1. The damaging consequences of childhood trauma: Research Findings

2. The following slides are from the presentation “A Child’s Path to Mental Illness and Suicide”, by Ann Jennings, PhD. www.TheAnnaInstitute.org ACE Study slides are from the CDC (Center for Disease Control and Prevention) and from the September 2003 Presentation at “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West, by Vincent J. Felitti, MD

3. Collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the Center for Disease Control and Prevention (CDC) The Adverse Childhood Experiences Study (ACE)

4. What is the Adverse Childhood Experiences (ACE) Study? Decade long. 17,000 people involved. Decade long. 17,000 people involved. Largest epidemiological study ever done. Largest epidemiological study ever done. Revealed health and social effects of adverse childhood experiences over the lifespan. Revealed health and social effects of adverse childhood experiences over the lifespan.

5. ACE Study Findings Childhood experiences are powerful determinants of who we become as adults Childhood experiences are powerful determinants of who we become as adults

6. ACE Study Findings and the Centrality of Trauma Adverse Childhood Experiences are the most BASIC cause of most health risk behaviors, morbidity, disability, mortality, and health and behavioral health care costs. Adverse Childhood Experiences are the most BASIC cause of most health risk behaviors, morbidity, disability, mortality, and health and behavioral health care costs. Which means trauma is a crucial public health issue – at the ROOT of and CENTRAL to development of health and mental health problems – and to recovery. Which means trauma is a crucial public health issue – at the ROOT of and CENTRAL to development of health and mental health problems – and to recovery.

7. Adverse Childhood Experiences* Abuse of Child Abuse of Child Recurrent Severe Emotional abuse Recurrent Severe Emotional abuse Recurrent Physical abuse Recurrent Physical abuse Contact Sexual abuse Contact Sexual abuse Trauma in Child’s Household Trauma in Child’s Household Environment Environment Substance abuse Substance abuse Parental separation or divorce - Parental separation or divorce - Chronically depressed, emotionally Chronically depressed, emotionally disturbed or suicidal household disturbed or suicidal household member member Mother treated violently Mother treated violently Imprisoned household member Imprisoned household member Loss of parent – (best by death, Loss of parent – (best by death, unless suicide, - worst by unless suicide, - worst by abandonment) abandonment) Neglect of Child Neglect of Child Abandonment Abandonment Child’s basic physical and/or Child’s basic physical and/or emotional needs unmet emotional needs unmet * Above types of ACEs are the “heavy end” of abuse. Impact of Trauma and Health Risk Behaviors to Ease the Pain Neurobiologic Effects of Trauma Disrupted neuro-development Disrupted neuro-development Difficulty controlling anger-rage Difficulty controlling anger-rage Hallucinations Hallucinations Depression Depression Panic reactions Panic reactions Anxiety Anxiety Multiple (6+) somatic problems Multiple (6+) somatic problems Sleep problems Sleep problems Impaired memory Impaired memory Flashbacks Flashbacks Dissociation Dissociation Health Risk Behaviors Smoking Smoking Severe obesity Severe obesity Physical inactivity Physical inactivity Suicide attempts Suicide attempts Alcoholism Alcoholism Drug abuse Drug abuse 50+ sex partners 50+ sex partners Repetition of original trauma Repetition of original trauma Self Injury Self Injury Eating disorders Eating disorders Perpetrate interpersonal violence Perpetrate interpersonal violence Long-Term Consequences of Unaddressed Trauma (ACEs) Disease and Disability Ischemic heart disease Ischemic heart disease Cancer Cancer Chronic lung disease Chronic lung disease Chronic emphysema Chronic emphysema Asthma Asthma Liver disease Liver disease Skeletal fractures Skeletal fractures Poor self rated health Poor self rated health Sexually transmitted disease Sexually transmitted disease HIV/AIDS HIV/AIDS Social Problems Homelessness Homelessness Prostitution Prostitution Delinquency, violence, criminal Delinquency, violence, criminal behavior behavior Inability to sustain employment Inability to sustain employment Re-victimization: rape, DV Re-victimization: rape, DV compromised ability to parent compromised ability to parent Intergenerational transmission of Intergenerational transmission of abuse abuse Long-term use of health, Long-term use of health, behavioral health, correctional, behavioral health, correctional, and social services and social services

8. ACE study views health risk behaviors as attempts to cope with impacts and ease pain of prior trauma, ACE study views health risk behaviors as attempts to cope with impacts and ease pain of prior trauma, NOT as symptoms, bad habits, self- destructive behavior, or public health problems. NOT as symptoms, bad habits, self- destructive behavior, or public health problems.

9. Existing Practice: Existing practice commonly asks “What is wrong with the person?” vs “what happened to the person?” Existing practice commonly asks “What is wrong with the person?” vs “what happened to the person?” Existing practice develops diagnoses, and treats symptoms instead of underlying causes. Existing practice develops diagnoses, and treats symptoms instead of underlying causes.

10. Adverse Childhood Experiences (ACEs) are Common Adverse Childhood Experiences (ACEs) are Common Of 17,000 HMO members: 72% had attended college 72% had attended college 77% were white 77% were white 62% were 50 or older 62% were 50 or older

11. Adverse Childhood Experiences are Common Adverse Childhood Experiences are Common Of the 17,000 HMO Members: 1 in 4 exposed to 2 categories of ACEs 1 in 4 exposed to 2 categories of ACEs 1 in 16 was exposed to 4 categories. 1 in 16 was exposed to 4 categories. 22% were sexually abused as children. 22% were sexually abused as children. 66% of the women experienced abuse, violence or family strife in childhood. 66% of the women experienced abuse, violence or family strife in childhood.

12. What is uncommon is What is uncommon is recognition recognition acknowledgement acknowledgement action action

13. health risk behaviors health risk behaviors adult diseases adult diseases disabilities disabilities severe social problems severe social problems severe mental health problems severe mental health problems For example: The following information and slides are from September 2003 Presentation at “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West, by Vincent J. Felitti, MD. The higher the ACE Score, the greater the likelihood of :

14. Adverse Childhood Experiences and Current Smoking %

15. A child with 6 or more categories of adverse childhood experiences is 250% more likely to become an adult smoker. A child with 6 or more categories of adverse childhood experiences is 250% more likely to become an adult smoker. A person with 4 categories of adverse childhood experiences is 260% more likely to have Chronic Obstructive Pulmonary Disease (COPD). A person with 4 categories of adverse childhood experiences is 260% more likely to have Chronic Obstructive Pulmonary Disease (COPD). Current Smoking

16. Childhood Experiences and Adult Alcoholism 0 1 2 3 4+

17. Adult Alcoholism A 500% increase in adult alcoholism is directly related to adverse childhood experiences. A 500% increase in adult alcoholism is directly related to adverse childhood experiences. 2/3rds of all alcoholism can be attributed to adverse childhood experiences 2/3rds of all alcoholism can be attributed to adverse childhood experiences

18. ACE Score and Intravenous Drug Use N = 8,022 p<0.001

19. Intravenous Drug Use A male child with an ACE score of 6 has a 4,600% increase in the likelihood that he will become an IV drug user later in life. A male child with an ACE score of 6 has a 4,600% increase in the likelihood that he will become an IV drug user later in life. 78% of drug injection by women can be attributed to ACEs 78% of drug injection by women can be attributed to ACEs

20. Childhood Experiences Underlie Rape 0 1 2 3 4+

21. Rape Women with an ACE score of 4+ are 500% more likely to become victims of domestic violence. Women with an ACE score of 4+ are 500% more likely to become victims of domestic violence. They are almost 900% more likely to become victims of rape. They are almost 900% more likely to become victims of rape.

22. ACE Score Ever Hallucinated* (%) Abused Alcohol or Drugs *Adjusted for age, sex, race, and education. ACE Score and Hallucinations

23. The making of madness….. There is a significant and graded relationship between a history of multiple childhood traumas (ACE’s) and hallucinations. There is a significant and graded relationship between a history of multiple childhood traumas (ACE’s) and hallucinations. Compared to persons with 0 ACEs, those with 7 or more ACEs had a five-fold increase in the risk of reporting hallucinations Compared to persons with 0 ACEs, those with 7 or more ACEs had a five-fold increase in the risk of reporting hallucinations Whitfield et al 2005

24. Abuse and trauma suffered in the early years of development resulted in a far greater likelihood of pre-psychotic and psychotic symptoms. Abuse and trauma suffered in the early years of development resulted in a far greater likelihood of pre-psychotic and psychotic symptoms. Perry, B.D. (1994) In an adult inpatient sample, 77% of those reporting CSA or CPA had one or more of the ‘characteristic symptoms’ of schizophrenia listed in the DSM-IV: hallucinations (50%); delusions (45%) or thought disorder (27%) Read and Argyle 1999 In an adult inpatient sample, 77% of those reporting CSA or CPA had one or more of the ‘characteristic symptoms’ of schizophrenia listed in the DSM-IV: hallucinations (50%); delusions (45%) or thought disorder (27%) Read and Argyle 1999

25. Childhood Experiences Underlie Chronic Depression

26. Adults with an ACE score of 4 or more were 460% more likely to be suffering from depression. Adults with an ACE score of 4 or more were 460% more likely to be suffering from depression.

27. Childhood Experiences Underlie Suicide 1 2 0 3 4+

28. Suicide The likelihood of adult suicide attempts increased 30-fold, or 3,000%, with an ACE score of 7 or more. The likelihood of adult suicide attempts increased 30-fold, or 3,000%, with an ACE score of 7 or more. Childhood and adolescent suicide attempts increased 51-fold, or 5,100% with an ACE score of 7 or more. Childhood and adolescent suicide attempts increased 51-fold, or 5,100% with an ACE score of 7 or more.

29. Suicidality is not usually caused by “mental illness”, drugs, rejection by peer groups, school pressure, failures, etc. Suicidality is not usually caused by “mental illness”, drugs, rejection by peer groups, school pressure, failures, etc. Rather, it is a coping device – a way to manage or escape from the unbearable impacts of adverse childhood experiences and/or adult trauma. Rather, it is a coping device – a way to manage or escape from the unbearable impacts of adverse childhood experiences and/or adult trauma.

30. ACE Score and Serious Job Problems

31. Much of what causes time to be lost from work is actually predetermined decades earlier by the adverse experiences of childhood.

32. Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners

33. Adverse Childhood Experiences and History of STD

34. Frequency of Being Pushed, Grabbed, Slapped, Shoved or Had Something Thrown at Oneself or One’s Mother as a Girl and the Likelihood of Ever Having a Teen Pregnancy Never Once, Sometimes Often Very Twice often Percent who had a teen pregnancy Pink =self Yellow =mother

35. Sexual Abuse of Male Children and Their Likelihood of Impregnating a Teenage Girl Not 16-18yrs 11-15 yrs <=10 yrs abused Age when first abused Percent who impregnated a teenage girl 1.3x 1.4x 1.8x 1.0 ref

36. ACE Score and Unintended Pregnancy or Elective Abortion

37. Effect of ACEs on Mortality Age Group 0 ACE 60% live to 65 4 ACE less than 3% live to 65

38. Many chronic diseases in adults are determined decades earlier, in childhood.

40. Other Studies on Childhood Sexual and/or Physical Abuse

41.  In my experience, early child sexual abuse (CSA) especially impairs resiliency especially impairs resiliency  My other children experienced multiple ACE’s. They coped.  Anna experienced early CSA and ACEs. She broke. Sarah Joe, Anna John Mary

42. A number of studies suggest that severe sexual and/or physical violation early in childhood appear to have the greatest impact and to be associated with the most serious disabilities later in life. A number of studies suggest that severe sexual and/or physical violation early in childhood appear to have the greatest impact and to be associated with the most serious disabilities later in life.

43. 2/3rds of men and women in substance abuse treatment report childhood physical and/or sexual abuse. 2/3rds of men and women in substance abuse treatment report childhood physical and/or sexual abuse. 75% of women in treatment programs for drug and alcohol abuse report having been sexually abused. SAMHSA/CSAT, 2000; SAMHSA, 1994 75% of women in treatment programs for drug and alcohol abuse report having been sexually abused. SAMHSA/CSAT, 2000; SAMHSA, 1994

44. 51 – 98% of public mental health clients with severe mental illness, including schizophrenia and bipolar disorder, have been exposed to severe childhood physical and sexual abuse. 51 – 98% of public mental health clients with severe mental illness, including schizophrenia and bipolar disorder, have been exposed to severe childhood physical and sexual abuse. Most have multiple experiences of trauma. Most have multiple experiences of trauma. Goodman et al, 1999, Mueser et al, 1998; Cusack et al, 2003 Goodman et al, 1999, Mueser et al, 1998; Cusack et al, 2003

45. There is a significant relationship between childhood sexual abuse and various forms of self-harm later in life, including suicide attempts, cutting, and self-starving. There is a significant relationship between childhood sexual abuse and various forms of self-harm later in life, including suicide attempts, cutting, and self-starving. Van der Kolk et al, 1991 Van der Kolk et al, 1991 One study found childhood sexual abuse to be the single strongest predictor of suicidality regardless of other factors. One study found childhood sexual abuse to be the single strongest predictor of suicidality regardless of other factors. Read et al, 2001 Read et al, 2001

46. “They do not want to hear what their children suffer. They’ve made the telling of the suffering itself taboo” From Possessing the Secret of Joy, Alice Walker Yet the Silence Continues From ACE Study Slides: Vincent Felitti From ACE Study Slides: Vincent Felitti

47. Prevalence of the Problem Prevalence of the Problem 1/4 th to 1/3 rd of all children and as many as 42% of girls are sexually abused before age 18 – with 9% experiencing persistent, genital assault. Saunders et al, 1992; Randall 1995; Epstein, 1998 1/4 th to 1/3 rd of all children and as many as 42% of girls are sexually abused before age 18 – with 9% experiencing persistent, genital assault. Saunders et al, 1992; Randall 1995; Epstein, 1998 93% of psychiatrically hospitalized adolescents had histories of physical and/or sexual and emotional trauma. 32% met criteria for PTSD. Lipschitz et al, 1999 93% of psychiatrically hospitalized adolescents had histories of physical and/or sexual and emotional trauma. 32% met criteria for PTSD. Lipschitz et al, 1999

48. Teenagers with alcohol and drug problems are 6 to 12 times more likely to have a history of being physically abused and Teenagers with alcohol and drug problems are 6 to 12 times more likely to have a history of being physically abused and They are 18 to 21 times more likely to have been sexually abused than those without alcohol and drug problems. Clark et al, 1997 They are 18 to 21 times more likely to have been sexually abused than those without alcohol and drug problems. Clark et al, 1997 Among juvenile girls identified by the courts as delinquent, more than 75% have been sexually abused. Calhoun et al, 1993 Among juvenile girls identified by the courts as delinquent, more than 75% have been sexually abused. Calhoun et al, 1993

49. The sexual and physical violation of children results in alterations in self-perception which are immediate, last throughout the life-span, and contribute to suicidality as a way to cope. Judith Herman, 1992 Lasting Alterations in Self Perception

50. Sense of helplessness, paralysis, captivity, inadequacy, powerlessness, danger, fear Continues over the lifespan

51. Sense of Shame, Guilt, Self-Blame, Being Bad Continues over the lifespan

52. Sense of defilement, contamination, spoiled, degraded, debased, despicable, evil Sense of defilement, contamination, spoiled, degraded, debased, despicable, evil Continues over the lifespan

53. Sense of complete difference from others, deviance, utter aloneness, isolation, non-human, specialness, unseen, unheard, belief no other person can ever understand Continues over the lifespan

54. Lasting Alterations In Relations With Others The sexual and physical violation of children results in alterations in relations with others, which often last throughout the life-span. Judith Herman, 1992 The sexual and physical violation of children results in alterations in relations with others, which often last throughout the life-span. Judith Herman, 1992

55. Isolation, Withdrawal Isolation, Withdrawal Disruption in Intimate Relationships Disruption in Intimate Relationships Repeated Search for Rescuer Repeated Search for Rescuer Persistent Distrust Persistent Distrust Repeated Failures of Self-Protection Repeated Failures of Self-Protection

56. So, what do our children ask of us?

57. That we pay attention That we pay attention That we overcome lack of knowledge – our own and others That we overcome lack of knowledge – our own and others That we overcome our fear That we overcome our fear That we speak out and end silence about the role of adverse childhood experiences in serious health, mental health and social problems of all kinds. That we speak out and end silence about the role of adverse childhood experiences in serious health, mental health and social problems of all kinds.