Transcript Clinical Sequelae of Child Trauma

STATE OF THE SCIENCE:
IMPACT OF TRAUMA ON MENTAL AND
PHYSICAL HEALTH
Nadine Burke Harris, MD, MPH
CEO, Center for Youth Wellness
May 23, 2013
CPMC Bayview Child Health Center
The ACEs Study


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Vincent J. Felitti, MD and
Robert J. Anda, MD, MS
Asked 26,000 adults at Kaiser,
San Diego’s Dept of
Preventive Medicine.
17,421 participated in the
study.
Participants completed a
questionnaire.
ACEs Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
Recurrent physical abuse
Recurrent emotional abuse
Contact sexual abuse
An alcohol or drug abuser in the household
An incarcerated household member
Someone who was chronically depressed,
institutionalized, or suicidal
Mother treated violently
One or no parents, or parents divorced.
Emotional or physical neglect
Results


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12.6% of population had ACE score ≥ 4
Dose-Response relationship between adverse
childhood events and numerous organic diseases.
Person with an ACEs score of ≥ 4 is 260% as likely
to have COPD than a person with a score of 0.
Relative Risk of disease for ACEs ≥ 4

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
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Hepatitis
STD
COPD
Depression
Suicidality
240%
250%
260%
460%
1,220%
Adverse Childhood Experiences
vs. Smoking as an Adult
20
18
16
14
12
% 10
8
6
4
2
0
0
1
2
3
ACE Score
4-5
6 or more
p< .001
Health
Risks
Childhood Experiences vs.
Adult
Alcoholism
18
16
4+
% Alcoholic
14
12
3
10
2
8
6
1
4
2
0
0
ACE Score
ACE Score vs Intravenous Drug
Use
% Have Injected Drugs
3.5
3
2.5
2
1.5
1
0.5
0
0
1
2
3
4 or more
ACE Score
p<0.001
% With a Lifetime History of
Depression
Chronic Depression
80
70
60
50
40
Women
Men
30
20
10
0
0
1
2
ACE Score
3
>=4
Death
Suicide Attempts
4+
% Have Injected Drugs
3.5
3
2.5
2
1.5
3
1
0.5
0
0
0
1
1
2
2
ACE Score
3
4 or more
Prescription rate
per 100 person-years)
ACE Score and Rates of Antidepressant
Prescriptions
100
90
80
70
60
50
40
30
20
10
0
5 or
4
3
2
1
0
ACE Score
more
ACE Score and Teen Sexual
Behaviors
45
Percent With Health Problem (%)
40
ACE Score
0
1
2
3
4 or more
35
30
25
20
15
10
5
0
Intercourse
by 15
Teen
Pregnancy
Teen
Paternity
Mechanism
Neurobiology
Stress Response
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Activation of the HPA Axis - release of adrenaline
and cortisol
Increase in sympathetic tone
Activation of nor-adrenaline throughout the
midbrain and forebrain including the cortex
Neuropathology
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Long term dysregulation of fight or flight response
Loss of feedback inhibition leads to increased responses
to subsequent stressors (hyper-arousal, irritability)
Alterations mood and attachment (through changes is
serotonin and GABA receptors)
Difficulty with memory and learning (due to toxicity of
the hippocampus)
Increased high-risk and pleasure-seeking behavior
(changes in the nucleus accumbens which is the reward
center of the brain)
Multi-systemic Impacts
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Neurologic:
 HPA Axis
Dysregulation
 Reward center dysregulation
 Hippocampal neurotoxicity
 Disrupted brain architecture
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Immunologic
 Increased
inflammatory mediators and markers of
inflammation such as interleukins, TNF alpha, IFN-γ
Effect of Child Maltreatment on
Inflammatory Mediators
Multi-systemic Impacts

Endocrine
 Long-term
changes in cortisol, adrenaline and other
hormones.

Epigenetic
 Changes
in the way DNA is read and expressed leads
to changes in the way the brain responds to stress
National Scientific Council on the Developing Child
Working Paper 10: Early Experiences Can Alter the Gene Expression and
Affect Long-Term Development
Updated Mechanism
CPMC Bayview Child Health Center
CPMC Bayview Child Health Center
ACEs ≥ 1
67.2%
ACEs ≥ 4
12%
ACEs ≥ 4 and BMI ≥ 85%
OR: 2.0
p< .02
OR: 32.6
p< .001
ACEs ≥ 4 and learning/beh probs
N.J. Burke et al/ Child Abuse and Neglect 35(2011) 408-413
Effect of ACEs on Educational Outcomes
Good news: Neuroplasticity!
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Brain architecture is
experience dependent
Social-emotional
buffering makes a big
difference
 Positive
parenting
 Trusted mentor
 Healthy attachment
 Social-emotional skills
Neuroplasticity

Cellular Plasticity
 Number
of nerve
connections
 Dramatically declines
by age 5

Synaptic Plasticity
 Strength
of individual
connections
 Lifelong
Positive Stress
Tolerable Stress
Toxic Stress
 Normal and essential part
of healthy development
 Brief increases in heart rate
and blood pressure
 Mild elevations in hormonal
levels
 Example: Tough test at
school. Playoff game.
 Body’s alert systems
activated to a greater
degree
 Activation is time-limited
and buffered by caring
adult relationships.
 Brain and organs recover
 Example: Death of a loved
one, divorce, natural
disaster
 Occurs with strong, frequent
or prolonged adversity
 Disrupts brain architecture
and other organ systems
 Increased risk of stressrelated disease and
cognitive impairment
 Example: abuse, neglect,
caregiver substance
dependence or mental
illness
Intense, prolonged, repeated, unaddressed
Social-Emotional buffering, Parental Resilience, Early
Detection, Effective Intervention
Center for Youth Wellness
31
Pediatric care
Mental
Health
Community
Education
Data
Gathering
Seamless
interaction
CYW
Case
Management
Training
Analysis
Evidencebased
holistic
interventions
SOURCE: Core Team
Best practice
development
Research
and
Education
Scope of the Challenge

Impacts are pervasive and long-lasting
Development
 Physical and Mental Health
 Social and Educational impacts
 Economic impacts
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Prevalence is high
Strong evidence relating the risk
Early intervention improves outcomes
PUBLIC HEALTH APPROACH IS NECESSARY
What We Can Do

Start Early!
 Identify
kids exposed to ACEs through routine
screenings and establish prevention programs in
healthcare, schools and youth-serving organizations

Focus on early childhood and early adolescence
 Critical

developmental stages
Invest in programs that heal
 Don’t
spend money on programs that don’t support the
health and development of our kids – punitive school
discipline/juvenile justice
What We Can Do

Change Public Policy
 Support
prevention and healing using policy to
prioritize funding for early detection and effective
intervention

Make ACEs a public issue.
 Educate
our community about the impact and the role
each of us can play.
Thank You!
Resources
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Centers for Disease Control and Prevention
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UCSF Child Trauma Research Program
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http://childtrauma.ucsf.edu/
Lucile Packard Early Life Stress Program
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http://www.cdc.gov/ace/index.htm
http://childpsychiatry.stanford.edu/clinical/stress.html
National Child Traumatic Stress Network
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http://www.nctsn.org/
References
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“The Relationship of Adverse Childhood Experiences to Adult Health: Turning gold
into lead” Felitti, VJ
“Insights Into Causal Pathways for Ischemic Heart Disease: Adverse Childhood
Experiences Study” Dong et al, Circulation. 2004;110:1761-1776
“Adverse Childhood Experiences and Chronic Obstructive Pulmonary Disease in
Adults” Anda et al, Am J Prev Med. 2008 May; 34(5):396-403
“Stress Predicts Brain Changes in Children: A Pilot Longitudinal Study on Youth
Stress, Posttraumatic Stress Disorder, and the Hippocampus” Carrion et al, Pediatrics
2007;119:509-516
“Adrenocorticotropic Hormone and Cortisol Plasma Levels Directly Correlate with
Childhood Neglect and Depression Measures in Addicted Patients” Gerra et al,
Addiction Biology, 13:95-104
“Adrenergic Receptor Regulation in Posttraumatic Stress Disorder” Perry et al,
Advances is Psychiatry: Biological Assessment and Treatment of Post Traumatic
Stress Disorder (EL Giller, Ed) American Psychiatric Press, Washington DC, 87-115,
1990
References
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Childhood maltreatment predicts adult inflammation in a life-course study Danese et
al, PNAS, January 2007, 1319-1324
“Treatment o f Posttraumatic Stress Disorder in Postwar Kosovo High School
Students Using Mind-Body Skills Groups: A Pilot Study” Gordon et al, Journal of
Traumatic Stress, 17(2):143-147
“Mindfulness-Based Stress Reduction in Relation to Quality of Life, Mood,
Symptoms of Stress, and Immune Parameters in Breast and Prostate Cancer
Outpatients” Carlson et al, Psychosom Med. 2003 Jul-Aug; 65(4):571-81.
“Usefulness of the transcendental meditation program in the treatment of patients
with coronary artery disease.” Zamarra et al, Am J Card 1996 Apr 15;77(10):867-70
“Alterations in Brain and Immune Function Produced by Mindfulness Meditation”
Davidson et al, Psychosomatic Medicine 65:564-570 (2003)
Effect of buddhist meditation on serum cortisol and total protein levels, blood
pressure, pulse rate, lung volume and reaction time. Sudsuang et al, Physiology &
Behavior, Volume 50, Issue 3 September 1991, Pages 543-548