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The Link Between ACEs,

Preconception Health

and Birth Outcomes

The Link

Between ACEs,

Preconception

Health and Birth

Outcomes Presenters: Ginger Clough

Buncombe County Nurse-Family Partnership

Jennifer Vickery and Brenda Stubbs

Regional Program Coordinators

NCPHC Campaign

May 16, 2018

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DISCLOSURES

Neither Ginger, Jennifer or Brenda - or their respective partners - have relationships with commercial companies that could be perceived as a conflict of interest

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ACKNOWLEDGEMENTS

This training was developed by the North Carolina Preconception Health Campaign, a program of the North Carolina Chapter of the March of Dimes, under a contract and in collaboration with the North Carolina Division of Public Health, Women’s Health Branch.

Thanks to Buncombe County Nurse-Family Partnership, MAHEC, and Resource for Resiliency for their contributions

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HOUSEKEEPING

• Obtaining credits

• Groups viewing together should

email:

randerson@marchofdimes.org

• Asking questions

• Accessing resources at a later date

• Credits and evaluation

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CreditsNursing: 1.5 Contact Hours

Wake AHEC, Nursing Education, is an approved provider of Continuing nursing education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Wake AHEC CEU: Wake AHEC will provide 0.2 CEU to participants upon completion of this activity.

Certified Health Education Specialists (CHES)/Master Certified Health Education Specialists (MCHES):

Application has been made for 1.5 total Category I continuing education hours. NCHEC Provider # 98985. Approval is pending.

National Association of Social Workers (NASW)

NC AHEC is a 2018 NASW-NC approved provider of distance continuing education. This program has been approved for 1.5 contact hours

A participant must attend 100% of the webinar to receive credit. Partial session credit will not be awarded.

Contact Hours: Wake AHEC will provide up to 1.5 Contact Hours to participants.

Wake AHEC is part of the North Carolina AHEC Program.

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•A statewide initiative aimed at improving birth outcomes in NC by reaching out to women with important health messages before they become pregnant

•Formerly functioned as the NC Folic Acid Campaign

•Goals of the Campaign are to reduce infant mortality, birth defects, premature birth, and chronic health conditions in women, while also aiming to decrease unintended pregnancies in NC through promoting reproductive life planning.

•Seeks to raise awareness and inspire positive action among the general public, health care professionals, and community agencies

MARCH OF DIMES

NORTH CAROLINA PRECONCEPTION

HEALTH CAMPAIGN

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OBJECTIVES

• Participants will understand what Adverse Childhood Experiences (ACEs) are and the lifelong impact they can have on an individual’s physical and mental health

• Participants will also learn how resiliency skills and protective factors can minimize the impact of ACEs and help individuals lead healthier lives. Webinar presenters will clearly demonstrate the link between ACES, preconception health, and birth outcomes.

• Participants will learn components of a trauma informed and resiliency focused service delivery and benefits of incorporating ACEs & Resiliency Questionnaires into Pre or Interconception Counseling

• Participants will learn self care strategies for reducing stress and secondary trauma

• Presenter will introduce the Resources for Resiliency’s Reconnect for Resilience Model

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Rapid Reset

Ground

GROUND

Many ways to ground

Notice sensations of support and safety when you sit, stand, lie down, lean into a wall or

walk.

Notice how the ground or the wall is supporting your feet or anywhere else in your body.

Pay attention to the sensations inside your feet and legs and how it feels physically on the

inside, noticing how your feet can lean into the ground and the ground can support you.

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QUESTIONNAIRES

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WHY IS PRECONCEPTION CARE SO IMPORTANT?

We now know that ONE-HALF of all infant deaths and health problems with babies are DIRECTLY RELATED to the health of the mother BEFORE she became pregnant!!

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REPRODUCTIVE LIFE PLANNING

• #1 on CDC’s list of preconception health recommendations is to encourage all men and women to have a reproductive life plan

• #1 Goal of reproductive life planning is to REDUCE UNPLANNED PREGNANCIES!

• 43% - 50% of pregnancies are unplanned!!

Johnson K et al, Recommendations to Improve Preconception Health and Health Care-United States A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care, MMWR Reports and Recommendations, April 21, 2006.

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• Increased risk for infant morbidity and mortality; including premature birth, low birthweight, and

birth defects

• Increased elective abortion rate

• Late entry into prenatal care

• Higher rates of smoking prior to pregnancy

• Increased risk of physical abuse and partner relationship ending for mothers

• Increased child abuse and neglect

• Increased Medicaid costs

Looking Back Moving Forward, North Carolina’s Path to Healthier Women and Babies, 2007;

NC PRAMS Fact Sheet 2009, Unintended Pregnancies, 2004 – 2006

Why are Unintended

Pregnancies a concern?

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Alcohol use

•Preterm birth

•Birth defects•Intellectual and Developmental Disorders

•Stillbirth•Miscarriage

Tobacco use

•Low birth weight

•Small for gestational age•Pre-term delivery

•SIDS•Still birth

Illicit drug use

•Fetal death

•Brain injuries•Pre-term birth

•Developmental problems•Birth defects

Adapted from California Preconception Care Provider training, County of Los Angeles, Department of Public Health, 2003

Women who have unintended pregnancies may be more likely to engage in behaviors that affect birth outcomes

Risky preconception health behaviors increase

infant mortality & morbidity

*especially with unintended pregnancies

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Obesity

• Fetal and neonatal death

• Neural tube defects

• Large baby (Macrosomia)

• Increased risk of childhood obesity

Hyper-tension

• Preterm birth

• Placental abnormalities

• Teratogenic risks from medication

• Low birth weigh

• Pregnancy loss

Diabetes

• Miscarriage/Still birth

• Preterm birth

• Birth defects

• Macrosomia

STIs

• STI transmission to infant

• Low birth weight

• Miscarriage/Still birth

• Preterm birth

• Pneumonia

Poor Mental Health

• Preterm birth

• Low birth weight

• Postpartum depression

• PMADsAsthma

• Preterm birth

• Low birth weight

• Small for gestational age

Adapted from California Preconception Care Provider training, County of Los

Angeles, Department of Public Health, 2003

Pre-existing adverse health conditions that increase

infant mortality & morbidity*especially with unintended pregnancies

Women with

unintended

pregnancies may be

more likely to have

pre-existing medical

conditions that

adversely affect

birth outcomes

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DESIRED OUTCOMES

Preconception healthcare that includes reproductive life planning

Intended pregnancies/better preparedness

Healthier pregnancies/better birth outcomes

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What are the most common health concerns you encounter

in the preconception or perinatal population?

Are the source of the problems new, long standing,

generational, institutionalized?

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CASE EXAMPLE

MARY

• 7 years old

• Parents divorced at age 4, moved with mother to new state away from friends and family

• Father is alcoholic- not available

• Lives with mother who suffers from depression

• Close relationship with her grandmother and they stay in contact even though Mary lives far from her

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USING THE LIFE COURSE

PERSPECTIVE FOR

UNDERSTANDING THE IMPACT

OF ADVERSE CHILDHOOD

EXPERIENCES (ACES) AND THE

POWER OF RESILIENCY

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LIFE COURSE PERSPECTIVE

CONCEPTS

Timeline Timing Environment Equity

US DHHS HRSA MCH Bureau

Life Span

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BIG PICTURE

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https://www.coursera.org/course/resilienceinchildren

RESILIENCY is when our

scale tips towards the

positive, even in the

presence of hard things

Things About YouUnique Nervous System

Genetics and DNA

Resiliency/ACE Score

Life Story

Personality

Good Things People you can count on

Physical safety

Community support

Hobbies, nature, pets

Spiritual beliefs or values

Hard Thingsproblems

Parenting without support

Violence

Serious health Poverty

Not enough safe relationships

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The ACE Study is largest study of its kind ever to examine over

the lifespan the medical, social, and economic consequences of

adverse childhood experiences.

The Adverse Childhood

Experiences Study

What is the ACE study?

> 17,000 participants

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Adverse Childhood Experiences (ACEs) Study

KPRJ Films LLC, (2015)

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The Pair of ACEs

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Brain Development is Driven

by Experience

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CASE EXAMPLE

MARY

• 13 years old

• Mother remarried, step-father is alcoholic and violent with Mary

and her mother when he drinks

• Begins to use electronic cigarettes (Juul)

• Begins to have issues with depression, though it’s not identified

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A Different Way of Thinking Think about preconception health in this way:

Parent’s Life

Individual’s Life

Child’s Life

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ACEs and Preconception Health

If we want people to achieve optimal preconception health – we have to be assessing for ACEs in the preconception period

ACEs and pre-existing mental health issues increase the risk for PMAD/PPD, birth trauma and PTSD

ACEs continue to impact health over the lifespan, including interconception health prior to subsequent pregnancies

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Toxic Stress & Pregnancy

http://www.telegraph.co.uk/news/health/news/5125994/Women-stressed-in-pregnancy-more-likely-to-have-children-with-

asthma.html

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Obesity

• Fetal and neonatal death

• Neural tube defects

• Large baby (Macrosomia)

• Increased risk of childhood obesity

Hyper-tension

• Preterm birth

• Placental abnormalities

• Teratogenic risks from medication

• Low birth weigh

• Pregnancy loss

Diabetes

• Miscarriage/Still birth

• Preterm birth

• Birth defects

• Macrosomia

STIs

• STI transmission to infant

• Low birth weight

• Miscarriage/Still birth

• Preterm birth

• Pneumonia

Poor Mental Health

• Preterm birth

• Low birth weight

• Postpartum depression

• PMADsAsthma

• Preterm birth

• Low birth weight

• Small for gestational age

Adapted from California Preconception Care Provider training, County of Los

Angeles, Department of Public Health, 2003

Adverse health conditions attributable to ACEs that can negatively

impact birth outcomes

*especially with unintended pregnancies

Pre-existing

medical conditions

that adversely

affect birth

outcomes

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Alcohol use

•Preterm birth

•Births Defects•Intellectual and Developmental Disorders

•Stillbirth•Miscarriage

Tobacco use

•Low birth weight

•Small for gestational age•Pre-term delivery

•SIDS

•Still birth

Illicit drug use

•Fetal death

•Brain injuries•Pre-term birth

•Developmental problems

•Birth defects

Adapted from California Preconception Care Provider training, County of Los Angeles, Department of Public Health, 2003

Women who have unintended pregnancies may be more likely to engage in behaviors that affect birth outcomes

Risky coping mechanisms for trauma that affect

birth outcomes

*especially with unintended pregnancies

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“We saw that things like intractable smoking,

things like promiscuity, use of street drugs,

heavy alcohol consumption, etc. – these were

fairly common in the backgrounds of many of

the patients. These were merely techniques

they were using, these were merely coping

mechanisms that had gone into place.”

- Dr. Felitti

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YOUTH MENTAL HEALTH & ACEs

• 1/3 of youth ages 12-17 have experienced 2 or more traumatic situations (35 million youth in US)

• 1 in 4 teens suffer from a mental health disorder; 80% don't get help

• 50% of lifelong mental illness onsets by age 14; 70% onsets by age 24

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CASE EXAMPLE

MARY IS 15

• Begins high school and develops close circle of friends whom she can talk with about her challenges and depressed feelings

• These friends are good influences on her health choices, Mary reduces vaping (nicotine products)

• Develops a creative outlet, enjoys writing and is praised at school for her talents

• Continues to have issues with mother and step-father

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Re-Thinking High Risk Health

Behaviors

• May not be the core problem

• They may be the coping devices

• A way to feel safe or just feel

better

Regional Child Abuse Prevention Councils 2011

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• Healing can occur

• Cycles can be broken

• Safe, stable, nurturing

relationships can heal

both parent and child

The Adverse Childhood Experiences Study, Arizona PBS

Illustration by Yuyi Morales

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Creating a Trauma Informed Resiliency Focused Culture

Connect

Freeze CollapseSubmit

Fight Flight

Life Course

Perspective Concepts

Timeline Timing Environment Equity

US DHHS HRSA MCH Bureau

Life Span

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Connect

Freeze CollapseSubmit

Fight Flight

Protective Factors

Trauma Informed Resiliency Focused

– Local women’s services (i.e. Rape Crisis, Safe Shelters)

– YWCAs or other women & family health civic agencies

– NC Community Care: OB & Case Management Programs

– Nurse-Family Partnership

– Triple P

– Legal Aid

– 12 Step Recovery Programs

– Planned Parenthood

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Connect

Freeze CollapseSubmit

Fight Flight

Using ACEs & Resiliency

Questionnaires

in Health Care Clinics,

Home Visits, and

Community Programs

AAP recommends ACE Questionnaire

The American Pediatric Association (AAP) now

recommends assessing for ACE in ALL children under 18

years old

• 80% believe screening for familial factors is important,

but…

• Nearly 1/3 do NOT ask about ACEs (“not my

responsibility”, "what do I do if they have an ACE

score?")

Informal survey of providers

Polled 20 providers in Guilford, Forsyth, and Rockingham

Counties

2 questions asked:

• Does your practice/clinic/program use the ACE

questionnaire with your patients or clients?

• Were you aware of AAP’s recommendation to assess for

ACEs in all patients under 18 yrs old?

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Connect

Freeze CollapseSubmit

Fight Flight

Using ACEs & Resiliency in

Health Counseling Sessions

Respiration, Heart Rate, Blood Pressure & Relationships

To heal, we need recognition & understanding

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Connect

Freeze Submit

Fight Flight

Resiliency Questionnaire

• Devereux Adult Resilience Survey

• True Resilience Scale

• http://www.acesconnection.com/blog/so-

many-resilience-surveys-so-little-time-what-

resilience-survey-or-scale-are-you-using

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Freeze Submit

Fight Flight

Universal Precautions

Assume anyone is an ACE Survivor

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Connect

Freeze Submit

Fight Flight

http://thenewmentality.ca/self-care-strategies-from-across-canada/

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CASE EXAMPLE

MARY

• 19 Years Old, begins college 4 hours away from home

• Doesn’t handle transition well, falls into rough crowd, begins to vape and smoke marijuana several times a week

• 3 past sexual partners, usually doesn’t use protection

• Becomes estranged from mother and step-father due to family history of IPV between her parents when step-father drank alcohol

• Gains mentor who encourages her to attend free counseling sessions through campus health center

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• Trauma-informed

• Resiliency-focused

• Responding to the public

health crisis of Adverse

Childhood Experiences

(ACES)

ConnectHelp create and increase safety in

relationship with others

Sense-InTune-in to positive sensations (used

with every other resiliency tool)

Rapid ResetQuickly calm your nervous system when

way out of balance, or help deescalate

others when they are out of balance

ResourceSense-In to a positive memory or

strength that helps you feel better

Re-DirectMove to attending to sensations in the

body that are neutral or positive

HighlightSense-In to life-affirming helpers

RestoreReturn to self-compassion when

there is shame

The Resiliency Tools

CONNECT

SENSE-IN

RAPID RESET

RESOURCE

RE-DIRECT

HIGHLIGHT

RESTORE

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Dr. Dan Siegel’s Hand Model of the Brain @ 2012 Mind Your

Brain, Inc. Siegel. D.J. (2012). The Developing Mind: How

Relationships and the Brain Shape Who We Are (2nd Ed.) New

York, NY: Guildford Press. Used with Permission. All Rights

Reserved.

BRAIN ORGANIZATION

SURVIVAL BRAINThe Body’s Automatic Functions

Decisions based on sensory input

Activates fight, flight, freeze, submit,

or collapse

EMOTIONAL BRAINFeelings and Connection

Decisions based on positive

or negative memories

Assesses levels of safety or threat

THINKING BRAINCritical Thinking and Executive Control

Decisions based on choice

Integrates Input from all 3 parts

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THE AMYGDALA

Assesses BOTH

Safety and Threat

Works like a smoke detector

Signals to other parts of the

nervous system when either

safety or threat is perceived

LeDoux, (1996)

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AUTOMATIC SURVIVAL RESPONSES

Connect

Freeze CollapseSubmit

Fight Flight

Porges, (2009)

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Nervous System

https://psychlopedia.wikispaces.com/Autonomic+Nervous+System

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Poly Vagal

Connect

CollapseSubmit

Fight Flight

Safety & Connection: Rest, Digest & RelateRelaxed, eye contact, facial expressions and voice signal safety

DANGER: Fight or FlightIncreased heart rate, stress, muscle tension, anger, fear, aggression, rage, high energy

Overwhelming Threat: Freeze/Submit/Collapsed

Image: https://dfay.com/archives/4670

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Immobilizes the

body during times

of rest

“Brake

Pedal”

Mobilizes the

body during times

of stress

“Gas Pedal”

SHUT DOWN

CIRCUIT AMP UP

CIRCUIT

Autonomic Nervous System Fuels Survival Responses

Things happen in life and our thoughts, feelings, and

reactions move around in the Resilient Zone

We can feel any emotion and still be in our Zone.

We can use a little or a lot of energy and still be in our Zone.

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“Jolts” are things that can (and do)

bump us out of our Resilient Zone

• Stress or trauma

• Witnessing another in distress

• Various kinds of triggers including

shame and upset in relationship

• Sometimes, we may not know

exactly what the jolt is, but we feel

it in our bodies

Jolts to our Nervous System

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Types of Trauma

Big TOverwhelming life-threatening

Little tLess obvious

and still overwhelming

Ongoing, Repeated Negative

Experiences

Trauma of Oppression

Occurs to minority groups

Natural disastersWar

Motor vehicle accidents

Catastrophic illnessDeath

AssaultSexual violence

Dog bitesMedical or

dental proceduresHumiliation

Rejection

ACEsPoverty

Witnessing trauma

Race (profiling)CultureGender

Sexual orientation or gender

identificationDisabilityReligionBullying

Carter, (2007) & Herman, (1997) & Paradies, (2006) & Shapiro, (1997)

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Stuck on AMPED UP

Stuck on SHUT DOWN

Adapted from graphic

by Peter Levine and Diane Poole-Heller

Anxious, hyper, sleepless,

angry, constantly on the

lookout for danger, pain

Helpless, sad,

disconnected, foggy,

numb, exhausted, pain

THREAT OR

TRIGGER

Your Resilient Zone – Out of Balance

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The Key to Resilience

To restore balance to

our nervous system –

we have to signal

safety to

THE

SURVIVAL

BRAIN

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• Sensations are physical feelings in the body, not

emotions

• Billions of cells detect sensations in each body system

• We are familiar with the five senses – taste, touch, smell,

sound, sight

• We also have important sensations in our guts, bones,

joints, and muscles

• Sensory input lets you know you are safe, sensory input

lets you know you are not safe

Sensation Speak 101

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Sensation Speak 101Things We Can Notice

• Muscles (tense or relaxed)

• Breathing (deeper/shallower or faster/slower)

• Heart rate (faster or slower)

• Temperature

• Pressure

• Vibration

• Sturdy or wobbly

• Where is it? How big or small does it feel?

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Sensation Speak 101 What to Expect When Things Get Better

Release Sensations that occur when no longer stuck

in amped-up or shut-down

Heat or warmth

Vibration or tingling

Trembling

Burping or Yawning

Tears (wetness around the eyes)

Balance

SensationsDeeper Breath

Slower heart rate

Relaxed muscles

Calmer voice

Grounded

Sense-In

Resiliency Tool 2

What do you notice…

on the inside?http://www.phuket.com/yourguide/romantic/beaches.htm

“What fires together

gets wired together”

Resource

Resiliency Tool 4

A Resource can be anything positive

that helps a person feel better.

Resources are specific and personal (not “in general”)

A memory of a moment with a person, place, animal, activity, or

any experience.

Something you are good at, or proud of

Something you value or believe in that helps you get through hard

times

Something that helps you feel good, calm, strong, even just okay.

A physical or personal attribute you have that is a strength

Your resources are personal and unique to you

– a trustworthy remedy –

to get back in your Resilient Zone!

Resource Tool

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Rapid Reset

Resiliency Tool

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Take a SipNotice the physical feelings that go with drinking liquid.

Pay attention to the sensations of liquid and how it feels on

the inside:

In your mouth;

In your throat; and

As it goes down to your stomach.

Take your time. What do you notice?

Where do you notice positive or neutral physical feelings?

What do you notice now about your breathing, heart rate,

muscle tension?

Rapid Reset

HELP NOW SKILL STATION 1

Drink a glass of water.

What do you notice on the inside?

Where do you notice

positive or neutral

sensations?

Rapid Reset

Take a Sip

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Now you add one…What activity can you think of that

brings positive sensory

awareness into the present moment

to produce calming?

Rapid Reset

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CASE STUDY

MARY IS 25

• Mary has graduated from college and is in a job that she enjoys

• Mary recently married to her long-term boyfriend, and they became pregnant a few months after the wedding

• Although the pregnancy was intended she entered pregnancy with unresolved health issues, including habitual nicotine use, and unmanaged depression

• Pregnancy had multiple complications and baby boy is born at 34 weeks

• Suffers from post-partum depression

Case Study Wrap Up - Mary

• What were her ACE factors?

• What were her resiliency factors?

• Where could have interventions have taken place?

And which ones would have been most effective?

• Do you think her baby’s prematurity or her post-

partum depression could have been prevented?

Reminders

Resiliency Can Be Increased

Create Partnerships with Family &

Understand their Goals

Celebrate Small Steps

Increasing Our Resiliency Helps

Families Build Their Resiliencyhttp://cliparts.co/clipart/108

Break the Cycle

of Adversity

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http://resourcesforresilience.com/Copyright © 2018 Resources for Resilience

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RESOURCES

https://www.goodreads.com/book/show/21549740-healing-neen

https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_h

ealth_across_a_lifetime

http://www.acesconnection.com/

https://resiliencetrumpsaces.org/

http://buncombeaces.org/ace-learning-collaborative/

https://acestoohigh.com

http://www.traumainformedcareproject.org

http://www.albertafamilywellness.org/

https://developingchild.harvard.edu/

https://www.frameworksinstitute.org/assets/files/ECD/resilience_em_report_final.

pdf

TMQuestions? Comments?

• Allison Gilliam-Sturdivant

• Beth Turner

• BCHHS Nurse-Family Partnership

THANK YOU!

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THANK

YOU!