Childhood Adversity & Trauma A Life Course Perspective for Prevention & Healing

1. Session # C4 October 29, 201110:30-11:15 AM Childhood Adversity & TraumaA Life Course Perspective for Prevention & Healing Roberta Waite, EdD, APRN, FAAN Assistant Dean of Academic Integration and Community Programs Patricia Gerrity, RN, PhD, FAAN Associate Dean for Community Programs Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Need/Practice Gap & Supporting Resources What is the scientific basis for this talk? The experiences of abuse and family dysfunction in childhood significantly shapes an individual’s future physical and mental health. These cumulative experiences are referred to as adverse childhood experiences (ACEs). Empirical data confirms the important role that ACEs have in increasing risk for many health conditions however public health and clinical practice has not proactively implemented evidence based interventions to address the problem.

4. Objectives • Identify common adult health outcomes that are correlated with adverse childhood experiences (ACEs) • Describe the role health care providers play in recognition and referral for treatment of person's affected by ACEs • List patient treatment interventions that can be useful in helping individuals affected by ACEs • Identify how organizational culture influences response to care among patients who have experienced ACEs

5. Expected Outcome What do you plan for this talk to change in the participant’s practice? • Assess and recognize that ACES are preventable and treatable • Address the life course and transgenerational effects of trauma • Treat root causes of many physical and mental illness and destructive health behaviors • Organizational trauma informed care Understanding ACEs from a life-course perspective promotes understanding how early-life experiences can shape health across an entire lifetime and potentially across generations.

6. Eleventh Street Family Health Services of Drexel Universityin partnership with Family Practice and Counseling Network

7. An Overview About ACEs What are they?

8. What do we mean by ACEs? Experiences that represent health or social problems of national importance, such as: • Emotional/Physical Abuse • Sexual Abuse • Emotional/Physical Neglect • Domestic Violence – Battered Mother • Single Parent Homes – Due to Separation/ Divorce/Death • Substance Abuse - One or Both Parents • Incarcerated Parent(s) • Parent(s) Suffering From Mental Illness • Parent(s) Suffering From Chronic Illness Chapman, Whitfield, Felitti, Dube, Edwards, & Anda , 2004

9. Why look at ACES? They’re a strong influence on how we develop and what we become as individuals, as communities, and as a nation

10. ACES can impact individuals along this trajectory Example: Children exposed to violence often grow up to become victims of violence. Some may also inflict violence on others Social

11. http://www.acestudy.org/Kaiser Permanente Medical Group Centers for Disease Control and Prevention (CDC) • The largest scientific research project of its kind to date • A decade long ongoing collaboration led by: • Vincent J. Felitti, MD • Robert F. Anda, MD, MS • Analyzing the relationship between multiple categories of childhood trauma and health and behavioral outcomes later in life.

12. Adverse Childhood Experiences Score Number of categories adverse childhood experiences are summed … ACE score Prevalence 0 48% 1 25% 2 13% 3 7% 4 or more 7% More than half have at least one ACE (Anda et al., 2009; Edwards, Holden, Felliti, & Anda, 2003;Felliti et al., 2002)

13. Health problems in Adults Increased with Exposures to Adverse Experiences in Childhood

14. The HEALing Project Roxana Arango Dr. Roberta Waite Dr. Patricia Gerrity Reeva Gupta

16. Original Study vs 11th St Results

17. Adult health outcomes that are correlated with ACEs from the HEALing Project What are they?

18. ACE vs. Feeling Depressed or “Down in the Dumps”

19. ACE vs. Ever Attempted Suicide

20. ACE vs. Ever Used Street Drugs

21. Death Early Death Disease, Disability Adoption of Health-Risk Behaviors Social, Emotional, and Cognitive Impairment Adverse Childhood Experiences Birth The Influence of Adverse Childhood Experiences Throughout Life ACE’s Major Determination of Health & Well Being (Felitti, 2003)

22. Health Care Providers what role do they play in recognition and referral for treatment of person's affected by ACES?

23. ACES: Implications for Clinical Practice • Problems that come into the clinic are complex and providers should be aware of the link between those problems and ACEs • Redefine ‘resistence’‘non-compliant’ • In all stages of the encounter – assessment & evaluation, treatment plan – providers must avoid easy answers • If the problems are complex, why would the solutions be simple?

24. Implications for Clinical Practice How do I think broadly about my patient(s)? Can I put myself in my patient’s shoes? Do my interventions empower?

25. Implications for Practice and Interventions These findings are particularly relevant to integrated care and wellness programs and practices. They reveal the need to address trauma as central to the health and well-being of people across a very wide spectrum of problems.

26. WHAT CAN WE DO……. • Pay attention • Get out of our comfort zone and explore the possibility of prevention • Overcome lack of knowledge – our own and others • Overcome our fear • Speak out and end silence about the role of ACEs in serious health, mental health, and social problems of all kinds. • Stop treating symptoms and treat the cause • Do a better job of routinely screening at the earliest point for ACEs. Identify cases early and allow treatment of basic causes rather than vainly treating the symptom.

27. Integrative Health Care To create a seamless engagement by patients and caregivers of the full range of physical, psychological, social, preventive, and therapeutic factors known to be effective and necessary for the achievement of optimal health throughout the lifespan.

28. Integrated Team • Family nurse practitioner • Primary behavioral health consultant • Child & adult • Couples & Family Therapist- energy psychology • Generalist social worker • Health educator/nutritionist • Complementary & integrated therapist • Physical therapist • Creative arts therapists

29. Traditional Care • What is wrong with this person? Integrated care Who is this person? What has happened to this person?

31. Ethical Imperative for Screening • Many clinicians are reluctant • Not disclosure by itself that results in harm, but rather negative responses the person receives when disclosing trauma • Need to be prepared to provide referral sources and respond in a supportive manner • Individuals are grateful to know that others care about these issues

32. Finding Your ACE Score While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? Yes / No If yes enter 1 ________ 2. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? Yes / No If yes enter 1 ________ 3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? Yes / No If yes enter 1 ________

33. Finding Your ACE Score continued…. 4. Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other? Yes / No If yes enter 1 ________ 5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes / No If yes enter 1 ________ 6. Were your parents ever separated or divorced? Yes / No If yes enter 1 ________

34. Finding Your ACE Score continued…. 7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? Yes / No If yes enter 1 ________ 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes / No If yes enter 1 ________ 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? Yes / No If yes enter 1 ________ 10. Did a household member go to prison? Yes / No If yes enter 1 _______ Now add up your “Yes” answers: _____ This is your ACE Score.

35. The ACEs Scoring Method • Exposure to one category (not incident) of ACE, qualifies as one point.   • An ACE Score of 0 (zero) would mean that the person reported no exposure to any of the categories of trauma • When the points are added up, a total ACE Score is provided.    • The ACE Score represents the cumulative effect of multiple exposures. http://www.acestudy.org/files/ACE_Score_Calculator.pdf

36. Patient Treatment Interventions What can be useful in helping individuals affected by ACEs?

37. Interventions to Treat Traumaat 11th Street • Outpatient behavioral health • Primary behavioral health therapists • Couples & Family Therapist • EFT • EMDR • Creative Arts Therapies Art Music Movement • Trauma Recovery & Empowerment Groups • Trauma informed yoga

38. EMDR

39. Art Therapy

40. Yoga

41. Life Course Perspective • The life course approach to conceptualizing health care needs and services evolved from research documenting the important role early life events play in shaping an individual’s health trajectory.  The interplay of risk and protective factors, such as socioeconomic status, toxic environmental exposures, health behaviors, stress, and nutrition, influence health throughout one’s lifetime.

42. Visit for Mother and Baby

43. Early Programming • Early experience can program an individual's future health and development • Prenatal- exposure in utero • Intergenerational-health of mother prior to conception • Adverse programing can directly result in a condition or make one vulnerable or more susceptible

44. Organizational Culture How does it influence response to care among patients who have experienced ACEs?

45. Trauma Informed Care • Dr. Sandra Bloom- international expert on trauma • Trauma-informed cultures understand it has broad and profound impacts‚ and the very diverse way in which people cope with and recover from traumatic events impacting the way that people think and act. • Example: Safety‚ trustworthiness‚ choice‚ collaboration‚ and empowerment are core to TIC. • Providers don’t’ ask “what is your problem or what is wrong with you”insteadask“what has happened to you and how have you dealt with it.” • Providers don’t say‚ “Here’s what I can do to fix you‚”instead ask‚ “How can you and I work together to achieve your goals of recovery and healing?”

46. Trauma Informed Care • All members of an organization must experience these same core TIC concepts • Staff can only create a setting of and offer relationships that are characterized by safety‚ trustworthiness‚ choice‚ collaboration and empowerment only when they experience these same factors in the organization as a whole. • Example. Trustworthiness. Can staff trust each other and the program supervisors and administrators? • Do staff exert some control over how they accomplish their task? Is creativity valued? • Collaboration. Do administrators actively seek and take seriously staff ideas about the program and empowerment? Do staff feel valued? Do they have resources to do their jobs well?

47. Health center seen as a safe place in the comunity

48. Implications - Research • Asking the questions that will have impact • Importance of moving beyond the clinic into the community  community based research • Transdisciplinary problems require transdisciplinary partners and teams Culture Policy Systems Environment Individual Programs and Outcome Measures Hays-Grudo (2008)

49. Summary • How we define ACEs– how we understand them  ultimately impacts how we decide to ‘solve’ them • For medical providers, 99% of effort in learning is oriented to BIOLOGY, which is fine, however biology is LINKED to social context and determinants • It’s important to let go of the individualistic models of blame – and widen our scope of analyses and treatment. Become a part of the emerging future care for communities and patients. • In a medical home model, such as 11th street, there is a team of people – all with different areas of expertise and knowledge that work collaboratively “ You don’t have to know everything – just accept different possibilities”

50. Resources • Chapman DP, Dube SR, Anda RF. Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals. 2007; 37(5):359–364. • Corso, PS, Edwards, VJ, Fang, X, Mercy, JA.. Health-related quality of life among adults who experienced maltreatment during childhood. Am J Public Health, 2008;98:1094-1100 • Dong M, Anda RF, Felitti VJ, Williamson DF, Dube SR, Brown DW, Giles WH. Childhood residential mobility and multiple health risks during adolescence and adulthood: the hidden role of adverse childhood experiences. Archives of Pediatrics and Adolescent Medicine. 2005;159:1104-1110. • Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB. Cumulative childhood stress and autoimmune disease. Psychom Med. 2009;71, 243-250. • Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. The Impact of Adverse Childhood Experiences on Health Problems: Evidence from Four Birth Cohorts Dating Back to 1900. Preventive Medicine, 2003;37(3):268–277. • Edwards, VJ, Holden, GW, Anda, RF, & Felitti, VJ Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences (ACE) study. American Journal of Psychiatry. 2003;160(8):1453-60. • Edwards, VJ, Dube SR, Felitti VJ, Anda RF. It's OK to ask about past abuse. American Psychologist. 2007; 62(4):327–328. • Felitti VJ, Anda RF, Nordenberg D et al. The relationship of adult health status to childhood abuse and household dysfunction. This issue American Journal of Preventive Medicine, April 1998 • Herman J. Trauma and Recovery. NY: Basic Books 1992. • Read, J & Fraser, A Abuse histories of psychiatric in-patients. To ask or not to ask? Psychiatric Services. 1998; 49, 355-359.