Adverse Childhood Events

Question 1

The ACEs study - background

Answer 1

Looked at the effects of adverse childhood experiences (trauma) over the lifespan; largest study ever done on this subject. It contained participants who were were receiving physical exams from SoCal (n=17,337, >75 % college educated, 75% white, 54%F)

Question 2

The ACEs study - methods

Answer 2

Participants completed confidential surveys regarding their childhood experiences and current health status and behaviors. The CDC continued follow up - assessed the medical status of the study participants via updates of morbidity and mortality.

Question 3

Categories of ACE

Answer 3

Abuse (physical, sexual, emotional), neglect (physical, emotional), household dysfunction (mental illness, incarcerated relative, mother treated violently, substance abuse, divorce)

Question 4

The ACEs study - Results

Answer 4

ACEs are more common than anticipated or recognized (about 66% reported at least one ACE; more than 20% reported 3+ ACEs). ACEs have powerful correlation to health outcomes later in life. ACEs still have a profound effect 50 years later, although now transformed from psychosocial experience into organic disease, social malfunction, and mental illness.

Question 5

Behaviors exhibited by participants with ACEs

Answer 5

Lack of physical activity, smoking, alcoholism, drug use, missed work.

Question 6

Physical and mental health exhibited by participants with ACEs

Answer 6

Severe obesity, diabetes, depression, suicide attempts, STDs, heart disease, cancer, stroke, COPD, broken bones

Question 7

Mechanisms by which adverse childhood experiences influence health and wellbeing throughout the lifespan

Answer 7

• Disrupted neurodevelopment
• Social, emotional, and cognitive impairment
• Adoption of health-risk behaviors
• Disease, disability, and social problems
• Early death

Question 8

Theories of stress

Answer 8

Stress has long been linked to disease

Question 9

Stress-response theory

Answer 9

Stress accompanied most illnesses, and it could be evoked. Stress was observed in patients with diverse health problems and it was considered a “call to arms” of the body’s defense forces in response to excessive demands. The demands could be positive or negative but the effects of stress on the body could also be beneficial or damaging.

Question 10

Stress can be positive or negative

Answer 10

There is a certain amount of stress that allows for optimal performance but anything more or less than that is not beneficial

Question 11

Localized Adaptation Syndrome (LAS)

Answer 11

Regional response to stress, localized inflammation, closely coordinated with GAS

Question 12

Generalized Adaptation Syndrome

Answer 12

Backup for LAS, system level response to stressor that has overwhelmed current adaptive resources; the manner in which the body copes with noxious agents (stress); when homeostasis is overwhelmed, you get 3 stages - alarm, resistance, exhaustion. Negative health effects due to hormone depletion.

Question 13

Alarm stage of GAS

Answer 13

HPA axis and SNA suppression

Question 14

Resistance stage of GAS

Answer 14

Decreased alarm reaction; attempts to coexist with stressor

Question 15

Exhaustion stage of GAS

Answer 15

Increased endocrine activity, continued high cortisol circulation, wear and tear or death

Question 16

Short term effects for the Allostasis/Allostatic Load Theory

Answer 16

Essential for adaptation, maintenance of homeostasis, and survival allostasis.

Question 17

Long term effects for the Allostasis/Allostatic Load Theory

Answer 17

Exact at a cost (allostatic load can accelerate disease process), measures as a chemical imbalance in the ANS and CNS, as well as immune system and endocrine activity, daily anxiety, and plasticity changes to the brain

Question 18

Indicators for Allostatic Load

Answer 18

Systolic and diastolic blood pressures, high density lipoproteins and total cholesterol, glycosylated hemoglobin levels of glucose metabolism over time, overnight urinary noradrenaline and adrenaline excretions

Question 19

4 types of Allostatic Load

Answer 19

1. Repeated elevations of blood pressure over weeks/months accelerates atherosclerosis, increasing the risk of MI. 2. When adaptation to repeated stressors is lacking, there may be prolonges exposure to stress hormones. 3. There may be an inability to shut off allostatic responses after stress is terminated, leading to conditions such as hypertension or decreased bone mineral density. 4. Inadequate responses in some allostatis systems, such as cortisol secretion, may lead to compensatory increased in other systems, such as proinflammatory cytokines

Question 20

Criticism of GAS

Answer 20

Stress definition and the GAS did not take into account cognition, perception and interpretation of the stimulus. It tried to address this through concepts such as eustress and distress

Question 21

Walter Cannon’s concept of stress

Answer 21

Behavior and emotions + autonomic and endocrine regulations = homeostasis

Question 22

Schachter and Singer’s concept of stress

Answer 22

Cognitions and perceptions shape emotions - emotional biasing

Question 23

Richard Lazarus’s concept of stress

Answer 23

Role of perception in the stress response; primary vs secondary appraisals; psychological stress theory

Question 24

Psychological Stress Theory

Answer 24

• Threat appraisal
• Perceived ability to cope
• Fear of potential physical harm and helplessness yield the highest stress response
• Brain mechanisms for this process are the same as those that maintain homeostasis in response to physical threats
• Both can lead to physical illness

Question 25

Transactional Model

Answer 25

Takes into account the person and their environment

Question 26

Other medical conditions related to stress

Answer 26

Wound healing, surgical recovery, GI disorders, pain, asthma, addiction, trauma and stress related disorders (like PTSD)

Question 27

Gender stress: women

Answer 27

Women report feelings of stress more often. They also react to a wider range of stressors, including community problems. Women often have 2 jobs, wage earner and (unpaid) homemaker (mother). Women tend to internalize stress, resulting in sleep disturbance, GI distress, and depression

Question 28

Gender stress: men

Answer 28

Men tend to externalize stress, through anger, blaming, and violence. Men with explosive anger episodes tend to have a sharper rise in BP when stressed and an increased risk of CVA, but suppressing anger can also increase BP

Question 29

Stress and Race

Answer 29

• Perceived discrimination is a key factor in chronic stress related health disparities.
• AA, Native Hawaiians, and LA have been impacted greatly by hypertension and diabetes due to chronic stress resulting from discrimination.
• Chronic experiences of racial and ethnic discrimination were significantly associated to presence of coronary artery calcification in AA women

Question 30

SES and Health

Answer 30

SES is one of the most powerful health predictors, including CVD, DM, arthritis, infant mortality, ID, and cancer. (More powerful than smoking, genetics, and exposure to carcinogens). There is a direct linear correlation - the lower the SES, the greater the risk of poor health

Question 31

Treating stress

Answer 31

Exercise universal precautions by creating systems of care that are trauma-informed.

Question 32

Trauma informed

Answer 32

Services that are provided for problems other than trauma but require knowledge about violence against humans and the impact of trauma, thereby increasing their effectiveness

Question 33

The 4 R’s and Key Assumptions of being trauma informed

Answer 33

Realize the widespread impact of trauma. Recognize the signs and symptoms of trauma in patients, families, staff, and others involved with the system. Respond by fully integrating knowledge about trauma into policies, procedures, and practices. Actively resist retraumatization.

Question 34

Core principles of trauma-informed care

Answer 34

Safety (physical and emotional), trustworthiness, choice, collaboration, empowerment, culture, historical and gender issues, and peer support.

Question 35

Interventions for Stress

Answer 35

Psychological interventions (hypnosis, disclosure interventions, cognitive styles), expressive writing, spirituality

Question 36

Nonpharmacological interventions related to perception and coping

Answer 36

Improve time management and sense of humor, pursue personal and vocational activities consistent with life values, explore the meaning and purpose of life, cultivate spiritual and transcendent activities, pursue psychotherapy, increase assertiveness, monitor sensory input, and help others

Question 37

Arousal reduction and health

Answer 37

Health enhancing activities - exercise, abdominal breathing, massage, contact with nature.
Health degrading activities - tobacco use, substance use, eating disorder

Question 38

Conclusions

Answer 38

• ACEs are common and they are best understood as a type of chronic stress rooted in childhood.
• The link between ACEs and disease can be explained by stress theories.
• Later models such as the transactional model, incorporates perception, coping, and arousal reduction style into its conceptualization of stress effects