Lifecourse and Chronic Disease

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Lifecourse and Chronic Disease Kathy Chapman, RN,
MN April, 26, 2012
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Overview

• Life Course Review
• Adverse Childhood Experience (ACE) Review
• ACEs as Health Risk
• Executive Function
• Application

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Life Course-Basic Principles

1. Health at one stage affects health later

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Life Course-Basic Principles

1. Health at one stage affects health later
2. Trajectory

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Life Course-Basic Principles

1. Health at one stage affects health later
2. Trajectory
3. Cumulative burden

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Life Course-Basic Principles

1. Health at one stage affects health later
2. Trajectory
3. Cumulative Burden
4. Sensitive or critical periods

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Critical Period

• Positive and Adverse events and exposures can
  impact at any point in life
• Impact is greatest at specific critical periods
  such as
• Pregnancy
• Childhood
• Adolescence

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Brain Development Critical Period

• In the first half pregnancy neurons are formed at
  an astonishing rate 8,000 neurons per second
• By birth all neurons are formed

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Brain Development in Childhood

• In early childhood, 700 synapses formed per
  second
• Pruning for efficiency
• what is used stays

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Exposure during Critical Period

• Adverse Child Events Study

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Pause
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Adverse Childhood Experiences (ACEs)

• CDC study partnering with Kaiser
• 17,000 patients middle class, employed, with
  insurance
• Access to client charts
• Asked questions about Early Childhood Experiences

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ACE Questions

• Respondents were asked about experiences in their
  childhood
• Abuse emotional, physical, sexual
• Neglect emotional, physical
• Household dysfunction
• Mother treated violently
• Household substance abuse, mental illness
• Parental separation or divorce
• Incarcerated Parent

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ACE Scores in this middle class cohort

• Zero 36
• One 26
• Two 16
• Three 9.5
• Four 12.5

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Poor Health Outcomesas the number of ACE
increase, the risk for the following health
problems increases in a strong and graded
fashion. -- CDC

• Alcoholism and alcohol abuse
• Chronic obstructive pulmonary disease (COPD)
• Depression
• Fetal death
• Health-related quality of life
• Illicit drug use
• Ischemic heart disease (IHD)
• Liver disease
• Risk for intimate partner violence

• Multiple sex partners
• Sexually transmitted diseases (STDs)
• Smoking
• Suicide attempts
• Unintended pregnancies
• Early initiation of smoking
• Early initiation of sexual activity
• Adolescent pregnancy

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Strong and Graded Fashion

• The higher the ACE Score the higher the risk for
  health risk behaviors and for various chronic
  diseases

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Questions, Reflections
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Impact of ACE on Brain Development

• Toxic Stress can lead to changes in brain
  structure and function.
• One example Executive Function

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Executive Function

• Executive Functioning helps us translate
  knowledge into action put into practice what we
  know.

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Executive Function

• Helps us to function in 3 ways
• Inhibitory Control filtering thoughts and
  impulses to resist temptation
• Working memory hold and manipulate information
  in our heads over a short period of time
• Cognitive Flexibility Adjust to changing
  demands, priorities and perspectives

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Executive Function

• Develops over many years
• 2 periods of rapid development
• Ages 3-5 years
• Ages 12-25 years
• Gives us the ability to keep plans in mind and
  act accordingly
• Developmental Plasticity responds to
  environment

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Focus on policy and practice

• Executive Function
• Risk Assessment

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Public Health Problem

• Or Personal Coping mechanism?

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Executive Function Implications

• How might issues with Executive Function impact
  interventions we use in chronic disease
  management or risk factor mitigation?
• Smoking Cessation

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ACEs as Health Risk
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ACEs as Health Risk

• We now know that a high Adverse Child Experience
  score puts a person at high risk for later
  physical and emotional illness.
• It is time to shift our thinking ACE as Health
  Risk
• Screening questions
• Provider education
• Prevention and mitigation

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ACEs and the Prevention Framework

• Primary prevention is easier than mitigation
• Secondary Prevention
• Screening for ACEs and interventions to help
  improve executive function
• Integrated approach to intervening with children
  with high ACE scores often treatment for
  multiple family members.
• Tertiary Prevention
• Treat disease/risk behavior and address exec
  function issues (tobacco cessation)

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Questions, Reflections
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More information about ACE

• http//www.cdc.gov/ace/index.htm
• http//www.healthychild.ucla.edu/PUBLICATIONS/Docu
  ments/ZerotoThree.pdf
• http//developingchild.harvard.edu/

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Other Resources

• Jack P. Shonkoff, Lifelong Effects of Early
  Childhood Adversity and Toxic Stress
  http//pediatrics.aappublications.org/content/earl
  y/2011/12/21/peds.2011-2663
• http//pediatrics.aappublications.org/content/124/
  Supplement_3/S163.full

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