Childhood Adversity & Trauma A Life Course Perspective for

Prevention & Healing

Roberta Waite, EdD, APRN, FAANAssistant Dean of Academic Integration and Community Programs

Patricia Gerrity, RN, PhD, FAANAssociate Dean for Community Programs

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session # C4October 29, 201110:30-11:15 AM

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources

What is the scientific basis for this talk?

The experiences of abuse and family dysfunction in childhood significantly shapes an individual’s future physical and mental health. These cumulative experiences are referred to as adverse childhood experiences (ACEs).

Empirical data confirms the important role that ACEs have in increasing risk for many health conditions however public health and clinical practice has not proactively implemented evidence based interventions to address the problem.

Objectives

• Identify common adult health outcomes that are correlated with adverse childhood experiences (ACEs)

• Describe the role health care providers play in recognition and referral for treatment of person's affected by ACEs

• List patient treatment interventions that can be useful in helping individuals affected by ACEs

• Identify how organizational culture influences response to care among patients who have experienced ACEs

Expected OutcomeWhat do you plan for this talk to change in the

participant’s practice?

• Assess and recognize that ACES are preventable and treatable • Address the life course and transgenerational effects of trauma• Treat root causes of many physical and mental illness and

destructive health behaviors• Organizational trauma informed care

Understanding ACEs from a life-course perspective promotes understanding how early-life experiences can shape health across an entire lifetime and potentially across generations.

Eleventh Street Family Health Services of Drexel University

in partnership with Family Practice and Counseling Network

WHAT ARE THEY?

An Overview About ACEs

What do we mean by ACEs?

Experiences that represent health or social problems of national importance, such as:

• Emotional/Physical Abuse• Sexual Abuse• Emotional/Physical Neglect • Domestic Violence – Battered Mother• Single Parent Homes – Due to Separation/ Divorce/Death• Substance Abuse - One or Both Parents • Incarcerated Parent(s)• Parent(s) Suffering From Mental Illness• Parent(s) Suffering From Chronic Illness

Chapman, Whitfield, Felitti, Dube, Edwards, & Anda , 2004

Why look at ACES?

They’re a strong influence on how we develop and what we become as individuals, as communities, and as a nation

Social

ACES can impact individualsalong this trajectory

Example: Children exposed to violence often grow up to become victims of violence. Some may also inflict violence on others

http://www.acestudy.org/Kaiser Permanente Medical Group

Centers for Disease Control and Prevention (CDC)

The largest scientific research project of its kind to date

A decade long ongoing collaboration led by: Vincent J. Felitti, MD Robert F. Anda, MD, MS

Analyzing the relationship between multiple categories of childhood trauma and health and behavioral outcomes later in life.

Adverse Childhood Experiences Score

Number of categories adverse childhood experiences are summed …

ACE score Prevalence 0 48% 1 25% 2 13% 3 7%4 or more 7%

More than half have at least one ACE

(Anda et al., 2009; Edwards, Holden, Felliti, & Anda, 2003; Felliti et al., 2002)

Health problems in Adults Increased with Exposures to Adverse Experiences in Childhood

The HEALing Project

Roxana Arango

Dr. Patricia Gerrity

Dr. Roberta Waite

Reeva Gupta

    Women (n=647) Men (n=154) Total (n=801)

Category of ACE   % % %

Abuse Emotional 16.7 16.8 16.7

  Physical 35.1 45.8 37.2

  Sexual 35.3 18.1 31.9

         

Neglect Emotional 59 57.4 58.7

  Physical 35.6 36.8 35.8

         

Household Dysfunction Battered Mother 25.5 28.2 26.1

  Parental Discord/Divorce 56.2 59.4 56.9

 Mental Illness in Household 36.7 37 36.7

 Household Substance Abuse 50.4 55.8 51.4

 Incarcerated Household Member 33.2 50.6 36.6

Original Study vs 11th St Results

Number of Adverse Childhood

Experiences (ACE Score) Women Men Total

11th Street Patients

Original Study

11th Street Patients Original

Study

11th Street Patients Original

Study

0 6.8% 34.5% 3.9% 38.0% 6.3% 36.1%

1 12.5% 24.5% 9.9% 27.9% 12.0% 26.0%

2 18.5% 15.5% 14.5% 16.4% 17.8% 15.9%

3 14.6% 10.3% 16.4% 8.6% 14.9% 9.5%

4 or more 47.5% 15.2% 55.3% 9.2% 49.0% 12.5%

WHAT ARE THEY?

Adult health outcomes that are correlated with ACEs from the

HEALing Project

ACE vs. Feeling Depressed or “Down in the Dumps”

ACE vs. Ever Attempted Suicide

ACE vs. Ever Used Street Drugs

Early Death

Disease, Disability

Adoption of Health-Risk Behaviors

Social, Emotional, and Cognitive Impairment

Adverse Childhood Experiences

Death

Birth

The Influence of Adverse Childhood Experiences Throughout Life

ACE’s Major Determination of Health & Well Being (Felitti, 2003)

WHAT ROLE DO THEY PLAY IN RECOGNITION AND REFERRAL FOR TREATMENT OF

PERSON'S AFFECTED BY ACES?

Health Care Providers

ACES: Implications for Clinical Practice• Problems that come into the clinic are complex and providers

should be aware of the link between those problems and ACEs– Redefine ‘resistence’ ‘non-compliant’

• In all stages of the encounter – assessment & evaluation, treatment plan – providers must avoid easy answers

• If the problems are complex, why would the solutions be simple?

Implications for Clinical Practice

How do I think broadly about my patient(s)?How do I think broadly about my patient(s)?

Can I put myself in my patient’s shoes?Can I put myself in my patient’s shoes?

Do my interventions empower?Do my interventions empower?

Implications for Practice and Interventions

These findings are particularly relevant to integrated care and wellness programs and practices. They reveal the need to address trauma as central to the health and well-being of people across a very wide spectrum of problems.

Pay attention

Get out of our comfort zone and explore the possibility of prevention

Overcome lack of knowledge – our own and others

Overcome our fear

Speak out and end silence about the role of ACEs in serious health, mental health, and social problems of all kinds.

Stop treating symptoms and treat the cause

Do a better job of routinely screening at the earliest point for ACEs. Identify cases early and allow treatment of basic causes rather than vainly treating the symptom.

WHAT CAN WE DO…….

Integrative Health Care

To create a seamless engagement by patients and caregivers of the full range of physical, psychological, social, preventive, and therapeutic factors known to be effective and necessary for the achievement of optimal health throughout the lifespan.

Integrated Team

• Family nurse practitioner• Primary behavioral health consultant

– Child & adult– Couples & Family Therapist- energy psychology

• Generalist social worker• Health educator/nutritionist• Complementary & integrated therapist• Physical therapist• Creative arts therapists

Traditional Care

•What is wrong with this person?

Integrated care

Who is this person?What has happened to this person?

Ethical Imperative for Screening

• Many clinicians are reluctant• Not disclosure by itself that results in harm,

but rather negative responses the person receives when disclosing trauma

• Need to be prepared to provide referral sources and respond in a supportive manner

• Individuals are grateful to know that others care about these issues

Finding Your ACE Score

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often or very often…Swear at you, insult you, put you down, or humiliate you? orAct in a way that made you afraid that you might be physically hurt?

Yes / No If yes enter 1 ________

2. Did a parent or other adult in the household often or very often…Push, grab, slap, or throw something at you? orEver hit you so hard that you had marks or were injured?

Yes / No If yes enter 1 ________

3. Did an adult or person at least 5 years older than you ever…Touch or fondle you or have you touch their body in a sexual way? orAttempt or actually have oral, anal, or vaginal intercourse with you?

Yes / No If yes enter 1 ________

Finding Your ACE Score continued….

4. Did you often or very often feel that …No one in your family loved you or thought you were important or special? orYour family didn’t look out for each other, feel close to each other, or support each other?

Yes / No If yes enter 1 ________

5. Did you often or very often feel that …You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? orYour parents were too drunk or high to take care of you or take you to the doctor if you needed it?

Yes / No If yes enter 1 ________

6. Were your parents ever separated or divorced? Yes / No If yes enter 1 ________

Finding Your ACE Score continued….

7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or Ever repeatedly hit at least a few minutes or threatened with a gun or knife?

Yes / No If yes enter 1 ________

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes / No If yes enter 1 ________

9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

Yes / No If yes enter 1 ________10. Did a household member go to prison? Yes / No If yes enter 1 _______

Now add up your “Yes” answers: _____ This is your ACE Score.

The ACEs Scoring Method

• Exposure to one category (not incident) of ACE, qualifies as one point.  

• An ACE Score of 0 (zero) would mean that the person reported no exposure to any of the categories of trauma

• When the points are added up, a total ACE Score is provided.   

• The ACE Score represents the cumulative effect of multiple exposures.

http://www.acestudy.org/files/ACE_Score_Calculator.pdf

WHAT CAN BE USEFUL IN HELPING INDIVIDUALS AFFECTED BY ACES?

Patient Treatment Interventions

Interventions to Treat Traumaat 11th Street

• Outpatient behavioral health• Primary behavioral health therapists• Couples & Family Therapist

– EFT– EMDR

• Creative Arts Therapies ArtMusicMovement

• Trauma Recovery & Empowerment Groups• Trauma informed yoga

EMDR

Art Therapy

Yoga

Life Course Perspective

• The life course approach to conceptualizing health care needs and services evolved from research documenting the important role early life events play in shaping an individual’s health trajectory. The interplay of risk and protective factors, such as socioeconomic status, toxic environmental exposures, health behaviors, stress, and nutrition, influence health throughout one’s lifetime.

Visit for Mother and Baby

Early Programming

• Early experience can program an individual's future health and development

• Prenatal- exposure in utero• Intergenerational-health of mother prior to

conception• Adverse programing can directly result in a

condition or make one vulnerable or more susceptible

HOW DOES IT INFLUENCE RESPONSE TO CARE AMONG PATIENTS WHO HAVE

EXPERIENCED ACES?

Organizational Culture

Trauma Informed Care• Dr. Sandra Bloom- international expert on trauma

• Trauma-informed cultures understand it has broad and profound impacts‚ and the very diverse way in which people cope with and recover from traumatic events impacting the way that people think and act.• Example: Safety‚ trustworthiness‚ choice‚ collaboration‚ and

empowerment are core to TIC.• Providers don’t’ ask “what is your problem or what is wrong with

you” instead ask “what has happened to you and how have you dealt with it.”

• Providers don’t say‚ “Here’s what I can do to fix you‚” instead ask‚ “How can you and I work together to achieve your goals of recovery and healing?”

Trauma Informed Care

• All members of an organization must experience these same core TIC concepts

• Staff can only create a setting of and offer relationships that are characterized by safety‚ trustworthiness‚ choice‚ collaboration and empowerment only when they experience these same factors in the organization as a whole.– Example. Trustworthiness. Can staff trust each other and the program

supervisors and administrators?– Do staff exert some control over how they accomplish their task? Is

creativity valued? – Collaboration. Do administrators actively seek and take seriously staff

ideas about the program and empowerment? Do staff feel valued? Do they have resources to do their jobs well?

Health center seen as a safe place in the comunity

Implications - Research

Individual

Systems

Policy

Environment

Culture

Programs

and

Outcome Measures

•Asking the questions that will have impact •Importance of moving beyond the clinic into the community community based research•Transdisciplinary problems require transdisciplinary partners and teams

•Asking the questions that will have impact •Importance of moving beyond the clinic into the community community based research•Transdisciplinary problems require transdisciplinary partners and teams

Hays-Grudo (2008)Hays-Grudo (2008)

SummarySummary• How we define ACEs– how we understand them ultimately

impacts how we decide to ‘solve’ them• For medical providers, 99% of effort in learning is oriented to

BIOLOGY, which is fine, however biology is LINKED to social context and determinants

• It’s important to let go of the individualistic models of blame – and widen our scope of analyses and treatment. Become a part of the emerging future care for communities and patients.

• In a medical home model, such as 11th street, there is a team of people – all with different areas of expertise and knowledge that work collaboratively

“ You don’t have to know everything – just accept different possibilities”

Resources

• Chapman DP, Dube SR, Anda RF. Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals. 2007; 37(5):359–364.

• Corso, PS, Edwards, VJ, Fang, X, Mercy, JA.. Health-related quality of life among adults who experienced maltreatment during childhood. Am J Public Health, 2008;98:1094-1100

• Dong M, Anda RF, Felitti VJ, Williamson DF, Dube SR, Brown DW, Giles WH. Childhood residential mobility and multiple health risks during adolescence and adulthood: the hidden role of adverse childhood experiences. Archives of Pediatrics and Adolescent Medicine. 2005;159:1104-1110.

• Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB. Cumulative childhood stress and autoimmune disease. Psychom Med. 2009;71, 243-250.

• Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. The Impact of Adverse Childhood Experiences on Health Problems: Evidence from Four Birth Cohorts Dating Back to 1900. Preventive Medicine, 2003;37(3):268–277.

• Edwards, VJ, Holden, GW, Anda, RF, & Felitti, VJ Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences (ACE) study. American Journal of Psychiatry. 2003;160(8):1453-60.

• Edwards, VJ, Dube SR, Felitti VJ, Anda RF. It's OK to ask about past abuse. American Psychologist. 2007; 62(4):327–328.

• Felitti VJ, Anda RF, Nordenberg D et al. The relationship of adult health status to childhood abuse and household dysfunction. This issue American Journal of Preventive Medicine, April 1998

• Herman J. Trauma and Recovery. NY: Basic Books 1992.• Read, J & Fraser, A Abuse histories of psychiatric in-patients. To ask or not to ask? Psychiatric Services. 1998; 49,

355-359.

“The truth about childhood is stored up in our bodies and lives in the depths of our souls. Our intellect can be deceived, our feelings can be numbed and manipulated, our perceptions shamed and confused, our bodies tricked with medication, but our soul never forgets. And because we are one, one whole soul in one body, someday our body will present its bill.”

Alice Miller

What society does to its children,its children will do to society.

~Cicero, 106-43 B.C.E.

IF you don’t deal with trauma, trauma will deal with you.

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