Embed Size (px)
Citation preview
Trauma-InformedApproachtoPrevention
Presentedby
PaulNolfo
§ DefinetraumaanditsrelationshiptoHealthEquity,theSocialDeterminantsofHealth,AdverseChildhoodExperiences(ACEs)andtheimpactonhealthbehaviorsandhealthdisparities.
§ ReviewdatasourcesthatidentifypopulationsathigherriskforACEs.
§ ExaminepreventionstrategiesthatcanimpacttheSocialDeterminantsofHealth,ACEs,traumaandultimatelyreducehealthdisparities.
LearningObjectives
WhatisTrauma?
Individualtraumaresultsfromanevent,aseriesofevents,orasetofcircumstancesthatisexperiencedbyanindividualasphysicallyoremotionallyharmfulorlifethreateningandthathaslastingadverseeffectsontheindividual’sfunctioningandmental,physical,social,emotional,orspiritualwell-being.
- SAMHSA
4
Trauma
§PreandPerinatalTrauma• eventsthatoccurbeforeorduringbirth• thewithholdingofmaterialornonmaterialresourcesessentialtohealthydevelopmentorwellbeing
§ SingleEpisodeTrauma§DevelopmentalorComplexTrauma
§HistoricalTrauma§ IntergenerationalTrauma
5
TypesofTrauma
Traumainvolvesthreatstolifeorbodilyintegrity,orclosepersonalencounterswithviolenceanddeath.Traumacan1) Rendervictimshelplessby
overwhelmingforce2) Confronthumanbeingswiththe
extremitiesofhelplessnessandterror3) Evoketheresponsesofcatastrophe4) Disruptasenseofcontrol,connection,
andmeaning
6
ImpactofTraumaonIndividuals
§Aggressionandlowimpulsecontrolinnewsituationsorwithnewpeople
§Powerstrugglesandfearinthecontextofruleenforcement
§Disengagementasmeansofdefense
§ Interpretationofsafetyenforcementaspredatory
§ “Minor”eventsprecipitatingcatastrophicreactions
§ Substanceusedisorders
7
PotentialSymptomsofTrauma
§Traumadisruptsasenseofcontrol,connection,andmeaning
§Anestimated55-99%ofwomenwithsubstanceusedisordershavealifetimehistoryoftrauma;30-59%areduallydiagnosedwithPTSD;and50%ofwomenintreatmenthaveahistoryofrapeorincest• (Najavits etal.,1997;Gov.CommissiononSexualandDomesticViolence,CommonwealthofMA,2006)
§PTSD,anxiety,depression,borderlinepersonalitydisorder,anddissociativedisorderswouldbebetterclassifiedastrauma-spectrumdisorder• (Bremner,2004;Dayton,2000;PollackandLevant,1998)
8
TraumaConsequences
WhatAreACEs?
Childhood experiences, both positive and negative, have atremendous impact on future violence victimization andperpetration, and lifelong health and opportunity. As such, earlyexperiences are an important public health issue. Much of thefoundational research in this area has been referred to asAdverse Childhood Experiences (ACEs).
ACEs refer to childhood experiences that are traumatic innature.
*CenterforDiseaseControlandPrevention
WhatareAdverseChildhoodExperiences(ACEs)
§ AbuseofChild• Psychologicalabuse• Physicalabuse• Sexualabuse
§ TraumainChild’sHouseholdorEnvironment• Substanceabuse• Parentalseparationand/ordivorce• MentalIllnessorsuicidalhouseholdmember• Violencetothemother• Imprisonedhouseholdmember
§ NeglectofChild• Abandonment• Child’sbasicphysicaland/oremotionalneedsunmet
11
AdverseChildhoodExperiences
ACEs
1. Conductedinthelate90’stoassessthecorrelationof10factors,orACEs,relatedtohouseholddysfunctionandchildmaltreatment
2. The10ACEswerechosenbasedonpriorresearchthathadshownthemtohavesignificantadversehealthorsocialimplications
3. JointeffortbetweenCentersforDiseaseControlandKaiserPermanente’sHealthAppraisalClinicinSanDiego
4. Included17,337people
TheKaiserAdverseChildhoodExperiences(ACEs)Study
1. ACEsaremorecommonthananticipatedorrecognized.DatademonstratedthatACEsarehighlyinterrelated:ifapersonhasoneACE,morethanlikelytheyhaveothers.
2. ACEshaveapowerfulcorrelationtohealthbehaviorsandhealthoutcomeslaterinlife.
MajorFindingsFromtheACEsStudy
1. In2008,anACEmodulewasincludedinthissurvey.2. Subsequently,themodulewasincludedinthe2009,
2011,and2013studies.3. Studysizeforallfouryearstotaled27,745.
CaliforniaBehavioralRiskFactorSurveillanceSystem(BRFSS)
1. BRFSShadsimilarfindingstotheKaiserStudy:ACEsareextremelycommonandhaveapowerfulcorrelationtohealthbehaviorsandoutcomes.
2. Inadditionapersonwith4ormoreACEsismorelikelytohaveadversesocio-economicfactors:• 21%morelikelytobebelow250percentofthe
FederalPovertyLevel(FPL)• 27%morelikelytohavelessthanacollegedegree• 39%morelikelytobeunemployed
ResultsfromtheCaliforniaBehavioralRiskFactorSurveillanceSystem
AContextforACEsDow
nstreamUpstream
••PoliciesandpracticesthatinfluencehealthequityInstitutionalPower
••ThedegreeofsocialjusticeinhealthHealthInequities
••Conditionsinwhichpeopleareborn,live,learn,work,play,worship,andage
SocialDeterminantsofHealth(SDOH)
••Factorsatthecommunity,family,individual,psychological,andbiologicallevelincreaseordecreasetheriskofproblembehaviors
IndividualRisk&
ProtectiveFactors
••BehaviorsandimpactsthateffectmorbidityandmortalityBehaviors&Impacts
••Healthconsequences(mortalityandmorbidity)andhealthdisparities
AdverseHealthConditions,Injury,andShortened
LifeExpectancy
AdverseChildhoodExperiences
(ACEs)
TheSocialDeterminants
EconomicStability
Poverty
Employment
FoodSecurity
HousingStability
Education
HighSchoolGraduation
EnrollmentinHigherEducation
Language&Literacy
EarlyChildhoodEducation&Development
Social&CommunityContext
SocialCohesion
CivicParticipation
PerceptionsofDiscrimination&
Equity
Incarceration/Institutionalization
Health&HealthCare
AccesstoHealthCare
AccesstoPrimaryCare
HealthLiteracy
Neighborhood&Build
Environment
AccesstoHealthyFoods
QualityofHousing
Crime&Violence
EnvironmentalConditions
ImpactofACEsonBrainDevelopment
AdverseChildhoodExperiences(ACEs)•ChildMaltreatment(AbuseandNeglect)
•DysfunctionalHousehold
Trauma• Social,EmotionalandCognitiveImpairment
• Disrupted Neurological Development
RiskBehaviors•Earlyinitiationofalcoholuse•Problemdrinkingbehaviorintoadulthood
• Increasedlikelihoodofearlysmokinginitiation
•Prescriptiondruguse• Lifetimeillicitdruguse,everhavingadrugproblem,andself-reportedaddition
ACEsImpactonHealthBehaviorsandHealthOutcomes
1. Earlyinitiationofalcoholuse2. Problemdrinkingbehaviorintoadulthood3. Increasedlikelihoodofearlysmokinginitiation4. Prescriptiondruguse5. Lifetimeillicitdruguse,everhavingadrugproblem,
andself-reportedaddition
ResearchhasdemonstratedastrongrelationshipbetweenACEsandavarietyof
substanceusebehaviors
Anda,2009.
Socio-economicfactorsrefertoincome,education,andoccupation.
Socio-economicfactorsareimportantdatapointsbecausetheyhaveastrongcorrelationtoACEs,areeasilyavailablemeasuresfromcensusdata,andcanbedisaggregateddowntothecensustract.
Socio-EconomicFactors:DataPointsforACEs
HealthEquityandaPublicHealthApproachtoImpactingACEsandTrauma
• Publichealthisconcernedwithprotectingthehealthofentirepopulations.Thesepopulationscanbeassmallasalocalneighborhoodorasbigasanentirecountryorregionoftheworld.• HealthinequitiesarepervasiveandthereforecanimpacttheSDOHmakingcertainpopulationsmorevulnerableforTrauma.• UsingapublichealthapproachtohealthequitycanimprovetheSDOH,ACEs,andreducetheoccurrenceoftraumainearlychildhood.
HealthEquityandPublicHealthApproachestoImpactACEsandTrauma
AContextforACEsDow
nstreamUpstream
••PoliciesandpracticesthatinfluencehealthequityInstitutionalPower
••ThedegreeofsocialjusticeinhealthHealthInequities
••Conditionsinwhichpeopleareborn,live,learn,work,play,worship,andage
SocialDeterminantsofHealth(SDOH)
••Factorsatthecommunity,family,individual,psychological,andbiologicallevelincreaseordecreasetheriskofproblembehaviors
IndividualRisk&
ProtectiveFactors
••BehaviorsandimpactsthateffectmorbidityandmortalityBehaviors&Impacts
••Healthconsequences(mortalityandmorbidity)andhealthdisparities
AdverseHealthConditions,Injury,andShortened
LifeExpectancy
AdverseChildhoodExperiences
(ACEs)
PreventionStrategiesthatCanImpacttheSocialDeterminantsofHealth,ACEs,andTrauma
• HealthInAllPolicies• UniversalScreeningsforACEs• BuildingResiliency• SystemsIntegration
1. Assurestheconditionsforeveryonetoreachthehighestlevelofhealth
2. Targetspoliciesandpracticesinamultitudeofsectorssuchasgovernment,finance,education,housing,employment,transport,andhealth
3. Addressesthestructuralandsystemicconditionsthatcreatedisadvantage
4. Targetsthosecommunitiesexperiencingthegreatestdisparities
5. Incorporateshealthequitymeasuresandmetricsintopoliciesandprogramstoensuretheintendedimpactonthepopulation(s)ofinterest
HealthInAllPolicies
1. ParentswhohaveahistoryofACEsincreasethelikelihoodofimpairedparenting,whichmayresultwiththetransmissionofACEstothenextgeneration.ParentsandchildrenshouldbescreenedforACEs.
2. ScreeningsorcasefindingsforACEsrequireachangeinpracticeandredefineshowahealthcareprovidertakesahealthhistoryfrompatients.
UniversalScreeningsforACEs
1. ResiliencecanbuffertheimpactoftheSDOH.Resiliencereferstotheabilitytobouncebackorriseaboveadversityasanindividual,family,community,orprovider.
2. Resiliencystrategiesuseavailableresourcestonegotiatehardshipand/ortheconsequencesofadverseevents,suchasACES.
3. Communitiesareresilientwhentheyusestrategiesthatutilizetheirstrengthstomanagethechallengesofeconomic,environmentalorculturalchange.
BuildingResiliency
1. AwarenessandknowledgeofthelinkbetweenSDOHandACEs,andtheimpactontrauma,mustbetranslatedintopracticalprimarypreventionapproachesforcommunitysystems.
2. Supportingandpartneringwithnon-traditionalsystems(i.e.housing,economicdevelopment,transportation,parks,andfoodandagriculture)canimpactSDOH.
3. WhiletheimpactofACEspermeateallofsocietyanditssystems,itisimportanttoprioritizecollaborationwithcertainsystems(education,health,childwelfare,lawenforcement,business)whenintegratingwithprimaryprevention.
SystemsIntegration
1. Theeducationalsystemcouldhelpwithearlyidentificationofchildrendisplayingmentalhealthproblems,ACEs,learningproblems,andbehaviorproblems.Theseissuesmaynotbeaprimarycondition,buttheeffectsofACEs.
2. Byknowingaboutachild’sACEs(atmultiplepointsintime),aschoolcouldbetterunderstandacademicperformanceandhelptotailorindividualizedstrategies.
SystemsIntegration- Education
1. Inprimarycare,routineknowledgeofaparent’sandchild’sACEscanleadtoearlyreferraltosupportservices.
2. Pediatriciansareinagoodpositiontoadvocateforpoliciesthatpromotechilddevelopmentwiththegoalofcreatinghealthy,well-functioningadults.
SystemsIntegration- Health
1. Incasemanagement,aparentwithACEsmaystrugglewithsupportiveparenting.
SystemsIntegration– ChildWelfare
2. CasemanagersshouldprovidereferralstoprofessionalswhoareversedintheSDOH,ACEs,andtheirimpactonthefamilyunit.
Chamberlain,2015.
1. TrainingforlawenforcementinACEscanencourageappropriateapproachesindealingwithpersonswhomaysufferfromACEs.Thiscouldencouragemoretruthfulcommunicationbetweenallegedassailantsandvictimswithofficersaboutanypreconditionsthatmaywarrantaphysicalormentalhealthreferral.
2. CommunicationandunderstandinghowtorespondtoapersonwithACEScreatesahealthyinteractionbetweenlawenforcementandallegedassailantsandvictims.
SystemsIntegration– LawEnforcement
1. Businesseshaveemployeeswhoexperiencedadversechildhoods.
2. Ratherthantakingapassive,sometimespunitiveapproachtotheproblemsthatACEscreateintheworkplace,thebusinesscommunitycouldpromoteformsofemployeewellnessthatbetterunderstandACEsandattemptto compensateforACE-relatedadversities.
3. Workforcedevelopmentistheprimarygoal.
SystemsIntegration– Businesses
ImportantConsiderations
§ACEsdonotequaltrauma;significantrelationshipscanbepivotalbuffers.
§Beingamemberofamarginalizedpopulationdoesnotequaltraumaoranadversechildhoodexperience(itisnotcausal,justariskfactor).
§DonotimplementACEsscreeningunlessyouhavetheinfrastructuretorespond.
§ It’snotabouttheevent,itsabouttheexperienceoftheevent.
§ACEsareuniversal,buttheaccesstohealingisnot.
QUESTIO
NS
ReferencesAnda, R. (2009). The health and social impact of growing up with adverse childhood experiences: The human and economic costs of the status quo. Retrieved from http://acestudy.org/files/Review_of_ACE_Study_with_references_summary_table_2_.pdf.
Paula Braveman, MD, MPH. What Are Health Disparities and Health Equity? We Need to Be Clear (Public Health Reports / 2014 Supplement 2 / Volume 129)
Hazel D. Dean, ScD, MPH Kim M. Williams, PhD Kevin A. Fenton, MD, PhD, FFPH. From Theory to Action: Applying Social Determinants of Health to Public Health Practice (Public Health Reports / 2013 Supplement 3 / Volume 128)
Unnatural Causes… is inequality making use sick? Backgrounders from the Unnatural Causes Health equity Database. Retrieved February 2015 at http://www.unnaturalcauses.org/assets/uploads/file/primers.pdf
World Health Organization website. Social Determinants of Health. Retrieved February 2015 at http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/
ReferencesAustralian Government, Department of Health website. The Social Determinants of Health. Retrieved February 2015 athttp://www.health.gov.au/internet/publications/publishing.nsf/Content/oatsih-healthplan-toc~determinants
The Conversation website. What are “social determinants of health”? November 20, 2012. Retrieved February 2015 at http://theconversation.com/what-are-social-determinants-of-health-10864
Local Government Association website. Understanding and tackling the wider social determinants of health. Retrieved February 15, 2015 at www.local.gov.uk/health/-/journal_content/56/10180/3511260/ARTICLE
Portrait of Promise: The California Statewide Plan to Promote Health and Mental Health Equity. A Report to the Legislature and the People of California by the Office of Health Equity. Sacramento, CA: California Department of Public Health, Office of Health Equity; August 2015.
Chamberlain, Linda, PhD, MPH. Partnering with Parents: Pathways to Prevention in the Pediatric Setting. Academy on Violence and Abuse. Retrieved from http://www.avahealth.org/aces_best_practices/partnering-with-parents.html.
