1. The Adverse Childhood Experiences Study
March 13, 2014 1

2. Presentation Overview
Adverse Childhood Experiences Study Findings
How to create stable, nurturing relationships and communities
Share Adverse Childhood Experiences Study findings and how early exposure to family dysfunction and abusive treatment can lead to health and social problems.
Learn how building safe, stable nurturing relationships and communities can break cycle of abuse and maltreatment. 2 2

3. The study
Examined health and social effects of adverse childhood experiences throughout lifespan
Conducted by Dr. Robert Anda, CDC and Dr. Vincent Felitti, Kaiser Permanente
Decade-long study involving 17,000 people
Demographics: primary care setting, educated, middle class, predominantly white
Largest study ever done on the subject
ACEs changed the landscape in many ways
With knowledge comes responsibility 3

4. 10 COMMON TRAUMAS CHILDHOOD ABUSE Physical Emotional Sexual
CHILDHOOD NEGLECT
HOUSEHOLD DYSFUNCTION
Substance Abuser
Mental Illness
Parental loss
Witnessing violence
Crime in household
Source: Dr. Robert Anda and Dr. Vincint Felitti, Adverse Childhood Experiences Study, 1995

6. Impact of ACEs on Early Brain Development
Here’s another visual representation of what can happen to the brain during those learned early attachment relationships:
You see a brain scan of a “healthy brain” and a scan of a traumatized child. The traumatized brain shows little to no activity in the temporal lobes- these areas are known to influence emotions, human attachment, and self-regulation. So… if a person was traumatized as a child, they might have to look outside of themselves to help regulate their internal emotional state.
Core Concepts of Development
Brains are built over time, neural circuits are wired in a bottom-up sequence, and the capacity for change decreases with age.
The interaction of genes and experience shapes the architecture of the developing brain, and the active agent is the “serve and return” nature of children’s relationships with the important adults in their lives. 6

7. Stress is Hard-Wired Into Biology
Emotional regulation
Verbal & spacial memory,
Management of fear, panic emotional understanding, emotional responses
Ability to put the brakes on outbursts
Thinking & judgment
Early Childhood
Middle Childhood
Cross-brain function
Language & math proficiency & integration
Notice & interpret social cues
Spoken language
Meaning from visual cues
Vulnerability: PTSD, suicide, profound depression
Long term memory
Executive function
Affect, attention
Regulating mental health
Movement through space
Reacting to peripheral details
Pre-puberty & Adolescence

8. What it found ACEs are common Of those surveyed:
1 in 4 exposed to 2 categories of ACEs
1 in 5 experienced 3 or more.
22% were sexually abused as children.
66% of the women experienced abuse, violence or family strife in childhood.
Almost two-thirds of study participants reported at least one ACE 8

11. Typical High School Classroom
Based on interpolation of Healthy Youth Survey data from Behavioral Risk Factor Surveillance System data, we are able to learn about the ACE scores of high school youth in an average classroom in Washington.
The punch line here is that 42% of high school sophomores and seniors have 3 or more ACEs; whereas 26% of adults in Washington have 3 or more ACEs.
This reality indicates that we, as a society, are failing to protect and prevent toxic stress in the lives of children. We can say it’s the parent’s fault, or the government’s fault… but we also must face that we are the adults alive today. We are somehow participating in a social dynamic that results in 42% of teens having 3 or more ACEs.
We are the ones that must change these social dynamics, and we absolutely can do that… communities in Washington are already having success.

12. 7,924 in households with a mentally ill member.
6,374 in household with alcohol or other substance.
1,769 have an incarcerated parent.
1,059 have been denied of critical care.
433 who parents have recently divorced.
265 present during a domestic violence incident.
234 founded cases of physical or sexually abuse

14. What it found
Childhood experiences are powerful determinants of who we become as adults.
Source: From Anda’s presentation
INCLUDE DEFINITION OF TRAUMA AT SOME POINT OR A SLIDE DISCUSSING IT?
SAMSHA: Trauma can result from experiences of violence. Trauma includes physical, sexual and institutional abuse, neglect, intergenerational trauma, and disasters that induce powerlessness, fear, recurrent hopelessness, and a constant state of alert.
Trauma:
Physical: the body’s response to serious injury and threat.
Mental: the mind’s response to serious injury and threat, including frightening thoughts and painful feeling
Trauma definition source: 14

15. What it found ACEs are commonly linked to:
Developmental impairment in children
Chronic depression
Attempted suicide
Alcohol use
Smoking
Illicit drug use
Risky sexual behaviors
Liver disease
Heart disease
Victim of domestic violence
Impaired worker performance
Health-related quality of life
Early mortality
Aces can lead to a vast amount of health issues down the road 15

16. What it found People with 4 or more ACEs compared to those with 0 ACEs
RISK FACTOR
% INCREASE
Smoking
242%
Obesity
222%
Depression
357%
Illicit drug use
443%
Injected drug use
1,133%
Sexually Transmitted Diseases
298%
Attempted suicide
1,525%
Alcoholism
555%
People with 4 or more ACEs compared to those with 0 ACEs
Aces dramatically increases risk for many health issues. 16

17. Probability of outcomes
Given 100 American Adults 33
Report No ACEs 51
Report 1-3 ACEs 16
Report 4-8 ACEs
WITH 0 ACEs
1 in 16 smokes
1 in 69 are alcoholic
1 in 480 uses IV drugs
1 in 14 has heart disease
1 in 96 attempts suicide
WITH 3 ACEs
1 in 9 smokes
1 in 9 are alcoholic
1 in 43 uses IV drugs
1 in 7 has heart disease
1 in 10 attempts suicide
WITH 7+ ACEs
1 in 6 smokes
1 in 6 are alcoholic
1 in 30 use IV drugs
1 in 6 has heart disease
1 in 5 attempts suicide
[i]Excerpt from “The High Cost of Adverse Childhood Experiences,” Power Point, Washington State Family Policy Council, (2007).

22. Impaired Worker Performance
Prevalence of Impaired Performance (%)
The higher the ACE score the harder time an individual may have in making a living. Here there is a graded relationship between ACE scores Absenteeism, Serious Financial Problems and Job Problems

23. Alcohol use and abuse Percent with alcohol-related problem Alcoholic
Married an Alcoholic 23

24. The ACE Score, Smoking, and Lung Disease

25. Teen Sexual Behaviors Intercourse by Age 15 Teen Pregnancy
Teen Paternity 25

26. Attempted Suicide 4+
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.
This is hugely significant. Relationships of this magnitude are rare in epidemiology. Especially how we see the stair stepped graded relationships. (which you will see throughout the slides)
Its easier to get to 7 ACEs than you might think……
In a family where there is domestic violence for example – there often exists additional problems or ACE categories such as substance abuse, drug use, separation/divorce, abandonment, physical abuse, sexual abuse, someone in correctional system, serious emotional problems e.g. depression, emotional abuse, neglect.
Once an individual experiences 1 significant ACE – it opens him or her to more – creates fragility, compromises resiliency. Like an immune system gets compromised. 3 2 1

28. The Magnitude of the Solution
ACE reduction
reliably predicts
simultaneous
decrease in all of
these conditions.
Population
attributable risk
Source: Washington Family Policy Council

29. The ACE survey
Please take a few minutes to complete the survey anonymously.

30. Reflections
Do you see any of these ACEs in children in your care? In your friends and colleagues? In yourself?
Does this survey make sense? What questions do you have about this survey or what it means?
What can we do with this information?

31. Now what? 31

32. children

36. Resilience Trumps ACEs
For children with ACEs, adults can help by
Understanding ACEs
Create environments where children feel safe
Help children identify their feelings and learn how to manage their emotions
Create protective factors in the schools, communities and at home
From Spokane Regional Health District: Community & Family Services Division; Stress and Brain Development, Understanding Adverse Childhood Experiences (ACEs)

37. Creating Protective Factors
Parental Resilience
Ability to problem-solve and build relationships
Nurturing and attachment
Listening and responding to a child in a supportive way
Social Connections
Having family, friends, or neighbors who are willing to help or listen
Concrete Supports
Having child’s basic needs met: housing, food, clothing, and healthcare
Knowledge of parenting and child development
Increasing parent’s knowledge of development and appropriate expectations for their child’s behavior
Social and emotional competence of children
Helping children to interact positively with others, manage their emotions, and communicate feelings
From Spokane Regional Health District: Community & Family Services Division; Stress and Brain Development, Understanding Adverse Childhood Experiences (ACEs)

38. Principle One: Always Empower, Never Disempower
Students affected by trauma often compete with their teachers for power. This is because they believe that controlling their environment is the way to achieve safety (Craig, 1992).

39. Principle Two: Provide Unconditional Positive Regard
Traumatic events make it difficult for children to trust. They make it difficult to feel worthy, take initiative, and form relationships. Students struggling with trauma don’t need another adult to tell them what is wrong with them. What they do need, what helps them thrive, is an adult who treats them with simple sustained kindness, an adult who can empathize with the challenges they face moving between home and school.

40. Principle Three: Maintain High Expectations
Teachers may be so concerned about disempowering their students that they may be hesitant to set limits. As a consequence, expectations for achievement are lowered. Doing so inadvertently sends negative messages such as “you are too damaged to behave” or “you are different than others so I am giving up on you.” Note that these messages can increase the perception of the student that they are powerless. Increased feelings of powerlessness lead to increased symptoms of traumatic affect.

41. Principle Four: Check Assumptions, Observe and Question
Traumatic events can affect any person, family or group of people. When we make assumptions about who is likely to be traumatized based on a stereotype of any one group of people, this may stop us from seeing who actually has been affected by trauma.
1) Identify Assumptions.
2) Observe.
3) Ask Questions; and
4) Listen.

42. Principle Five: Be a Relationship Coach
Compassionate teachers think of themselves as relationship coaches. After all, the relationships we establish with and among students influence the tone and demeanor in our classrooms.

43. Helpful Participation
Principle Six: Provide Guided Opportunities for
Helpful Participation
Meaningful participation gives us opportunities to be heard, to make choices, to have responsibilities, to belong, and to engage in problem solving. When we make meaningful contributions to the welfare of others, we improve our own feelings of self-worth. Helping others strengthens resiliency. Providing guided opportunities for participation is an important principle of compassionate teaching. Such supervised opportunities can provide solace, create mutual trust, and affirm the self-worth of those involved.

45. 10 Ways to Build Resilience
Make connections
Avoid seeing crises as insurmountable problems
Accept that change is a part of living
Move toward your goals
Take decisive actions
1) Make connections. Good relationships with close family members, friends or others are important. Accepting help and support from those who care about you and will listen to you strengthens resilience. Some people find that being active in civic groups, faith-based organizations, or other local groups provides social support and can help with reclaiming hope. Assisting others in their time of need also can benefit the helper.
2) Avoid seeing crises as insurmountable problems. You can't change the fact that highly stressful events happen, but you can change how you interpret and respond to these events. Try looking beyond the present to how future circumstances may be a little better. Note any subtle ways in which you might already feel somewhat better as you deal with difficult situations.
3) Accept that change is a part of living. Certain goals may no longer be attainable as a result of adverse situations. Accepting circumstances that cannot be changed can help you focus on circumstances that you can alter.
4) Move toward your goals. Develop some realistic goals. Do something regularly — even if it seems like a small accomplishment — that enables you to move toward your goals. Instead of focusing on tasks that seem unachievable, ask yourself, "What's one thing I know I can accomplish today that helps me move in the direction I want to go?"
5) Take decisive actions. Act on adverse situations as much as you can. Take decisive actions, rather than detaching completely from problems and stresses and wishing they would just go away.
Source: America Psychological Association

46. 10 Ways to Build Resilience
6) Look for opportunities for self-discovery 7) Nurture a positive view of yourself 8) Keep things in perspective 9) Maintain a hopeful outlook 10) Take care of yourself
6) Look for opportunities for self-discovery. People often learn something about themselves and may find that they have grown in some respect as a result of their struggle with loss. Many people who have experienced tragedies and hardship have reported better relationships, greater sense of strength even while feeling vulnerable, increased sense of self-worth, a more developed spirituality and heightened appreciation for life.
7) Nurture a positive view of yourself. Developing confidence in your ability to solve problems and trusting your instincts helps build resilience.
8) Keep things in perspective. Even when facing very painful events, try to consider the stressful situation in a broader context and keep a long-term perspective. Avoid blowing the event out of proportion.
9) Maintain a hopeful outlook. An optimistic outlook enables you to expect that good things will happen in your life. Try visualizing what you want, rather than worrying about what you fear.
10) Take care of yourself. Pay attention to your own needs and feelings. Engage in activities that you enjoy and find relaxing. Exercise regularly. Taking care of yourself helps to keep your mind and body primed to deal with situations that require resilience.
Additional ways of strengthening resilience may be helpful. For example, some people write about their deepest thoughts and feelings related to trauma or other stressful events in their life. Meditation and spiritual practices help some people build connections and restore hope.
Source: America Psychological Association

47. Thank You!
Questions?

48. Group Discussion: What now?
What principles or ways to build resilience resonated with me?
What didn’t I like or agree with about this information?
What is one real thing I can do with this information?
Change in mindset – the way we see children.
How have my views changed with this information?
Change in action – the way we act with children, colleagues, etc.
What will I do with this information?
Change in advocacy – telling friends about this information.
Who will I tell about this information?