What Doesnt Kill You MIKAH OWEN M D

What Doesn’t Kill You… MIKAH OWEN, M. D. , M. P. H. ASSISTANT PROFESSOR, COMMUNITY AND SOCIETAL PEDIATRICS UNIVERSITY OF FLORIDA COLLEGE OF MEDICINE – JACKSONVILLE MIKAH. OWEN@JAX. UFL. EDU

Disclosures I have no relevant financial disclosures.

Objectives Understand the impact of Adverse Childhood Experiences on health and wellbeing. Understand the relationship between Adverse Childhood Experiences and Toxic Stress. Discuss the importance of a Trauma. Informed Approach to Legal Advocacy.

Adverse Childhood Experiences (ACE) Study CDC and Kaiser Clinic in San Diego, CA Initial phase: 1995 -1997 >17, 000 participants > 50 scientific articles published Prospective phase is currently underway

Defining Adverse Childhood Experiences Abuse Emotional Physical Sexual Household Dysfunction Domestic violence Household substance abuse Household mental illness Divorce Incarcerated family member

Race African-American, Asian/Pacific Other, 1. 90% 4. 60% Islander, 7. 20% Hispanic/Latino, 11. 20% [CATEGORY NAME], [VALUE]

Age (Years) Age (years) 19 -29 0% 5% 30 -39 10% 60+ 46% 40 -49 19% 50 -59 20%

Education 7% 18% 39% Not High School Graduate Some College Degree or Higher 36%

Prevalence of Adverse Childhood Events Percent of Respondents 40% 35% 30% 25% 20% women 15% men total 10% 5% 0% 0 1 2 3 4+ Number of Adverse Childhood Experiences

ACEs and Severe Obesity BMI Greater Than or Equal to 35 1. 8 1. 6 Odds Ratio 1. 4 1. 2 1 0. 8 0. 6 0. 4 0. 2 0 0 1 2 ACE Score 3 4+

ACEs and Smoking Status 2. 5 Odds Ratio 2 1. 5 1 0. 5 0 0 1 2 ACE Score 3 4+

ACEs and Lifetime Use of Illicit Drugs 5 Odds Ratio 4 3 2 1 0 0 1 2 3 ACE Score 4 5+

ACEs Sexual Risk Behaviors in Women First Sexual Encounter Prior to 15 years of Age 12 Odds Ratio 10 8 6 4 2 0 0 1 2 3 ACE Score 4 or 5 6 or 7

ACEs and Sexual Risk Behaviors in Women 30+ Partners 14 Odds Ratio 12 10 8 6 4 2 0 0 1 2 3 ACE Score 4 or 5 6 or 7

ACEs and Adolescent Pregnancy 7 Odds Ratio 6 5 4 3 2 1 0 0 1 2 3 4 ACE Score 5 6 7 or 8

ACEs and Depressive Disorders Lifetime History of Depressive Disorders Among Women 6 Odds Ratio 5 4 3 2 1 0 0 1 2 3 ACE Score 4 5+

ACEs and Depressive Disorders Lifetime History of Depressive Disorders in Men 3. 5 3 Odds Ratio 2. 5 2 1. 5 1 0. 5 0 0 1 2 3 ACE Score 4 5+

ACEs and Suicide Attempts During Childhood/Adolescence 60 Odds Ratio 50 40 30 20 10 0 0 1 2 3 4 ACE Score 5 6 7+

ACEs and Prevalence of Ischemic Heart Disease 2. 5 Odds Ratio 2 1. 5 1 0. 5 0 0 1 2 3 ACE Score 4 5 or 6 7 or 8

ACEs and COPD Chronic Bronchitis or Emphysema 5 Odds Ratio 4 3 2 1 0 0 1 2 ACE Score 3 4+

ACEs and Stroke History of Stroke Odds Ratio 3 2 1 0 0 1 2 ACE Score 3 4+

ACEs and History of Cancer Any Cancer 2 1. 8 Odds Ratio 1. 6 1. 4 1. 2 1 0. 8 0. 6 0. 4 0. 2 0 0 1 2 ACE Score 3 4+

ACEs and Mortality Average YLL (years) 30 25 20 15 10 5 0 0 1 2 3 4 or 5 6, 7 or 8 ACE Score Brown, et al. Am J Prev Med 2009; 37 (5)

ACEs and Mortality Risk of Death Prior to Age 65 (per 1000 population) 30 25 20 15 10 5 0 0 1 2 3 ACE Score 4 or 5 6, 7 or 8 Brown, et al. Am J Prev Med 2009; 37 (5)

Are These Results Reproducible?

ACEs and Developmental Risk in Elementary School Children 7 6 Odds Ratio 5 4 1 ACE 3 2 ACEs 3+ ACEs 2 1 0 Academic Failure Severe Attendance Problem Severe School Behavior Concern Frequent Reported Poor Health Christopher Blodgett Ph. D, Spokane County Community Network, 2012

ACE Scores and PACT Risk Level Baglivio, M. et al. ”The Prevalence of Adverse Childhood Experiences (ACE) in the Lives of Juvenile Offenders. ” OJJDP Journal of Juvenile Justice. 2014

Are There Other Adverse Childhood Experiences?

Adverse Childhood Experiences Pyramid

Types of Stress Positive Tolerable Toxic • Physiologic state that is brief and mild to moderate in magnitude • Serious, temporary stress response, buffered by a supportive adult • Extreme, frequent or extended activation of the stress response, without the buffering presence of a supportive adult

Relationship between the HPA axis, immune systems, and other body systems. Johnson S B et al. Pediatrics 2013; 131: 319 -327 © 2013 by American Academy of Pediatrics

Four types of allostatic load. Bruce S. Mc. Ewen Physiol Rev 2007; 87: 873 -904 © 2007 by American Physiological Society

Behavior/Emotional Problems Associated With Trauma: Complex PTSD Reactive Aggression Unresolved Grief Delinquency Depression Impulsivity Panic School Failure Defiance Obsessions/Compulsion s Addictions Sexual Problems Self-harm Hopelessness Extreme Risk Taking Substance Abuse

3 Domains of Child Advocacy Policy Community & Systems Clinical

The Health Impact Pyramid. Frieden TR. N Engl J Med 2015; 373: 1748 -1754

American Academy of Pediatrics, The Resilience Project

Why Focus on the Attorney-Client Relationship?

Challenges of Trauma-Informed Lawyering Building Relationships Communication & Counseling Impaired sense of safety Information processing Dissociation Impaired self-expression Controlling emotions Lack of trust Difficulty sharing trauma histories Decision making

Trauma-Informed Lawyer-Client Relationship Transparency Patience Predictability Role Client Control Preparing Reliability Proactive Definition and Boundaries Support for and Responding to triggers

3 Domains of Child Advocacy Policy Community & Systems Clinical

3 Domains of Child Advocacy Policy Community & Systems Clinical

www. stopsolitaryforkids. org

Questions/Comments? Mikah. owen@jax. ufl. edu