From Overwhelming Adversity to Medical School and Beyond – Why

Communities Matter

As Told Through My Patients ‘ Stories

Together we can help every child realize their Hopes and Dreams

and Most Importantly Their Fullest Potential

“There is no trust more sacred than the one the world holds with children. There is no duty more

important than ensuring that their rights are respected, that their welfare is protected, that their

lives are free from fear and want and that they grow up in peace”

Kofi A. Annan

Why is It Important for all of Us To Consider Trauma

• Trauma has a widespread impact on people and understanding trauma leads to potential paths for recovery

• Recognizing the signs and symptoms of trauma in congregations, families, staff in organizations, patients and others allows trauma to be addressed

• Understanding trauma allows us to be integrate knowledge and compassionate in our interaction with others and ourselves

• To actively resist re-traumatization of people.

SAMHSA Substance Abuse and Mental Health Services Administration Trauma-Informed Approach and Trauma-Specific Interventions

Percentage of Children in an Urban Pediatric Community Clinic with Learning or Behavioral

Problems Based on ACE Score

ACE 0 ACE 1-3 ACE 4->0

10

20

30

40

50

60

70

80

90

100

No Learning or Behavioral ProblemYes Learning or Behavioral Problem

N. Burke et al, Child Abuse and Neglect 35(2011) 408-413This gives an Odd Ratio of 32 for an ACE score of 4 or more versus ACE 0

Estimates of Population Attributable Risk of ACES for Selected Concerns in Adult Women

Drug Abuse:• Alcoholism 65%• Drug Abuse 50%• IV Drug Abuse 80%Mental Health:• Current Depression 54%• Suicide Attempt 60%Crime Victim: • Sexual Assault 62%• Domestic Violence 52%

CDC’s Ace Study: http://www.cdc.gov/violenceprevention/acestudy/

If we Miss Childhood Trauma the Consequences are Severe

• If we misdiagnosis or incorrectly label trauma as a mental illness in children, we often recommend treatment that will not alleviate the child’s suffering or symptoms.

• The child may come to believe that adults are not interested in their suffering or may come to feel that they have an illness when they are experiencing normal reactions to environments unhealthy for normal child development.

• Doctors looking to help with the child’s trauma symptoms, may

attempt to treat the child’s “mental health problem” with stimulant medications. When symptoms persist they may add more powerful medications due to misdiagnosis. The child’s trauma and ongoing suffering remains unrecognized and unacknowledged.

• We limit children’s adult potential for success when we fail to recognize their trauma as their emotional pain and suffering is neither addressed nor acknowledged.

Case 1: Eighteen Month Old Head Banging, Violent Temper Tantrums

• Maternal ACE Score – 8– Domestic Violence– Emotional, Physical, Sexual Abuse– Emotional, Physical Neglect– Alcoholic Parent– Parental Mental Illness

• Child ACE Score – 6– Parental Loss– Domestic Violence– Alcohol Use in Home– Mental Illness in Parent– Emotional, Physical Neglect

Case 2: 5 Year Old Severe Aggression Towards Stepmother, Learning Problems, School Aggression

• Maternal ACE Score – Cannot Calculate as child in Foster Care and we don’t have complete History

• Child ACE Score – 7– Domestic Violence– Alcoholism/Poly-Drug Use in Parent– Mental Illness in Parent– Emotional, Physical Abuse– Emotional Neglect– Parental Loss

What Does The AAP Say?ADDRESSING TOXIC STRESS

It’s part of being a Pediatrician (and something everyone who interacts with kids should know about)

Toxic Stressors (Adverse Childhood Experiences) are the early roots of disease, early death, and lifelong health and social

disparities.

Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health’ PEDIATRICS Vol. 129 No. 1 January 1, 2012 pp. e224 -e231

Toxic Stress Children Behavioral Changes and Adult Responses

• Childhood presentations of attention deficits, emotional dis-regulation, and oppositional behaviors may have their roots in early trauma. Early childhood adversity can dramatically affect the child’s perceptions of, and responses to new stimuli.

• Early maltreatment can result in long-term behavioral changes. These behavioral changes in turn draw responses from those around the trauma-adapted child, responses that can either help or hinder the child’s attempts at re-adaptation to the non-traumatic world.

Pediatricians, Teachers and Faith Leaders are Uniquely Positioned to Intervene Through Their

• Regular interactions with children.

• Appreciation for the important role that families and communities play in determining child wellness.

• Developmental approach to health.

• Understanding of the advantages of prevention over remediation.

• Awareness of the critical importance of effective advocacy to promote changes in well-established systems that influence health and development.

Asking Families about Exposure to Stress and Potential Associated Symptoms:

• Communicates to families that toxic stress is a common problem.

• Begins to reduce the isolation associated with troublesome behaviors that those exposed to toxic stress develop.

• Communicates that there are solutions such as trauma-informed treatments that can help children resume a healthy developmental trajectory and help families recover.

• Conveys that trauma threatens the healthy growth and development of children and has detrimental consequences across the lifespan.

Trauma Screening Options (for Parents with Children) - Use Open Ended Questions First

• “Do you know of any really scary or upsetting things that happened to you (your child)?”

• “Since the last time I saw you (your child), has anything really scary or upsetting happened to you (your child) or anyone in your family?”

Trauma Screening Options - Then Directed Questions

• “You have told me that your child is having some problems with aggression, acting out, attention and sleep. Just as fever means the body is dealing with an infection, when these behaviors happen, they may mean that the brain and body are responding to a stress or threat. Do you have any concerns that your child is being exposed to a threat or feeling stressed?”

• “The behaviors you describe and the trouble she is having with school and learning are often warning signs that the brain is trying to manage stress or threat. Sometimes children respond this way if they are harmed, or if they saw others they care about being harmed. Do you know if your child saw or witnessed violence at school, with friends, or at home?”

“If you think you’re too small to make a

difference, try sleeping in a room with a

mosquito.”

African Proverb

Everyone can offer Social Supports for Parents (Spiritual Leaders, Teachers, Doctors)

• Spiritual support (such as providing hope and encouragement)

• Emotional support (such as being empathic and non- judgmental)

• Informational support (such as providing parenting guidance or recommending resources)

• Instrumental support (such as providing transportation or links to job support)

Strengthening Families Protective and Promotive Factors

Everyone can Offer Social Supports for Children and Adolescents (Spiritual Leaders, Teacher, Doctors)

• Children and adolescents who have a formal or informal “mentor-like” relationship with someone outside their home are less likely to have externalizing behavior problems (bullying) and internalizing problems (depression).

• Supported children are more likely to complete tasks they start, remain calm in the face of challenges, show interest in learning new things, volunteer in the community, engage in physical activities, participate in out-of-school time activities, and be engaged in school.

• Additionally, those who have a caring adult outside the home are more likely to talk with their parents about “things that really matter.”

• These results suggest that mentor-like adults outside the home can be a helpful in promoting positive well-being for children and adolescents.

Child Trends, December 2013

Starting the Conversation about a Parent’s ACE Score Requires Sensitivity

• Parents can be told that the science is NEW to avoid feelings of guilt or shame about what their own parents did or what they have done as parents.

• Parents can be told that most people have an ACE score of 1 or 2 and that responses to higher ACE Scores --- such as alcoholism, drug use, obesity and depression --- ARE NORMAL.

• For somebody who is an ACE survivor, a sense of shame is going to be one of the fundamental feelings.

• By normalizing this, explaining ACEs as science based, it helps parents reframe and move away from shame.

Typical Parent Responses

• “Well duh!”

• “No wonder I’m so messed up.” “No wonder I’m sick all the time.” “No wonder I can’t quit using ……. alcohol, drugs, cigarettes.”

• “These are very good questions. Nobody has asked me about this before.”

• “Now my life makes sense.”

Also• It is important acknowledge how difficult life is with a high

ACE score.

• One can say, “People with a high ACE score like yours usually have to work harder at just about everything.”

• This acknowledgement really helps people feel understood, sometimes for the first time.

• The ultimate goal is to help people find their own motivation to change by giving them an understanding of their own life story and health risks, to encourage them to make things different for their children. Parents want things to be different for their children.

Those Who Are Not Ready

• Generally will say that their ACE score is Zero or that a High ACE score has not affected their life. It is not helpful to press.

• However, it is still an opportunity to discuss how ACES affect brain development which in itself can be powerful and thought provoking education for parents.

A Great Future

A time when everyone understands that a difficult childhood can

contribute to a lifetime of health problems and personal suffering. A time when everyone realizes that

we are all vested and can all assist in reducing the impact of adverse

childhood experiences. A time when we give every child the

opportunity to reach their fullest potential in life.