The Violence – Mental Health Connection: The Impact of Adverse Childhood Experiences
66
The Violence – Mental Health Connection: The Impact of Adverse Childhood Experiences LISC Chicago - Neighborhood Health Initiative “Healthy Wednesday” Discussion January 30, 2012
description
The Violence – Mental Health Connection: The Impact of Adverse Childhood Experiences. LISC Chicago - Neighborhood Health Initiative “Healthy Wednesday” Discussion January 30, 2012. - PowerPoint PPT Presentation
Transcript of The Violence – Mental Health Connection: The Impact of Adverse Childhood Experiences
The Violence – Mental Health Connection:
The Impact of Adverse Childhood Experiences
LISC Chicago - Neighborhood Health Initiative“Healthy Wednesday” Discussion
January 30, 2012
Adverse Childhood Experiences: An overview of the pioneering work of Drs. Robert Anda (CDC) & Vincent Felitti (Kaiser
Permanente), and Laura Porter (Family Policy Council)
Presented by Elena Quintana, Ph.D.Executive Director of the Adler Institute on Public Safety & Social Justice
“The Science Behind What You Know in Your Heart” – Anne Studzinski, Childhood Trauma Coalition
“The power to warn those downstream” -- Laura Porter
What is The ACE Study?
• The ACE Study is ongoing collaborative research between the Centers for Disease Control and Prevention in Atlanta, GA, and Kaiser Permanente in San Diego, CA.
• Data from over 17k participants reveals staggering proof of the health, social, and economic risks that result from childhood trauma.
Vincent Felitti, M.D., 2012
4 Branches of ACEs Related Work
• Basic Science
• Brain Research
• Resilience Research
• Program & Intervention Development
What ACEs Were Measured?
A HISTORY OF THE FOLLOWING BY AGE 18:• Physical, Emotional, or Sexual Abuse• Physical or Emotional Neglect• Mental Illness• Prison• Domestic Violence• Divorce or Parental Loss• Substance Abuse
Finding Your Score
• Please be aware that there are trends that are discussed, and that NO INDIVIDUAL SCORE explains all.
• There are very high functioning high scorers, and low functioning low scorers.
• All can agree: ACEs are powerful forces that we want to prevent by whatever means possible.
Prevalence Percentiles of Adverse Childhood Experiences
Abuse, by Category• Psychological (by parents) 11% • Physical (by parents) 28% • Sexual (anyone) 22%
Neglect, by Category• Emotional 15% • Physical 10%
Household Dysfunction, by Category • Alcoholism or drug use in home 27% • Loss of biological parent < age 18 23% • Depression or mental illness in home 17% • Mother treated violently 13% • Imprisoned household member 5%
Vincent Felitti, M.D., 2012
ACEs Conceptual Framework People with 6 ACES die, on average, 20 years sooner than
those with zero.
ACEs OCCUR IN CLUSTERS
• 2/3 experience at least one category of ACEs
• If any one ACE is present, there is an 87% chance at least one other category of ACE is present, and a 50% chance that there will be 3 or more.
• WOMEN ARE 50% MORE LIKELY TO HAVE A SCORE OF >5. Vincent Felitti, M.D., 2012
OLDER CHILDREN – WA High School Sophomores and Seniors
Population
Average:
43% have 3 or
more ACEs
as compare
d with
26% of WA
Adults
Child Suicide Attempts Percent Attempting Suicide
0 1 2 3 40
2
4
6
8
10
12
14
16
18
20
Vincent Felitti, M.D., 2012
Childhood Experiences Underlie Chronic Depression
0 1 2 3 4
0
10
20
30
40
50
60
MenWomen
Vincent Felitti, M.D., 2012
ACE Score & Perpetration Domestic Violence
0 1 2 3 4 5
0
2
4
6
8
10
12
14
MenWomen
Robert Anda, M.D., 2012
Prevalence of Being Raped Later in Life
0 1 2 3 40
5
10
15
20
25
30
35
Vincent Felitti, M.D., 2012
BEHAVIORAL HEALTH
0 1 2 3 4 or 5 6,7, or 805
1015202530
10.413.2 11.1
16.320.8
28.5
Current Smoking
Number of ACE Categories
Perc
ent o
f Pop
ulati
on
0 1 2 3 4 or 5 6,7, or 80
2
4
6
8
10
12
23.7
65.1
7.3
10.2
Risk for HIV
Number of ACE Categories
Perc
ent o
f Pop
ulati
on
CHRONIC DISEASE
0 1 2 3 4 or 5 6,7, or 802468
101214
6.17.5 8 7.5 7.9
11.7
Diabetes
Number of ACE Categories
Perc
ent o
f Pop
ulati
on
0 1 2 3 4 or 5 6,7, or 80
2
4
6
8
10
4.9 5.66.7
5.6
9.48.1
Cardio Vascular Disease
Number of ACE Categories
Perc
ent o
f Pop
ulati
on
Laura Porter, 2012
MENTAL HEALTH
0 1 2 3 4 or 5 6,7, or 805
10152025
5.8 6.610.6 12.6
17.620.6
>14 of 30 Unhealthy Mental Health Days
Number of ACE Categories
Perc
ent o
f Pop
ulati
on
0 1 2 3 4 or 5 6,7, or 805
1015202530
7.311
14 15.519.3
24.5
Treatment for Mental Health Condition
Number of ACE Categories
Perc
ent o
f Pop
ulati
on
DISABILITY
0 1 2 3 4 or 5 6,7, or 802468
10
1.1 1.8 2.5 3.2
5.5
8.5
Missed Work > 14 of 30 Days Due to Mental Health
Number of ACE Categories
Perc
ent o
f Pop
ulati
on
0 1 2 3 4 or 5 6,7, or 80
4
8
12
16
5.2 5.2 6.48.6
11.3
14.8
Health Problems Require Special Equipment
Number of ACE Categories
Perc
ent o
f Pop
ulati
on
Laura Porter, 2012
Shame & Blame
• Make people feel that they can not speak their truth
• Make providers feel it’s impolite to ask certain questions
• Lead us all to believe that this suffering is uncommon
• Paralyze us* from taking life-saving action*everyone
A large portion of many health, safety and prosperity conditions is attributable to Adverse Childhood Experience.
ACE reduction reliably predicts a decrease in all of these conditions simultaneously.
POPULATION ATTRIBUTABLE
RISK
EARLY CHILDHOODHIPPOCAMPUS
CONTROLS EMOTIONAL REACTIONS,
CONSTRUCTS VERBAL & SPATIAL MEMORY
SENSITIVE TO ALL FORMS OF
MALTREATMENT IN FIRST 2-3 YEARS OF LIFE,
ESPECIALLY SEXUAL ABUSE
ADAPTATION*EMOTIONALLY
REACTIVE – BRAIN’S BRAKING MECHANISM
FAILS*POOR REGULATION OF
BEHAVIOR*DIFFICULTY WITH VERBAL & SPATIAL
MEMORY*NET VOLUME LOSS
BECOMES EVIDENT IN 20S.
ADOLESCENCE – THE CORTEXCENTER FOR THINKING & JUDGEMENT, EXECUTIVE
FUNCTION, LONG TERM MEMORY, & VISIONSENSITIVE TO WITNESSING VIOLENCE, AND SEX ABUSE
ADAPTATION*POOR EXECUTIVE FUNCTION * IMPULSIVENESS
*DIMINISHED ABSTRACT REASONING * DIMINISHED HOPE * LIMITING FIELD OF VISION
MIDDLE CHILDHOOD
CORPUS COLLOSUMINTEGRATES
HEMISPHERES & FACILITIES
INCLUDING LANGUAGE DEV.,
MATH ABILITY, AND PROCESSING SOCIAL
CUES SUCH AS FACIAL EXPRESSIONS
SENSITIVE TO NEGLECT IN INFANCYSEX ABUSE AT AGES
~9&10
ADAPTATION*LANGUAGE DELAY *DIMINISHED MATH
CAPACITY*DIMINISHED
INTEGRATION & COORDINATION
*DIFFICULTY WITH SOCIAL CUES
TRAUMA IS HARD-WIRED INTO BIOLOGYLaura Porter, 2011
Resilience for the Walking Wounded
Important factors for the walking wounded:1) Have a trustworthy person you can talk to
about your true situation and feelings2) The ability to reframe your life (e.g. as a 9
year old I was not responsible for my parent’s drinking behavior)
3) Have hope for your future
Other Possible Influences on Resilience
• Intelligence• Talent and Skill Mastery• Creative Expression• Physical Activity• Positive Human Touch
Community Safety Formula
R+O (hp²)=CSWhere human potential is squandered
communities are less safe
How would systems be changed if we put human development at the center of our decision
making?
Schools, juvenile detention center, immigration detention and policy,
imprisonment, security, mental health
Urban Violence and Adverse Childhood Experiences
LISC Chicago Healthy Wednesday Mental Health - Violence RoundtableChicago, IL, January 30, 2013
Bradley C. Stolbach, PhDProgram Director, Chicago Child Trauma CenterLa Rabida Children's Hospital
Lead Technical Advisor Midwest Region Complex Trauma Training and Technical Assistance CenterNCTSN Complex Trauma Treatment Network
Associate Professor of Clinical PediatricsThe University of Chicago Pritzker School of Medicine
Who is a Child Soldier?
A child soldier is any person under 18 years of age who is part of any kind of regular or irregular armed force or armed group in any capacity, including but not limited to cooks, porters, messengers and anyone accompanying such groups, other than family members. The definition includes girls recruited for sexual purposes and for forced marriage. It does not, therefore, only refer to a child who is carrying or has carried arms.
Cape Town Principles and Best Practices on the Recruitment of Children into the Armed Forces and on Demobilization and Social Reintegration of Child Soldiers in Africa (Cape Town, 27-30 April 1997).
The Power of a Lens Criminal or Maltreated Child or Child Soldier
U.S. incarcerates more than twice as many youth per 100,000 than next highest youth incarcerator.
Many of these youth are classified by statute as adults.
Youth of color are much more likely than others to be incarcerated. In Cook County, Illinois, African American youth are 46 times more likely than White youth to be incarcerated.
Adverse Childhood Experiences Study (ACES)*
Felitti et al. 1998
Physical abuse by a parent
Emotional abuse by a parent
Sexual abuse by anyone
An alcohol and/or drug abuser in the household
An incarcerated household member
Someone who is chronically depressed, mentally ill, institutionalized, or suicidal
Domestic violence
Loss of a parent
Emotional neglect
Physical neglect
Adverse Childhood Experiences Study (ACES)*
Felitti et al. 1998
“Individuals with a trauma history rarely experience only a single traumatic event, but rather are likely to have experienced several episodes of traumatic exposure.”
Cloitre et al., 2009 (Retrospective studies, e.g., Kessler, 2000; Stewart et al.,
2008; Coid et al., 2001; Dong et al., 2004 )
NCTSN Core Data Set (2012)Children Served in the National Child Traumatic Stress Network (n=11,138)Fewer than 24% had experienced only one type of trauma or ACE.Over 40% had experienced 4 or more.
Chicago Child Trauma Center (FY12)Among children receiving services in FY12, 86% of those exposed to Domestic Violence were also exposed to Physical and/or Sexual Abuse.
The Co-Occurring Nature of Trauma
The Attachment Behavioral System
Attachment: an evolved behavioral system that functions to promote the protection and safety of the attached person
Attachment system is activated strongly by internal and external stressors or threats.
It is through healthy attachment (i.e., a behavioral system that effectively protects and comforts the infant or child) that a child develops the capacity for emotional and behavioral self-regulation, as well as a coherent self.
Some Basic Assumptions About Psychological Traumatization
Traumatic experiences are those which overwhelm an individual’s capacity to integrate experience in the normal way. (e.g., Putnam, 1985)
Following exposure to trauma, if integration does not occur, traumatic experience(s) are split off and an individual alternates between functioning as if the trauma is still occurring and functioning as if the trauma never occurred. (e.g., Nijenhuis et al., 2004)
Although traumatic memories and associations remain inaccessible to consciousness much of the time, they have the power to shape an individual’s daily functioning and behavior. (e.g., Allen, 1993)
What is Complex Trauma?Exposure to multiple forms of violence and other potentially
traumatic stressors in the context of attachment behavioral systems that are unable to provide protection, care, and comfort
Focus on cumulative trauma and the developmental context in which exposure occurs rather than on discrete episodes
Proposed Developmental Trauma Disorder Criterion A:
A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:
A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and
A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse
Key Developmental Capacities Affected by Complex Trauma
Ability to modulate, tolerate, or recover from extreme affect states
Regulation of bodily functions Capacity to know emotions or bodily states Capacity to describe emotions or bodily statesCapacity to perceive threat, including reading of safety
and danger cuesCapacity for self-protectionCapacity for self-soothingAbility to initiate or sustain goal-directed behaviorCoherent self, IdentityCapacity to regulate empathic arousal
Complex Trauma and Reactive vs. Instrumental
AggressionReactive aggression entails impulsivity, anger, and intolerance for perceived provocation whereas instrumental aggression is motivated by material or social gain (Crapanzano et al., 2010).
In a study of juveniles convicted of committing violent crimes, Silvern & Griese (2012) found that:
Multiple maltreatment positively predicted reactive aggression. The significant relationship between multiple maltreatment and reactive aggression was fully mediated by dissociative symptoms and partially mediated by PTSD symptoms.
Trauma Exposure in CeaseFire Chicago Violence Interrupters and Outreach Workers
n = 9
Mean total traumatic stressors and other ACES = 10.33
Range = 4 -15
Mean age of first trauma = 9 years, 2 months
89% exposed to domestic violenceDV was first trauma exposure for 67%
100% experienced at least 4 forms of ongoing traumatic stress.
Bocanegra & Stolbach, 2012
CeaseFire Self-Reported Trauma Exposure
Physical Abuse 100% Witnessed Physical Abuse 100%Witnessed Community Violence 100%Witnessed School Violence 100% Witnessed Domestic Violence 89%Loss Through Violent Death 89%Witnessed Sexual Victimization 78%Motor Vehicle Accident 56% Witnessed Homicide(s) 44%
Other trauma types include fire, burn, dog attackBocanegra & Stolbach, 2012
Youth Self-Reported Trauma Exposuren = 8
Physical Abuse 100% Witnessed Physical Abuse 100%Witnessed Domestic Violence 100%Witnessed Community Violence 100%Witnessed School Violence 100% Witnessed Homicide(s) 75%Loss Through Violent Death 75%Witnessed Sexual Victimization 62.5%Motor Vehicle Accident 50% Victim of Extrafamilial Violent Crime 50%Dog Attack 37.5%Burns 37.5%Other trauma types include fire, natural disaster, torture
Bocanegra & Stolbach, 2012
Youth Self-Reported Trauma Exposure
100% experienced both family violence and community violence.
100% experienced at least one form of ongoing traumatic stress.
Average age of first trauma exposure = 6 years, 1 month
Mean # Types of Trauma Experienced = 10
Range = 7 - 13Bocanegra & Stolbach, 2012
Youth Other Adverse ExperiencesImpaired Caregiver 75%Exposure to Drug Use or Criminal Activity in Home
75% Exposure to Prostitution or other Developmentally
Inappropriate Sexual Behavior in Home 37.5% Substitute Care 25%
Other ACEs include incarcerated significant other, homelessness, neglect
Mean # Types of Adverse Experiences = 2.75
Range # Types of Adverse Experiences = 0 – 5Bocanegra & Stolbach, 2012
Youth Mean Combined Total Types
of Traumatic Stressors + Other Adverse Childhood Experiences =
12.75
Range = 7 - 18
Bocanegra & Stolbach, 2012
“Alfonso”Torture 5 Physical Abuse 5 - 13 Substitute Care 7Witnessed Community Violence 8 – 13Witnessed Physical Abuse 9 - 13 Impaired Caregiver 9 - 13Extrafamilial Violent Crime Victim 9 - 13Witnessed Domestic Violence 10 - 13 Witnessed Sexual Assault 10Motor Vehicle Accident 12Traumatic Loss 12 Witnessing Homicide (3) 12, 13School Violence 12 - 13 Dog Attack 12Burn 12Total Types of Traumatic Stress 13 Total Types of Adverse Other Experiences 2
Bocanegra & Stolbach, 2012
Trauma History Timeline: “Alfonso”Age at which Trauma/ACE Occurred In Years
Trauma/Adverse Experiences 0 1 2 3 4 5 6 7 8 9 10 11 12 13
TorturePhysical Abuse
Substitute CareWitnessed Community Violence
Witnessed Physical Abuse
Impaired Caregiver
Extrafamilial Violent Crime Victim
Witnessed Domestic Violence
Witnessed Sexual Assault
Witnessed School Violence
Witnessed Homicides (3)
Motor Vehicle Accident
Traumatic Loss
Burn
Dog AttackBLACK LINE = AGE WHEN FIRST PERFORMED ACTIONS ON BEHALF OF STREET ORGANIZATION
20-Year-Old 2nd Generation Latina
Fire 1 Domestic Violence 5 Impaired Caregiver 5 - 20Physical Abuse 5, 15, 16 Sexual Abuse/Assault 7, 15, 16Community Violence 10School Violence 10 - 16Extrafamilial Violent Crime Victim 12 - 20Motor Vehicle Accident 14, 19Incarceration 17 - 21Traumatic Loss 18 Witnessing Homicide 18, 19Homelessness 19, 20Employment in Sex Industry 19, 20 Burn 20
Total Types of Traumatic Stress 12 Total Types of Adverse Other Experiences 4
Trauma History Timeline: 20-Year-Old 2nd Generation Latina Age In Years
Trauma/Adverse Experiences 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
House Fire
Domestic Violence
Physical Abuse
Impaired Caregiver
Neglect
Drug Use or Criminal Activity in Home
Sexual Abuse/Assault
School Violence
Street Violence, Witnessing Homicide
Extrafamilial Violent Crime Victim
Motor Vehicle Accident
Incarceration
Traumatic Loss or Bereavement
Homelessness, Sex Trade Worker
Burn
Dr. Paul Farmer: “Structural violence is one way of describing social arrangements that put individuals and populations in harm’s way… The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people … neither culture nor pure individual will is at fault; rather, historically given (and often economically driven) processes and forces conspire to constrain individual agency. Structural violence is visited upon all those whose social status denies them access to the fruits of scientific and social progress.”
Child Trauma, “Race” and Urban Poverty Urban Black and Brown families face a unique set of adversities and stressors. The massive historical traumas of attempted genocide and slavery have never been addressed, yet create the context in which present traumas occur and are dealt with. Those of us working with children and families whose daily existence is shaped by the legacy of slavery and racial injustice cannot optimally intervene if we fail to understand and address the effects of the trauma of the past.
Societal Traumatization and the Legacy of Imperialism, Attempted
Genocide, & SlaveryJust as in cases of individual traumatization, avoidance of
acknowledging and addressing the traumatic past makes it impossible for integration to occur.
As long as historical trauma remains taboo, the racial divisions that pervade every aspect of American life will persist.
Community Based Programs that Address Trauma and
Build ResiliencyEddie Bocanegra,
Community Renewal Society M.A. Candidate, University of Chicago
School of Social Services
Present 4 community-based interventions that I founded to address trauma as a result of participation/ exposure to community violence
Disclaimer: All of these programs were developed without funding and drawing upon volunteers from major universities as well as other professionals
Motivation behind developing these programs
Brief Overview
2 Components: Support group for
parents who have lost children to violence (Spanish, started June 2010)
Support group for surviving siblings of the homicide victims Critical point of
intervention
Grupo Consuelo
Community arts group that engages gang-involved youth and uses art as a medium for processing trauma and identity exploration
LuchARTE
Physical Abuse 100% Witnessed Physical Abuse 100%Witnessed Domestic Violence 100%Witnessed Community Violence 100%Witnessed School Violence 100% Witnessed Homicide(s) 75%Loss Through Violent Death 75%Witnessed Sexual Victimization 62.5%Motor Vehicle Accident 50% Victim of Extrafamilial Violent Crime 50%Dog Attack 37.5%Burns 37.5%Other trauma types include fire, natural disaster, torture
ACEs survey of LuchARTE Participants
100% experienced both family violence and community violence.
100% experienced at least one form of ongoing traumatic stress.
Average age of first trauma exposure = 6 years, 1 month
ACES survey findings on exposure to community violence
Peer educator group bringing together combat veterans and young men to process trauma as a result of violence
12 Week Peer Educator Program that focuses in the following areas: Mentorship Identity Development Empowerment Self-Empathy Protective Factors and Resources
Themes in the curriculum:Combat and SurvivalReframing and Reshaping Personal Experiences of Violence
Urban Warriors
Coalition led by ex-offenders to create more opportunities for gainful employment by advocating for policy change Addressing trauma through organizing for
systems change
FORCE (Fighting to Overcome Records and Create Equality)
Advocating for Community Based
Trauma- Informed InterventionsKathryn Saclarides, LCSW
Director of Violence PreventionEnlace Chicago
Children exposed to violence are more likely to have behavior problems
Children who witness violence are at increased risk for becoming victims themselves, suffering from PTSD, substance abuse, running away from home, or engaging in criminal activity
Males are more likely than females to be victims and witnesses of violent acts
African American and Latino youth have reported higher rates of exposure to violence
Exposure to Violence
Trauma can occur often enough when it becomes part of the common human experience. ◦ Overt expressions of trauma: Violence, assault◦ Insidious forms of trauma: discrimination, racism,
oppression, and poverty
When experienced chronically, the cumulative impact can be life-altering
When trauma goes unrecognized…
Social determinants of health and mental well-being at individual, community, and social system level
Case study of Derrion Albert’s murder
Changing Places: How Communities Will Improve the Health of Boys of Color
Ed: Christopher Edley, Jr and Jorge Ruiz de Velasco
Case Study- Root Cause Analysis
Son of immigrant parents Born in Little Village Exposed to domestic violence and
substance abuse within the household Father left the family when Freddy was in
5th grade, mother becomes sole provider for family
Academic difficulties Bullying in school and from police Gang initiation Living in “opposition” territory Freddy drops out of school
Freddy gets out of the gang
Little Village example: Freddy, murdered November 2012
Freddy’s death was 20 years in the making, just as was Derrion Albert’s
ACES as a crucial paradigm for who we target, why we target these youth with our resources, and how we advocate for them within multiple systems.
Programs and resources cannot just target the top of the pyramid- unless you want superficial results or none at all
Violence Prevention as Health Promotion
Discussion
