1 BIOLOGICAL HARM Randell Alexander MD PhDUniversity of Florida – Jacksonville Statewide Medical Director, FL CPTs

2 HARMS Range from immediate physical trauma to short term trauma to long term trauma – with overlaps and changing sequelae Therefore the situation often is fluid Talking about “fixing” or even “preventing” can sound static, not dynamic

3 PHYSICAL ABUSE HARMS

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7 SEXUAL ABUSE HARMS

10 SYPHILIS: THE CULPRIT

11 NEGLECT HARMS Often the worstIntentionality is often not the issue – children die with unsafe sleep, drownings, and other situations. In many senses, neglect harms underlie many physical abuse and sexual abuse as well

13 DIRTY HOMES Is infection risk the harm? Is safety a greater harm?Or is it what the symptom represents?

14 SOMETIMES LONGER TERM SEQUELAE OF HARMSGI symptoms Pain or exaggeration of pain Others??

16 SAVE THE BRAIN – PREVENT ABUSE GROW THE BRAIN - STIMULATIONBrains need both: Freedom from abuse Positive stimulation

17 WHAT HAPPENS IF WE DON’T PREVENT ABUSEWHAT HAPPENS IF WE DON’T PREVENT ABUSE? FOUR AREAS OF RESEARCH CONVERGENCE ACES STUDY NEUROSCIENCE TELOMERES BRAIN IMAGING

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19 ACES

20 The Influence of Child Maltreatment Throughout LifeHealth-risk Behaviors Sexual promiscuity Sexual perpetration Alcohol abuse Illicit/injected drug use Smoking Behavior problems Mental/Social Problems PTSD Depression Anxiety Eating disorders Academic achievement Unwanted pregnancy Obesity Revictimization Disease and Injury Conditions Ischemic heart disease Diabetes Stroke Cancer Suicide Skeletal fractures Chronic bronchitis/ emphysema STDs (e.g., HIV) Hepatitis Child Maltreatment

21 Many chronic diseases in adults are determined decades earlier, in childhood

22 Evidence from ACE Study Adverse childhood experiences are the most basic cause of * health risk behaviors * morbidity * disability * mortality * healthcare costs Well hidden by time, shame, secrecy, and social taboo.

23 SOCIAL NORMS CHANGE

24 Vision for DVP’s Child Maltreatment Prevention WorkAssuring safe, stable, nurturing relationships and environments for all children Why focus on safe, stable, nurturing relationships and environments: history of development An important role of public health is to assure safe, stable, nurturing relationships and environments for all children Essentials for Childhood: the broad “umbrella” for all of our child maltreatment work Vision for DVP’s Child Maltreatment Prevention Work

26 OPPORTUNITY FOR NORMS CHANGE: CORPORAL PUNISHMENTIn the following 38 countries, children are protected by law from all corporal punishment (most recent first): Bolivia (2014) Brazil (2014) Malta (2014) Honduras (2013) TFYR Macedonia (2013) South Sudan (2011)

27 OPPORTUNITY FOR NORMS CHANGE: CORPORAL PUNISHMENTAlbania (2010) Congo, Republic of (2010) Kenya (2010) Tunisia (2010) Poland (2010) Liechtenstein (2008) Luxembourg (2008) Republic of Moldova (2008) Costa Rica (2008) Togo (2007) Spain (2007) Venezuela (2007)

28 OPPORTUNITY FOR NORMS CHANGE: CORPORAL PUNISHMENTUruguay (2007) Portugal (2007) New Zealand (2007) Netherlands (2007) Greece (2006) Hungary (2005) Romania (2004) Ukraine (2004) Iceland (2003) Turkmenistan (2002) Germany (2000) Israel (2000) Bulgaria (2000) Croatia (1999) Latvia (1998) Denmark (1997)

29 OPPORTUNITY FOR NORMS CHANGE: CORPORAL PUNISHMENTCyprus (1994) Austria (1989) Norway (1987) Finland (1983) Sweden (1979)

30 ACE Score and Work ProblemsAnalyzed data for ACE study from 9,633 currently employed adult members of Kaiser Foundation Health Plan in San Diego Strong graded relations found between ACE Score and each measure of impaired worker performance Each of the ACEs was associated with an increased likelihood of: job problems financial problems, and absenteeism Job Problems

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33 NEW ZEALAND SOVEREIGN INSURANCE

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37 Synaptic Density 700 new synapses (neural connections) every secondNOTES TO PRESENTERS: This slide shows the importance of supporting healthy brain development, particularly in younger children. TALKING POINTS FOR PRESENTERS: The basic architecture of the brain is constructed through an ongoing process that begins before birth and continues into adulthood. During the first few years of life, 700 new synapses (neural connections) are formed every second. After a period of rapid proliferation, connections are reduced through a process called pruning, so that brain circuits can become more efficient. Early experiences affect the nature and quality of the brain’s developing architecture by determining which circuits are reinforced and which are pruned through lack of use. Some people refer to this as “use it or lose it.” 700 new synapses (neural connections) every second SOURCE: Harvard Center on the Developing Child 37

38 Brain activity of a normal five-year-old child (left)and a five-year-old institutionalized orphan neglected in infancy (right). 38

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40 SEXUAL ABUSE AND THE BRAINChildren may be more susceptible than adults to cellular microenvironments and impact on brain development High rate of PTSD (42% to 90%) [Physical abuse rate of PTSD may be 50%] Limbic-hypothalamic-pituitary-adrenal axis is at risk (may be “over sensitive”) De Bellis, M. Spratt E, Hooper S. Neurodevelopmental Biology Associated with Childhood Sexual Abuse. JCSA 2011.

41 SEXUAL ABUSE AND THE BRAINIncreased sensitivity of the locus ceruleus/SNS/chatecholamine system? Responsible for high heart rate, blood pressure, other effects Becomes dysregulated?

42 SEXUAL ABUSE AND THE BRAINSerotonin may become low in the prefrontal cortex – associated with depression, suicidal behaviors, impulsivity May lead to “learned helplessness”

43 SEXUAL ABUSE AND THE BRAINNeuroimaging of adults supports the concept that medial prefrontal regions responsible for executive functions are hyporesponsive when abused as children Amygdala is hyperresponsive Corpus callosum is decreased (males more than females?) Smaller overall brain volume (e.g. 8%) as adults

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45 TELOMERES Telomeres are the ends of DNA strands which are shortened with each cellular division. With each replication, telomeres shorten until the “Hayflick limit” is reached and the cell enters senescence. Telomeres are thought to be a sign of cellular aging (and perhaps overall aging of the organism).

46 Physical abuse caused more erosion EXPOSURE TO VIOLENCE DURING CHILDHOOD IS ASSOCIATED WITH TELOMERE EROSION FROM 5 TO 10 YEARS OF AGE: A LONGITUDINAL STUDY Same children examined for telomere erosion between 5 and 10 years of age Physical abuse caused more erosion Combination of physical abuse, exposure to domestic violence, or bullying caused the most erosion Children will have decreased life span, earlier diseases Shalev I, Moffitt TE, Sugden K, Williams B, Houts RM, Danese A, Mill J, Arseneault l, Caspi A. Molecular Psychiatry doi: /mp

47 ; EPIGENETICS Epigenetics is the study of heritable changes in gene activity that are not caused by changes in the DNA sequence

48 FOUR LINES OF CONVERGENCENot only does abuse alter which neurons are selected, how different parts of the brain develop, and how neuro-hormonal pathways are altered but now it can be seen that it leaves its very footprints deep in the cells. Abuse creates different children

49 ADULTS TELL YOU ABOUT THEIR BRAINS

50 ADULTS TELL YOU ABOUT THEIR BRAINSHow people react gives you clues about their life

51 ADULTS TELL YOU ABOUT THEIR BRAINSExample 1: A guy goes into a bar and gets into a discussion with another guy That guy suddenly hits him without warning What kind of brain behavior is he showing? Limbic-hypothalamic-pituitary-adrenal over-reactivity?

52 ADULTS TELL YOU ABOUT THEIR BRAINSExample 2: A woman says that her 3 year old will not mind and she needs to hit him, but it doesn’t work You give alternatives, but she insists nothing works and doesn’t really try What kind of brain behavior is she showing?

53 CHILDREN TELL YOU ABOUT THEIR BRAINS

54 THERAPISTS ARE BRAIN CHANGERSMentalistic terms are ok, but they reflect actual physical underpinnings 21st century therapists envision the brain they are seeing and treating – if not, you are in the previous century

55 ALTERNATE REALITIES

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57 WHAT IS PREVENTION? It is a value judgment whether a brain is shaped toward peace or war But the brain will be shaped regardless Our role: shape the future possibilities we want

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60 Categories of Adverse Childhood ExperiencesCategory Prevalence (%) Abuse, by Category Psychological (by parents) % Physical (by parents) % Sexual (anyone) % Household Dysfunction, by Category Substance Abuse % Mental Illness % Mother Treated Violently % Imprisoned Household Member 3%

61 Adverse Childhood Experiences ScoreNumber of categories of adverse childhood experiences are summed … ACE score Prevalence 0 48% 1 25% 2 13% 3 7% 4 or more 7% More than half have at least one ACE If one category of ACE is present, there is an 84% likelihood of additional categories being present. 7

62 HEALTH CONSEQUENCES

63 SEX

64 Number of Adverse Childhood Experiences and Teen Sexual Behaviors

65 ACE Score and HIV Risks 2

66 DRUGS

67 Childhood Experiences vs. Adult Alcoholism4+ 3 2 1

68 Relationship Between Number of Adverse Childhood Experiences and Smoking Behaviors and Smoking-Related Lung Disease

69 ACE Score vs. Intravenous Drug UseN = 8, p<0.001

70 Estimates of the Population Attributable RiskEstimates of the Population Attributable Risk* of ACEs for Selected Outcomes in Women *That portion of a condition attributable to specific risk factors

71 MENTAL HEALTH

72 Childhood Experiences Underlie Chronic Depression

73 Childhood Experiences Underlie Attempted Suicide4+ 3 2 1

74 ACE Score and HallucinationsAbused Alcohol or Drugs Ever Hallucinated* (%) ACE Score *Adjusted for age, sex, race, and education.

75 Estimates of the Population Attributable RiskEstimates of the Population Attributable Risk* of ACEs for selected outcomes in women *That portion of a condition attributable to specific risk factors

76 Childhood Experiences Underlie Rape4+ 3 2 1

77 ACE STUDY FINDINGS As ACE score goes up, so does risk for: SmokingOrganic disease Adult alcoholism Depression and suicide attempts Having 50+ lifetime sexual partners STD’s and Rape (from 5% to 33%) Hallucinations Domestic Violence Addictions Dying early Job Problems and lost time from work Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, et al JS. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine. 1998;14:

78 Adverse Childhood Experiences Reported by Adults Five States, 2009First published report to document prevalence of ACEs in population-based representative sample from multiple states stratified by demographic characteristics, including sex, age, education, and race/ethnicity. Approximately 59% reported one or more ACEs These BRFSS estimates are similar to the findings in the Kaiser-CDC ACE study (2) and similar research, including study in Texas CDC MMWR, December 17, 2010/59(49); 78

79 Adverse Childhood Experiences determine the likelihood of the 10 most common causes of death in the US Top 10 Risk Factors: smoking, severe obesity, physical inactivity, depression, suicide attempt, alcoholism, illicit drug use, injected drug use, 50+ sexual partners, history of STD

80 With an ACE Score of 0 The majority of adults have few, if any, risk factors for these diseases

81 However, with an ACE Score of 4 or more The majority of adults have multiple risk factors for these diseases or the diseases themselves