Looking Upstream: The Impact of Preventing Adverse Childhood Experiences

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: viewing adverse childhood experiences through a longer lens; understanding their root causes to improve young lives.

DR. JUDY CAMERON:
The end result is you build pathways based on your experiences. You can’t erase pathways, but you can modify them so that they work in your favor.

DR. JOHN HELLERSTEDT:
If we're serious about the health of the next generation of children; if we're serious about breaking cycles of poverty, of violence, of behavioral health problems that we know and we see all around us, that exist; if we're serious about trying to improve some of the disparities in health outcomes that we see around us—we have to be serious about adverse childhood events.

DR. DAVID LAKEY:
It is heartbreaking when you have a child that comes in and you start figuring out that there's other reasons why this child is in the emergency room or that you are seeing them, and that this isn't a one-time event. And that’s as tough as it gets in pediatrics.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we consider the importance of a healthy and safe childhood and the lifelong negative impacts of child abuse, neglect, or other adverse experiences.

Texas tackled the topic with a pediatric brain summit last November. We'll speak with two public health leaders from the Longhorn State pressing for more focus on this topic: Dr. John Hellerstedt, commissioner of the Texas Department of State Health Services; and Dr. David Lakey, vice-chancellor for health affairs and chief medical officer for the University of Texas system—he also is a former president of ASTHO.

But first, we talk brain circuits, the impact of life experiences on behavior, and plasticity with Dr. Judy Cameron, who leads groundbreaking work in this field at the University of Pittsburgh.

CAMERON:
This has been an area of some controversy and confusion for some time because lots of children experience adversity, and there are many different forms of adversity.

And adversity could be a really traumatic event that the child either participates in or sees. It could be a natural disaster—a hurricane, a fire, tornado. It could be a more personal, stressful situation like having your parents be divorced or having an abuse situation going on. So, there are lots of things that are stressful.

The stresses can have a long-term impact on brain development or not depending on how much support the child has—so, do they have to try to deal with the stress themselves? If they do, it's much more likely that the stress will really impact brain development. But if they have a lot of social support systems in place, they're much less likely to have a long-term impact of that stress.

So, when you ask the question, “What is an adverse event?” It's a complicated answer because it's not only, “What is the event?” It's “What is the event, and how much support do you have to deal with it?”

JOHNSON:
What is the impact? How does it manifest itself in an example child?

CAMERON:
So, our research program is called Working for Kids Building Skills, and we've developed an educational program with kind of hands-on, active learning material. So, I can tell you something about how we would teach that, but I think it will answer your question in a pretty straightforward manner.

These materials have been developed in order to teach people in the community—that don't necessarily want to know about brain development—about brain development in a fun and engaging manner.

So, the way we do this is we have a poster of the brain, and we have laminated pictures of different brain functions—so, things we've talked about, like seeing, speaking, emotion regulation, thinking—and we have people put the picture on the brain in the areas that does that function.

We then give them a piece of yarn, and they are going to make brain connections using the yarn. And so, you can imagine if you wanted a child to be a good reader and build strong brain circuits for reading during the plastic period for the circuits involved in reading—those would be the eyes that are involved in seeing and the communication pathways that you use for speaking—you need to make a connection between seeing the words on the page and knowing what the words mean.

And so, lots of parents will say, I'm going to read to my child to strengthen their reading skills. And that is fantastic. We let people make one loop of yarn for each idea they come up with, even though they may say, “Well, I read to my child every night.”

Yeah, but the child needs to use that pathway thousands of times to make it strong and permanent so it won't be pruned. So, they make one loop for reading to their child. They then have to think of another thing their child would do that they could get them to do, an activity.

So, perhaps they'll take them to the library and get them to pick up books they really like. Or perhaps they'll have them read while they're cooking dinner the directions in the recipe. Perhaps they'll have them read road signs while they're driving. So, you can see that they have to actively learn what are you going to have to do to really get that child to use a pathway enough to strengthen it and make it permanent.

JOHNSON:
So, you have parents in this program. Is that who participates?

CAMERON:
We have parents, but we also have a number of people that work with parents that provide social services: so, social service providers, public health specialists, physicians.

We have training programs that basically will meet the needs of the professionals and the parents, figuring that children will have a much better chance of developing with the social support they need if everybody in the community understands this information.

JOHNSON:
Unfortunately, some of the parents in these situations have their own set of issues, and they're struggling with those, and you know that list can be long sometimes.

Are those children lost, or can they still be taught to think and react differently to lift themselves mentally out of whatever condition they are facing?

CAMERON:
They are definitely not lost. And we get asked this question frequently.

So, we spend quite a bit of time really talking about different periods of brain plasticity. Yes, a lot is going on in early development. And if you have a child who's faced a lot of adversity early in life, they've built brain pathways to deal with that adversity.

But they're going to continue to build brain pathways until they're about 25. And so, you have a long period of time to build pathways that will help give them resilience, that will help them deal with stresses. You have to put effort into getting them to strengthen brain pathways for those skills, but it's certainly doable, and it's done all the time.

So, we make a point of teaching people that the kinds of skills you're trying to strengthen are reasoning, problem-solving, decision-making, impulse control. If they can strengthen those skills, they will be able to deal really well moving forward.

They won't erase the circuits that they built when they were young and facing adversity, but they'll be able to modify their behavior and, if they use those circuits a lot in the teenage years, they'll have really strong brain pathways for modifying behavior. And they are likely to do very well later in life.

JOHNSON:
Dr. John Hellerstedt leads the Texas public health program, but has 18 years of experience treating kids as a pediatrician in Austin.

Dr. Hellerstedt says a child's trauma is not always obvious when he or she is sitting in an exam room.

HELLERSTEDT:
What the evidence is showing us is that, you know, some types of adverse events may be worse than others. The same adverse event may be worse for a particular child than for another child. But ultimately, the concept is about building resilience. So, resilience is your ability to get over it, if you will, or function beyond it.

So, to go back to your original question, can you spot it if you haven't seen a child before? I think in some ways if they become resilient somehow and have been able to overcome it, you may not see that.

But on the other hand, sometimes they're going to be presenting in situations of crisis, if you will, where it really seems as if either, you know, the crisis is the adverse childhood event itself—for instance, child maltreatment—or the circumstances lead you to conclude that there is a very serious underlying behavioral health issue or need in this child. And that should lead you into the adverse childhood event because of the lack of resiliency that you see.

JOHNSON:
It's interesting that Hurricane Harvey has been mentioned by some as one of these experiences.

Can you talk about that?

HELLERSTEDT:
Well, yeah, I mean, you know, here's Hurricane Harvey, and I think that's a great example of an adverse childhood event, actually. Because some adverse childhood events we can maybe prevent, others we can't. So, something like Hurricane Harvey, there is no way we had to prevent it, and people had to live through it.

But for many children, this meant a very frightening event; it meant—many times—having to be evacuated from home, staying in a strange environment like the shelter, and even, in some cases, there may have been a loss of a family member, someone very close with them, as a result of Hurricane Harvey.

And even in the aftermath, not everything has been rebuilt. So, not every place that was damaged and it would have been repaired has been rebuilt. Not everyone has moved back to where their original neighborhood was. And so, that disruption is ongoing and only kind of adds to the stress that you have in a situation like this.

And, of course, we know from science that adverse childhood events are cumulative. So, just the frightening experience of being in a flooding situation. I've heard people talk—adults that talk—about the fact it rains so hard; that now every time it rains, they get very afraid, but it's this sort of almost a phobic reaction, if you will.

So, you can have an adverse event where, yes, there was this rainfall, this storm that's a very frightening, natural phenomenon. Then, there were rising floodwaters. That was kind of different waves of danger and risk that took place. Then people, you know, had to be displaced from their homes. They had to go to a different area, had to leave for a while, and can't come back.

And so, that's a list in my mind of more than one potential adverse childhood event that all came out of the same historical phenomenon that took place.

JOHNSON:
We talk about a number of challenges on this podcast being tackled by public health professionals around the states and territories. But this one just seems to be more complex; it doesn't seem as easy to solve.

Do you agree, or do you think it is something that can be addressed and taken care of?

HELLERSTEDT:
I couldn't agree more that it's a very difficult problem because, ultimately, the science around adverse childhood events really tells us that if children aren't protected and kept safe, they are going to be scarred potentially by adverse events that occurred and those scars may last for the rest of their lives.

And so, how do you best protect children? Well, you really best protect children by protecting their environment. And one of the most important things in their environment, of course, is their household, their family. And so, how do you support the family in such a way that it lessens the chance for the risk that an adverse childhood event is going to take place?

So, when we're talking about the family, we're talking about the basic unit of all human society; and if we're talking about decreasing adverse childhood events, we're talking about a very broad consensus and collaboration to bolster the family and to help allow those communities and those families to better protect children.

So, yes, it's a very daunting task because it is so multifactorial, but it's one that we have to undertake if we're serious about the health of the next generation of children; if we're serious about breaking cycles of poverty, of violence, of behavioral health problems that we know and we see all around us that exists; if we're serious about trying to improve some of the disparities in health outcomes that we see around us—we have to be serious about adverse childhood events.

JOHNSON:
How are you targeting your efforts in Texas?

Are you looking at other factors—the social determinants, for example?

What is the criteria, if there are any, for helping focus what you're trying to do there?

HELLERSTEDT:
Well, I think much of what we are trying to do here in Texas is to reach out to community organizations and to reach out to, for instance, city and county local health departments in our state and offer them resources and training that they can then adapt to their particular communities.

So, it's not so much about—there's no such thing as really one size fits all. There's no way that we know what the best way to approach a particular community is. We really like to try and work with the local folks and local organizations, and they know what's going to be most helpful for their communities.

So, it's all about us picking our programs, reaching out, making them available to local folks, and allowing the local folks to lead.

JOHNSON:
This isn't an effort that's limited to physicians, public health professionals, or policymakers.

It really involves everyone that comes in contact with a child on a daily basis, doesn't it?

HELLERSTEDT:
Yes, absolutely so. And that's why, again, I think one of the most important roles that public health can play, that healthcare providers can play, is, first of all, to spread the knowledge. And then, particularly on the level of public health, be the conveners. Go out there and look for the individuals and organizations that care about this, that understand it, and can help move the needle on some of these challenging problems.

You know, the example I always like to give is smoking. For instance, when I was growing up, smoking was normative. Everybody smoked. Nowadays, everybody knows it's bad for you, including the people who do smoke. So, that tells you a couple of things. I mean, that knowledge isn't enough to stimulate behavior change.

I think that it's the same thing with ACEs. I think that we, as we get out there, as people become more aware of this, nobody wants to see a child have to suffer through these adverse childhood events. And, in particular, to understand that there is a direct relationship between these adverse childhood events and their ability to essentially cope and thrive as adult citizens.

You know, if there is a way to improve a lot of the next generation of kids, I think ACEs is a big, big piece of that. And the more people we get to understand that and to coalesce in action around it, the better our chances of making life better.

JOHNSON:
Can you think of anything more important as the leader of the public health effort in Texas?

Is there anything else that ranks as high, ultimately, when it comes to sort of the future of the community?

HELLERSTEDT:
I would definitely put this at the top of my list, mainly because, again, I'm a pediatrician. I'm a dad and a grandpa. I care very much, along with many, many other people in the world, about what the next generation is all about. And I think the most powerful thing about the concept of adverse childhood experiences is that it provides the scientific data, if you will, that supports and proves on a scientific level.

But I think most of it comes from what we've known in our hearts, and that is that in order to have a fully functioning, self-actualized human being, they need—that child, that human being—needs to be nurtured in space and protective environment.

And that's really what the adverse childhood event concept is all about. So, it's proof, if you will, of something that we've known in our hearts, all along.

JOHNSON:
Dr. David Lakey has gone from treating patients to using data to keep them out of emergency rooms. His team at the University of Texas has released the early version of a mapping tool intended to help predict and preempt maltreatment cases within zip codes across the state.

LAKEY:
Several years ago, after I moved from the Department of State Health Services, I started working with the Department of Family and Protective Services through a contract that we have with them.

One of my investigators, Dorothy Mendell, Dr. Mendell, had a lot of experience working with them. We had done a lot of work looking at improving birth outcomes in the state of Texas. We wanted to bring a public health lens to preventative services and child abuse in the state of Texas.

And so, one of the components of that project was to try to figure out—like we would do with infectious diseases or chronic diseases—really get a better handle on the community aspects related to child abuse maltreatment.

And so, working with the Department of Family Protective Services, they were able to provide us with several data sets—such as the birth certificate data, death certificate data, hospital inpatient and outpatient data, and data from the American Community Survey—and use that to develop predictive models by zip code for children to be maltreated.

Including, you know, we divided up into different age groups between birth and one, between one and four, between the age of five and nine, 10 to 14, 15 to 17, and look at each of those age groups. You know, what are the predictors that a child would be maltreated?

And again, we had the maltreatment data by the Department of Family Protective Services, but we knew that it wasn't perfect. We thought we need to have a better model to really help us figure out which zip codes in the state of Texas we needed to really concentrate on.

And so, Dr. Mendell and our team used those different data sets to develop these models of looking at child safety in health, infant mortality, the families in poverty, low income, and developed that predictive model for each of those age groups I listed on whether a child would be maltreated.

We put this calculation, we calculated this out by zip code, and then put it in an interactive map for our agencies, for the general population in Texas, to really look at that so we can look at the community and figure out what do we need to address in our community to really decrease the chances that a child would be maltreated in this zip code.

JOHNSON:
So, you're not able to predict which child might be next to suffer from some sort of maltreatment, but rather which communities are most likely to have the conditions present for this kind of thing to happen.

LAKEY:
That's exactly right, Robert.

And the goal isn't to predict the child—we don't want to stigmatize a child—but we want to figure out which zip codes have the components that will make them less likely to maltreat kids and which ones have certain factors that we can address, if we address them will decrease the chances that any child in that zip code will be maltreated.

JOHNSON:
Is this model in use today in Texas?

LAKEY:
The maps are relatively new. We put them out a couple of months ago, we've gotten a lot of interest from the state legislature related to it.

But these interactive maps are live and are being used to help us strategize for a variety of programs and the Department of Family Protective Services.

And so, yes, we are using those here in the state of Texas now.

JOHNSON:
Tell us about some of the observations you've made from the data once it was put into the model.

It comes back to you, you've got these results—what did you find? Anything surprising?

LAKEY:
Well, it's not just poverty related to the maltreatment.

There's a host of other factors: there's infant mortality; there's predictions related to whether the mother is smoking during pregnancy and how it can help predict that or their children are maltreated; the rates of breastfeeding; the number of kids that end up in the emergency departments for visits; the rates of non-abuse injuries among children.

All of these are helpful in predicting as is what happens with adults. You know, if you have a large number of adults between the ages of 35 and 64 that are on disability, the chances that kids will be maltreated in that community go up significantly.

And so, I think that's the value of the model is that it looks at a variety of community factors, and some of them can be addressed. Some are harder to address, but by addressing those, we can decrease the chances that kids will be maltreated in our communities.

JOHNSON:
It sounds like this model is still essentially in the beta format or beta phase of its life, but are caseworkers in Texas able to draw from its conclusions right now?

LAKEY:
I think communities across Texas are looking at this and figuring out how they can use this data because this is relatively new data.

Where it's been helpful is in our policy discussions with the legislature. So, for example, you know, as we look at how do we expand nurse-family partnership or other home visiting programs, you can use this type of data to say, “Here are the communities which we're really not reaching right now and we need to increase the services in these communities.”

We've also had a lot of interest from newspapers and a variety of other journalists as they look at their own community, local health departments as they look at their community; that they say, you know, “These are the zip codes that we really need to, to focus on, tell those stories and figure out how do we improve those zip codes.”

So, you can imagine for a community—such as Houston, Texas, which has 4 million people, and at the city of Harris County, which has over 6 million individuals—that it's hard to figure out where do you concentrate your services.

But for data like this, where you have geospatial data, you can concentrate in the exact zip codes that you really need to have greater impact.

JOHNSON:
So, let's go back to the data and review again the inputs that are a part of the model today.

LAKEY:
There are several components of the data that go into this modeling.

We have this data from birth certificates; there is data from death certificates; there is data from hospitals, inpatient services, and outpatient data; and then there's community data that we get from the American Community Survey, which would have information such as the disability, income levels, educational attainment, a variety of other measures.

JOHNSON:
You're getting policy attention. You're getting media attention. People in this business are looking at it.

In the end, though, you want to get to that point where people on the ground can use this information to target their resources and go into pockets of the community where this is more likely to happen so they can try and stop it, right?

LAKEY:
Yeah. That's exactly right, Robert.

You get the attention, you elevate the issue; but then we’re putting the data in the hands of the people at the local level.

And they can tell us whether, you know, this is helpful or not or how it can be more helpful, and how do you adjust the services in the community based on this type of data.

JOHNSON:
You also have a national view, having once served as the president of ASTHO. So, you're talking to other people around the country who are leading state health departments doing this important work.

Is there a national interest in what's going on with this model and its development there in Texas?

LAKEY:
I think that there is.

Again, this model is relatively new. We will see how valid and how useful it is in our communities across the state of Texas.

But there is a desire in Child Protective Services to move out of the current issues of taking care of kids once they're already abused and maltreated. How do we move upstream and prevent these types of events?

And our Child Protective Services is trying to move upstream. They have new section, prevention and early intervention, designated to try to prevent maltreatment of the kids. I think they are out there a little bit further than other states are at right now, that a lot of states are very interested in this type of work to prevent maltreatment.

And it's hard to do that without good data and without good models. And this is where, again, I think this type of data can be helpful as we try to adjust our family protective services from just responding to the current events to preventing child abuse in the first place.

JOHNSON:
I assume once you feel like this is ready for full deployment, you would be happy to entertain conversations with other states that might want to understand your model, maybe even adopt it themselves.

LAKEY:
Absolutely. We would be more than happy to share this information.

You know, one of those mantras that I've used in public health as I try to share seamlessly and still shamelessly when we're trying to improve the health of people in our communities: you have to be able to share this type of information, and figure out what worked and what didn't work, and share that with our colleagues so we can all move forward in improving the health of communities across our nation.

JOHNSON:
When it comes to infant brain maltreatment, is there anything worse that you could see come through your doors as a medical doctor?

LAKEY:
You know, abuse is just heartbreaking, and it has so many impacts: the deception of a family; the disruption of trust; the neglect; knowing that because moms and dads aren't reading to their kids, aren't putting them in an environment that stimulates them, that, you know, the brain architecture is being developed differently.

That will have impacts for the rest of the child's life because the brain is going to develop differently; and not only the abuse that has taken place, the maltreatment that has taken place in the past, but the whole social dynamic of that child.

It is heartbreaking when you have a child that comes in and you start figuring out there are other reasons why this child is in the emergency room or that you are seeing them, and that this isn't a one-time event. That is as tough as it gets in pediatrics.

JOHNSON:
Links to Dr. Cameron's research, information about the Texas Brain Summit, and the UT geo-mapping project can be found in the show notes for this episode.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And, if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.