ACES AND FAMILY PLANNINGBuilding Bridges over Barriers

Caitlin Suginaka, MPH

2014

OVERVIEW

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

REVIEW ACESand their impact on individuals, family systems and communities

TIT

LE

Click icon to add picture

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

ACES

Adverse Childhood Experiences (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:

TIT

LE

Click icon to add picture

Trau·maˈtroumə, 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.

ACES

• 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

TIT

LE

Click icon to add picture

ACES

• 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.

2. Cluster:

Almost 40% reported 2 or more,12.5% reported 4 or more.

3. Cumulative effect:

Multiple health problems added up contribute to morbidity.

TIT

LE

Click icon to add picture

1. ACEs are common

2. ACEs occur in a cluster

3. ACEs have a cumulative effect

0 ACEs45%

1 ACE21%

2 to 3 ACEs20%

4 to 5 ACEs9%

6 to 8 ACEs5%

Iowa BRFSS Results0 ACEs

1 ACE

2 to 3 ACEs

4 to 5 ACEs

6 to 8 ACEs

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.

ACE IMPACT- INDIVIDUAL

Health Condition

0 ACEs 1 ACEs 2 ACEs 3 ACEs 4+ ACEs

Arthritis 100% 130% 145% 155% 236%

Asthma 100% 115% 118% 160% 231%

Cancer 100% 112% 101% 111% 157%

COPD 100% 120% 161% 220% 399%

Diabetes 100% 128% 132% 115% 201%

Heart Attack 100% 148% 144% 287% 232%

Heart Disease 100% 123% 149% 250% 285%

Kidney Disease 100% -17% 164% 179% 263%

Stroke 100% 114% 117% 180% 281%

Vision 100% 167% 181% 199% 354%

ACE IMPACT- INDIVIDUAL

0 ACEs 1 ACEs 2,3 ACEs 4+ ACEs0%

5%

10%

15%

20%

25%

30%

35%Poor General Health*

Activity Limitations**

ACE IMPACT- INDIVIDUAL

ACE IMPACT- INDIVIDUAL

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

ACE IMPACT- INDIVIDUALEarly Death

Disease, Disability & Social Problems

Adoption of Health-

Risk Behavior

Social, Emotional & Cognitive Impairment

Disrupted Neurodevelopment

Adverse

Childhood Experience/Toxic Stress

Conception

Death

ACE IMPACT- FAMILY SYSTEMS

ACE categories related to family systems 1-10! Early relationship building

Some outcomes specific to family planning Unintended pregnancy Partner choice Sexual Risk behaviors

ACE IMPACT- FAMILY SYSTEMS

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.

ACE IMPACT- FAMILY SYSTEMS

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

ACE IMPACT- FAMILY SYSTEMS

Outcomes specific to family planning

Sexual risk behaviorsAs 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.

ACE IMPACT- COMMUNITIES

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.

ACE IMPACT- COMMUNITIES

Schools

Offices

Churches

Community Centers

THE VALUEof resilience and prevention

TIT

LE

Click icon to add picture

Re·sil·ienceriˈzilyəns/

Noun

1. The ability of a substance or object to spring back into shape; elasticity.

"nylon is excellent in wearability and

resilience"

RESILIENCE

• 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

TIT

LE

Click icon to add picture

ESSENTIAL BUILDING BLOCKS OF RESILIENCE

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

TIT

LE

Click icon to add picture

RESILIENCE

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

TIT

LE

Click icon to add picture

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

THE IMPORTANCE OF FAMILYWhen 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.

0 or 1 2 or 3 4 or 5 6 or 7

Family Strengths and Risk of adolescent

pregnancy

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

TIT

LE

Click icon to add picture

THE IMPORTANCE OF FAMILY

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

TIT

LE

Click icon to add picture

ACE PREVENTION

What we know:• Experiencing ACEs may

have an impact even in ideal circumstances

• The goal: prevent ACEs from occurring outright

TIT

LE

Click icon to add picture

PREVENTION

Protective Factors1. Nurturing and attachment2. Knowledge of parenting and child development

3. Parental resilience4. Social connections5. 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

OUTCOMES• 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?

SOCIAL ECOLOGICAL MODEL

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

BUILDING BRIDGES OVER BARRIERS

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

Be the bridge.

THANK YOU!Caitlin Suginaka, MPH

Caitlin.Suginaka@gmail.com

Be the bridge.