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The Public Health Approach to Bullying Prevention
Part IIKentucky Bullying Prevention Task Force
February 11, 2015
2
The Public Health Approach“The public heath perspective asks foundational questions:
Where does the problem begin?How could we prevent it from occurring in
the first place?Public Health uses a systematic, scientific approach for understanding and preventing violence.” (CDC, 2014)
3
Optimal Outcome
Poor Outcome
Lu and Halfon, 2003
Life Course Development of Health and Well-being
Neural Circuits are Wired in a Bottom-Up Sequence
(700 synapses formed per second in the early years)
Source: C.A. Nelson (2000)
FIRST FIVE YEARS
1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Months Years
Sensory Pathways(Vision, Hearing)
LanguageHigher Cognitive Function
Structural Brain Changes due to Early Experiences
5“The Two Year Window”
Healthy Brain Deprivation
Life Course Health Development Critical Period of Brain Development
• Social-Emotional development is based on secure attachment and becomes the foundation for cognitive development and sense of self-identity.
• Attachment comes from a nurturing relationship with a caregiver that is consistent and caring.
Birth – 2 years; critical window for hardwiring the brain for social-emotional development.
AttachmentSocial-Emotional Hardwiring
Self- Identity
Security
Cognitive Skills
ExecutiveFunctioning
Resilience
Recognition
Routines
Responsiveness
Relationship
Problem solvingPerseverance
Planning
Learning, focus
Delayed gratificationCuriosity
ConfidenceSelf-control
EmpathyConnectedness
Social-emotional Hardwiring forms the Foundation for Learning and Executive Function
How Risk Reduction and Health Promotion Strategies
influence Health Development
FIGURE 4: This figure illustrates how risk reduction strategies can mitigate the influence of risk factors on the developmental trajectory, and how health promotion strategies can simultaneously support and optimize the developmental trajectory. In the absence of effective risk reduction and health promotion, the developmental trajectory will be sub-optimal (dotted curve). From: Halfon, N., M. Inkelas, and M. Hochstein. 2000. The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3):447-497.
Trajectory Without RR and HP Strategies
0 20
Healt
h
Deve
lopm
en
t
40 60 80Age (Years)
HP
RR Risk Reduction Strategies
Health Promotion Strategies
Optimal Trajectory
Protective Factors
HP HPHP
RR
RR
RR
Risk Factors
8
9
Social Determinants of Health
Kaplan, et al. (2000). A Multilevel Framework for Health in :Promoting Health. Washington, DC: National Academy Press
Life Course Health Development - Environmental interaction and Disparate Outcomes
Poor NutritionStressAbuseTobacco, Alcohol, DrugsPovertyLack of Access to Health CareExposure to Toxins
Poor Birth Outcome
0 5 Puberty PregnancyAge
SAFER · HEALTHIER · PEOPLE
The Adverse Childhood ExperiencesWhen you were growing up, during your first 18 years of life, did you experience:
• Physical abuse
• Emotional abuse
• Sexual abuse
• Domestic violence
• Substance abuse in home
• Mental illness in parent
• Lost parent due to separation or divorce
• Household member in jail
• 2/3 of people had at least one ACE
• Almost 40% had 2 or more
“Did you live with anyone who was depressed, mentally ill, or suicidal?”
● Reduce Kentucky’s rate of uninsured individuals to less than 5%. ● Reduce Kentucky’s smoking rate by 10%. ● Reduce the rate of obesity among Kentuckians by 10%. ● Reduce Kentucky cancer deaths by 10%. ● Reduce cardiovascular deaths by 10%. ● Reduce the percentage of children with untreated dental decay by
25% and increase adult dental visits by 10%. ● Reduce deaths from drug overdose by 25% and reduce by 25% the
average number of poor mental health days of Kentuckians.
http://governor.ky.gov/healthierky/kyhealthnow
kyhealthnow 2019 Goals
ACE Score and Indicators of Impaired Worker Performance
Absenteeism (>2 days/month
Serious Financial Poblems
Serious Job Problems
0
5
10
15
20
25
0 1 2 3 4 or more
ACE Score
Pre
vale
nce
of
Im
pai
red
P
erfo
rman
ce (
%)
The higher their ACE score (the more they were abused or traumatized as children) the more absenteeism, serious financial problems and on the job problems they have.
0
5
10
15
20
25
0 1 2 3 4 >= 5
Regular smoking by age 14
ACE Score
Pe
rce
nt
(%)
Kyhealthnow goal: Reduce Kentucky’s Smoking rate
by 10%
Anda et al., 1999, JAMA
The higher the ACE score, the more likely a person will become a smoker by age 14.
90% of current adult smokers started smoking as a teenager.
ACEs, Smoking, and Lung Disease
Slide from Dr. Robert Anda
SAFER · HEALTHIER · PEOPLE
AOR = 1.9 (1.6-2.2)
Prevalence (% with BMI >35)
•Adapted from Anda RF et al., 2006. Eur Arch Psychiatry Clin Neurosci 256: 174-186.
•12 •10
•6 •4 •2 •0
•8
0 1 2 3 4 or
ACE Score
more
kyhealthnow goal: Reduce the rate of Obesity among Kentuckians by 10%
with 4 or more ACE’s, the risk of Obesity doubles
Adverse Childhood Experiences are associated with the Risk of Lung Cancer: A prospective cohort. Brown DW, Anda RF, Feletti VJ, et al
BMC Public Health 2010;10:20-32
• Prospective data showed graded relationships between the ACE score and the risk of Lung Cancer.
• Relationships between a high ACE score and lung cancer were particularly strong for those who died from lung cancer at younger ages.
• The increased risk of lung cancer was only partly due to relationships between ACE’s and an intermediate causal factor, smoking.
• The occurrence of ACE-related lung cancer not attributable to conventional risk factors suggests other mechanisms by which childhood traumatic stressors negatively affect health.
Kyhealthnow goal: Reduce cancer deaths in Kentucky by 10%
Compared childhood trauma and mortality
Identified 1,539 deaths within the cohort between 1995 and 2006
People with 6 or more ACE’s died nearly 20 years earlier than those without ACE’s-60.6 yrs versus 79.1
ACE Study---Early Death
Risk Factors for Adult Heart Disease are Embedded in Adverse Childhood Experiences
ACEs Source: Dong et al, 2004
Od
ds R
ati
o
0 1 2 3 4 5,6 7,8
0.5
1
1.5
2
2.5
3
3.5
Kyhealthnow goal: Reduce cardiovascular deaths by 10%
● Reduce Kentucky’s rate of uninsured individuals to less than 5%. ● Reduce Kentucky’s smoking rate by 10%. ● Reduce the rate of obesity among Kentuckians by 10%. ● Reduce Kentucky cancer deaths by 10%. ● Reduce cardiovascular deaths by 10%. ● Reduce the percentage of children with untreated dental decay by
25% and increase adult dental visits by 10%.
●Reduce deaths from drug overdose by 25%● and reduce by 25% the average number of poor mental health
days of Kentuckians.
http://governor.ky.gov/healthierky/kyhealthnow
kyhealthnow Goals
SAFER · HEALTHIER · PEOPLE
0
2
4
6
8
10
12
14
1615–18 Years
Relationship Between Number of ACEs and the Age at Initiation of Illicit Drugs
0 1 2 3 4 > 5
ACE Score
Pe
rce
nt
(%)
Dube et al., 2003, Pediatrics
ACE Score and Intravenous Drug Use
0
0.5
1
1.5
2
2.5
3
3.5
% H
ave I
nje
cte
d D
rug
s
0 1 2 3 4 or more
ACE Score
N = 8,022 p<0.001
A male child with an ACE score of 6 has a 4,600% increase in the likelihood that he will become an IV drug user later in life
78% of drug injection by women can be attributed to their experience of cumulative kinds of trauma in childhood. (ACES)
Adverse Childhood Experiences And Chronic Depression as an
Adult
0
10
20
30
40
50
60
70
80
% W
ith
a Li
feti
me
His
tory
of
Dep
ress
ion
0 1 2 3 >=4
ACE Score
WomenMen
SAFER · HEALTHIER · PEOPLE
0
5
10
15
20
25
30
35
40
0 1 2 3 4 5 6 >=7
ACE Score
Per
cen
t (%
)
Relationship Between the ACE Score and the Risk of Ever Attempting Suicide
Dube et al., JAMA, 2001
SAFER · HEALTHIER · PEOPLE
0
2
4
6
8
10
12
14
16
0 1 2 3 4 5 6 >=7
Attempted suicide < = 18 years
ACE Score
Pe
rce
nt
(%)
Relationship Between the ACE Score and Attempting Suicide During Adolescence
Dube et al., JAMA, 2001
ADVERSE CHILDHOOD EXPERIENCESAND ADULT DISEASE:
54% of depression58% of suicide attempts39% of ever smoking26% of current smoking65% of alcoholism50% of drug abuse78% of IV drug abuse48% of promiscuity (>50
partners) are attributable to ACE’s.Dr. V. Felitti. 2011
Seeking to Cope The risk factors/behaviors underlying
these adult diseases are actually effective coping devices.
What is viewed as a problem by the health care provider is actually a solution to bad experiences for the patient.
Dismissing these coping devices as “bad habits” or “self destructive behavior” misses their source of origin.
To lessen the burden of these adult diseases, we must reduce the toxic stress and heal the trauma of the adverse childhood experiences that underlie these diseases
The ACE Study is evidence that….
ADVERSE CHILDHOOD EXPERIENCES are the most basic and long lasting cause of : health risk behaviors,
mental illness, social malfunction, disease, disability, death, and healthcare costsDr. V. Felitti. 2011
Experiences in Childhood Matter for a Lifetime
Science Tells Us that Early Life Experiences Are Built Into Our Bodies
Research on the biology of stress illustrates how threat raises heart rate, blood pressure, and stress hormone levels, which can impair brain architecture, immune status, metabolic systems, and cardiovascular function.
ToxicProlonged activation of stress response systems
in the absence of protective relationships.
Three Levels of Stress
TolerableSerious, temporary stress responses, buffered by supportive relationships.
PositiveBrief increases in heart rate,
mild elevations in stress hormone levels.
Stress and Brain DevelopmentFIGHT OR FLIGHT RESPONSE
•Hypothalamus •VS •Danger
Cortisol Epinephrine Norepinephrine
Elevated Heart RateRapid breathing
RUN!!!
Allostasis: Maintain Stability through Change
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
Allostastic Load
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
Poor Children Experience Elevated Stress
Cortisol Epinephrine Norepinephrine
.035
.03
.025
.02
.015
.01
.005
0
6
5
4
3
2
1
0
33
32.5
32
31.5
31
30.5
30
29.5
Middle Poverty Middle Poverty Middle Poverty Income Income Income
Overnight levels in rural 9-year-old white children
•Source: Evans, GW and English, K. (2002)
Stress & Programming of the Brain
• Physiologic reaction to stress – Hippocampus
• Site of learning & memory formation, contextual learning• Stress down-regulates glucocorticoid receptors• Loss of negative feedback; overactive HPA axis
– Amygdala
• Site of anxiety and fear• Stress up-regulates glucocorticoid receptors• Accentuated positive feedback; overactive HPA axis
Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain.J Neuroendocrinol 2001;13:113-28.
Fear Response
Active “fight-or-flight” or hyper-arousal response
Passive response, known as the surrender response, which involves varying degrees of dissociation – “disengaging from stimuli in the external world and attending to an ‘internal’ world” (Perry et al, 1995).
Each of these are of adaptive benefit to the organism and promote human survival.
Fight, Flight, Freeze
Fight, Flight, Freeze
Toxic Stress
TOXIC STRESS can result from strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive, adult relationship.
• This growing scientific understanding into causal mechanisms that link early adversity into later impairments in learning, behavior, and both physical and mental well-being are potentially TRANSFORMATIONAL.
• Toxic stress in children can lead to less outwardly visible yet permanent changes in brain structure and function.
• Persistently elevated levels of stress hormones can disrupt the developing architecture of the brain. Exposure to stressful experiences has been shown to alter the size and neuronal architecture of the amygdala, hippocampus, and pre-frontal cortex.
• Thus the developing architecture of the brain can be impaired in numerous ways that create a weak foundation for later learning, behavior, and executive function.
The New Science the New Paradigm
• American Academy of Pediatrics: The Lifelong Effects of Early Childhood Adversity and Toxic Stress PEDIATRICS 2012 129(1):E232-E246
Acute Response To Trauma
Terror
Fear
Alarm
Vigilance
Calm
Traumatic Event
Vulnerable “with supports”
Normalwith
supports
Dissociationor
Resilient
Vulnerablefew
supports
Slide from Dr. David Willis, 2010
Multiple Traumatic Events
Event #1
Event #2
Event #3
Terror
Fear
Alarm
Vigilance
Calm
Slide from Dr. David Willis
The Brain Architecture of Anxiety and Fear
Cognitive, Emotional, and Social Capacities Are Inextricably Intertwined Within the
Architecture of the Brain
The Brain Architecture of Memory and Learning
Life Course Trajectory: A Balance of Risk and Protective Factors
Risk FactorsChild
FamilyCommunity
School
Protective FactorsChild
FamilyCommunity
School
Outcome
Negative vulnerability
Positiveresilience
Child Abuse
School Readiness
Family Skills and Support -+
Life Course Trajectory: A Balance of Risk and Protective Factors
Poor RelationshipsSecure Relationships• Poor coping & problem solving
skills• Failure to thrive > Chronic illness• Learning delays / Devel. delay• Behavior problems• Speech/Language delays• Alienation, Inability to form
relationships• Lack of trust, compassion,
remorse• Aggression, Violence, Anti-social
behavior• Eating disorders • Misdiagnosed as bipolar / severe
depression
HARDWIRING OF THE BRAIN for Social-emotional fxn
• Strong social-emotional pathways
• Cognition, problem solving• Trusting relationships with
caring adults• Ability to explore their
environment without fear; curiosity
• Tolerate disappointments• Stay on task, persevere• Able to form close
friendships, networks of support
ATTACHMENT
Life Course Trajectory: A Balance of Risk and Protective Factors
“Amydgala Hijack”Executive Function
Responses to chronic/ toxic stress
• Impaired memory, esp. “working” and contextual memory
• Inability to concentrate
• Harder to follow directions
• Hard to sit still• Constantly on edge• Easily provoked• Impulsive
• Ability to problem solve
• Self-control• Self confidence• Able to calm self• Follows directions• Persists on task• Able to manage
their tempers when provoked
• Able to delay gratification
• Able to plan
Life Course Trajectory: A Balance of Risk and Protective Factors
4 ACE’sHigh risk for:
0-3 ACE’sMore likely:
ACE
• Tobacco Use• Drug abuse• Obesity• Promiscuity, teen
pregnancy• Pathologic Gambling• Risk taking behaviors• Lack of social networks• High risk for school failure• Gang membership• Unemployment• Incarceration
• Good mental health• Normal growth and
development• Less chronic disease• Less tobacco use• Less drug abuse• School readiness &
success• Employment
Substance Exposed Infants/Drug Endangered Children
Emotional Problems:- Attachment Disorders- Anxiety- Depression- Complex emotions
Cognitive Problems- Difficulty talking and listening- Difficulty Paying Attention- Difficulty Remembering- Trouble reading- Do not learn from mistakes or
experiences- Do not pick up on social cues
Behavioral Problems:- Interpersonal Problems- Inappropriate sexual behaviors- Impulsive, low threshold for stimulation- Eating disorders
“Children who experience child abuse and neglect are 59% more likely to be arrested as a juvenile, 28% more likely to be arrested as an adult, and 30% more likely to commit violent crime.” SOURCE: childhelp.org
Moriarty L, 2014 National Conference on Drug Endangered Children
Trauma-Sensitive Schools- Trauma-informed classrooms (Compassionate Schools)
• “It all boils down to this: Kids who are experiencing the toxic stress of severe and chronic trauma just can’t learn...
It’s physiologically impossible.”• In trauma-sensitive schools, teachers don’t punish
a kid for “bad” behavior– they don’t want to traumatize an already traumatized child. They did deeper to help a child feel safe. Once a child feels safe, she or he can move out of stress mode, and learn again.
Datasource:
National Survey of Children’s Health
Maternal and Child Health Bureau of HHSConducted 2011-2012Representative sample of children age 0-17Approximately 1800 per stateParent report
www.childhealthdata.org
National and Kentucky Prevalence of Adverse Childhood Experiences Among Children Age 0-17
Adverse Child or Family ExperiencesKentucky
PrevalenceNational
PrevalenceState Range
Child had ≥ 1 Adverse Child/Family Experience 55.3% 47.9% 40.6% (CT) – 57.5% (AZ)
Child had ≥ 2 Adverse Child/Family Experiences 30.0% 22.6% 16.3% (NJ) – 32.9% (OK)
Extreme economic hardship 29.6% 25.7% 20.1% (MD) – 34.3% (AZ)
Family discord leading to divorce or separation 28.9% 20.1% 15.2% (DC) – 29.5% (OK)
Having lived with someone who had an alcohol or drug problem 14.4% 10.7% 6.4% (NY) – 18.5% (MT)
Having been a victim or witness of neighborhood violence 9.3% 8.6% 5.2% (NJ) – 16.6% (DC)
Having lived with someone who was mentally ill or suicidal 11.1% 8.6% 5.4% (CA) – 14.1% (MT)
Witnessing domestic violence in the home 9.7% 7.3% 5.0% (CT) – 11.1% (OK)
Parent served time in jail 13.2% 6.9% 3.2% (NJ) – 13.2% (KY)
Treated or judged unfairly due to race/ethnicity 3.7% 4.1% 1.8% (VT) – 6.5% (AZ)
Death of parent 4.2% 3.1% 1.4% (CT) – 7.1% (DC)
Source: 2011/2012 National Survey of Children’s HealthAvailable at http://www.childhealthdata.org/home
Percentage of High School Students Who Were Bullied on School Property in Kentucky and U.S., 2009-2013
2009 2011 20130.0%
5.0%
10.0%
15.0%
20.0%
25.0%
20.8% 18.9%21.4%
13.0%
20.3%21.2%
KYUS
Source: Youth Risk Behavior Survey, 2009, 2013
Percentage of Children 6-17 Years Who Have Repeated One or More Grades Since Kindergarten
KY is 44th Among 50 States and District of Columbia
Repeated Grades0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%14.2%
9.1%KYUS
Source: 2011/2012 National Survey of Children’s HealthAvailable at http://www.childhealthdata.org/browse/survey/results?q=2515&r=1&r2=19
58
The Public Health ApproachThe public heath perspective asks foundational questions:
Where does the problem begin?How could we prevent it from occurring in
the first place?
Public Health recommends a systematic, scientific approach for understanding and preventing violence. (CDC, 2014)
Life Course of Health Development
Optimal Outcome
Poor Outcome
Lu and Halfon, 2003
Social Determinants of Health
Kaplan, et al. (2000). A Multilevel Framework for Health in :Promoting Health. Washington, DC: National Academy Press
New Protective Interventions Significant Adversity
Healthy Developmental Trajectory
Parenting Education, Sound Nutrition, Stimulating Experiences, and Health-Promoting Environments
Counseling and Education
Individual Interventions
Population based and Long-lasting Protective
interventions
Changing the ContextTo make individual’s default decisions healthier
Socio-economic Factors
Smallest impact
LARGEST IMPACT
Frieden TR. A framework for public health impact: The health impact pyramid. AJPH 2009
Public Health: Interventions by Impact
The CDC Impact Pyramid
63
Percentage of Adverse Child and Family Experiences among Kentucky Children (0-17 Years)
44.7%
25.3%
30.0%
No adverse family ex-periences
One adverse family experience
Two or more adverse family experiences
55% of Kentucky children have had at least one adverse
childhood experience
Source: 2011/2012 National Survey of Children’s HealthAvailable at http://www.childhealthdata.org
64
“School wide prevention program lowers teen suicide risk” The Lancet Jan 8, 2015
168 high schools in 10 European countriesThree programs with different approaches:
Training teachers to recognize children at riskTargeted all students with lectures, role-play, and educationReferrals to professionals for at-risk pupils
No Changes in three months, significant changes by 1 year Largest effect from targeting all students
Improving supervision of
students
; engage parents and families; mentoring programs; behavio
r management in classrooms; reporting
and consequences for bullying
Univers
al programs to
teach
skills
(self-
control, problem
solving, conflict resolution, teamwork)
; Trauma-
informe
d Schools
Socio-
economic Factors:
Address
violence in neighborhoods; form com
munity
coalitions; enhance com
munity
connectedness, com
munity
pride and
belonging; enga
ge teens/peer
s in creati
ng culture of
acceptance
; provi
de supports for
families
Smallest impact
LARGEST IMPACT
Adapted from Frieden TR. A framework for public health impact: The health impact pyramid. AJPH 2009
Interventions for Anti-BullyingCan be applied at multiple levels:• Individual• Family• School • Neighborhood• Community• Region/District• State