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$Page 1: Flying with the ACEs - Handout vs July 2019 Kentucky School...ñ l í ò l î ì í õ ð $&( 6WXG\ )LQGLQJV K ( Z í ó U ì ì ì = } v v Y D } Z v î ñ 9 P Á µ ] v Z } µ Z }$
5/16/2019

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Flying with the ACEsHow Prevention Efforts Can Impact Trauma within the Community By Albert Gay

The Cards You Are Dealt (make all the difference in the world)

THE ADVERSE CHILDHOOD EXPERIENCES (ACE)

Something happens between infancy and adulthood to create a lifetime of addictions, abuse and mental health problems.

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Hidden ACEs

• “Probably the most important public health study you never heard of”

• ACEs sometimes referred to as toxic stress or childhood trauma

• Toxic stress caused by ACEs can profoundly alter the otherwise healthy development of a child

• “Children’s exposure to ACEs is the greatest unaddressed public health threat of our time.” Dr. Robert Block, former president, American Academy of Pediatrics

What is the Adverse Childhood Experiences (ACE) Study?

• Early 1990’s, Center for Disease Control and Kaiser Permanente (an HMO) Collaboration

• Dr. Robert Anda & Dr. Vincent Felitti - Investigators

• Over a ten year study involving 17,000 people (mostly middle income)

• Looked at effects of adverse childhood experiences (trauma)over the lifespan

• Largest study ever done on this subject

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• The key concept underlying the ACE Study is that stressful or traumatic childhood experiences can result in social, emotional, and cognitive impairments.

• Examples: Increased risk of unhealthy behaviors, risk of violence or re-victimization, disease, disability and “early death.”

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What is an Adverse Childhood Experience / ACE?Growing up experiencing any of the following conditions in the household prior to age 18:

1. Recurrent physical abuse

2. Recurrent emotional abuse

3. Contact sexual abuse

4. An alcohol and/or drug abuser in the household

5. An incarcerated household member

6. Family member who is chronically depressed, mentally ill, institutionalized, or suicidal

7. Mother is treated violently

8. One or no parents

9. Physical neglect

10. Emotional neglect

Three Types of ACEs

ABUSE NEGLECT HOUSEHOLD DYSFUNCTION

Physical

Emotional

Sexual

Physical

Emotional

Mental Illness

Mother treated violently

Divorce

Incarcerated Relative

Substance Abuse

The ACE Score

• The ACE Study used a simple scoring method to determine the extent of each study participant’s exposure to childhood trauma. Exposure to one category (not incident) of ACE, qualifies as one point.

• When the points are added up, the ACE Score is determined.

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

• An ACE Score of 10 would mean that the person reported exposure to all of the categories of trauma listed above.

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ACE Study Findings

Of the 17,000+ respondents…

• More than 25% grew up in a household with an alcoholic or drug user

• 25% had been beaten as children

• Two-thirds had 1 adverse childhood event

• 1 in 6 people had four or more ACES

Source: Adverse Childhood Experiences (ACE) Study. Information available at http://www.cdc.gov/ace/index.htm

ACE Study FindingsACE Scores Linked to Physical & Mental Health Problems

• Twice as likely to smoke

• Seven times as likely to be alcoholics

• Six times as likely to have had sex before age 15

• Twice as likely to have cancer or heart disease

• Twelve times more likely to have attempted suicide

• Men with six or more ACEs were 46 times more likely to have injected drugs than men with no history of adverse childhood experiences

Compared with people with no ACEs, those with four or more ACEs were:


Untreated Adverse Early Childhood Events Only Get Worse Over Time


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ACES Impacts Learning

51% of children with 4+ ACE scores

had learning and behavior problems in school

Compared with only 3% of children with NO ACE score

Why is This Study So Important?ACEs are:

• Surprisingly common

• Strong predictors of later social functioning, well-being, health risks, disease, and death

If Any One ACE is Present

• 87% chance at least one other ACE is present, and

• 50% chance of 3 others

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ACEs Everywhere

ACE SCORE of ZERO

• 1/3 of Adults have ACE Score of 0

• Majority of adults withACE score of 0, have few, if any, risk factors for diseases that are

common causes of death in US

• 4 or more may result in multiple risk factors for chronic diseases or disease themselves• 6 or more may result in a 20 year decrease in life expectancy

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With 0 ACEs

1 in 16 smokes

1 in 69 are alcoholic

1 in 480 use IV drugs

1 in 14 has heart disease

1 in 96 attempts suicide

With 3 ACEs

1 in 9 smokes





With 7+ ACEs

1 in 6 smokes





33%Report No ACEs

51%Report 1-3 ACEs

16%Report 4-10 ACEs

Out of 100 people…

ACEs are Interrelated and Predictive

Without interruption, ACEs escalate across generations

FAMILY TREE

ACEs Have Cumulative Stressor Effect

It’s the number of different categories, not the intensity or frequency, that determine health outcomes

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The Disease Link

• Many chronic diseases in adults are determined decades earlier, by experiences in childhood

• Risk factor/ behaviors for these diseases are initiated during childhood and adolescents and continue into adult life

• Even if individuals with high ACE Scores do not adopt high risk behaviors, they are still much more likely to have negative health consequences

Positive Stress

• Moderate, short-lived physiological response – Increased heart rate, higher blood pressure– Mild elevation of stress hormone, cortisol , levels

• Activated by: – Dealing with frustration, meeting new people

(National Scientific Council on the Developing Brain, Harvard University 2006)

Tolerable Stress

• Physiological responses large enough to disrupt brain architecture

• Relieved by supportive relationships:– that facilitate coping, – restore heart rate and stress hormone levels– reduce child’s sense of being overwhelmedActivated by:– Death of loved one, divorce, natural disasters

(National Scientific Council on the Developing Brain, Harvard University 2006)

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Toxic Stress

• Strong & prolonged activation of stress response systems in the absence of buffering protection of adult support– Recurrent abuse, neglect, severe maternal depression,

substance abuse, family violence– Increased susceptibility to cardiovascular disease,

hypertension, obesity, diabetes and mental health problems

Toxic Stress

• “Extreme, frequent or extended activation of the body’s stress response, withoutthe buffering presence of a supportive adult.”

Sara B. Johnson, et al., The science of early life toxic stress for pediatric practice and advocacy, 131 PEDIATRICS 319 (2013), available at http://pediatrics.aappublications.org/content/131/2/319.full

Toxic Stress Early in Development

• Affects functioning of 3 highly integrated systems: – the immune system

– the neuroendocrine system

– the central nervous system (Danese & McEwen, 2012)

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Stressors

• Biologically predisposed to more physiologic stress

• Brain structures that modulate this stress mature later

• Young children need safe, stable, and nurturing relationships to assist them in regulating their stress

Relationships HealTo heal from toxic stress, children need recognition and understanding from their caregivers

The Brain Frame

• Built in a cumulative, bottom-up manner

• Solid foundation required for future skills

• Interaction between genes and experience shapes the architecture of the developing brain

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Plasticity & Age

• Brain’s ability to rewire itself in response to changes in the environment is waning by kindergarten

• Remediation, while possible, is much more difficult

Creating A Caring Environment

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What is trauma

A traumatic event is one in which a person experiences (witnesses or is confronted with):

• Actual or threatened death• Serious injury• Threat to the physical integrity of self or

another

What is trauma

“Prolonged exposure to repetitive or severe events such as child abuse, is likely to cause the most severe and lasting effects.”

“Traumatisation can also occur from neglect, which is the absence of essential physical or emotional care, soothing and restorative experiences from significant others, particularly in children.”

(International society for the study of Trauma and Dissociation, 2009)

Responses to a traumatic event may include

• Intense fear• Helplessness• Horror• Attachment

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Interpersonal trauma?

• Interpersonal violence tends to be more traumatic than natural disasters because it is more disruptive to our fundamental sense of trust and attachment, and is typically experienced as intentional rather than as “an accident of nature.”

(International society for the study of trauma and dissociation, 2009)

Conceptualizing Trauma Extreme stress that is brought on by shocking or

unexpected events that overwhelm a person’s ability to cope, resulting in feelings of helplessness, and extreme fear and horror. The survivor perceives the event as a bodily violation or a threat of serious injury or death or to self or a loved one. The event may be witnessed or experienced directly.

The defining factor that separates a traumatic experience from a distressing one is the perception of a threat to survival to self or a loved one. (Miller, 2011)

Who Experiences Trauma?

• Virtually everyone experiences distressing events, but not everyone experiences trauma.

• What is traumatic for one person may not be traumatic for another.

• We must, therefore, consider carefully not only the EVENT but the individual’s PERCEPTION of the event.

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Types of Traumatic Events

• Physical• Emotional• Sexual• Neglect• Torture• Combat• Witnessing Extreme Injury or Death• Witnessing Abuse• Terrorism• Natural Disasters• Accidents

ACTIVITY

1. List as many traumatic situations that have caught national / international news

2. List as many traumatic situations that are statewide or regional impacting

3. List as many traumatic situations that are locally impacting

DSM – 5 Definition of Trauma

NASMHPD (2006):The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disaster

DSM-5 (APA 2013):The previous edition, DSM-IV, had addressed PTSD as an anxiety disorder.The DSM-5 includes a new chapter on Trauma- and Stressor-Related Disorders. Trauma includes:• direct experience of the traumatic event;• witnessing the traumatic event in person; • learning that the traumatic event occurred to a close family member or close friend

(with the actual or threatened death being either violent or accidental); or • experiences first-hand repeated or extreme exposure to aversive details

of the traumatic event (not through media, pictures, television or movies unless work-related).

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Traumas Most Likely To Lead to Serious Mental Health Problems in Youth:

• Sexual & physical abuse, neglect, emotional abuse, abandonment, poverty, sudden and traumatic loss

• A severe one-time or repeated event (Yes, even just once)• Actions perpetrated by someone known• Acts that betray trust

Generally speaking, the most harmful trauma experiences tend to be those that were perpetrated by someone close - someone well-known to the victim - and/or were:

• Intentional• Repeated• Prolonged• And the earlier in life it happened, the more profound the

impact on brain development.

One-time events can be as traumatic as repeated events. We do not want to minimize single occurrences like a rape, a serious automobile accident, or being involved in a natural disaster, like Hurricane Katrina or Irene, or Superstorm Sandy. Obviously these types of events can be devastating.

Typical Trauma-related Symptoms• Dissociation• Flashbacks• Nightmares • Hyper-vigilance• Terror• Anxiety• Pejorative auditory

hallucinations• Difficulty w/problem solving

• Numbness• Depression• Substance abuse• Self-injury• Eating problems• Poor judgment and continued

cycle of victimization• Aggression

What we want you to understand is that these “symptoms” are not signs of pathology - rather, they are survival strategies that have helped them cope with terrible pain and challenges.

The key is learn how the behavior developed and teach new coping strategies.

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ACEs and Addiction

ACEs in Foster Care

• More than half of kids reported for Child Maltreatment experienced 4 or more ACEs by time of contact with child welfare

• More than 90% referred to child welfare have experienced multiple ACEs

(Nat’l Survey Child and Adolescent Well-Being (NSCAW), No. 20: Adverse Child Experiences in NSCAW, 2013)

ACEs Impact on the Economy

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Impact on Prison• ACEs result in a range of

behaviors punishable by the law

• ACEs raises chances of juvenile arrest by 59%

• Increased adult criminal behavior by 28%

• Violent crime by 30%

ACEs in the Face (the lives of children)

“Many of the kids who end up in the juvenile justice system, the vast majority of them have been exposed to high doses of adversity,” Screening is the key to prevention, not just for illness but for jail time, too. We’re looking at it from a health standpoint, but we know for a fact that if we’re screening for ACEs and doing effective intervention, it’s going to impact justice outcomes.”

Nadine Burke Harris, CEO of the Center for Youth Wellness and a pediatrician.

A House of Cards

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A House of Cards

Move Over Into A Different Structure

Move into House of Support

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The goal…Healthy behaviors

Start with…

Healthy beliefs & clear standards…in families, schools, communities and peer groups

Build…

Bonding• Attachment • Commitment

…to families, schools, communities and peer groups

By providing…Opportunities

By providing…

SkillsBy providing…

Recognition

And by nurturing…

Individual characteristics

…in families, schools, communities and peer groups

Building Systems of Support

Trauma Informed Care Approach1. Realizes the widespread impact

of trauma and understands potential paths for recovery;

2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;

3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and

4. Seeks to actively resist re-traumatization."

SAMHSA’s 6 Key Principals1. Safety2. Trustworthiness and

Transparency3. Peer support4. Collaboration and

mutuality5. Empowerment, voice and

choice6. Cultural, Historical, and

Gender Issues

You Are the Team

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Trauma-Specific Interventions

• The survivor's need to be respected, informed, connected, and hopeful regarding their own recovery

• The interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety

• The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers

Family

Community

School

Peers

Build Some Flying ACEs. Find Community Partners Today!

Our Public Health Response

I. Prevention

II. Detection and Early Intervention

III. Safe, Strengthening and Healing Environments and Responses

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I. PREVENTIONA PROCESS OF PROTECTION

Successful Prevention

Collaborative

Data-driven

Developmentally appropriate

Based on theory and research

These characteristics

should be present in infrastructure and personnel.

Sustainable

Culturally competent

Planned thoroughly

Evaluated for effectiveness

How to do it

• With evidence-based programs, policies, strategies• Education• Normalize healthy decisions and behaviors• Skill building and development

– Coping– Resistance– Refusal

• Strategic Prevention Framework

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Strategic Prevention Framework• Data-problem behavior and

Risk/Protective Factors

• Readiness of the community

• Mobilizing community

• Strong coalition

• Determine costs• Determine resources• Get organized

• Implement EBP• Use fidelity

• Did you do what you said you would do?

• Reduce problem behavior• Change knowledge,

skills & attitudes

Risk Factors

A characteristic at the

biological, psychological, family, community, or cultural level

that precedes and is associated with

a higher likelihood of

problem outcomes

Predictors of Problem Behaviors

Risk factors can predict

–Substance abuse– Delinquency– Teen pregnancy– School drop out– Violence– Depression &

Anxiety

Family School

Community Peer & Individual

Domains

Source: SAMSHA Communities that Care Trainer’s Manual

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Family Risk Factors

• Family history of the problem behavior

• Family management problems

• Family conflict

• Parental attitudes and involvement in drug use, crime and violence

Blend & Balance

• Risk factors predict substance abuse• Protective factors buffer substance abuse• To prevent substance use, programs must:

Risk factors

Protective factors

Protective Factors

A characteristic

at the individual, family

or community level

that is associated with

a lower likelihood of

problem outcomes

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Protective Factors

Good news!! There are predictors of positive youth outcomes

• Protective factors bufferexposure to risk

– Based on research– Present throughout

development– Present in all areas of

influence

Source: SAMSHA Communities that Care Trainer’s Manual

The Social Development Model:Building a Community Model of Protection

Social Development Strategy

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II. DETECTION AND EARLY INTERVENTIONA PROCESS OF PROTECTION

Screen & ReferLinking with Mental Health Services

• Create a process for screening for early detection

• Build linkages with Mental Health Service Agencies

• Follow Protocols for Mandated Reporting

• Create Process for referrals

III. SAFE, STRENGTHENING AND HEALING ENVIRONMENTS AND RESPONSES

A PROCESS OF PROTECTION

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Trauma-Informed Care• Recognition of prevalence of trauma• Assessment and treatment for trauma• Focus on What happened to you? vs. What is wrong with you?• Informed by current research• Recognition that coercive environments are re-traumatizing

Universal precautions apply to all!

Trauma-Informed Care

• Recipient is center of his/her own treatment• Recipient and family are empowered• Wellness and self management are the goal• Transparent and open to outside parties• Power/control are minimized• Staff are trained and understand function of behavior

TIC respects and empowers the individual as the center of their own wellness!

Trauma-Informed Care

The focus is on collaboration -

• Not engaging in interactions that are demeaning, disrespectful, dominating, coercive, or controlling

• Responding to disruptive behaviors with empathy, active listening skills, and questions that engage the person in finding solutions

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Trauma-Informed Language

• Person-centered• Respectful - get permission to use first name• Conscious of tone of voice and noise level• Body language• Helpful and hopeful• Objective, neutral language

Trauma-Informed Environment• Respectful interaction• Opportunities for individual “space” and

activities• Welcoming settings• Person-centered signage

In TIC, each person is appreciated and respected. Individuality and acknowledgement of individual needs is a priority.

Open communication is signaled by an atmosphere where staff are approachable.

Example: The use of “Do Not” signs and rules is transformed into helpful and encouraging verbiage.

Non-Trauma-Informed

• Lack of education on trauma

• Over-diagnosis of schizophrenia, singular addictions, bipolar and conduct disorders

• Focus is on rule enforcement and compliance

• Behavior seen as intentionally provocative

• Labeling: “manipulative, needy, attention-seeking”

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Problems Associated with a Controlling Culture

• Focus is on staff, not the recipient

• Addressing a problem is built around staff and program convenience

• Rules become more important as staff knowledge about their origin erodes

• The person’s compliance and containment are mistaken as actual learning of new skills and/or real improvement

Problems Associated with a Controlling Culture

• Minor violations often lead to control struggles

• Fosters a belief that privileges (rights) must be earned

• Reinforces a need to control the recipient

• Poorly trained staff who bully people into compliance are not identified or disciplined

• These same staff may be rewarded for maintaining safety or creating a quiet shift

Exercise

Rephrase the following using trauma-informed language:

“You need to get out of bed now!”“You need to get in line for lunch.”“No, you can’t go back to your room.”

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What Happens when Traumatized People are Restrained or Secluded?

Research studies have found that children who were secluded:

• Experienced vulnerability, neglect, shame

• Repeatedly express being reminded of their original abuse

• Express feelings of fear, rejection, anger and agitation (verbally and in drawings)

Wadeson et al., 1976; Martinez, 1999; Mann et al., 1993; Ray et al., 1996

What Happens when Traumatized People are Restrained or Secluded?

• Felt they were being punished

• Were confused by staff use of force

• Did not feel protected from harm

• Report feelings of bitterness and anger one year later

Wadeson et al., 1976; Martinez, 1999; Mann et al. 1993; Mohr, 1999; Ray et al., 1996

Trauma Assessment

Purpose:

• Used to identify past or current trauma, violence, and abuse, and assess related consequences

• Provides context for current symptoms and guides clinical approaches and recovery progress

• Informs the treatment culture to minimize potential for re-traumatization

Cook et al., 2002; Fallot & Harris, 2002; Maine BDS, 2000

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Trauma AssessmentShould minimally include:

• Type: sexual, physical, or emotional abuse or neglect, exposure to disaster

• Age: when the abuse occurred

• Who: perpetrated the abuse

• Assessment of such symptoms as: dissociation, flashbacks, hyper-vigilance, numbness, self-injury, anxiety, depression, poor school performance, conduct problems, eating problems, etc.


Trauma Assessment

• Results and “positive responses” must be addressed in treatment planning or assessment is useless

• Interview is conducted upon intake or shortly after

• Importance of therapeutic engagement during interview cannot be over-emphasized

• For children, assessment through play and behavior observations


Core Elements in the Most Effective Treatment Programs

• Memory identification, processing and regulation

• Anxiety management

• Identification and alteration of maladaptive cognitions

• Interpersonal communication and social problem-solving

• Direct intervention in the home/community

• Appropriate use of medication

Hodas, 2004

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Organizational Commitment to Trauma-Informed Care

Adoption of a trauma-informed policy to include:

• Commitment to appropriately assess trauma

• Avoidance of re-traumatizing practices

• Key administrators on board

• Resources available for system modifications and performance improvement processes

• Education of staff prioritized

Fallot & Harris, 2002; Cook et al., 2002


• Unit staff can access expert trauma consultation

• Unit staff can access trauma-specific treatment if indicated



• Assessment data informs treatment planning in daily clinical work

• Advance directives, safety plans and de-escalation preferences are communicated and used

• Power & Control are minimized by attending constantly to unit culture


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In Summary

• Appreciate high prevalence rates• Understand the characteristics of

trauma-informed care and how this differs from care that is not informed by trauma

• Assess histories and symptoms of trauma and link to treatment plans/crisis plans

• Provide support and skill development

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