Disclosures. Acknowledgements. Housekeeping. Objectives. Opportunistic Care 11/9/2015. November 9, 2015

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1 Adverse Childhood Experiences & Preconception Health: Life Planning Across Generations Michaela Penix, MPH Eastern Regional Program Coordinator Ginger Clough, BSN, BA Buncombe County Nurse-Family Partnership November 9, 215 Disclosures Neither Michaela, Ginger, or their respective partners have relationships with commercial companies that could be perceived as a conflict of interest (within the past 12 months). There will be no discussion of a product that is still investigational or not labeled for the use under discussion. Per ACCME Content Validity Value Statements: This talk is based on evidence that is accepted within the profession of medicine and all materials used conform to the generally acceptable standards of experimental design, data collection, and analysis. All materials related to this discussion are not libelous or unlawful, will not cause harm or injury, and do not infringe on any copyright or other proprietary, personal, or contractual rights of any other party. Housekeeping Acknowledgements Obtaining credits: Groups should Kweli Rashied-Henry Krashied-henry@marchofdimes.org Asking questions Accessing slides at a later date This training was developed by the North Carolina Preconception Health Campaign, a program of the North Carolina Chapter of the March of Dimes, under a contract and in collaboration with the North Carolina Division of Public Health, Women s Health Branch. This material was developed through support provided by the Department of Health and Human Services, Office of the Assistant Secretary for Health, Office of Adolescent Health (grant #SP1AH4). Buncombe County Nurse-Family Partnership and MAHEC for their contributions to ACES and maternal child health. Area L AHEC for their support in providing continuing education credit for this webinar. Objectives Opportunistic Care Understand the role of preconception health counseling in women s health services Understand how reproductive life planning relates to opportunistic preconception health counseling Increase knowledge about the key components of reproductive life planning Increase awareness about the Life Course Perspective and Adverse Childhood Experience Survey as tools available to assist with reproductive life plan counseling Improve reproductive life planning counseling skills and learn strategies to improve reproductive life planning service delivery Preconception care is for every woman of childbearing age every time she is seen Every woman, every time 1

2 What is Reproductive Life Planning? Start out with Life Planning One of the primary CDC preconception health recommendations is to encourage all men and women to have a reproductive life plan Academic Goals High School Graduation Career Goals Ultimate Career Financial Goals Desired Salary Personal Goals Travel A reproductive life plan is more than birth control College Plans Career Exploration Savings Plan Entertainment Then add in Reproductive Plans Do you want to have children? If no, how do you avoid a pregnancy? If yes, When do you want to start? What type of relationship do you want to be in? (married, committed, donor, etc.) How many children do you want to have? How far apart should they be spaced? What do you want to have in place first? Circle back to Life Goals How do Academic, Career, Finance, and Personal Goals work with reproductive life goals? Are life and reproductive goals achievable? Are there competing interests? Reproductive Life Plan Resource Updating Reproductive Life Plans Reproductive Life Plans should be revisited at least annually. Consider some basic questions: What goals have you met? What goals should be changed? New health concerns? 2

3 Percentage 11/9/215 Why is Reproductive Life Planning important? Lack of planning for pregnancy and lack of pregnancy spacing, as well as Failure to manage Health conditions affecting pregnancy outcomes, Environmental risk factors, and Negative health behaviors affecting pregnancy outcomes Leads to: Unintended pregnancies Increased risk for premature births Increased risk for low-birthweight births Increased rates of birth defects Poorer health status for women Increased health disparities Pregnancy Intendedness Thinking about to just before you got pregnant with your new baby, how did you feel about becoming pregnant? Sooner Later Then Did not want to be Pregnant then or in the Future NC PRAMS Fact Sheet 29, Unintended Pregnancies, NC PRAMS, Pregnancy Intendedness, Pregnancy Intendedness Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant? Why are Unintended Pregnancies a concern? Increased risk for infant morbidity and mortality; including premature birth, low birthweight, and birth defects Increased elective abortion rate Late entry into prenatal care Higher rates of smoking prior to pregnancy Then Sooner Later Did not Want to be Pregnant then or in the Future NC PRAMS, Pregnancy Intendedness, Increased risk of physical abuse and partner relationship ending for mothers Increased child abuse and neglect Increased Medicaid costs Looking Back Moving Forward, North Carolina s Path to Healthier Women and Babies, 27; NC PRAMS Fact Sheet 29, Unintended Pregnancies, Pre-existing Medical Conditions & Unintended Pregnancies Obesity Asthma Fetal and neonatal death Neural tube defects Large baby (Macrosomia) Increased risk of childhood obesity Women with unintended pregnancies may be more likely to have pre-existing medical conditions that adversely affect birth outcomes Preterm birth Low birth weight Small for gestational age Poor Mental Health Hypertension Preterm birth Low birth weight Adapted from California Preconception Care Provider training, County of Los Angeles, Department of Public Health, 23 Preterm birth Placental abnormalities Teratogenic risks from medication Low birth weight Diabetes Miscarriage/Still birth Preterm birth Birth defects Macrosomia STI transmission to infant Low birth weight Transmitted Miscarriage/Still birth Infection Preterm birth Pneumonia Risk Behaviors & Unintended Pregnancies Smoking, Alcohol Use, and illicit drug use during early pregnancy can: Cause certain birth defects, Increase the risk of miscarriage, preterm labor, and low birthweight. Women ages NC % US % Smoking 19.5% 2.5% Obesity 28.2% 25.2% Poverty 19.8% 18.5% March of Dimes Peristats Centers for Disease Control and Prevention, Facts about FASDs; Tobacco Use & Pregnancy; National Prematurity Awareness Month 3

4 Reproductive Life Planning & the Life Course Perspective Men and women use Reproductive Life Plans to plan their future improve their health have healthy birth outcomes. But let s consider Could a woman s health as a child, or even a fetus, affect her future children s health? NC DHHS Children and Youth Branch What is the Life Course Perspective? Developed in the 196 s Used in a variety of social behavior and public health settings Health is a developmental process occurring throughout the lifespan Emphasizes life-long prevention efforts that promotes optimal health from conception and is passed on to the next generation NC DHHS Children and Youth Branch Life Course Perspective Concepts A Different Way of Thinking Think about preconception health in this way: Timeline Timing Environment Equity Child s Life Parent s Life Life Span Individual s Life US DHHS HRSA MCH Bureau US DHHS HRSA MCH Bureau Applying the Life Course Perspective Timeline: Are your services linked and integrated for your clients across their lifespan? Timing: Do you have services and supports available for clients during their critical or sensitive periods? Environment: Can you link your clients with services to meet their environmental needs? Equity: Do you have or are you using any initiatives to address health disparities among your clients? Starting the Reproductive Life Planning Conversation Would you like to become pregnant in the next year? One Key Question Initiative Oregon Foundation for Reproductive Health 4

5 Using the One Key Question Summary Would you like to become pregnant in the next year? Yes No Reproductive Life Planning Life Course Perspective Intended Pregnancies Better Birth Outcomes When? Vitamins? Health Check list Let s Plan Family Planning Method? Health Check list Let s Plan The Adverse Childhood Experiences (ACEs), Resiliency & The Reproductive Life Plan Presented by Ginger Clough, BSN, BA Innovative Approaches ACES Sub-Committee Member Buncombe County Health & Human Services ginger.clough@buncombecounty.org OUTLINE Adverse Childhood Experiences Study Resiliency Using ACEs & Resiliency Questionnaires & Reproductive Counseling Community Resiliency Model Questions Objectives Summarize the finds of the ACEs Study and implication for health across the life span Understand the role of Resiliency for optimizing health and social outcomes Consider current NC maternal health data in the context of ACEs Study Learn strategies to incorporate ACEs & Resiliency Questionnaires in Pre or Intra Conception Counseling Recognize our own vulnerabilities to and protective factors for reducing stress and secondary trauma Introduce the Community Resiliency Model Big Picture 5

6 North Carolina Kim North Carolina Pregnancy Risk Assessment Monitoring System Survey Results 21 Unintended Pregnancies by Age Sharon & Kelvin Health Conditions & Chronic Diseases of North NC BRFSS Data, 29 Carolina Woman Ages years old Source: NC BRFSS 29 Sandra & Stephen 6

7 What are the most common health concerns you encounter in your clinic setting related to Reproductive Health? The Adverse Childhood Experiences Study (ACE) Origins of the Adverse Childhood Experiences Study Collaboration between Kaiser Permanente s Department of Preventive Medicine in San Diego and the Center for Disease Control and Prevention (CDC) Dr. Vincent Felitti Dr. Robert Anda ACEs Questionnaire ACEs Questionnaire 3 Categories of Experiences up to 18 years old Childhood abuse: emotional, physical, or sexual Childhood Neglect: emotional or physical Household Dysfunction: domestic violence, substance abuse (alcohol or drugs), mental illness, parental discord, crime 1 point for type of adverse experience Did not include questions regarding community violence, historical trauma, racism, sexism, homophobia, income, education 7

8 Response gets bigger 11/9/215 ACEs Study Demographics Prevalence of Adverse Childhood Experiences Abuse, by Category Psychological (by parents) Prevalence (%) 11% Physical (by parents) 28% Sexual (anyone) 22% Neglect, by Category Emotional 15% Physical 1% Household Dysfunction, by Category Alcoholism or drug use in home 27% Loss of biological parent < age 18 23% Depression or mental illness in home 17% Mother treated violently 13% Imprisoned household member 5% The ACE Study Summary of Findings: Adverse Childhood Experiences (ACEs) are very common, but largely unrecognized. ACEs are strong predictors of later social functioning, well-being, health risks, disease, medical costs, and death. ACEs are thus the basis for much of adult medicine and of many major public health and social problems. Adverse childhood experiences are interrelated, not solitary. Adverse Childhood Experiences Score Number of categories (not events) is summed ACE Score Prevalence 33% 1 25% 2 15% 3 1% 4 6% 5 or more 11%* Two out of three experienced at least one category of ACE. If any one ACE is present, there is an 87% chance at least one other category of ACE is present, and 5% chance of 3 or >. Women are 5% more likely than men to have a Score >5. Dose Response in ACEs A CLASSIC CAUSAL RELATIONSHIP MORE ACEs = MORE HEALTH PROBLEMS Dose gets bigger Dose-response is a direct measure of cause & effect. The response in this case the occurrence of the health condition is caused directly by the size of the dose in this case, the number of ACEs. Childhood Experiences Underlie Chronic Depression % With a Lifetime History of Depression >=4 ACE Score Women Men 8

9 The Impact of ACEs High ACE scores have a direct correlation with higher rates of depression, substance abuse, smoking, and difficulties earning a living. Felitti % Alcoholic Childhood Experiences vs. Adult Alcoholism 1 2 ACE Score 3 4+ % have Unintended PG, or AB ACE Score and Unintended Pregnancy or Elective Abortion Jennings Unintended Pregnancy Elective Abortion or more ACE Score Felitti Adverse Childhood Experiences and History of STD Adjusted Odds Ratio or more ACE Score ACE Score and Teen Sexual Behaviors Percent With Health Problem (%) Felitti ACE Score or more 4 Intercourse by Age 15 Looking for love Teen Pregnancy Teen Paternity 9

10 Adverse Childhood Experiences and Likelihood of > 5 Sexual Partners ACEs & Violent Behavior Adjusted Odds Ratio High ACE scores are associated with becoming a VICTIM of domestic violence, and PERPETUATING violence or more ACE Score Felitti Childhood Sexual Abuse and the Number of Unexplained Symptoms Percent Abused (%) Number of Unexplained Symptoms Felitti Anda Felitti Effect of ACEs on Death Rate Percent in Age Group (Null hypothesis) 2 4 ACE Score Age Group => 1

11 Comparing ACEs Scores People with 4 or more ACEs compared to people with ACEs The higher the ACE Score, the greater the likelihood of : health risk behaviors adult diseases disabilities severe social problems severe mental health problems The following information and slides are from September 23 Presentation at Snowbird Conference of the Child Trauma Treatment Network of the Intermountain West, by Vincent J. Felitti, MD. ACEs Toxic Stress Jennings Disrupted Neurodevelopment 11

12 Miller-Karas & Leitch Fight, Flight, Freeze Pre-existing Medical Conditions & Unintended Pregnancies Obesity Fetal and neonatal death Neural tube defects Large baby (Macrosomia) Increased risk of childhood obesity Hypertension Preterm birth Placental abnormalities Teratogenic risks from medication Low birth weight Women with unintended pregnancies may be more likely to have pre-existing medical conditions that adversely affect birth outcomes Miscarriage/Still birth Preterm birth Diabetes Birth defects Macrosomia STI transmission to infant Low birth weight Transmitted Miscarriage/Still birth Infection Preterm birth Pneumonia Asthma Preterm birth Low birth weight Small for gestational age Poor Mental Health Preterm birth Low birth weight Adapted from California Preconception Care Provider training, County of Los Angeles, Department of Public Health, 23 Toxic Stress & Pregnancy Stress and the Brain Excessive and repeated stress: Neglect, violence Chaos, unpredictability Hostility, rejection Causes disruption of brain architecture: Impairs cell growth Interferes with healthy neural circuits Regional Child Abuse Prevention Councils

13 Brain Development is Driven by Experience By adolescence, children seek relief through: Drinking alcohol Smoking tobacco Sexual promiscuity Using drugs Overeating/eating disorders Delinquent behavior Jennings Regional Child Abuse Prevention Councils 211 High Risk Health Behaviors May not be the core problem They may be the coping devices A way to feel safe or just feel better Seeking to Cope What are the top high risk health behaviors or factors you see in your clinic setting? Regional Child Abuse Prevention Councils

14 Seeking to Cope The risk factors/behaviors underlying these adult diseases are actually effective coping devices. What is viewed as a problem is actually a solution to bad experiences. Dismissing these coping devices as bad habits or self destructive behavior misses their functionality. Regional Child Abuse Prevention Councils 211 Behavior is Predictable All behavior has meaning - both good behavior and bad behavior We need to look closely at what preceded the behavior - What happened first that is causing this behavior? Regional Child Abuse Prevention Councils 211 Using ACEs & Resiliency Questionnaires In Reproductive Counseling Jennings Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress such as family and relationship problems, serious health problems or workplace and financial stressors. It means "bouncing back" from difficult experiences. Resiliency Questionnaire /got-your-ace-score/ Connor-Davidson Resilience Scale 14

15 Protective Factors Are conditions that increase health and well being Are critical for everyone regardless of age, sex, ethnicity or racial heritage, economic status, special needs, or the dynamics of the family unit Are buffers that provide support and coping strategies Protective Factors that Strengthen Families and Communities Nurturing and Positive Relationships Knowledge of Parenting and Child Development Parental Resilience Social Connections Concrete Support in Time of Need Regional Child Abuse Prevention Councils 211 Regional Child Abuse Prevention Councils 211 Integrating Resiliency ACEs ACEs & Resiliency Questionnaires in Health Counseling Sessions Reproductive Life Plan Universal Precautions Assume all clients are ACE Survivors Better Birth Outcomes ACES and Public Health Practice Quen Zorrah, PHN, MSN Using ACEs & Resiliency in Health Counseling Sessions Normalize Respond to answers and give score Ask, How have these childhood experiences affected you? Gives the client the opportunity to respond if she wants to Thank her for answering questions Toolkit: scripts for responding Case Example Beth 19 Years Old 4 Past Sexual Partners (3 male, 1 female) Starting new relationship with 21 year old male college classmate Smokes Marijuana several times a week Kicked out of family home at 17 due to sexuality Family history of IPV between her parents when Father drank alcohol ACES and Public Health Practice; Quen Zorrah, PHN, MSN 15

16 What Thrive Washington Learned by Asking Asking did not create crisis in the interview Some clients are not ready or feel safe to talk about their ACE score or childhood experiences Some clients keep safe by denying their ACE score or the impact the experiences had on their lives Some have thoughts reflecting on their mother s ACE score & how that affected her decisions, health and parenting ACES and Public Health Practice; Quen Zorrah, PHN, MSN Using ACEs & Resiliency in Health Counseling Sessions Opportunity to sit with someone and listening to and finding hope in their story Help normalize the findings Even when someone does not acknowledge ACEs, may want to share information about what many people experience Find strengths in clients and end with positive note ACES and Public Health Practice. Quen Zorrah, PHN, MSN The Six Principles 1. Always Empower, Never Disempower 2. Provide Unconditional Positive Regard 3. Maintain High Expectations 4. Check Assumptions, Observe and Question - Listen 5. Be a Relationship Coach 6. Provide Guided Opportunities for Helpful Participation Client Responses ACES and Public Health Practice. Quen Zorrah, PHN, MSN One Key Question Reproductive Life Plans Would you like to become pregnant in the next year? One Key Question Initiative Oregon Foundation for Reproductive Health

17 Slowly, I have come to see that Asking, and Listening, and Accepting are a profound form of Doing. - Dr. Felitti Clinic Flow: MAHEC PILOT Screen Discussion & Brief Intervention Treatment and/or Referral Follow-up with Patient & Outside Providers ACEs in Your Practice Site How can you add ACEs and Resiliency Questionnaires in your Work? What Resources does your community have to offer for ACEs and building Resiliency? Local women s services (i.e. Rape Crisis, Safe Shelters) YWCAs or other women & family health civic agencies NC Community Care: OB & Case Management Programs Nurse-Family Partnership Triple P Legal Aid 12 Step Recovery Programs Planned Parenthood Beginning: Self Care Drive to help others Acknowledging the difficulty & suffering Balancing our Roles & Responsibilities Neglecting our Selves: Over giving Protecting Ourselves: Choices in Presence (Not Hardening but Softening in our Presence with Others). Realities of Risks for Secondary Trauma 17

18 Miller-Karas & Leitch Miller-Karas & Leitch Miller-Karas & Leitch Miller-Karas & Leitch Miller-Karas & Leitch 18

19 Miller-Karas & Leitch Miller-Karas & Leitch Miller-Karas & Leitch Miller-Karas & Leitch ACE Study slides are from: Adverse Childhood Experiences and their Relationship to Adult Adult Well-Being and Disease: Turning Gold into Lead. Vincent Felitti, MD & Robert Anda, MD, MS Overview of Adverse Childhood Experiences (ACE) Study. Robert Anda multco.us/file/37959/download The ACE Study: Unaddressed Childhood Trauma s Tragic Consequences. The AnnaInstitute.org Ann Jennings, PHD. ACE Study slides are from: The Can Narratives Strong Communities Raise Strong Kids Compassionate Schools: The Heart of Learning & Teaching. The Adverse Childhood Experiences Study

20 ACE Study slides are from Adverse Childhood Expereinces and Public Health Practices, Blogett, PhD & Zorrah, PHN, MSN Thrive Washington: ToolKit thrivewa.org Shift Your Perspective: Trauma Informed Care. Elizabeth Hudson. handouts/elizabeth%2hudson- Adverse%2Childhood%2Experience%2Study/ace-ccf.pd Homework Case Example Mary 19 Years Old, Native American, Married, with one child, 36 weeks pregnant Husband is undocumented resident, Spanish speaking History of IPV; currently husband is verbally abusive Mary s ACE score: 1 Several ER Visits during this pregnancy Participates in 2 home visiting programs Does not desire a 3 rd Pregnancy Summary Campaign Contacts ACES & Resiliency Campaign Contacts Goal Setting Life Course Perspective Future Webinars Thank You! Date Time Webinar Topic December 11, 215 January 28, 216 February 29, 216 March 16, p.m. 11 a.m. 12 p.m. 2 3 p.m. 1 2:3 p.m. Healthy Weight Matters: Act Locally The Power of Preconception Health Peer Education Cultural Diversity: Improving the Health of North Carolina s Latino Women You are the Key to HPV Cancer Prevention For more information about the Campaign and other preconception health topics visit, EveryWomanNC.com Find us on Facebook: Follow us 2

21 March of Dimes North Carolina Preconception Health Campaign A statewide initiative aimed at improving birth outcomes in NC by reaching out to women with important health messages before they become pregnant Formerly functioned as the NC Folic Acid Campaign Goals of the Campaign are to reduce infant mortality, birth defects, premature birth, and chronic health conditions in women, while also aiming to increase intended pregnancies in NC Seeks to raise awareness and inspire positive action among the general public, health care professionals, and community agencies 21