Impact of Trauma on Adult Children: Mental Health and Addiction

1. Impact of Trauma on Adult Children: Mental Health and Addiction Mary F. Hardy, LPC, LADC LIFE Senior Services

2. Objectives: • Understand how Adverse Childhood Experiences (ACE) and ACE Scores (ACEs) related to childhood trauma and living with addiction in the home prior to the age of 18 can ultimately impact health, mental health and addiction over the persons lifespan • Understand how cumulative childhood trauma and addiction in the family creates imbalance or dysfunction in the family system. • Understand the need to provide early identification, intervention and treatment for persons who are affected by cumulative childhood trauma.

3. Adverse Childhood Experiences (ACE) Research • The Relationship of Adverse Childhood Experiences to Adult Health: Turning Gold Into Lead, Felitti, Kaiser Permanente 2002 • The Origins of Addiction: evidence from the Adverse Childhood Experiences Study Felitti, Kaiser Permanente 2003 • Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use, Dube and Others, Pediatrics 2003; 111;564 • Impact of Adverse Childhood Experiences on Health Problems: Evidence from Four Birth Cohorts Dating Back to 1900, Dube and Others, Preventive Medicine 37, 2003.

4. Research Continued • The Health and Social Impact of Growing Up with Alcohol Abuse and Related Adverse Childhood Experiences: The Human and Economic Costs of The Status Quo, Anda, Board of Scientific Advisors, National Association for Children of Alcoholics and Co-Principal Investigator, Adverse Childhood Experiences Study, online at http://www.nacoa.org • A Non ACE Study: Relationship Dynamics Within the Addicted/Traumatized Family System, Tian Dayton, Huffington Post, Posted 9/25/10 02:45 PM ET

5. Adverse Childhood Experiences Study • Decade-long study examine childhood origins of leading health and social problems • Collaboration between Centers for Disease Control and Prevention (CDC) and Kaiser Health Plan’s Department of Preventive Medicine • Key concept of Study suggests stressful or traumatic childhood experiences are a common pathway to social, emotional, and cognitive impairments that lead to increased risk of unhealthy behaviors, violence, re-victimization, disease, disability and premature mortality.

6. Adverse Childhood Experiences Or ACEs Refer to Growing Up With Any Of The Following: Abuse: • Emotional Abuse • Physical Abuse • Sexual Abuse Neglect: 4. Lack of Support • Poverty Household Dysfunction: 6. Witnessing domestic violence 7. Alcohol/Substance Abuse 8. Mental Illness 9. Parental Discord 10.Crime

7. Conceptual Framework Of The ACE Study

8. ACEs Are CommonPrevalence of Adverse Childhood Experiences (ACE) Original StudyCDC Website: http://cdc/gov/needphp/ace ACE Category Women Men Total N=9,367 N=7,970 N=17,337 • Abuse Emotional Abuse (#1) Physical Abuse (#2) Sexual Abuse (#3) • Neglect Lack of Support (#4) Poverty (#5) • Household Dysfunction Witnessing Domestic Violence (#6) Household Alcohol/Substance Abuse (#7) Household Mental Illness (#8) Parental Separation or Divorce (#9) Crime or Person in Household Incarcerated (#10)

9. Prevalence of the ACE Score by Gender:

10. ACE Score - General Findings • Cumulative impact of multiple exposures can be captured in an “ACE Score” • ACE score has strong, graded relationship to numerous health, social, and behavioral problems throughout a person’s lifespan • Adverse childhood experiences (ACEs) are common • 1 in 4 grew up with substance abuse • More than 10% had 5 or more ACEs • ACE- related problems tend to be co-morbid or co-occurring

11. ACES Have AStrong Influence On: • Adolescent Health • Teen Pregnancy • Smoking • Alcohol Abuse • Illicit Drug Abuse • Sexual Behavior • Mental Health • Risk of Re-Victimization • Stability of Relationships • Performance in the Work Place

12. ACEs Increase The Risk Of: • Heart Disease • Chronic Lung Disease • Liver Disease • Suicide • Injuries • HIV and STDs • And Other Risks For The Leading Causes Of Death

13. The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study, Felitti, Kaiser Permanente 2003 • Same ACE data from original study • Added look at ACE Score vs. Adult Alcoholism • Looked at Vietnam Veteran Data • Many Veterans used heroin regularly in Vietnam • Only 5% of those considered addicted were still using 10 months after their return – Why? • ACEs Suggests Smoking, Alcoholism And Injected Drug Use As Coping Mechanisms To Get Relief

14. ACE Score vs. Smoking

15. Ace Score vs. COPD

16. Prevalence of ACE Continued • ACEs of 4 or Higher Result in Increase Prevalence of Intravenous Drug Abuse and Depression • ACEs of 4 or Higher Result in Increased Suicide Attempts; 2/3rd of Attempts May Be Attributable to ACEs • ACEs of 6 or More Has a 4,600% Increase in Likelihood of Later Becoming an IV Drug User When Compared to an ACE Score of 0

17. ACE Score vs. Intravenous Drug Use

18. ACE Score vs. Attempted Suicide

19. ACE Score vs. Adult Alcoholism

20. Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use 2003 Retrospective Study – N=8,613 found ACEs Correlates With Early Adolescent Drug Initiation • Initiation by Age 14 increases the Adulthood Risk of Illicit Drug Use 2-4 Fold • Risk Appears Stratified by Birth Cohort For Lifetime Use – 5 or More ACEs • 1900-1932 – 4.3% • 1933-1947 – 20.8% • 1948-1962 – 56.8% • 1963-1978 – 57.7%

21. A Descriptive Epidemiology of Lifetime Trauma and the Physical Health Status of Older Adults (Not An ACE Study) • Research Evaluated Exposure to 22 Trauma Events Over the Life Course by Age Cohort • Research Included Exposure Over Age 18, Versus the ACEs (Under 18). • Findings Indicated Older Adults Experience Cumulative Exposure to Trauma Over Their Lifetime

22. TRAUMATIC EVENT Spouse died Child died At or near birth Major fire, flood, earthquake, natural disaster Fired a weapon in combat Sexual abuse or assault Physical abuse or assault Addiction in the family Parent dies or divorces before you are age 18 % of 65-74 75-84 85+ Sample % % % 37.4 23.2 46.4 69.1 19.9 16 23.1 26.8 6.8 6.7 7.0 7.3 16.2 15.7 17.2 17.9 9.9 6.1 17.1 6.5 2.1 2.7 1.7 0.8 3.8 5.2 2.1 2.1 10.6 12.8 8.4 6.5 6.8 8.5 5.6 3.1 Lifetime Exposure To Trauma Examples - Ages 65-85+ (N=1,518)

23. SAMHSA, Treatment Episode Data Set (TEDS) (From 1992-2008 – Age 50+), www.samhsa.gov • SA Treatment Admissions more than doubled from 6.6% in 1992 to 12.2% in 2008 • Age 50+ Alcohol Admissions Decreased from 84.6% to 59.9%, while primary heroin abuse more than doubled (from 7.2% to 16.0%) • Age 50 + Admissions of multiple substance abuse tippled from 13.7% to 39.7% • Age 50 + Those who initiated use of their primary substance of abuse within the past 5 years were more likely that those in 1992 to have reported prescription pain relievers as their primary substance (25.8% vs. 5.4%)

24. ACE As Indicator of Effects of Cumulative Stress on (Neuro) Development • Link of childhood maltreatment to long-term changes in brain structure and function involving several interconnected brain regions • Prefrontal Cortex • Hippocampus • Amygdala • Corpus Callosum • Cerebellum

25. Early Stress Associated With Lasting Alterations in Stress-Responsive Neurobiological Systems • Hypothalamic-pituitary-adrenal axis • Monoamine neurotransmitter systems Lasting effects on the developing brain would be expected to affect numerous human functions into adulthood, i.e. emotional regulation, somatic signal processing, substance abuse, sexuality, memory, arousal and aggression

26. ACE Captures A Graded “Dose-Response” • ACE appears to capture cumulative exposure to the developing brain to activate stress response • This appears to be the pathway by which ACEs exert their neurobiological impact • As “dose-response” goes up, risk of problems from adolescence to adulthood also go up

27. A Closer Look at Relationship Dynamics Within the Addicted - Traumatized Family System

28. Source: TianDayton, Huffington Post, Posted 9/25/10 02:45 PM ET

29. Family Dynamics

30. Dynamics In The Family System • “No Talk” Rule • Trauma Extremes: High Intensity vs. Shutting Down • Impulsivity versus Rigidity • Despair vs. Denial • Enmeshment vs. Disengagement • Over Functioning vs. Under Functioning • Caretaking vs. Neglect • Abuse vs Victimization

31. The Cost of “No Talk” Rules • Defenses such as denial and minimization • Resist talking about resulting fear and anxiety • Emotions explode into the container of the family (get acted out rather than talked out) • Acting out results in temporary relief – nothing gets fixed • Walls go up – may blame others • Avoid discussion – may not be able to take action

32. Trauma Extremes: High Intensity vs. Shutting Down • Emotions of fear and high states of stress • Often accompanied by living with addiction • Ignite fight or flight trauma response • Feeling trapped (can not fight or flee to safety) • May shut down or freeze to avoid negative emotions • Recurrence of fleeing flooded with feelings to shutting down reoccur affect how you p0rocess emotions • Emotional see sawing affects thinking, feeling, and behavior of the family

33. Impulsivity vs. Rigidity • Impulsive behavior – may be manifested by blame, anger, rage, emotional, physical or sexual abuse, over or under spending and sexually acting out • Rigidity - may be manifested by rigid rules or routines or becoming both controlled and controlling • Recovery Option – Self regulation of thoughts, feelings and behavior so they fall within appropriate range for the situation

34. Despair vs. Denial • Denial – is a dysfunctional attempt to ward off every growing feelings of Despair. • Reality is “rewritten” in an attempt to make it less threatening • Cover up anxiety, guilt, resentment and fear • Denial replaces honest self-disclosure • Despair deepens

35. Enmeshment vs. Disengagement • Enmeshment is a relational style that lacks boundaries and often discourages differences or disagreement or a way of coping with the fear the family is “falling apart” • Disengagement is when family members see the solution to keep pain from their inner worlds from erupting and avoid subjects, people, places and situations that might trigger it – isolation. • Recovery Option: Balanced relationships (allowing yourself to move in and out of close connection with others in a natural fashion)

36. Over Functioning vs. Under Functioning • Over Functioning – may wear many hats to maintain order (while the addict goes in and out of “normal” functioning) • Under Functioning – may be associated with learned helplessness is part of the trauma response. • Recovery Option: Balanced functioning is the obvious in between over and under-functioning.

37. Caretaking vs. Neglect • Caretaking – can be an attempt to attend to, in another person, what needs to be attended to within the self. We cant see the real need within another person because we can’t identify the real need within ourselves. • Neglect – Thinking they have too many needs to meet and mistrustful of deep connection – may push away others that might help – mainly relationships • Recovery Option: Balanced care of self and others is a part of healthy life

38. Abuse vs. Victimization • When individuals can’t process personal pain, they are at risk of acting it out instead. • Sometimes roles become stratified and obvious abuser and obvious victim • Abuse and Victimization are roles that often get passed down inter-generationally. • Recovery Option: Learn or relearn the skill of emotional regulation

39. What Adult Children Have in Common With The Identified Addict • Self-Delusion or Denial • Compulsive Behavior • Frozen Feelings • Low Self-Esteem • Medical Complications

40. Common Stratified Family Roles • Dependent • Enabler • Hero • Scapegoat • Lost Child • Mascot Can play multiple roles Can play different roles over their lifespan

41. Dependent Motivating Feeling Identifying Symptoms Payoff for Individual Payoff for Family Possible Price INSIDE: Pain & Shame OUTSIDE: Blaming, withdrawal & perfectionism Shame Chemical Use Relief of Pain None Addiction

42. Enabler • Motivating Feeling • Identifying Symptoms • Payoff for Individual • Payoff for Family • Possible Price INSIDE: Pain, Anger OUTSIDE: over responsible, low self-esteem, powerlessness Anger Powerlessness Importance; self-righteousness Responsibility Illness; “martyrdom”

43. Hero • Motivating Feeling • Identifying Symptoms • Payoff for Individual • Payoff for Family • Possible Price INSIDE: inadequacy, guilt OUTSIDE: overachiever, performance driven, works for approval Inadequacy; guilt Overachievement Attention (positive) Self-worth Compulsive drive

44. Scapegoat • Motivating Feeling • Identifying Symptoms • Payoff for Individual • Payoff for Family • Possible Price INSIDE: Hurt OUTSIDE: Delinquency, peer acceptance, low achiever, defiant Hurt Delinquency Attention (negative) Focus away from Dependent

45. Lost Child • Motivating Feeling • Identifying Symptoms • Payoff for Individual • Payoff for Family • Possible Price INSIDE: Loneliness OUTSIDE: Shy, loner, physical illness, treasures pets & things Loneliness Solitariness; shyness Escape Relief Social isolation

46. Mascot Motivating Feeling Identifying Symptoms Payoff for Individual Payoff for Family Possible Price INSIDE: Fear, confused OUTSIDE: Humor, attention seeking, slow learner Fear Clowning; hyperactivity Attention (amused) Fun Immaturity; emotional illness

47. Families and Recovery Family members may continue their dysfunctional behavior in order to try to cope and/or feel safe OR They may get into treatment and recovery themselves Family members can and do recover. They need to be involved in primary treatment and get counseling for their own health, mental health and substance abuse issues, including past trauma. Important aspects of recovery that help especially where there is a history of trauma include 12 step programs, therapy, meditation, yoga, massage, deep breathing and exercise: activities that quiet and soothe the emotional system and teach skills of mind/body regulation. Family members in recovery can begin to reconnect and move toward balance and harmony in their lives. There is HOPE for the family

48. ACEs Calls For Integrated Perspective of Health and Social Problems Throughout The Lifespan The results of the ACE study call for an integrated approach to intervene early on children growing up with alcohol abuse in the home and the abuse, violence, neglect that frequently co-occur in these homes. Prevention and treatment of one ACE frequently can mean that similar efforts are needed to prevent and treat multiple persons in affected families.

49. Our Job as Professionals • Identify the impact of family dysfunction and trauma across the life span • Recognize the far reaching effects of childhood stress and trauma in the family system • Provide primary prevention, intervention and treatment to impacted family members across the life span • Don’t allow family members to become a “lost child” in the recovery process

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