Kasserian ingera ? ( Are the children well ?)

1. Kasserianingera?(Are the children well?) What is to be our response?

2. Adverse Childhood Experiences Chronic Childhood Stress and Implications for Families, Communities and Human Services Presented by Ann Jennings PhD www.TheAnnaInstitute.com KidsLINK May 28 – 29, 2012

3. This is Anna at age one and a half This is Anna years later – in a mental institution What happened?

4. Anna Caroline Jennings 1960 - 1992

5. A Wall of Missed Opportunities1960 - 1992 • Pre-birth: Mom, Dad, Extended family, Family Doctor, Obstetrician, Church, Community, Friends, Neighbors, Pediatrician, Age 3 to 7: Child Psychiatrist, Nursery School Teachers, Kindergarten Teachers, Housekeeper, Family support group; Age 7 to 11: Public School Teachers, (including gym, art, music), school counselors, mom’s college teachers in Psychology and Human Development, Age 11 – 15: Private school teachers, Family doctor, Divorce lawyer, “Brain-Bio Center”, Public School Teachers, Social Worker, Child Welfare, Special Ed Teacher, School Counselor, Community Mental Health Center Child Therapist, CMH Psychiatrist, Special Ed Tutor, Family Therapists, HR personnel at mom’s work, Age 15 – 18: Psychiatric nurse , High School teachers (including art, gym etc) , Multiple Psychiatrists, Children’s Psychiatric Hospital staff, Adult Psychiatric Hospital staff; Age 18 – 32: Private and Public Psychiatric Hospital staff of all professional disciplines and levels, Crisis Services and ER staff, More psychiatrists, CMHC staff, Police, MH Hearing Courts Judges, Private Practice therapists, Outpatient and Community services staff, Advocacy and Peer Groups, Rape Crisis Center staff, Residential services staff, • Failed Systems: Healthcare; School; Mental Health; MH Court; Legal; Higher Education, Child Welfare, Psychiatric; Law enforcement; ER and Crisis;

6. The Adverse Childhood Experiences (ACE) Study • CDC and Kaiser Permanente Collaboration • Nearly 15 years long. Over 20,000 people involved • Looked at effects of adverse childhood experiences over the lifespan • Largest study ever done on this subject. “In my beginning is my end” TS Eliot Four Quartets

7. ACE Study Findings • Childhood experiences are powerful determinants of who we become as adults

9. HMO Members in ACE Study • 80% White, including Hispanic • 10% Black • 10% Asian • 50% men, 50% women • 74% had attended college • 62% age 50 or older

10. Adverse Childhood Experiences (ACEs) are Common Of the 17,000 HMO Members: • 1 in 4 were exposed to 2 types of ACEs – which would equate to 1/4th of this group • 1 in 6 had an ACE Score of 4 or higher • 25% of women and 17% of men reported sexual abuse as children. • Women were 50% more likely than men to have an ACE score of 5 or more • Women had higher scores in all types of ACEs except physical abuse and physical neglect which men scored higher in.

11. Family Strengths and Resiliency • Family closeness • Family support • Family loyalty • Family protection • Family importance • Family love • Responsiveness to health care needs Hillis S, Anda R, Dube S, Felitti V, Marchbanks P, Macaluso M, Marks J. The Protective Effect of Family strengths in Childhood against Adolescent Pregnancy and its Long-Term psychosocial Consequences.

12. MechanismsbyWhichACEsInfluenceHealth and Well-BeingThroughouttheLifespan

13. Emotional Pain and Mental Health Problems

14. Childhood Experiences Underlie Chronic Depression

15. Childhood Experiences Underlie Suicide 4+ 3 2 1 0

16. 2/3rd (67%) of all suicide attempts • 64% of adult suicide attempts • 80% of child/adolescent suicide attempts Are Attributable to Childhood Adverse Experiences Women are 3 times as likely as men to attempt suicide Men are 4 times as likely as women to complete suicide.

17. Childhood sexual abuse is strongest most independent risk factor for suicidality • As many as 42% of girls are sexually abused before age 18 • 79.8% of American Indian Alaskan Native (AIAN) girls experience sexual abuse in early childhood. • Young AIAN women are over 3 ½ times more likely to commit suicide than females in the general population

18. Iraq Combat Veterans More troops are taking their own lives than are killed in combat.

19. Are We Misdiagnosing? ACE Score and Hallucinations Abused Alcohol or Drugs Ever Hallucinated* (%) ACE Score *Adjusted for age, sex, race, and education.

20. Childhood Experiences Underlie Serious and Persistent Mental Health Problems Depression Anxiety Psychosis

21. Coping

22. Health Risks

23. Adverse Childhood Experiences and Current Smoking %

24. Childhood Experiences and Adult Alcoholism 4+ 3 2 1 0

25. ACE Score and Intravenous Drug Use N = 8,022 p<0.001

26. Adverse Childhood Experiences andLikelihood of > 50 Sexual Partners

27. Serious Social Problems

28. Childhood Experiences Underlie Rape 4+ 3 2 1 0

29. ACEs Underlie Domestic Violence Women with ACE Score of 4+ are 500% more likely to become victims of domestic violence. Both men and women are more likely to become perpetrators of domestic violence

30. ACE score and unintended pregnancy or elective abortion ACEs & Unwanted Pregnancy or Elective Abortion Sexual Abuse of Male Children and Their Likelihood of Impregnating a Teenage Girl Sexually abused male children & teenage pregnancies % who impregnented a teenage girl Not 16-18yrs 11-15 yrs <=10 yr abused Age when first abused

31. ACE Score and Indicators of Impaired Worker Performance Prevalence of Impaired Performance (%)

32. Adverse childhood experiences are risk factors for adult homelessness • A neglected child is 13 times and a physically abused child is 16 times more likely to ever experience homelessness as adult. • Male and female children who suffer both neglect and physical or sexual abuse are 26 times as likely than those who haven’t – to become homeless during their adult lives. • 79 – 90% homeless families headed by women: 92% suffer physical and/or sexual violence – 43% were sexually abused as children. • 97% of all homeless seriously mentally ill women have histories of physical and sexual abuse. 87% were abused both as adults and as children

33. Childhood Trauma and Adult Violence • Although not all abused children grow up to be abusers, there is strong correlation that those who are seriously abused become the most violent members of society. • Of juveniles sentenced to death each suffered severe repeated physical and sexual abuse in childhood. • 83.8% of convicted killers suffered severe physical and emotional abuse and 32.2% were sexually violated as children. • Girls and women considered dangerously violent are 2-7 times more likely than female controls to have been exposed to childhood violence. • Children from violent homes 24 times more likely to commit sexual assault than their counterparts from non-violent homes.

34. Adult Disease and Disability

35. Higher ACE Score Results in Significant Rises in Chronic Health Conditions: • Ischemic heart disease • Autoimmune diseases • Lung cancer • Chronic obstructive pulmonary disease • Liver disease • Skeletal fractures • Sexually transmitted infections • HIV/AIDS

36. Higher ACE Score Results in Significantly Poorer Life Expectancy • On average, adults with a high ACE score had double the risk for early death compared with adults who had not endured ACEs. • On average, children exposed to 6 or more ACEs died at age 60, whereas children without ACEs died at age 79.

37. The Many Faces of Trauma

38. The financial burden to society of childhood abuse and trauma is staggering. Economic Impact Study, 2007 • Annual Direct Costs: Hospitalization, Mental Health Care System, Child Welfare Service System and Law Enforcement = $33,101,302,133.00 • Annual Indirect Costs: Special Education, Juvenile Delinquency, Mental Health and Health Care, Adult Criminal Justice System, Lost productivity to Society = $70,652,715,359.00 • Total Annual Cost: $103,754,017,492.00 (Over $184 million dollars a day) Prevent Child Abuse America

39. Federal Roundtable Report 2007 and 2009 Studies: • The cost of chronic illness goes far beyond the actual medical expenses ($277 billion in 2003). • According to a 2007 study, the annual financial cost of chronic illness on lost work productivity is $1.1 trillion. (DeVol and Bedroussian) • Research on the full cost of violence and abuse to the health and social service systems has not yet been d one; however, a study using 2008 health care and population data shows that the predicted incremental cost to the health care system alone ranges between $333 billion and $750 billion annually, or nearly 17 percent to 37.5 percent of the total health care dollar. (Dolezl et al) http://www.rwjf.org/files/research/50968chronic.care.chartbook.pdf. DeVol, R, and Bedroussian, A. (2007) Unhealthy America: The economic burden of chronic disease. Report from the Milken Institute. (http://www.chronicdiseaseimpact.com) Dolezl, T., McCollum, D., and Callahan, M. (2009) Hidden costs in health care: The economic impact of violence and abuse. Eden Prairie, MN: Academy on Violence and Abuse.

40. 2012 CDC Press Release • Total lifetime estimated financial costs associated with just one year of confirmed cases of child maltreatment is approximately $124 billion • Estimated average lifetime cost per victim of non-fatal child maltreatment is $210,012 including: • $32,648 in childhood health care costs • $10,530 in adult medical costs • $144,360 in productivity losses • $7,728 in child welfare costs • $6,747 in criminal justice costs • $7,999 in special education costs • The estimated average lifetime cost per death includes: • $14,000 in medical costs • $1,258,800 in productivity losses From CDC press release Feb 1, 2012. “The economic burden of child maltreatment in the US and implications for prevention”. http://www.sciencedirect.com/science/journal/aip/01452134

41. The Trauma Movement in US • Trauma Champion at Federal Level SAMHSA • National Conferences Dare to Vision 1995 – to ACT – 2000, to Transform- 2005 • SAMHSA Initiatives – 80 – 90% women in Behavioral Health System • 5 Year Women and Violence Study • New Trauma-Specific Treatment Models. Group; psychoeductional, Gender. • NASMHPD Seclusion and Restraint Initiative • State System Trauma Champions – many with lived experience • Resistance. Perception trauma was passing fad Also Growing public awareness • Growing consciousness of retrauma, especially in inpatient and residential settings • NASMHPD: Publications. Expert Groups. Identification of Criteria for Trauma Informed Service Systems: 45 State Report Activities to meet TI Criteria • National Network of State Trauma Champions SPSCOT • NCTIC And NCTSN funded by SAMHSA : consultation and training • Growing disclosure by consumer groups of childhood trauma • Growing # of research studies linking childhood trauma to onset of MH issues • ACE Study 1998 now taking hold. From confines of Behavioral Health to Public Health • Advancement of neurosciences and resiliency findings • Federal Round Table

42. Trauma-Specific Treatment Models • Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services. 2008 Update SAMHSA/CMHS National Center for Trauma Informed Care Download from www.TheAnnaInstitute.org

43. Trauma-Informed ModelsFor Developing Trauma-Informed Systems and Organizations • Blueprint: State Systems Trauma-Informed Activities. 2007 NASMHPD National Association of Mental Health Program Directore Download from www.TheAnnaInstitute.org • “Using Trauma Theory to Design Service Systems” Maxine Harris, Roger D. Fallot (2001)

44. Why are organizations becoming trauma-informed? • Existing paradigm doesn’t work • Anomalous is now expected • Trauma based in hard science • We know what to do & have tools to do it • Multiple informational systems exist • Increased disclosure and demand • Helps resolve most intractable problems • Glues disparate service systems together • May cost less to modify existing services than to provide new trauma specific services

45. Trauma Informed vs Trauma Specific • Trauma specific services are designed specifically to address impacts (sequelae) of trauma and facilitate healing and recovery • Trauma-informed services address the culture within which services take place and incorporate knowledge about trauma in all aspects of service delivery and practice (Harris & Fallot, 2001)

46. A Trauma Informed Service System: • Universal Assumption of Inclusion • Above all else, Do No Harm • Apply Isomorphic Rule: Parallel Process • Prioritize relational context • Address sources of Organizational Stress • All inclusive scope of change: All Staff, Families, Youth • Clients, peers, families as most vital sources of information and leadership • Focus on environment (what happened to this person?) vs pathology (what’s wrong with this person?) • Universal Screening Artist: Holly Williams

47. Criteria for Trauma-Informed Service Systems

48. NASMHPD Essential Elements of Trauma-Informed State Systems: 1. Trauma function and focus in state behavioral health department 2. Trauma Policy or Position Paper 3. Workforce recruitment, hiring, retention, orientation, training and standards 4. Consumer/Trauma survivor involvement and rights 5. Financing criteria and mechanisms 6. Clinical practice guidelines 7. Policies, procedures, rules, regulations and standards 8. Needs assessment, evaluation and research 9. Trauma screening and assessment 10. Trauma-Informed services and/or systems 11. Trauma-Specific services Provide Leadership, Support, and Infrastructure For TI Agencies and Service Providers

49. Increase from 2004 to 2008 in # States reporting they met trauma-informed criteria: 1. Trauma function and focus in state Increased 13 to 24 behavioral health department 2. Trauma Policy or Position Paper Decreased 16 to 13 3. Workforce recruitment, hiring, retention, Increased 28 to 40 orientation, training and standards 4. Consumer/Trauma survivor involvement Increased 17 to 29 and rights 5. Financing criteria and mechanisms Increased 17 to 29 6. Clinical practice guidelines Increased 14 to 19 7. Policies, procedures, rules, regulations Increased 13 to 32 and standards 8. Needs assessment, evaluation and research Increased 21 to 27 9. Trauma screening and assessment Increased 27 to 36 10. Trauma-Informed services and/or systems Increased 19 to 37 11. Trauma-Specific services Increased 24 to 28

50. Criteria for Trauma-Informed Behavioral Health Organizations: A Change in CultureThe Fallot and Harris Model • Originated concept of “trauma-informed” • Built on Five Core Values of safety, trustworthiness, choice, collaboration, and empowerment – for clients and for staff • Tools: Has written protocol and Self-Assessment scale with Criteria and Indicators to determine present status, changes needed, and to measure progress • Approximately 75 behavioral health and health organizations and systems across the country have engaged in this process Involves a shift in thinking and culture Asks ‘What has happened to you” and “How have you tried to deal with it” vs “What is wrong with you” or “What is your problem”