Archive for ‘Uncategorized’

July 10, 2019

Adverse Childhood Experiences Can Detrimentally Affect Health

Even when current stress is low, the lingering effects from adverse childhood experiences can detrimentally affect health. We’re often reminded that current or ongoing stress is bad for us, but the stress we experienced long ago can be just as significant. Researchers who conducted The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study concluded: “We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults”.1
woman
This week I’m going to give you information about the study. Next week, I’ll talk more about real-life scenarios that are playing out in the statistics. With adverse childhood experiences affecting more than half of us, this is a very big topic. And with the increase in chronic disease, it seems important and timely.

How The Study Came About

As sometimes happens, a doctor set out on one mission only to have his curiosity piqued by something he discovered along the way. This eventually led to the groundbreaking ACE Study. Vincent Felitti, head of Kaiser Permanente’s Department of Preventive Medicine in San Diego, set out to determine why the dropout rate of participants at Kaiser Permanente’s obesity clinic there was about 50% even though all of the dropouts successfully lost weight under the clinic’s program.

While conducting interviews with people who had left the program, Dr. Felitti discovered that a majority of some 286 people he had spoken to reported sexual abuse as children. Felitti wondered if weight gain was being used to cope with depression, anxiety, and fear. He decided to learn more.

Participants in the Study

With a team, Dr. Felitti and the CDC’s Dr. Robert Anda interviewed 17,337 study participants asking five questions relating to personal trauma and five relating to trauma within the family. About half of the participants were female; 74.8% were white; the average age was 57; 75.2% had attended college; all had jobs and good health care. Each positive response to a question counted as one point. The resulting total is the ACE score.

About two-thirds of participants had experienced at least one adverse childhood event. Of those, 87% (almost 10,000) had experienced more than one. Over 15% of women and 12% of men in this mostly white, middle and upper-middle class, college educated group had experienced more than four.

According to the CDC, rates of child abuse and neglect are five times higher for those who live in families with low socioeconomic status as compared to children in families with higher socioeconomic status. That means the original ACE rates of occurrence may be much higher in some segments of the population.

Questions That Were Asked

The questions asked included physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect, a parent who’s an alcoholic, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment. All of these are major stressors chosen in part because they had been identified in earlier research, but they are not a comprehensive list of adverse childhood experiences.

The study did not address food insecurity, homelessness, loss of a caregiver other than a parent, surviving a severe accident, recurring hospitalization, a medically fragile family member, neighborhood violence, living with a hoarder, drug addiction within the family, involvement with the foster care system, racism, bullying, watching a sibling being abused, witnessing a father being abused by a mother, witnessing a grandmother abusing a father, or involvement with the juvenile justice system. All of these events and others that create toxic stress can increase the risk of long-term health consequences.

How Answers Relate to Health Risks

Through 2015, more than 70 publications have expanded on the knowledge gained through The ACE Study and parallel research has shown the effects of traumatic stress on children’s developing brains. In general, an ACE score of 4 or higher increases the likelihood of chronic pulmonary lung disease 390%; hepatitis 240%, depression 460% and attempted suicide 1220%. Yes, you read that right. The risk for attempted suicide increases over 1000 percent.

In addition, children who experience four or more categories of exposure compared to those to have none will have a 4- to 12-fold increased health risk for alcoholism, drug abuse, and depression; a 2- to 4-fold increase in smoking, poor self-rated health, ≥50 sexual intercourse partners and sexually transmitted disease; and a 1.4- to 1.6-fold increase in risk for physical inactivity and severe obesity.

Costs of Adverse Childhood Events

While the greatest cost of ACEs is to the individual and, by extension, the family, societal costs are also great. According to the CDC, “In the United States, the total lifetime economic burden associated with child abuse and neglect was approximately $124 billion in 2008. This economic burden rivals the cost of other high profile public health problems, such as stroke and type 2 diabetes.” And it appears that it contributes to those high profile health costs as well.

There are also intangible costs. ACEs affect our classrooms, our friendships, our marriages, and our ability to work well with others. They can also be self-perpetuating. A child who does not feel valued may not value the lives of others including his/her children. Without intervention or mitigating circumstances, the cycle repeats.

Addressing the Problem

The CDC has developed a technical package that identifies a number of strategies to help communities prevent and reduce child abuse. They include strengthening economic support, providing quality child care & early education, enhancing parenting skills, intervening to lessen harm & future risk, and changing social norms.

We Have a Long Way to Go

At this moment, I cannot stop thinking about the two-month-old child living in Missouri who is being kept at home by a total stranger while her parents vacation in the Caribbean. There is significant risk in this scenario. Yes, the caregiver works for a service and, in theory, has been vetted by the employer, but the parents will not meet him/her in advance.

On top of this, the mother’s housekeeper has observed this baby being repeatedly left alone in bed in her room all day other than feeding time. When she cries, she is not talked to, picked up, or comforted. It’s easy to say: she’s too little to know the difference; kids are resilient; she won’t remember; I’m sure they usually pick her up; her parents have plenty of money so she’ll be fine…. But taken together these are red flags that are significant and indicative of insidious neglect that often flies under the radar.

My cousin who is a psychologist relayed the story of this baby to me a few weeks ago. She and the mother are friends who share both a yoga class and a housekeeper. She is concerned, but there is a stable home; the baby is changed, fed, bathed, and dressed in cute clothes; and she sees the pediatrician as scheduled. There is simply no documentable problem.

I’m not sure how to help this baby. My high school friend whose daughter has become addicted to opioids after back surgery struggles to determine how to and how often to step in to help her son-in-law with the grandchildren who live 3 hours away. In the past year, I’ve seen babies removed from parental care while lying in CVICU. They may be legally fostered by a physician, but they are experiencing traumatic procedures in a noisy, unfriendly environment without a consistent caregiver to comfort them. It is heartbreaking.

The only ACE questions I’ve seen in a healthcare setting were on a proposed opioid risk assessment recently reviewed by the PFCC Hospital Advisory Council on which I sit. I cannot recall ever having a physician ask me a question related to ACEs. In spite of the strong relationship between ACEs and health risk, in the 20 years since the original study, we have not managed to incorporate this important piece of patient history into routine preventative care.

It feels like we are spinning our wheels in a place where we have plenty of data to support systematic change, but not the will or courage to implement it. Instead, we continue to spend billions to fight chronic disease without including programs to reduce or mitigate the effects of adverse childhood experiences.

We Can Make a Difference With Simple Changes

We may not be able to prevent every occurrence of child abuse, but we can improve overall community health by including ACE assessment questions in our patient information forms, then providing trauma-informed treatment for those with high ACE scores.

We can lose the us vs them language of mental health care. Saying abuse “changes who you are” is not productive, helpful, or even true. Abuse and neglect change how you respond to the world, but they do not change the person you can get back to with healing. Calling a patient’s response to a wound inflicted by someone else a “disorder” or “mental illness” is uninformed. It makes his/her adaptation for survival (an internally heroic thing) sound like a defect. Many victims already feel defective. Confirming that feeling does significant damage. Detrimental behavior that results from adaptation can still be dealt with, but in a different manner. The ability to reframe past events can make the difference between hope and hopelessness.

We can train all health professionals, social workers, teachers, human services workers, and law enforcement professionals in Mental Health First Aid.

We can focus on mindfulness (shown to change the brains of PTSD patients) in fitness and mental health programs and let weight loss be a side effect.

Gynecological exams can begin with a conversation while the patient is clothed before proceeding to the physical exam. I think this is good policy no matter what the patient’s background, but can be extremely important for some survivors of childhood sex abuse.

Pediatricians can include questions regarding indicators of attachment in well-care exams and instruct parents regarding the importance of bonding.

Breastfeeding education can include information regarding the benefits of holding a child close and looking into his/her eyes while feeding in addition to the health benefits of consuming breast milk.

Parents can be gently reminded that they must comfort, sooth, protect, and respond to their child’s needs before the child can learn to sooth itself. Withdrawing into itself is not the same as self-soothing. It may mean the child is quiet, but it is dysfunction.

We can stop trying to make ourselves feel better by dismissing subtle signs of distress in our grandchildren, nieces, nephews, and students. Acknowledging a problem is the first step toward fixing a problem.

And we must remember that it is extremely stressful to make life and death decisions; to care for ill and dying patients; to go into homes of severely abused children; and to watch an addict relapse. If we expect professionals to approach patients with compassion, we have to provide them adequate emotional support and safe environments in which to voice their feelings.

Compassion is Always Appropriate

More than likely, you interact with multiple people who had adverse childhood experiences on a regular basis. You may not even know who they are. Some of them will suffer health effects. Some of them will not. Some will act out. Some are doing their best just to get through the day. A high ACE score is both an indicator of risk and a call to practice compassion and patience with everyone you encounter-especially the difficult ones. Compassion is a great starting point for improving health.

Stevens, Jane Ellen (8 October 2012). “The Adverse Childhood Experiences Study — the Largest Public Health Study You Never Heard Of”. The Huffington Post.

https://www.ajpmonline.org/article/S0749-3797(98)00017-8/abstract
Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults
The Adverse Childhood Experiences (ACE) Study
Vincent J Felitti MD, FACPA,*’Correspondence information about the author Vincent J Felitti, Robert F Anda MD, MSB, Dale Nordenberg MDC, David F Williamson MS, PhDB, Alison M Spitz MS, MPHB, Valerie Edwards BAB, Mary P Koss PhDD, James S Marks MD, MPHB

https://acestoohigh.com/got-your-ace-score/

https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/about.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4917040/

May 28, 2019

Coulda, Woulda, and Should Have!

I’m wondering why my relatives who coulda, woulda, and should have thrown out the trash chose to hang on to it? I just spent yet another weekend in my hometown cleaning out my mom’s cousin’s house. Although I thought I’d already emptied all of the bags and boxes that have to be slowly sorted, I discovered I was wrong!

There were bags behind a chair, boxes under the dresser and the beds, and piles on top of the cedar chest. There’s unopened mail from 1987 mixed with family photos, used Kleenex, financial records for still active accounts, pharmacy bags with prescriptions attached, and pill bottles filled with quarters all in the same box or bag.
bags
In the past 3 years, I’ve been tasked with cleaning out two houses and a 3000 sqft storage building filled with similar mixtures of trash, recycle, shred, keep, and donate. Trash, recycle, shred, keep, donate. Trash, recycle, shred, keep, donate.

I can quickly think of four relatives no more distant than second cousins who have stopped throwing things away. They don’t shop compulsively. They are proponents of recycling. They pay their bills. They have active social lives. And they keep trash. And they mix trash with non-trash. And they leave the trash casserole for someone else to deal with.

This weekend I was joined in the cleanup by my psychologist cousin who thinks this is a form of hoarding or obsessive-compulsive behavior. Of course, my first question was, “Is it genetic?” According to Dr. Nancy, there is most likely a genetic component, but no specific marker has been identified. I know I came home with a compulsive desire to get rid of something.

In my mom’s house, there was an identifiable point in time at which filing and organization stopped. Prior to that, she saved a lot of things, but it wasn’t unheard of for her to pare down. There is an identifiable year when things changed in her cousin’s house as well.

While the cousin’s change in habits seems timed to correlate with the loss of her mother, my mom’s appears to correspond with her marriage to her second husband. I guess the commonality in the two is significant life change.

Logically I understand how loss might trigger a desire to hang onto things that belonged to a person you lost or that hold fond memories of a person lost. It’s interesting that it might trigger hanging onto junk mail or ceasing to file.
pile
I think it’s possible that a triggering change can cause a freeze response that manifests in an inability to take care of yourself in some way. Perhaps it interrupts your maintenance of your environment or perhaps you struggle to feed yourself.

Saying it’s a triggering change implies a previous wound or a latent biological response. Obsessive-Compulsive disorders and Eating Disorders are closely related to anxiety. Anxiety is at its most simple, distress.

Distress can come from old or new feelings of terror, grief, sadness, helplessness, humiliation, danger, distrust, rejection, invisibility, shunning, defectiveness, and unloveability. Old incidents of neglect, abuse, or cruelty sensitize us to anything that feels the same.

All of these feelings can be so powerful that we can become overwhelmed. Pushing ourselves gently into action may seem like the straw that will break us. Of course, the reality is that the only way to heal the distress is to find a way to feel then release the feelings.

Hopefully most of us will find a way to do this instead of ceasing to throw away trash. Living in the midst of clutter weighs us down. The dust collected can irritate allergies. Piles can create a falling or fire hazard.

Neglected kitchens and bathrooms can pose other health risks. During my weekend, I observed that canned vegetables can sit unused long enough that the can begins to disintegrate and leak thick, black tar-like liquid that runs out of the cabinets and drips onto the countertop. I’m not sure I can describe to you how gross this is!

I donned a mask and gloves, but I felt like I needed a full hazmat suit to dispose of the cans. An antique Kerr jelly glass with a metal lid accidentally tumbled into the contractor bag along with a can. I did not go after it. I realize they sell for almost $20 on Etsy. It still wasn’t worth the dive.

Yesterday, I drove the three hours home wanting nothing more than to wash the day off of me and go to bed. Now that I’m back, everything in my house is suspected trash! I’m looking to see if there’s anything I coulda, woulda, or should have thrown away by now.

I sometimes feel like taking the position of my mom’s cousin Jimmy. Jimmy had a barn in disrepair that he wanted to tear down. The barn was located on the original homestead and contained some family heirlooms. Jimmy tried to get the family to come claim those treasures so he could proceed with demolition.

Instead, they stalled, lobbied, guilted, humiliated, and generally made him so miserable that for 15 or 20 years whenever someone mentioned that barn he’d just shake his head and say, “Light a match!” That was almost 40 years ago. He never demolished or torched the barn.

In fact, he finally sold the land to my dad and I now own the repaired, refurbished barn. I have no idea what’s in it. Maybe I coulda, woulda, or should have, but I’m afraid to open the door!

…Light a match?

https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder

https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml

https://www.eatingdisorderhope.com/information/eating-disorder/eating-disorders-anxiety
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April 29, 2019

Out of the Mouth of Babes, Snakes, and Scientists – Smell Begins With the Tongue

Sometimes a new idea comes out of the mouth of babes, snakes, and scientists. A study published last week online in advance of the print edition in Oxford Academic Chemical Senses finds that smell may begin with the tongue rather than the brain. One of the study’s authors, Mehmet Hakan Ozdener, MD, PhD, MPH, became intrigued with the idea when his adolescent son asked whether snakes stick their tongues out in order to smell.
tongue
A current model of taste and smell shows two genetically different receptor systems located in anatomically distinct locations that send signals to different targets. While the two are known to intertwine to form the perception of flavor, scientists thought that the first merger occurred in the insular cortex – a part of the cerebral cortex in the brain. The insulae are believed to play a role in functions that include perception, motor control, self-awareness, cognitive functioning and interpersonal experience.

The abstract of this new study states: “Here we report that olfactory receptors are functionally expressed in taste papillae…The results provide the first direct evidence of the presence of functional olfactory receptors in mammalian taste cells. Our results also demonstrate that the initial integration of gustatory and olfactory information may occur as early as the taste receptor cells.” (1) Other experiments confirm that smell and taste receptors may be found within the same cell.

There are 400 different types of functional human olfactory receptors and scientists do not know what molecules activate the vast majority of them. While fascinating, this study alone does not answer that question or have a practical application other than to advance knowledge that will lead to other studies.

That’s the beauty of science. It’s a living body of changing knowledge. One layer builds on another. The more we understand about how things work, the more options we have for enhancing our lives. It’s good to remind ourselves of that occasionally.

Believing science has become a battle cry among those who want to stand firm on what we currently know. There’s a danger in that because tomorrow we will know more and that may mean that what we know today is no longer supported by the evidence. It also makes science sound like a restrictive rule book. Who wants to learn a bunch of rules? Certainly not bright minds that can imagine big ideas.

Instead of believing science, I’d rather we love it! And while we’re loving it, let’s be curious. Curiosity leads to advancement. Questioning is good. Skepticism can play a valuable role. Allowing our understanding to shift and change does not threaten our way of life. It has the potential to vastly improve it.

But don’t take that from me, take it from the mouth of a scientist: “I have no special talents. I am only passionately curious.” – Albert Einstein.

(1)https://academic.oup.com/chemse/advance-article-abstract/doi/10.1093/chemse/bjz019/5470701?redirectedFrom=fulltext

https://www.sciencedaily.com/releases/2019/04/190424083405.htm

https://encyclopedia.thefreedictionary.com/insular+cortex
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April 23, 2019

Treasures Among the Trash

recipeYou never know what treasures you’ll find among the trash when you begin to clean out clutter. I’m sure the reason most of us have clutter is that we think too many things are treasures. Marie Kondo is making sure we know how to see the difference. But when we clean out an incapacitated or deceased relative’s home, we don’t have the luxury of choosing what is saved. We only have the opportunity to discover treasures among the trash.

Every month or two I spend a couple of days in my 98-year-old cousin’s house cleaning out the compilation of trash and treasure that includes: bank records from 1972, unopened mail from 1987, family photos from 1896, report cards from 1910, a wedding invitation from 1919, and a baby book from 1920. Because these items are mixed in with junk mail, decaying candy, promotional products, and wadded Kleenex, it is an arduous and sometimes icky process. I love it when I find some treasure that makes the effort worth it!

Recently, I’ve been working my way through the den toward the kitchen. Kitchens have the best variety of memorabilia. A few years ago, I discovered my grandmother’s ceramic green pepper spoon rest in my mom’s kitchen. I was thrilled. Now it’s on my counter by the stove. I love that visual reminder of my grandmother.
pepper
I also love finding old recipe cards. Not only do they give me a chance to prepare my favorite family dishes, there’s something charming about the varying shapes, sizes, and legibility of old recipes. Some assume you are extremely knowledgable about cooking techniques. Some have an ingredient list. Some do not. Many are spattered with remnants of food. Some are in handwriting I recognize. Some have clearly been handled more than others.

This look into the past seems more enticing to me than an old photograph or a tarnished silver service. Perhaps it’s because the recipes are a living memory. They can be created again and again. They can be shared with generation after generation along with stories of previous times they were enjoyed! If you think your kids don’t appreciate those stories, tell them to your grandkids.

At 2-and-a-half, JD loves any story about my experiences; he asks me to repeat them over and over. He never tires of hearing the details again and again. Adding food into the mix creates an indelible experience that he will no doubt share with his children and grandchildren. The recipe cards may not be preserved, but hopefully the recipes will find their way into his heart and his smart appliances or voice-activated replicator or whatever generates food in 2077.

Experimenting with unfamiliar flavor combinations is fun for me, but when I’m tired and hungry or it’s my birthday I’ll take my grandmother’s beef and noodles and a lemon meringue pie any day. Throw in some fresh green beans with new potatoes and I can smell the dirt from the garden when I helped my grandmother dig potatoes. These memories bring with them a sense of belonging to my family and to the earth. I had a place and a purpose.
pie
Such simple things can have a large and lasting effect. In this era of disconnection and short attention spans, we are often lacking a feeling of belonging and purpose. If you can provide that for your family by sharing the stories and food that you loved, is time spent in the garden or the kitchen worth it? I think so! I know time spent connecting is.

https://konmari.com/

https://ideas.ted.com/finding-our-way-to-true-belonging/

http://www.cooking2thrive.com/blog/the-benefits-of-cooking-part-1-the-food/

http://www.cooking2thrive.com/blog/the-benefits-of-cooking-part-2-the-fun-2/

http://www.cooking2thrive.com/blog/the-benefits-of-cooking-part-3-the-lessons/

Disclosure of Material Connection: I have not received any compensation for writing this post. I have no material connection to the brands, products, or services that I have mentioned. I am disclosing this in accordance with the Federal Trade Commission’s 16 CFR, Part 255: “Guides Concerning the Use of Endorsements and Testimonials in Advertising.”