Cluster: Almost 40% reported 2 or more,12.5% reported 4 or more. 1. Cumulative effect: Multiple health problems added up contribute to morbidity.

7. T ITLE 1. ACEs are common 2. ACEs occur in a cluster 3. ACEs have a cumulative effect Gudmunson, C. G., Ryherd, L. M., Bougher, K., Downey, J. C., & Zhang, D. (2013). Adverse childhood experiences in Iowa: A new way of understanding lifelong health.

8. ACE I MPACT - I NDIVIDUAL Health Condition0 ACEs1 ACEs2 ACEs3 ACEs4+ ACEs Arthritis100%130%145%155%236% Asthma100%115%118%160%231% Cancer100%112%101%111%157% COPD100%120%161%220%399% Diabetes100%128%132%115%201% Heart Attack100%148%144%287%232% Heart Disease100%123%149%250%285% Kidney Disease100%-17%164%179%263% Stroke100%114%117%180%281% Vision100%167%181%199%354%

9. ACE I MPACT - I NDIVIDUAL

11. Stress Response System When the bear lives at home The developing brain’s response to traumatic stress Attention and coping An inability to down regulate Life course perspective Coping, habits and health

12. ACE I MPACT - I NDIVIDUAL Early Death Disease, Disability & Social Problems Adoption of Health-Risk Behavior Social, Emotional & Cognitive Impairment Disrupted Neurodevelopment Adverse Childhood Experience/Toxic Stress Conception Death

13. ACE I MPACT - F AMILY S YSTEMS ACE categories related to family systems 1-10! Early relationship building Some outcomes specific to family planning Unintended pregnancy Partner choice Sexual Risk behaviors

14. ACE I MPACT - F AMILY S YSTEMS Outcomes specific to family planning Unintended pregnancy Women who experienced 4 or more types of abuse during their childhood were 1.5 times more likely to have an unintended first pregnancy during adulthood than women who did not experience any abuse. Dietz PM et al., Unintended pregnancy among adult women exposed to abuse or household dysfunction during their childhood, Journal of the American Medical Association, 1999, 282(14):1359-1364.

15. ACE I MPACT - F AMILY S YSTEMS Outcomes specific to family planning Partner choice and the self-fulfilling prophecy Increased risk of being a victim of domestic violence for both women and men Felitti VJ et al., Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine 1998;14:245–258

16. ACE I MPACT - F AMILY S YSTEMS Outcomes specific to family planning Sexual risk behaviors As ACEs increased, so did the risk of having been exposed to a sexually transmitted disease Each category of adverse childhood experiences was associated with an increased risk of Intercourse by age 15 Having had 30 or more partners Hillis SD et al., Adverse childhood experiences and sexual risk behaviors in women: a retrospective cohort study. Fam Plann Perspect, 2001, 33(5); 206-11 Hillis SD et al., Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study. Pediatrics 2000;106(1):E11.

17. ACE I MPACT - C OMMUNITIES On average, 5 out of every 30 students in an Iowa school classroom will live with a parent who has a score of 4 or more. Gudmunson, C. G., Ryherd, L. M., Bougher, K., Downey, J. C., & Zhang, D. (2013). Adverse childhood experiences in Iowa: A new way of understanding lifelong health.

18. ACE I MPACT - C OMMUNITIES Schools Offices Churches Community Centers

19. T HE VALUE of resilience and prevention

20. T ITLE Re·sil·ience ri ˈ zily ə ns/ Noun 1. The ability of a substance or object to spring back into shape; elasticity. "nylon is excellent in wearability and resilience" R ESILIENCE The process of adapting well in the face of adversity, trauma, tragedy, threats and other significant or chronic sources of stress. It is the ability to overcome and, in some cases, benefit from challenging experiences. Prevent Child Abuse Iowa Research brief- Promoting resilience, 2014

21. T ITLE E SSENTIAL B UILDING B LOCKS OF R ESILIENCE Competence – encouraging the feeling that “I have skills and I have abilities.” Confidence – encouraging a willingness to take chances. Connection – assuring a sense of belonging; feeling supported by others. Character – teaching children to operate with a sense of “right and wrong” and personal integrity. Contributing – showing that the world is a better place because of them; teaching that “people care about what I say and do.” Coping – giving children a selection of positive strategies for working through challenges. Sense of Control – promoting the feeling that choices can be made; taking responsibility is important and empowering Prevent Child Abuse Iowa Research brief- Promoting resilience, 2014

22. T ITLE R ESILIENCE How can I promote it? Caregivers and providers have to believe that they can be effective and that that their efforts are worthwhile. Children need positive messages as early as possible, reinforced in various settings Prevent Child Abuse Iowa Research brief- Promoting resilience, 2014

23. T ITLE Questions used to assess family strengths during childhood covered 1. Family closeness 2. Family support 3. Family loyalty 4. Family protection 5. Feelings of being loved and important 6. Responsiveness to needs for health care T HE I MPORTANCE OF F AMILY When childhood abuse and household dysfunction were present, risk of adolescent pregnancy decreased as family strengths increased: Adjusted OR of risk: 1.0,.8,.6,.54 Partly explained by delays in initiation of sexual activity as family strengths increased. Risk of psychosocial problem occurring decades later also decreased as family strengths increased. Hillis SD et al, The protective effect of family strengths in childhood against adolescent pregnancy and its long- term psychosocial consequences, Perm J, 2010, 14 (3): 18-27

24. T ITLE T HE I MPORTANCE OF F AMILY CONCLUSIONS: Childhood family strengths are strongly protective against adolescent pregnancy, early initiation of sexual activity and long-term psychosocial consequences. Questions used to assess family strengths during childhood covered 1. Family closeness 2. Family support 3. Family loyalty 4. Family protection 5. Feelings of being loved and important 6. Responsiveness to needs for health care Hillis SD et al, The protective effect of family strengths in childhood against adolescent pregnancy and its long- term psychosocial consequences, Perm J, 2010, 14 (3): 18-27

25. T ITLE ACE P REVENTION What we know: Experiencing ACEs may have an impact even in ideal circumstances The goal: prevent ACEs from occurring outright

26. T ITLE P REVENTION Protective Factors 1. Nurturing and attachment 2. Knowledge of parenting and child development 3. Parental resilience 4. Social connections 5. Concrete supports Prevention Efforts may focus on services that educate and support families. Building these 5 “protective factors” in a family has been shown to reduce the likelihood of abuse and neglect

27. O UTCOMES We understand the impact of ACEs We discussed some ways to prevent them or mitigate their impact What do we do to achieve positive outcomes?

28. S OCIAL E COLOGICAL M ODEL Society Community Family Individual Direct interaction- care! Care for yourself and care for others Direct interaction- educate! Educate colleagues, clients, neighbors or friends and support parents you know Access available resources- refer! Use available referral sources or develop them and educate community leaders Build systems- think strategically! Develop policy, public health responses or economic opportunities

29. B UILDING B RIDGES O VER B ARRIERS 1. It’s never too early to educate 2. It’s never to late to promote resilience 3. It’s never wrong to show concern 4. It’s everyone’s responsibility

30. Be the bridge.

31. T HANK Y OU ! Caitlin Suginaka, MPH Caitlin.Suginaka@gmail.com Be the bridge.