1. Lifecourse and Chronic Disease Kathy Chapman, RN, MN April, 26, 2012 April, 26, 2012

2. Overview Life Course Review Adverse Childhood Experience (ACE) Review ACEs as Health Risk Executive Function Application

3. Life Course-Basic Principles 1.Health at one stage affects health later

4. Life Course-Basic Principles 1.Health at one stage affects health later 2.Trajectory

5. Life Course-Basic Principles 1.Health at one stage affects health later 2.Trajectory 3.Cumulative burden

6. Life Course-Basic Principles 1.Health at one stage affects health later 2.Trajectory 3.Cumulative Burden 4.Sensitive or critical periods

7. Critical Period Positive and Adverse events and exposures can impact at any point in life Impact is greatest at specific critical periods such as: Pregnancy Childhood Adolescence

8. Brain Development: Critical Period In the first half pregnancy neurons are formed at an astonishing rate; 8,000 neurons per second By birth all neurons are formed

9. Brain Development in Childhood In early childhood, 700 synapses formed per second Pruning for efficiency – what is used stays

10. Exposure during Critical Period Adverse Child Events Study

11. Pause

12. Adverse Childhood Experiences (ACEs) CDC study partnering with Kaiser 17,000+ patients; middle class, employed, with insurance Access to client charts Asked questions about Early Childhood Experiences

13. ACE Questions Respondents were asked about experiences in their childhood Abuse: emotional, physical, sexual Neglect: emotional, physical Household dysfunction: Mother treated violently Household substance abuse, mental illness Parental separation or divorce Incarcerated Parent

14. ACE Scores in this middle class cohort Zero 36% One 26% Two 16% Three 9.5% Four 12.5%

15. Poor Health Outcomes “…as the number of ACE increase, the risk for the following health problems increases in a strong and graded fashion.” -- CDC Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Fetal death Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sex partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy

16. Strong and Graded Fashion The higher the ACE Score the higher the risk for health risk behaviors and for various chronic diseases

18. Questions, Reflections

19. Impact of ACE on Brain Development Toxic Stress can lead to changes in brain structure and function. One example: Executive Function

20. Executive Function Executive Functioning helps us translate knowledge into action; put into practice what we know.

21. Executive Function Helps us to function in 3 ways: Inhibitory Control: filtering thoughts and impulses to resist temptation Working memory: hold and manipulate information in our heads over a short period of time Cognitive Flexibility: Adjust to changing demands, priorities and perspectives

22. Executive Function Develops over many years; 2 periods of rapid development Ages 3-5 years Ages 12-25 years Gives us the ability to keep plans in mind and act accordingly Developmental Plasticity – responds to environment

23. Focus on policy and practice Executive Function Risk Assessment

24. Public Health Problem Or Personal Coping mechanism?

25. Executive Function Implications How might issues with Executive Function impact interventions we use in chronic disease management or risk factor mitigation? Smoking Cessation

26. ACEs as Health Risk

27. We now know that a high Adverse Child Experience score puts a person at high risk for later physical and emotional illness. It is time to shift our thinking – ACE as Health Risk Screening questions Provider education Prevention and mitigation

28. ACEs and the Prevention Framework Primary prevention is easier than mitigation Secondary Prevention: Screening for ACEs and interventions to help improve executive function Integrated approach to intervening with children with high ACE scores – often treatment for multiple family members. Tertiary Prevention Treat disease/risk behavior and address exec function issues (tobacco cessation)

29. Questions, Reflections

30. More information about ACE http://www.cdc.gov/ace/index.htm http://www.healthychild.ucla.edu/PUBLICATIO NS/Documents/ZerotoThree.pdf http://www.healthychild.ucla.edu/PUBLICATIO NS/Documents/ZerotoThree.pdf http://developingchild.harvard.edu/

31. Other Resources Jack P. Shonkoff, Lifelong Effects of Early Childhood Adversity and Toxic Stress http://pediatrics.aappublications.org/conten t/early/2011/12/21/peds.2011-2663 http://pediatrics.aappublications.org/conten t/early/2011/12/21/peds.2011-2663 http://pediatrics.aappublications.org/content/12 4/Supplement_3/S163.full http://pediatrics.aappublications.org/content/12 4/Supplement_3/S163.full