Exploring a Life course perspective on adult health outcomes

Question 1

What is ACEs

Answer 1

• Adverse childhood experiences

- these can impact health in future life and impact how individuals deal with healthcare

Question 2

What did the ACEs study look at

Answer 2

Abuse - physical, emotional and sexual

Neglect - physical and emotional

Household dysfunction - mental illness, incarcerated relative, mother treated violently, substance abuse, divorce

Question 3

the more ACEs people have…

Answer 3

the higher the chance they have of having diseases such as ischemia heart disease, cancer, chronic lung disease, skeletal fractures and liver disease and sucidial attempts

Question 4

How much is the risk of suicide increased by those who have ACEs

Answer 4

30 times

Question 5

What are the pathways to poor health from ACEs

Answer 5

Link between ACEs and coping strategies
- Smoking*, drug and alcohol use

Link between ACEs and other social determinants of health

Neurobiological, physiological, and genetic + epigenetic pathways

Question 6

Describe the ACEs study

Answer 6

Kaiser Permanente’s San Diego Health Appraisal Clinic, 1998
- A story which begins with failure (obesity study) and the importance of maintaining curiosity (and an argument for qualitative research)
- Vincent Felitti started speaking with patients who had regained weight
- Then interviewed 100 patients and found 55% reported childhood sexual abuse (and also endorsed other coping behaviours such as smoking, drug and alcohol use)
- Began to identify that intractable public health problems might actually represent coping behaviours
Introduced to Robert Anda from CDC
- Nearly 10,000 responses
- More than half (52%) of respondents had experienced one or more ACEs
- 6.2% reported 4 or more ACEs
- Graded (dose-response relationship) between ACEs and ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.

Question 7

How many people reported at least once ACE in hughes et al 2017

Answer 7

Nationally representative sample of 3885 people in 2013

47% reported at least one ACE (Hughes et al., 2017)

Question 8

What does SAMHSA describe as the 3Es

Answer 8

• event - series of event or circumstances
• experienced - events that are experienced by an individual that are physically or emotionally harmful or life threatening
• effects = effects on the individuals as a result of the experiences

Question 9

What things in the body happen when it experiences toxic shock

Answer 9

• Sympathetic nervous system (Fast) + hypothalamus-pituitary-adrenal axis (HPA) (Slower)

Release of cortisol mobilises stored glucose and lipid stores (helpful in the short term, toxic if chronic)

Chronically elevated cortisol is damaging and leads to hyperglycaemia and inflammation

Hippocampus has high levels of glucocorticoid and mineralocorticoid receptors

Elevated basal levels of cortisol found in maltreated children, later hypoactivity (blunting of effect)

Adults show increased responsiveness and failure to control HPA activation

Significant associations between childhood trauma and adult TNFa, IL-6, CRP

Dose response relationship with shortening of telomeres

Question 10

What brain structures change if you experience ACEs (Teicher et al)

Answer 10

• Smaller hippocampi
• Increased amygdala volume
• Reductions in cortical grey and white matter
• Reduced volume of DLPFC, OFC, ACC
• Reduced integrity of language areas
• Reduced area of corpus callosum
• Reduced volume left fusiform and left middle occipital gyrus

Question 11

How does trauma look

Answer 11

Frequent attending

Never attending

Attending only as an emergency

Not attending screening

Medically unexplained symptoms

Poorly managed chronic conditions

Multimorbidity

Refusals of treatment

Question 12

Why to patients present that way with trauma

Answer 12

Hypervigilance

Shame

Dissociation

Coping and symptom control

Question 13

Why is healthcare re-trumatizing

Answer 13

Invasive procedures

Removal of clothing

Physical touch

Vulnerability

Personal questions

Power dynamics

Blaming

Lack of privacy

Loss of control

Requires trust in “authority” figures

Question 14

What are 3 reasons why people do not disclose

Answer 14

Intrapersonal:
- Self-doubt and pre-verbal abuse, neglect hard to articulate, shame and self-blame, fear of feeling worse

Interpersonal:

• Fear of others’ reaction, rejection, exposure, previous bad experience of disclosure, not being asked, expectation of narrative
• Negative attitudes and perceived social disapproval is related to PTSD severity (Mueller et al, 2008)

Social and cultural:
- Stigma, misunderstanding, disbelief

Question 15

How many people with an AED have been to mental health services

Answer 15

22%

Question 16

What are factors that influence disclosure

Answer 16

Facilitators:
- Sense that talking about early life might give an understanding to current experiences

• A wish to avoid the same experiences for children, protect young family members
• Safe and trusting relationships
• High levels of social support
• Media stories (#metoo)
• “Test Balloons” (common finding in children)

Question 17

What doesn’t help someone when they are disclosing

Answer 17

Blaming or doubting the survivor

Minimising, dismissing, and/or distracting responses

Treating the survivor differently after disclosure

Displaying a cold and/or detached demeanour

Unnecessary interest in sexual details or anger toward the offender or the survivor and insensitivity to the survivor’s needs

Promising to keep a secret (if others are at risk)

Forgetting to take care of yourself

Saying or communicating “don’t tell me, I haven’t got time/qualifications for this

Question 18

What are the three ways in which AEDs can heal and recover

Answer 18

Establishing safety:
- Environment, home, health, (Maslow’s hierarchy of needs,) safety from future abuse, gaining autonomy, reconstructing self-care, arts and music therapies

Remembrance and mourning
- Trauma specific therapies (not what everyone wants), integrating fragmented memories

Reconnection with ordinary life
- Re-establishing trust, awareness of boundaries

Question 19

name what healthcare professionals can do

Answer 19

Primary preventions:

• prevent the occurence of adverse childhood events so that fewer children experience them
  e. g. = programmes preventing child cause and neglect, increase family and community stability

Secondary prevention

• reduce the severity and acute consequences of the ACES
• e.g. trauma informed care to identify and intervene on ACEs, psychological first aid that reduces psychological impact of trauma

tertiary

• treat and reduce the lung term consequences of ACEs
• e.g.= Programs that identify and reduce risky health behaviours associated with ACES, social marketing campaigns that build empathy with ACE consequences