Hello and welcome. My name is George Woods. I'm the Chief Scientific Officer for Crestwood Behavioral Health here in California. We are in California, so it's just turning noon here. I'm pleased that you are joining us for today's Striving for Excellence series, Developmental Cascades After Early Life Adversity in a National Sample of African American Adolescents. Can we move to the next slide, please? Funding for the striving for this series, hold on one second. Funding for the striving of this series made possible by grant number, long numbers and letters 879FG000591 from SAMHSA of the US Department of Health and Human Services. The content are those of the authors and do not necessarily represent the official views nor an endorsement by SAMHSA, HHS or the US government. Okay, now I've got to make it smaller so I get back to the slides. Please move it to the next slide, Dr. Gillis. In support of improving patient care, the American Psychiatric Association is jointly accredited by the Accreditation Council for Continuing Medical Education, the AACME, the Accreditation Council for Pharmacy Education, the ACPE and the American Nurses Credentialing Center, ANCC, to provide continuing education for the healthcare team. The APA designates this live event for a maximum of 1.0 AMA PRE category one credits. Physicians who claim only the credit commensurate with the extent of their participation in the activity. So stay the whole time folks, it's gonna be great. Moving on to the next slide. So this is how to download handouts. You can click the chat tab to access the link to the presentation slide and select the link to view. Next slide please, Dr. Gillis. Captioning for today's presentation is available. Click shows captions at the bottom of your screen to enable. Click the arrow and select view full transcript to open captions in the side window. And that's how you will turn on the captions. Next please. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q and A. Next slide please. Dr. Arthur Gillis, MD, PhD. And Dr. Gillis, would you move on to one slide so that I can read no disclosures? So, let me read the bio for Dr. Gillis, and I want you to listen to this carefully, because Dr. Gillis is really representative of the, in my opinion, the future of psychiatry. Dr. Gillis is an assistant clinical professor in the Division of Child and Adolescent Psychiatry within the Department of Psychiatry and Biobehavioral Sciences at UCLA. She holds a PhD in biomedical engineering from Texas A&M. She received her doctorate in medicine and completed general psychiatry residency training at the University of California, Davis. She subsequently completed a series of fellowship trainings at UCLA, Child and Adolescent Fellowship and T32 postdoctoral research training and a fellowship in forensic psychiatry, as well as a fellowship in developmental disability in the UCLA Tarjan Center. She also completed a Max Gray Fellowship in child and adolescent mood disorders. Currently, she is board certified in general psychiatry, child and adolescent psychiatry, and forensic psychiatry, and she holds an endowed chair in hospital psychiatry. She directs the Child and Adolescent Inpatient Unit at the Resnick Neuropsychiatric Hospital in UCLA and specializes in evaluating and treating children who have been sexually traumatized in identifying mental, intellectual, learning, and developmental disabilities in justice-involved youth. Her research focuses on developmental cascades and early intervention after early life adversity, and I just want to say this before we go on. This is who I want looking at our children. This is who I want to understand the issues that we have with our children and to bring the humility, as well as the science, to make a real difference in what we're trying to do. Welcome, Dr. Iglesias. Thank you so much. I really appreciate your vote of confidence, and I wasn't planning to do this, but I'll start with a very short kind of explanation of what drove me into this research for context. So I am a juvenile forensic psychiatrist, as Dr. Woods mentioned, and over and over I saw in the system almost the same kids, so to speak. It was obviously different kids I was evaluating, and they all had this same trajectory where when I took the history from them and from a caregiver or a parent, there were these kids who had some kind of learning problem, maybe some undiagnosed, uncaught ADHD, and then they were progressed, either pushed out of school, dropped out of school, maybe were into drugs because what do you do if you're not in school all day, and then ultimately in the juvenile system, carceral system, where I interacted with them. They would be 17 years old, and I would think, oh, man, what if we had caught this kid when he was seven, and the court wants to know what do we do, how do we intervene, and I'm like, well, they're so close to being out of the juvenile carceral system and so at risk of being in our adult carceral system, and so I'm driven into the research to look at the data for how we might intervene early. With that, I will get started because there's a lot of data in this presentation, and so I want you to listen for our readers, you can definitely read, and you can download the slides and look at them closely later, but I want you to really listen to where things are going in this area. So to give you a landscape of what we're going to talk about today, we're going to talk about what ACEs are, we're going to talk about why we should study ACEs in adolescents, the prevalence of ACEs in adolescents based on a couple of data sets, and then outcomes in multiple areas, so developmental cascades academically in terms of substance use, which is a risky behavior that starts during adolescence, and then the carceral outcomes, and then we're going to end with ideas about early intervention, and I would love to hear your ideas as well. So what are ACEs? ACEs are Adverse Childhood Experiences, and how do we define these? These are experiences of interpersonal violence, deprivation or neglect, family dysfunction, or other just like a broad category of potentially damaging experiences that occur during childhood. So in terms of interpersonal violence, these are things that you may think of like physical abuse, emotional abuse, sexual abuse, it could include bullying, deprivation and neglect include things like physical, emotional neglect, also poverty, and then family dysfunction are things that can go wrong in the household, like there's a family member or a household member abusing substances actively, mentally ill actively, and maybe not receiving care or adequate care, a family, a parent that's absent, maybe by death or incarceration or divorce. So those are some examples of what we mean by ACEs, and I'll go into what different studies have defined as ACEs and measured. So starting with in 1998, Vincent Felitti did a study using Kaiser patients, patients who were receiving their care through Kaiser, and he surveyed 8,500 adults on seven different experiences they had had during childhood, and these included psychological abuse or emotional abuse, physical abuse, sexual abuse, whether they had witnessed violence against their mother, whether they lived with household members who abused substances, live with household members who were mentally ill or suicidal, or live with household members who had ever been imprisoned. And then they looked at the outcomes, what sort of adult risk behaviors that they had engaged in, what their health status was, and then what kind of diseases they had been diagnosed with. And they adjusted their results for age, race, sex, and educational attainment. And before I show you the results, I want you to know that this sample was 80% white, the average age or the mean age was 56 years old, and 43% of the sample were college graduates. What they found was that over half of the respondents reported experiencing at least one ACE, and about a quarter had experienced, reported experiencing at least two ACEs, so average childhood experiences. In terms of outcomes, people who experienced ACEs were 1.4 to 1.6 times at increased risk of physical inactivity and severe obesity, two to four times at increased risk of smoking, to rate their health as poor, to have had over 50 sexual partners, and to have had at least one sexually transmitted disease. They were four to 12 times more likely to be suffering from an alcohol use disorder, a drug use disorder, depression, or have attempted suicide. In terms of the specific ACEs they reported and the prevalence of these ACEs, a little lower than what we'd expect for physical abuse and emotional abuse based on what we know in the literature, but really almost a quarter reported experiencing sexual abuse during childhood. The highest prevalent, most prevalent ACE was having a family member or a household member who had abused substances during childhood, but almost 20% also reported household mental illness, and then domestic violence was around 12%, and the lowest, least prevalent ACE was having a household member who had been incarcerated or wasn't involved in some kind of criminal behavior. Overall, like I said before, a little over half reported experiencing at least one ACE, and then about 5% reported experiencing at least four ACEs, and I'll explain in a little bit why the number four in terms of ACEs is important. So then the CDC, they had been already administering this survey called the Behavioral Risk Factor Surveillance System since 1984 where they surveyed on the health behaviors and health outcomes and service utilization in US residents since 1984, and then in 2008, they added ACEs. They started to survey on ACEs, and so between 2011 and 2020, they surveyed almost 265,000 residents, US residents, on eight different ACEs. So they included the seven ACEs from the Kaiser study or the Felitti study and added parental separation or divorce as an ACE, and they surveyed adults throughout all 50 states and the District of Columbia. In terms of their sample, before I show you the results, their sample also was about 80% white. About 86% of the sample was over the age of 35, and 38% were college grads. So really a sample, even though it's a national sample in the Felitti study, was more regional sample, a sample that was really similar to the sample in the Kaiser study. So here in the national sample that was surveyed using the Behavioral Risk Factor Surveillance System, there was much higher rates of physical abuse and emotional abuse, and this is more in line with what we would expect based on current literature and a lower rate of sexual abuse. Whether that's an accurate rate of what people care to report is always the question in terms of sexual abuse. You'll notice in terms of family dysfunction, the prevalence between the two different studies or surveys was quite similar. And then for the first time in this broad national sample, we have a sampling of parental separation or divorce as an ACE, and almost 30% of that sample reported parental separation or divorce as an ACE, and that was the second most commonly reported ACE behind emotional abuse. And then criminal behavior is, again, the least prevalent ACE in this sample. Overall, the prevalence of ACEs in that sample was over 60%, and that's the number you'll see most commonly cited in the literature, that over 60% of adults in the U.S. report experiencing at least one ACE during their childhood. For this sample, almost 20% reported experiencing at least four ACEs. So then in 2013, there was a Philadelphia Urban ACEs study because they wanted to look at whether there were some characteristics that people experienced in an urban setting versus kind of the more national, regional settings. Were there ACEs specific to living in an urban area? So they surveyed almost 1,800 Philadelphia residents, over 10 ACEs. So they add physical, emotional, and emotional abuse to the behavioral risk factor surveillance system questions. And then they also add questions related to the experience of living in an urban area, such as how much you trust your neighbors and you feel safe in your neighborhood, whether you had been exposed to bullying as a child or witnessed community violence, were you subjected to racism, and were you involved with the foster care system? In terms of their sample, their sample was more diverse, and I'll show you the results in just a second, 38% white, 36% black, 11% Latino or Hispanic, 6% Asian, 7% biracial, so definitely more diverse, 22 to 23% were college grads. And so in terms of the prevalence of ACEs in Philadelphia, they were very similar in terms of the interpersonal violence with the national study, the behavioral risk factor surveillance system. For the first time, we have this sampling of emotional neglect and physical neglect as an ACE, and these rates were lower than what we'd expect from what we know in the literature. Neglect is actually a higher, there's higher exposure to neglect during child and adolescence than there is abuse, usually. And then in terms of household dysfunction, those rates were pretty similar to the other two studies, and then criminal behavior was, again, the least prevalent ACE. Overall though, in Philadelphia, their residents reported over 80% of the residents had experienced at least one ACE during childhood and adolescence, and almost 40% had experienced at least four ACEs, so a big difference there. So those were all ACEs surveyed in adults, and if you notice, I was saying average age is over 35, 56 years old, why would we want to study ACEs during adolescence? Well, we know this is a very critical period of neurodevelopment, so brains are developing. And we also know that exposure to ACEs or any really type of traumatic experience or potentially damaging experience can activate toxic stress in any of us and impact neurodevelopment during this critical period of neurodevelopment. This is also a developmental period during which risk-taking emerges, so risk-taking is normal during adolescence, and we're looking at health risk behavior, so we should look at when these emerge and not 20, 30, 40 years later when the outcomes are more entrenched and hard to reverse. Also poor outcomes in multiple domains, such as an academic domain or in the carceral domain, those begin to emerge during adolescence, so it would be nice to intervene earlier. And then assessing the exposure to ACEs retrospectively during adulthood increases recall bias, so if you're asking people to remember something from childhood and they're 35, 45, 55, you're asking them to remember things that happened 30, 40, 50 years ago, it's harder to remember that than if you ask about things that maybe experienced within the past year or three years or maybe 10 years. Also because of the risk that comes with exposure to ACEs, people who have a higher burden of ACEs face premature mortality, so in our older adult population, it can seem like there were lower prevalence of ACEs, but really their colleagues have passed on because of their exposure to ACEs and toxic stress, and so it's not really an accurate assessment of ACEs to wait so long to ask about them. And like I mentioned, it's an opportunity to intervene early. If you listen to what some of the ACEs are, especially in terms of household dysfunction, if you're a parent and you have children and you're experiencing some of the outcomes of ACEs, such as substance abuse or mental illness, suicidality, then your conditions are actually ACEs for your children. And so if we can intervene during adolescence, hopefully before people have started the kind of childbearing and family process, then we can actually break the cycle of ACEs to some degree. So what do we already know about ACEs, and what am I looking at in particular? So first I'm going to show you data from the National Survey on Children's Health, which was done in 2016. This was a survey administered to the parent or caregiver with at least one child from birth to age 17 who was residing in the home with them. Approximately 45,000 people responded, and they were surveyed on nine ACEs that their child experienced. So these were parental separation and divorce, parental death, witnessing household violence, witnessing violence in the community or neighborhood, parental mental illness, household incarceration, household substance abuse, or racial or ethnic mistreatment, and an economic hardship. If you've been following along, you'll know that what's missing from this is any kind of child abuse, any kind of neglect. So those were not surveyed, so please keep that in mind as you look at the results. And I want to say for this sample, the 54% were non-Hispanic or white children. Their parents identified them as non-Hispanic whites. 73% of the parents had attended some college, and then 74% of respondents were from a metropolitan area, just so you have a point of reference. So we're going to compare this with the adult data that you've seen before, and again, we don't have any data for the interpersonal violence or the emotional or physical neglect, but you'll see really low rates relative to the adult data. Now you could say, well, the kids are young, yes, but we asked the adults in the other surveys to recall things that happened during childhood, and so the numbers should be similar. In terms of household, what's going on in the household, you have to remember we asked the caregivers, and so there could be some social desirability bias not to report some things that are happening in childhood, and maybe even some frank denial about what their kids may be experiencing or how it's impacting them. The rates of parental separation and divorce are one of the most prevalent ACEs reported in the National Survey on Children's Health, and that was a little above 20%. Even with that, our most prevalent is economic hardship, so families definitely reported that. In terms of household criminal behavior, it seems to be in line with the adult data, and then racial discrimination and community violence were low, even though 74% of the sample lived in metropolitan areas. In terms of the overall prevalence, it was almost 50% of parents saying that their child had experienced at least one ACE, and then they didn't ask about an accumulation of ACEs, so we don't have data from that particular study. What I do in my research, or what I've been working on, is getting data from the Global Appraisal for Individual Needs. This is actually a structured assessment. It's a standardized biopsychosocial assessment. It's comprehensive, and it's structured. It's used in clinical interviews. It can be used in research interviews. Its primary purpose is to support clinical decision-making, so diagnosis, treatment planning in terms of placement, to quantify the progress of treatment, and to document service utilization. It's been normed on adults and adolescents, and it's been used in over 500 agencies and research projects since 2003. The benefit is, other than being a clinical sample, is that it includes samples that are not accessed through household surveys or schools, so a lot of these population surveys are administered through households or schools, so you have to be housed, or you have to be attending school to be included in the sample, and so we can miss some populations. The GAIN has been used in student and employee assistance programs, criminal and juvenile justice agencies, mental health agencies, child protective services, family service agencies, and so it can pass a broader net. The GAIN was not designed to study ACEs, but it does capture eight ACEs, and those are physical abuse, emotional abuse, sexual abuse, domestic violence, familiar substance abuse, whether someone was raised with a single parent, so the question is, who has custody of you or who had custody of you during childhood? It does not, you cannot tease out whether the parent, you know, a parent was absent because of divorce or separation, death or incarceration, whether the child was homeless or ran away during the childhood period, or whether they were living below the poverty level, and So between the years of 2003 and 2018 the gain was administered to approximately 97,000 adolescents between the ages of 12 and 17. The median age was 15 and a half years and so that's the data I'll be presenting today. In terms of the sample, 40 percent of the sample identified as Caucasian, 19 percent Black, 21 percent Latino or Hispanic, 16 percent presented as other which includes people who identified with multiple races, and then one and a half percent each were our Asian Pacific Islanders and our indigenous teens. 71 percent of the sample was male and a little less than 28 percent, a little 29 percent was female and then a tenth of a percent identified as transgender. So in terms of the ACEs that people reported or adolescents reported using the gain, we see similar prevalences for interpersonal violence as we did with the adult data. The most prevalent ACEs were household substance abuse reaching almost 70 percent for the sample and then followed by economic hardship which is over 60 percent of the sample living below the poverty level and that's followed by parental separation or divorce which is about 50 percent of the sample. In terms of homelessness and running away, I wanted to point out that is almost 40 percent of the sample which is high and most of that data is driven by adolescents saying they had run away. The homelessness data was actually a smaller proportion of that. In terms of overall prevalence, almost 90 percent of this sample had experienced at least one ACE and in terms of four, experienced at least four ACEs, it's over 20 percent. The reason why four ACEs is important is if you read the literature, that is like the magic number or whatever the opposite of magic is because it's not good, it's the bad magic number where you start to really, your risk of all these poor health outcomes is much higher. So if we break it down by race, the data I just showed you, what is the prevalence by race and I'm going to go through this chart pretty quickly but I'll show you more specifically in the following charts. So you can see that the relative prevalences of these different ACEs, we see again a lot of familial substance abuse relatively low for our Black youth, really high for our Indigenous youth. Parental separation and divorce approaching 50 percent for most groups and really high for, relatively high for our Black youth. In terms of homelessness and running away, again higher than I think we would expect even for a clinical sample. Economic hardship really high and especially for our Black youth. Then overall, like I said before, the prevalence is really high across groups. It doesn't matter what racial group you were in for this sample, really high and again highest for our Indigenous youth. And in terms of experience at least for ACEs, there's a lot of variability there, around 20 percent like I said but lower for our Black youth and really high for our Indigenous youth. So here's going through it a little more slowly and also with, you know, so you can compare to the total sample, how different groups compare to the total sample. So physical abuse, emotional abuse, again really low or low report in our Black youth. Sexual abuse, really high in our, relatively high in our Hispanic or Latino youth. Domestic violence, also substance abuse. The prevalence of living with a single parent, again really high for our Black youth or relatively high I should say. Whether the kids were ever homeless or ran away, again I've looked at these numbers several times, I'm alarmed that it's 30 percent at the low end of things. And then prevalence of economic hardship, again much higher in our, or relatively high in our Black and Indigenous youth, followed by our Hispanic youth. And then overall, like everybody's, all these kids have experienced at least one ACE. Almost, it was 95 percent of our Indigenous youth, so almost 100 percent of them experienced something, which is really heartbreaking when you think about these are kids ages 12 to 17. And in terms of experiencing a lot of ACEs, over 35 percent of our Indigenous youth and a little over 10 percent of our Black youth, just for comparison, but overall approaching 25 percent. So across groups, what was the mean number of ACEs? I told you that four is the magic number. How did the groups compare? So looks low for our Black youth and our Asian Pacific Islander youth looks much higher, you know, approaching three as a mean for our American, our Indigenous youth. Again, this is a mean, and these kids are, the mean age is 15 and a half, so they're not 17 yet, they're not 18. So still some time to go to accumulate what we consider ACEs, you know, because you have until you turn 18 for it to be still considered an ACE. And maybe, you know, surprisingly high for our White youth, maybe more than we would expect. However, when you look at the mean age that the kids reported experiencing their first abuse, or not their first ACE, because some ACEs can start even at birth or before birth even, we count, we start from birth counting ACEs, but, you know, the mean age at first abuse, meaning physical abuse, emotional or sexual abuse, was higher for our African American and Black youth. So that may explain why the mean ACEs are lower, they just haven't had the time to accumulate as many, which sounds sad, but hopefully, you know, hopefully there's some intervention going on there or will be. And then the White youth started accumulating younger, so their age of first abuse is almost about a year and a half earlier than the Black youth in this particular sample. So what does this all mean? So in adult samples, they looked at, you know, health risk behaviors, health outcomes. We're going to look at outcomes that we know determine, like, what those health risk behaviors are and what, you know, what the outcomes are. So academic, how people do in school, how far they go to school is a social determinant of health, so we really want to know, how do ACEs, how are they associated with academic outcomes? We know that ACEs already has been found to be associated with poor engagement in school, so they're attending, but they're not really engaged in school, not doing homework, they're absent from school chronically, they have poor school performance, including on standardized achievement measures, they need special education interventions, they've been held back at least a grade, or they have increased behavioral problems, which makes it hard to learn if you're having a hard time regulating your behavior. So what were the prevalence of academic outcomes? This doesn't get at the association yet, so in terms of whether there were any indications of developmental disability, low-ish across the spectrum, relatively higher in the Black youth, a few more problems, reading and writing, especially for our Hispanic youth, some chronic absenteeism, high behavioral problems, which again is problematic in a classroom, makes it really hard to learn, whether the kids have been expelled or dropped out, approach 20%, which is quite high, and then whether they needed special education intervention, so as a sample, over 30% of them needed that, our mixed race group was that needed them the most, and then this is really high, whether they're behind at least one grade, so the mean grade that the this population had completed was less than ninth grade education, and remember I told you they were 15 and a half, so they should be kind of going into 10th grade-ish, and they're not done with eighth grade yet as a group. So since special education interventions was one of the most prevalent academic outcomes, what can we look at in terms of association with ACEs? So I'm going to show you these, and then I'm going to point out what's most prevalent in the Black youth, because this is what this talk is focused on, so for our Black youth, there were strongest associations between special education and having experienced physical abuse, having experienced homelessness or running away, familial substance abuse, emotional abuse, and domestic violence in order of kind of how likely it was, and in terms of likelihood ratio, we're comparing Black youth who had the ACE with Black youth who didn't have the ACE, and kind of how much more likely the kids who experienced ACE had a special education intervention or vice versa, and so you can see for physical abuse, the Black youth who experienced physical abuse were 77 times more likely to need special education intervention, so that's how this statistic is working. For our Black youth, there was not an association between needing special education intervention in sexual abuse or with living with a single parent, and overall across the whole sample, there was no association between needing special education and poverty. Now in terms of being behind one grade, because we saw that that was highly prevalent across all groups, what was that associated with in terms of ACEs? Again, I'll show you this data for all the groups, and then I'll tell you for Blacks, being behind one grade was associated with the age they first experienced abuse, emotional abuse, and then approach significance for living with a single parent or ever being homeless or running away is not associated with being physically abused, familial substance abuse, or poverty, and there was no association for any group between being behind at least one grade and sexual abuse, although it did approach, the association did approach significance for our White youth. So remember for our Black youth, living with a single parent, that was relatively high for that group, so we want to look at what outcomes were most strongly associated with this ACE for our Black youth, and so I'll show you for all the youth, and then I'll tell you that for our Black youth, living with a single parent was most strongly associated with the last grade or highest grade completed. You'll see those two different, those distinguished in the sample, but it's because they sample kids from as young as really 10 all the way up to adults, older adults, and so the highest grade completed includes whether you completed a GED. That's not really pertinent for our youth, and so you'll see both of those there, but for our youth, they're really very similar measures, and so for Blacks, those were associated. Living with one parent or a single parent was not associated with increasing behavioral problems for our Black youth or cognitive impairment score, absenteeism, or whether they needed special education interventions, and then for across the whole sample, there was no association between living with a single parent and having an indication of a developmental disability, problems reading and writing, or although the White, our White youth approached significance being expelled or the number of times you were expelled, the number of days you were in trouble at school, or the number of days you were expended or suspended, or any kind of evidence of cognitive impairment. Now, also, our Black youth, there was a high level of academic hardship or poverty in the sample, but for our Black youth, it was relatively high, so let's look at kind of what academic outcomes were associated with poverty, and for our Black youth, it was really that either the last grade or highest grade you completed. There was not associations with the other academic outcomes, like being expelled or dropping out of school, how many days you got in trouble, how many days you missed school, whether you were behind at least one grade or absenteeism, and across the whole sample, there was no association between poverty and whether you had problems reading or writing, indications there was a developmental disability, whether you needed special education interventions, whether you had a lot of behavioral problems, how many days you were suspended, or how many times you were expelled, or any kind of evidence of cognitive impairment or your cognitive impairment score. Now, we also want to look at accumulation, because it's not just which ACEs you experienced and whether you have poor outcomes, but it's also like your accumulation of ACEs, because there is a strong ghost response that's been reported consistently in the literature, so I'll show you all of these, and for you people who like numbers, like me, you can see the numbers. I'll tell you, though in shorthand, so you don't have to read if you don't want to, is that for our Black youth, the number of ACEs you experienced was highly associated with having a lot of behavioral problems at school, cognitive impairment, your cognitive impairment screen, the result of your screen or score, the highest or last grade you completed, having problems reading and writing, whether you needed special education interventions, and absenteeism, so while, you know, specific ACEs like poverty or living with a single parent may not have done it, if you start to accumulate ACEs, that'll do it for you. In terms of what Black youth didn't have a strong association with as they accumulate ACEs, it was being behind one grade in school, the number of days they got in trouble, whether they were expelled or dropped out, any evidence of a developmental disability, evidence of cognitive impairment, or the number of days they missed school, and in the interest of time, I'll show you that whether you reached that threshold of four was pretty similar. I'm not, you can, since you can download the slides, I'll let you go through these later so we have more time for questions. So let's move on to the substance use outcomes and how these are associated with experiencing ACEs, so same sample, and what we looked at was really, we looked at it ecologically, so where were your exposures? Were you aware of drug use and alcohol use in the home? Was it a problematic drug use or alcohol use in the home, so becoming intoxicated? Was that that kind of use or your awareness of that use in a social setting, school setting, and then your own use? So were you using daily? Were you using most days, most of the day on most days? Were you using in risky settings like you're actually using at school or work? And then whether you met criteria for DSM-4 or DSM-5 use disorder or substance dependence or DSM-4 abuse, and so I'm going to show you the just kind of relative prevalences quickly and show you like recent drug use was really amongst your social peers was really high in this group. These are just outcomes, these are not the ACEs yet, and then you know daily use for 30 percent of our sample is pretty high. Heavy use is even more prevalent. It was risky use, and then lifetime dependence for the total sample approached 50 percent. Remember these are 12 to 17 year olds. For our Black youth, it was over 30 percent, and then lifetime abuse was lower probably because of the time frame in which it was measured. We stopped using terms like abuse independence with DSM-5 in 2013. So in terms of recent drug use among social peers, you'll remember that that was one of the most prevalent outcomes. I'll show you the these data but then tell you that for our Black youth, being aware that your peers, your social peers, had used drugs recently was associated with the mode of substance use, whether you'd ever been homeless or run away, whether you witnessed domestic violence, or you've been subjected to physical emotional abuse. It was not related to or associated with your age at first abuse or poverty, and then for all of our groups across the whole sample, there was no association between recent drug use among social peers and sexual abuse, although this did approach significance for our Hispanic youth, whether you lived with a single parent, although it approached significance for our Black and white youth. And so moving on to daily drug use, that's something where an outcome we're interested in. Obviously we don't want kids using drugs daily. It's normal to experiment. It is not normal to use drugs daily. And so again, I'll show you the numbers, but in terms of our Black youth, in the interest of time, daily drug use was associated with most strongly with homelessness or running away, familial substance use, physical abuse, emotional abuse, sexual abuse, and domestic violence. It's not associated with living with a single parent. So if you were Black youth and you used drugs daily, that was not associated with living with a single parent. And then there was no association for any of the groups between daily drug use and the age at which they first reported experiencing physical, emotional, sexual abuse. In terms of living with a single parent, we're going to look at this across all domains because these were the most prevalent ACEs for our Black youth. And so what was that associated with in terms of substance use outcomes? Very little for our Black youth. So you see there are a lot of outcomes we looked at. And for our Black youth, the strongest association was really with the severity of alcohol use, whether they were aware of drug use in the home and weekly intoxication in the home, and that's it. Everything else, there was no association between living with a single parent and these substance use outcomes if you were Black youth. In terms of poverty, again, another prevalent ACE for our Black youth. I'll show you the data so you can look at while I tell you how our Black youth, oops, sorry, fared. And for our Black youth, poverty was not associated with any of the substance use outcomes. So if there are substance use outcomes, at least for this sample, it was not because kids were living below the poverty level. Now, where are we in terms of accumulation of ACEs and substance use outcomes? Again, there are a lot of these. I'll just show you these so you can look at them. And then as you're looking at them, I'll let you know for our Black youth, accumulating ACEs was associated with these outcomes, lifetime substance dependence, whether your social peers were becoming intoxicated weekly, whether there was weekly intoxication in the home, and then the number of drug problems that you had. Those were the most strongly associated ACEs with an accumulated ACEs. And very similarly for high ACEs. And so because you can download the slides, excuse me, I'll let you look at these more closely later so we have ample time for questions. Now, getting to my favorite subject, because I really care about our kids being incarcerated and whether that's the appropriate place for them, my answer is no. Let's talk about the carceral outcomes and kind of wind down the talk so we can get into discussion and questions. So what outcomes did we look at? We looked at whether they had been arrested in the past 90 days, and you can see that's pretty high. This is a clinical and research sample. Overall, over 40% of our youth have been arrested in the past 90 days, 50% of our Black youth. And then these are just kind of the stages they were in the process. So whether they were awaiting trial, out on bail, awaiting sentencing, detained, many of the kids were on probation, some of them were assigned to alternative or diversion program. But overall, almost 80% of the total sample have been involved in the carceral system in their lifetime. This is a short lifetime because these are adolescents, over 80% of our black youth. Number of arrests, relatively low. It's their kids though, so I think any number of arrests is high. So around two-ish is the mean. Number of convictions around a little over one. The age at first conviction is a little less than 15. So it's been a little less than a year between when they were convicted and then when we saw them, where they assessed using the gain. And then just so you have kind of an idea of the distribution of the types of drugs that these teens reported committing, this is the spread between drug crimes and any other crime that wasn't interpersonal or property. And then the interpersonal crimes and property crimes. And you'll see, this is about what we'd expect for teens. Like there are a lot of property crimes, less interpersonal crimes, which is great because there's a high burden of, you know, interpersonal violence perpetrated onto them. So it's good to see that that's a lower number, although we'd love to see none. And then there's, you know, some drug and other crimes. In terms of the total crimes, you'll see that, you know, the mean number of crimes reported across the sample, that these are teen self-reporting, was 25. It was lower for our black youth and highest for our mixed youth. There is some concern in this slide that the blacks reporting less crimes, but they have the highest prevalence of recent arrests and highest prevalence of lifetime carceral system involvement. So definitely some evidence of disproportionate by minority contact there, I think. And so in terms of recent arrests, which is one of the most prevalent outcomes, what was that associated with? Again, just like before, I'll show you all the data. And again, don't worry or stress, you can look at this later. But I'll tell you for our black youth, being arrested within the past 90 days was most strongly associated with living with a single parent, the age at which you first reported being abused, ever being homeless or running away, and whether you had been abused, so physically, emotionally, or sexually. It was not associated with witnessing domestic violence, whether there was familial substance abuse or the accumulation of ACEs, so number of ACEs or high ACEs. And for any of our groups, there was no association between being arrested and poverty, being arrested recently in poverty, although for our Hispanic youth, this did approach significance. And then lifetime carceral system involvement, you'll remember was a really prevalent ACE across the whole sample as well. So let's look at that for the whole group, and I'll talk to you about where we are with our black youth. And so for our black youth, this was most strongly associated with how many ACEs you had accumulated, followed by living with a single parent, the age at which you first reported abuse, and whether you had accumulated a lot of abuses, so more than four, whether you had ever been homeless or ran away, and then physical and sexual abuse. It's not strongly correlated, or there was no association, significant association with emotional abuse, with witnessing domestic violence, or whether there was substance abuse in the home. And then for none of our kids, this is interesting to me, that there was no association between lifetime carceral system involvement and poverty. So when I'm interacting with our youth in the juvenile carceral system, always wondering what have we criminalized? What are we really punishing? According to this data in this sample, they are not being punished for poverty, although there are some sequelae of poverty that could be, you know, that we're looking at in this sample. In terms of what was most prevalent, the most prevalent ACE for our black youth, so we're looking at association between living with a single parent and carceral outcomes for our black youth. So this is how they compare to the larger sample, but for our black youth, living with a single parent was most strongly associated with the number of times they've been arrested, whether they had been arrested recently, the number of times they've been convicted, and whether there was lifetime carceral system involvement. Living with a single parent for a black youth was not associated with the age at which they were first convicted, or the number of type of crimes they reported committing in the past year. And across our whole sample, there was no significant association between living with a single parent and the total of drug crimes or interpersonal crimes or property crimes. In terms of poverty, again, highly prevalent amongst our black youth in this sample, lots of associations across the board, but for our black youth, the only outcome, carceral outcome it was associated with was the number of drug crimes they've committed, they reported committing in total. Whether they were currently detained approached significance. It was not associated for a black youth with the age they were first convicted, the number of property crimes or drug crimes they committed in the past year. And across our whole sample, there was no significant association between poverty and the number of arrests or convictions, whether youth have been arrested recently, the number of interpersonal crimes they reported in the past year, although for our white youth, it approached significance. The total number of interpersonal crimes they reported or property crimes and then lifetime carceral system involvement. Now coming into the home stretch, we're looking at significant associations between accumulation of ACEs, so number of ACEs. And so what was this for our black youth? For our black youth, a number of ACEs was most strongly associated with the number and type of crimes they reported committing lifetime carceral system involvement. And then it approached significance for whether they've been arrested recently and the number of times they've been arrested, but not significantly associated with the age at which they were first convicted or the number of convictions they reported. And then for high ACEs, where they met that threshold, really the same associations for our black youth, number and type of crimes, lifetime carceral system involvement and approached significance for a number of arrests and not associated with the same. The data are not really different. The associations are not as strong though. Finally, early intervention. What do we do about all this? So first, you're probably asking the question, well, this is cross-sectional data. You assess the kids at, or someone assess these kids at intake. We don't really have a longitudinal picture, do we? We got to do though. So first I want to say, this is the age, just for point of reference, which this sample reported experiencing their first mental health problem. It is around 10 years old for our sample. The age at which they first reported being abused was a year or two later for our sample. So between as a sample 11 and a little older than 12. So a year there. And then they first become intoxicated about a year later across the sample. So around age 13, they're convicted around age 14. And then we're assessing them around age 15 and a half. So I want you to look back and see maybe if we started assessing for mental health problems when they are reporting that these are emerging, we can maybe prevent delay, slow the cascade. I would like to hope. So I want you to remember, if you don't remember any of the slide in this talk, that we have time. Five years is not a small amount of time to be doing things to help our kids' brains develop, give them a shot at how tough it is to live in our country. So early intervention. These are my ideas. I'd love to hear yours. Screen routinely. We have a lot of ways to screen. There's a pediatric ACEs and related life events survey, a tool that you can use. The thing about the PEARLS is it comes with a training called ACEs Aware that teaches you how to ask questions so that you don't get into this quandary of mandated reporting that can deter some people who are mandated reporters from asking about ACEs and so that we have accurate numbers. The thing I don't like about PEARLS is that it depends on the caregiver report. So there's that, but there is a way to ask about ACEs without igniting mandated reporting. I'm not totally against mandated reporting. Well, reporting in general. The mandated part is controversy, I know, but our kids do need protection. We just have an imperfect system for protecting and it is biased. So I want to own that. We should be doing mental health screenings by age 10 wherever our kids intersect with the systems because if they're reporting those are happening, then why wouldn't we try to get them connected with services five years earlier than this clinical national sample was able to connect the services? And then we need to engage multiple systems of care and I use care in quotes because I don't know that all systems care, but our kids interact with so many systems. So we should engage them all. So schools, why can't schools screen for ACEs and know what the ACE burden is in their school and be able to do trauma-informed education, really help our kids with maybe high behavioral problems, be able to engage in their education and really understand that they're not just, there's not just these educational interventions. We really need to address the kids' home environments and so that they can connect in school. Obviously our pediatricians should screen for ACEs and I think our pediatricians are leading the way here, but we need it more kind of universal and routine screening for ACEs. I recently watched a documentary. I'm not going to give it a plug, but I will say that there is something in the information in documentary and I remember this from medical school that we were trained to assess pain as the fifth vital sign and that that was really employed by the kind of pharma, by the pharmaceutical industry to push opioid prescriptions. Well, we don't have to talk about that today. This is not the topic of this webinar, but we can think about ACEs as a fifth vital sign because they do determine things. They're just as important as knowing someone's blood pressure or heart rate, how their cardiovascular system is functioning because it is going to impact their cardiovascular outcomes. So I would argue for someone's ACE score as a vital sign that providers are aware of as they're doing interventions. Obviously, I think our child welfare system should be screening for ACEs and know what kid's ACE score. Our carceral system, if they're going to enter the carceral system, we need to know what the ACE burden is. It can be used in terms of primary, secondary prevention of substance use. We know what they are for a lot of different groups and so we can definitely intervene there to prevent the health outcomes such as liver disease and heart disease that come from chronic substance use. And then there's a thing called positive childhood experiences. And I'm thankful that the game did assess for these. I'll be able to analyze data, but these are things like having an adult, a trusted adult in your life. There are other things that happen in the environment that really help a kid thrive. And so we can look at the mitigating factors of positive childhood experiences. We're all, you know, like if you're attending this talk, you're an intelligent person. And there's a lot of intelligent people in our country. And yet we have a long way to go to figure out things like poverty and homelessness, unfortunately. But I think we easily can adapt positive childhood experiences to mitigate the outcomes in the domains I've talked about to you today. With that, I will stop talking. I will let you ask questions. Oh, actually I will say this. I think we can think about funding prevention and early intervention over funding our carceral system. I'm not saying defund the carceral system. I think we do need a way to punish people, deter people. I don't know that it looks like a prison, but, and that's a different talk, but we should think about funneling the money towards prevention and early intervention to keep our kids out of the carceral system. There, I'm done. Some references and time for your questions. I don't want you to be done. I don't want you to be done. Thank you. Not at all. Not at all. As someone that has been working with people on death row for the last 35 to 40 years, I am so moved by so many things that you said. But one thing that I really want to tell you, when you say kids, it really moves me. You know, they're not children, they are kids, right? And for you to recognize that and understand that that's where it starts is so very, very important. So let me see if we have any questions. I think we have a couple of questions. Do we have any questions? Violet, I cannot see the, I cannot see the question. It looks like we don't have any yet. Okay, so then let me ask them. Okay. So, Dr. Gillis, so you gave us a brief view of what got you into thinking about this. One of my areas is really intellectual disability. And I looked through, as you were looking at it, where it really points out, you know, the impact of cognition. Can you tell us more about how you see cognitive deficits and where are they embedded in your thinking? Yeah, yeah, and I'd love to, you know, my research map for my career is really getting at what changes are happening in the brain that really, you know, kind of lead to these cascades and can we intervene before that point? And so I think it has to do with the toxic stress that I mentioned just briefly and how, you know, that's mediated through our HPA axis, our hypothalamic pituitary adrenal axis and really impacts areas of the brain that are trying to develop. And that includes our cognition. So definitely the HPA axis, you know, chronic stress, increased exposure or prolonged exposure, I should say, to cortisol really impacts our hippocampus functioning. If we can't remember things, then we have a hard time learning. We have a hard time engaging cognitively. You know, I'm torn when I'm doing analyses. I wanna know the answer so that we can intervene, but I also would be heartbroken to see and realize in the course of my research that we are, that these ACEs have impacted kids' cognition so early. And so I'm torn. I'll say that that's my theory and remains to be seen, but I will be doing that. I'm actually at a neuroscience, developmental neuroscience conference today myself. So I'm engaging in more learning to understand how we get at the cognitive impact of ACEs on our kids' brains. Well, you know, I think the relationship between the ACEs and the social determinants of health on our kids' brain, right? I think one of the things that's really so beautiful now, probably poor choice of words, but for us nerds, it kind of makes a lot of sense, is that these social determinants of health are in fact, they are not just sociological. They are impactful and they are directly impactful and they are directly impactful genetically. I mean, what you eat is literally what you become. Right, right? Absolutely, absolutely. How you sleep are literally what you become. And so the question of poverty and the discussion and association between poverty, I think it would be interesting to see when you were able to break that down, if you were able to break that down and really kind of dissect, well, what do you mean by poverty? You know what I mean? And are there perhaps certain specific areas that are impacted by poverty? Nutrition, for example. Absolutely. That speak to it more greatly, right? Absolutely, absolutely. Yeah, I don't know that I'll be able to do that with the gain sample. I may be able to. They surveyed 8,000 data points for each participant. So that's huge. So it may be buried in there, but I think it's a larger question. So I don't care what the data set is. You're right to get at the context of these things. That's one thing that we can't get at with just asking someone about ACEs is the context. Like, we hear a lot of information about how it's so negative to live with a single parent, but it doesn't ask about in this sample context of maybe you had other family members actually in the home supporting, and maybe that's why some outcomes were better than others. And so there were some surprises there, and it definitely, I was surprised by the data, especially for some groups relative to other groups, but I think you're right. Like, context matters. What does poverty really mean? Just because you live beneath the poverty level, what does that mean? Like, what does that picture look like? And what do you have access to and don't have access to? So unfortunately it's one o'clock. I think we have to stop. For those that are in, please complete the Pulse event survey. You can visit the link or use the QR code. The upcoming seminar will be September 13th from three o'clock to four o'clock Eastern time, Justice Involved Youth and Juvenile Competency to Stand Trial. The speaker will be Dr. Kiana Andre-Tigre, MD, PhD. And I really want to encourage people that are interested in justice-involved issues to look at this one. One of the things that we're working with here in Northern California are the cognitive aspects of competency rather than what we've always thought about is it psychosis? Without really taking into consideration how does cognition impair competency as well? So I think that'll be a very interesting conversation. Dr. Gillis, really a pleasure for you and I, the first of many. So I really appreciate you coming on today. And thank you very much. Thank you.

adverse childhood experiences

ACEs

adolescents

African American youth

neurodevelopment

prevalence

academic outcomes

substance use

carceral system

early intervention