The Violence – Mental Health Connection: The Impact of Adverse Childhood Experiences

1. The Violence – Mental Health Connection:The Impact of Adverse Childhood Experiences LISC Chicago - Neighborhood Health Initiative “Healthy Wednesday” Discussion January 30, 2012

2. Adverse Childhood Experiences: An overview of the pioneering work of Drs. Robert Anda (CDC) & Vincent Felitti (Kaiser Permanente), and Laura Porter (Family Policy Council) Presented by Elena Quintana, Ph.D. Executive Director of the Adler Institute on Public Safety & Social Justice

3. “The Science Behind What You Know in Your Heart”– Anne Studzinski, Childhood Trauma Coalition “The power to warn those downstream” -- Laura Porter

4. What is The ACE Study? • The ACE Study is ongoing collaborative research between the Centers for Disease Control and Prevention in Atlanta, GA, and Kaiser Permanente in San Diego, CA. • Data from over 17k participants reveals staggering proof of the health, social, and economic risks that result from childhood trauma. Vincent Felitti, M.D., 2012

5. 4 Branches of ACEs Related Work • Basic Science • Brain Research • Resilience Research • Program & Intervention Development

6. What ACEs Were Measured? A HISTORY OF THE FOLLOWING BY AGE 18: • Physical, Emotional, or Sexual Abuse • Physical or Emotional Neglect • Mental Illness • Prison • Domestic Violence • Divorce or Parental Loss • Substance Abuse

7. Finding Your Score • Please be aware that there are trends that are discussed, and that NO INDIVIDUAL SCORE explains all. • There are very high functioning high scorers, and low functioning low scorers. • All can agree: ACEs are powerful forces that we want to prevent by whatever means possible.

8. Prevalence Percentiles of Adverse Childhood Experiences Abuse, by Category • Psychological (by parents) 11% • Physical (by parents) 28% • Sexual (anyone) 22% Neglect, by Category • Emotional 15% • Physical 10% Household Dysfunction, by Category • Alcoholism or drug use in home 27% • Loss of biological parent < age 18 23% • Depression or mental illness in home 17% • Mother treated violently 13% • Imprisoned household member 5% Vincent Felitti, M.D., 2012

9. ACEs Conceptual Framework People with 6 ACES die, on average, 20 years sooner than those with zero.

10. ACEs OCCUR IN CLUSTERS • 2/3 experience at least one category of ACEs • If any one ACE is present, there is an 87% chance at least one other category of ACE is present, and a 50% chance that there will be 3 or more. • WOMEN ARE 50% MORE LIKELY TO HAVE A SCORE OF >5. Vincent Felitti, M.D., 2012

11. OLDER CHILDREN – WA High School Sophomores and Seniors Population Average: 43% have 3 or more ACEs as compared with 26% of WA Adults

12. Child Suicide Attempts Percent Attempting Suicide Vincent Felitti, M.D., 2012

13. Childhood Experiences Underlie Chronic Depression Vincent Felitti, M.D., 2012

14. ACE Score & Perpetration Domestic Violence Robert Anda, M.D., 2012

15. Prevalence of Being Raped Later in Life Vincent Felitti, M.D., 2012

16. Laura Porter, 2012 Behavioral health Chronic disease

17. Laura Porter, 2012 Mental health disability

18. Shame & Blame • Make people feel that they can not speak their truth • Make providers feel it’s impolite to ask certain questions • Lead us all to believe that this suffering is uncommon • Paralyze us* from taking life-saving action *everyone

19. Population attributable risk A large portion of many health, safety and prosperity conditions is attributable to Adverse Childhood Experience. ACE reduction reliably predicts a decrease in all of these conditions simultaneously.

21. Laura Porter, 2011 Trauma is hard-wired into biology Early Childhood Hippocampus CONTROLS EMOTIONAL REACTIONS, CONSTRUCTS VERBAL & SPATIAL MEMORY Sensitive to all forms of maltreatment in first 2-3 years of life, especially sexual abuse Adaptation *Emotionally reactive – brain’s braking mechanism fails *Poor regulation of behavior *Difficulty with verbal & spatial memory *Net volume loss becomes evident in 20s. MIDDLE CHILDHOOD CORPUS COLLOSUM INTEGRATES HEMISPHERES & FACILITIES INCLUDING LANGUAGE DEV., MATH ABILITY, AND PROCESSING SOCIAL CUES SUCH AS FACIAL EXPRESSIONS SENSITIVE TO NEGLECT IN INFANCY SEX ABUSE AT AGES ~9&10 ADAPTATION *LANGUAGE DELAY *DIMINISHED MATH CAPACITY *DIMINISHED INTEGRATION & COORDINATION *DIFFICULTY WITH SOCIAL CUES ADOLESCENCE – THE CORTEX CENTER FOR THINKING & JUDGEMENT, EXECUTIVE FUNCTION, LONG TERM MEMORY, & VISION SENSITIVE TO WITNESSING VIOLENCE, AND SEX ABUSE ADAPTATION *POOR EXECUTIVE FUNCTION * IMPULSIVENESS *DIMINISHED ABSTRACT REASONING * DIMINISHED HOPE * LIMITING FIELD OF VISION

22. Resilience for the Walking Wounded Important factors for the walking wounded: • Have a trustworthy person you can talk to about your true situation and feelings • The ability to reframe your life (e.g. as a 9 year old I was not responsible for my parent’s drinking behavior) • Have hope for your future

23. Other Possible Influences on Resilience • Intelligence • Talent and Skill Mastery • Creative Expression • Physical Activity • Positive Human Touch

24. Community Safety Formula R+O (hp²)=CS Where human potential is squandered communities are less safe

25. How would systems be changed if we put human development at the center of our decision making? Schools,juvenile detention center, immigration detention and policy, imprisonment, security, mental health

26. Urban Violence and Adverse Childhood Experiences Bradley C. Stolbach, PhD Program Director, Chicago Child Trauma Center La Rabida Children's Hospital Lead Technical Advisor Midwest Region Complex Trauma Training and Technical Assistance Center NCTSN Complex Trauma Treatment Network Associate Professor of Clinical Pediatrics The University of Chicago Pritzker School of Medicine LISC Chicago Healthy Wednesday Mental Health - Violence Roundtable Chicago, IL, January 30, 2013

27. Who is a Child Soldier? A child soldier is any person under 18 years of age who is part of any kind of regular or irregular armed force or armed group in any capacity, including but not limited to cooks, porters, messengers and anyone accompanying such groups, other than family members. The definition includes girls recruited for sexual purposes and for forced marriage. It does not, therefore, only refer to a child who is carrying or has carried arms. Cape Town Principles and Best Practices on the Recruitment of Children into the Armed Forces and on Demobilization and Social Reintegration of Child Soldiers in Africa (Cape Town, 27-30 April 1997).

28. The Power of a Lens Criminal or Maltreated Child or Child Soldier U.S. incarcerates more than twice as many youth per 100,000 than next highest youth incarcerator. Many of these youth are classified by statute as adults. Youth of color are much more likely than others to be incarcerated. In Cook County, Illinois, African American youth are 46 times more likely than White youth to be incarcerated.

29. Adverse Childhood Experiences Study (ACES)* Physical abuse by a parent Emotional abuse by a parent Sexual abuse by anyone An alcohol and/or drug abuser in the household An incarcerated household member Someone who is chronically depressed, mentally ill, institutionalized, or suicidal Domestic violence Loss of a parent Emotional neglect Physical neglect Felitti et al. 1998

30. Adverse Childhood Experiences Study (ACES)* Felitti et al. 1998

31. “Individuals with a trauma history rarely experience only a single traumatic event, but rather are likely to have experienced several episodes of traumatic exposure.” Cloitre et al., 2009 (Retrospective studies, e.g., Kessler, 2000; Stewart et al., 2008; Coid et al., 2001; Dong et al., 2004 ) NCTSN Core Data Set (2012) Children Served in the National Child Traumatic Stress Network (n=11,138) Fewer than 24% had experienced only one type of trauma or ACE. Over 40% had experienced 4 or more. Chicago Child Trauma Center (FY12) Among children receiving services in FY12, 86% of those exposed to Domestic Violence were also exposed to Physical and/or Sexual Abuse. The Co-Occurring Nature of Trauma

32. The Attachment Behavioral System • Attachment: an evolved behavioral system that functions to promote the protection and safety of the attached person • Attachment system is activated strongly by internal and external stressors or threats. • It is through healthy attachment (i.e., a behavioral system that effectively protects and comforts the infant or child) that a child develops the capacity for emotional and behavioral self-regulation, as well as a coherent self.

33. Some Basic Assumptions About Psychological Traumatization Traumatic experiences are those which overwhelm an individual’s capacity to integrate experience in the normal way. (e.g., Putnam, 1985) Following exposure to trauma, if integration does not occur, traumatic experience(s) are split off and an individual alternates between functioning as if the trauma is still occurring and functioning as if the trauma never occurred. (e.g., Nijenhuis et al., 2004) Although traumatic memories and associations remain inaccessible to consciousness much of the time, they have the power to shape an individual’s daily functioning and behavior. (e.g., Allen, 1993)

34. What is Complex Trauma? Exposure to multiple forms of violence and other potentially traumatic stressors in the context of attachment behavioral systems that are unable to provide protection, care, and comfort Focus on cumulative trauma and the developmental context in which exposure occurs rather than on discrete episodes Proposed Developmental Trauma Disorder Criterion A: A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including: A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse

35. Key Developmental Capacities Affected by Complex Trauma Ability to modulate, tolerate, or recover from extreme affect states Regulation of bodily functions Capacity to know emotions or bodily states Capacity to describe emotions or bodily states Capacity to perceive threat, including reading of safety and danger cues Capacity for self-protection Capacity for self-soothing Ability to initiate or sustain goal-directed behavior Coherent self, Identity Capacity to regulate empathic arousal

36. Complex Trauma and Reactive vs. Instrumental Aggression Reactive aggression entails impulsivity, anger, and intolerance for perceived provocation whereas instrumental aggression is motivated by material or social gain (Crapanzano et al., 2010). In a study of juveniles convicted of committing violent crimes, Silvern & Griese (2012) found that: Multiple maltreatment positively predicted reactive aggression. The significant relationship between multiple maltreatment and reactive aggression was fully mediated by dissociative symptoms and partially mediated by PTSD symptoms.

37. Trauma Exposure in CeaseFire Chicago Violence Interrupters and Outreach Workers n = 9 Mean total traumatic stressors and other ACES = 10.33 Range = 4 -15 Mean age of first trauma = 9 years, 2 months 89% exposed to domestic violence DV was first trauma exposure for 67% 100% experienced at least 4 forms of ongoing traumatic stress. Bocanegra & Stolbach, 2012

38. CeaseFire Self-Reported Trauma Exposure Physical Abuse 100% Witnessed Physical Abuse 100% Witnessed Community Violence 100% Witnessed School Violence 100% Witnessed Domestic Violence 89% Loss Through Violent Death 89% Witnessed Sexual Victimization 78% Motor Vehicle Accident 56% Witnessed Homicide(s) 44% Other trauma types include fire, burn, dog attack Bocanegra & Stolbach, 2012

39. Youth Self-Reported Trauma Exposure n = 8 Physical Abuse 100% Witnessed Physical Abuse 100% Witnessed Domestic Violence 100% Witnessed Community Violence 100% Witnessed School Violence 100% Witnessed Homicide(s) 75% Loss Through Violent Death 75% Witnessed Sexual Victimization 62.5% Motor Vehicle Accident 50% Victim of Extrafamilial Violent Crime 50% Dog Attack 37.5% Burns 37.5% Other trauma types include fire, natural disaster, torture Bocanegra & Stolbach, 2012

40. Youth Self-Reported Trauma Exposure 100% experienced both family violence and community violence. 100% experienced at least one form of ongoing traumatic stress. Average age of first trauma exposure = 6 years, 1 month Mean # Types of Trauma Experienced = 10 Range = 7 - 13 Bocanegra & Stolbach, 2012

41. Youth Other Adverse Experiences Impaired Caregiver 75% Exposure to Drug Use or Criminal Activity in Home 75% Exposure to Prostitution or other Developmentally Inappropriate Sexual Behavior in Home 37.5% Substitute Care 25% Other ACEs include incarcerated significant other, homelessness, neglect Mean # Types of Adverse Experiences = 2.75 Range # Types of Adverse Experiences = 0 – 5 Bocanegra & Stolbach, 2012

42. Youth Mean Combined Total Types of Traumatic Stressors + Other Adverse Childhood Experiences =12.75Range = 7 - 18 Bocanegra & Stolbach, 2012

43. “Alfonso” Torture 5 Physical Abuse 5 - 13 Substitute Care 7 Witnessed Community Violence 8 – 13 Witnessed Physical Abuse 9 - 13 Impaired Caregiver 9 - 13 Extrafamilial Violent Crime Victim 9 - 13 Witnessed Domestic Violence 10 - 13 Witnessed Sexual Assault 10 Motor Vehicle Accident 12 Traumatic Loss 12 Witnessing Homicide (3) 12, 13 School Violence 12 - 13 Dog Attack 12 Burn 12 Total Types of Traumatic Stress 13 Total Types of Adverse Other Experiences 2 Bocanegra & Stolbach, 2012

45. 20-Year-Old 2nd Generation Latina Fire 1 Domestic Violence 5 Impaired Caregiver 5 - 20 Physical Abuse 5, 15, 16 Sexual Abuse/Assault 7, 15, 16 Community Violence 10 School Violence 10 - 16 Extrafamilial Violent Crime Victim 12 - 20 Motor Vehicle Accident 14, 19 Incarceration 17 - 21 Traumatic Loss 18 Witnessing Homicide 18, 19 Homelessness 19, 20 Employment in Sex Industry 19, 20 Burn 20 Total Types of Traumatic Stress 12 Total Types of Adverse Other Experiences 4

47. Dr. Paul Farmer: “Structural violence is one way of describing social arrangements that put individuals and populations in harm’s way… The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people … neither culture nor pure individual will is at fault; rather, historically given (and often economically driven) processes and forces conspire to constrain individual agency. Structural violence is visited upon all those whose social status denies them access to the fruits of scientific and social progress.”

48. Child Trauma, “Race” and Urban Poverty Urban Black and Brown families face a unique set of adversities and stressors. The massive historical traumas of attempted genocide and slavery have never been addressed, yet create the context in which present traumas occur and are dealt with. Those of us working with children and families whose daily existence is shaped by the legacy of slavery and racial injustice cannot optimally intervene if we fail to understand and address the effects of the trauma of the past.

49. Societal Traumatization and the Legacy of Imperialism, Attempted Genocide, & Slavery Just as in cases of individual traumatization, avoidance of acknowledging and addressing the traumatic past makes it impossible for integration to occur. As long as historical trauma remains taboo, the racial divisions that pervade every aspect of American life will persist.

50. Community Based Programs that Address Trauma and Build Resiliency Eddie Bocanegra, Community Renewal Society M.A. Candidate, University of Chicago School of Social Services