1. Healthy Women, Healthy Hoosiers: Healthcare Practice Across the Lifecourse October 7, 2011

2. Michelle Hoersch, MS Office on Womens Health - Region V U.S. Department of Health and Human Services Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin

3. Office on Womens Health Who We Are Established in 1991 to improve womens health Charge expanded to include girls Focal point for womens health activities in HHS

4. OWH Vision & Mission VISION All women and girls are healthier and have a better sense of well-being. MISSION Provide leadership to promote health equity for women and girls through sex/gender-specific approaches

6. Violence Against Women Violence against women is so pervasive that the United Nations has addressed and defined violence against women as any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life. (United Nations General Assembly, 1993).

7. Definition of Trauma Trauma occurs when an external threat overwhelms a persons internal and external positive coping resources. Bloom & Fallot, 2009

8. Trauma A traumatic event is defined as one in which a person experiences, witnesses, or is confronted with actual or threatened death or serious injury, or threat to the physical integrity of oneself or others. These events can include violence between people, abuse of any kind, neglect, institutionalization, disasters, or war. Sources: The American Psychiatric Associations Diagnostic and Statistical Manual (DSM-IV) and SAMHSA-National Center for Trauma Informed Care

9. Trauma Women who suffer from trauma carry it with them everywhere they go. Despite the impact trauma has on the health of women and girls, it is rarely considered when delivering services

10. T rauma Defined Traumatic experiences come in many forms, and can leave survivors with overwhelming feelings of loss, danger, and helplessness. They include: Unexpected loss of a loved one Accidents School violence Community violence Domestic violence Neglect Physical abuse Sexual abuse Man-made and natural disasters Terrorism

11. The Adverse Childhood Experience (ACE) Study What is the ACE Study? It is a scientific research study analyzing the relationship between multiple categories of childhood trauma (ACEs), and health and behavioral outcomes later in life. An on-going collaboration between the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente Health System.

12. What is an ACE? Growing up experiencing any of the following conditions in the household prior to age 18 Recurrent physical abuse Recurrent emotional abuse Contact sexual abuse An alcohol/and or drug abuser in the household An incarcerated household member Someone who is chronically depressed, mentally ill, institutionalized or suicidal Mother is treated violently One or no parents Emotional or physical neglect

13. The Numbers Between 51% and 98% of public mental health clients diagnosed with severe mental illness have trauma histories. An individual with an ACE Score of 4 or more was 460% more likely to be suffering from depression than an individual with an ACE Score of 0. A person with an ACE Score of 4 is 260% more likely to have COPD than is a person with an ACE Score of 0. There was a 250% increase in the odds of having a sexually transmitted disease between individuals with an ACE Score of 4 compared to individuals with an ACE Score of 0 Between two-thirds and 80% of all attempted suicides could be attributed to adverse childhood experiences

14. http://www.cdc.gov/ace/pyramid.htm

15. Findings The impact of ACEs on adult health status is strong and cumulative. (2) Of 17,337 study participants, 16% of the men and 25% of the women reported being sexually abused as children. (1) 25% of respondents had at 1 ACE (3) 6.25% had 4 ACEs (3) A person with a midrange ACE score of 4 is 390% more likely to have COPD than is a person with an ACE Score of 0. (3) a person with ACE score >4 was 460% more likely to be depressed than a person with ACE score of 0 (3) two thirds of suicide attempts could be attributed to adverse childhood experiences. (3) 1. Kaiser Permanente Press Release, Kaiser Permanente Research: Gender And Sexual Abuse Female Perpetrators More Common than Known Previously; Boys Abused Almost as Often as Girls. July 6, 2005. 2. Fellitte, Vincent J. MD, FACP, Robert F. Anda MD, MS, Dale Nordenberg, MD, David F. Williamson, MS, PhD, Alison M. Spitz, MS, MPH, Valerie Edwards, BA, Mary P. Koss, PhD, James S. Marks, MD, MPH, Relationship of Childhood Abuse and Household Dysfunction to Mnay of the Leading Causes of Death in Adults Am J Prev Med 1998;14(4). 3. Felitti, MD., Vincent J., The Permanente Journal Winter 2002/Vol. 6, No.1

16. From SAMHSAs website: http://www.samhsa.gov/children/social_media_apr2011.asp

19. Graph shows relation between Adverse Childhood Experiences (ACE) Score and smoking status. Felitti, MD., Vincent J., The Permanente Journal Winter 2002/Vol. 6, No.1

20. Graph shows relation between ACE Score and illicit use of injected drugs. a male child with an ACE score of 6 has a 4600% increase in the likelihood of later using intravenous drugs Felitti, MD., Vincent J., The Permanente Journal Winter 2002/Vol. 6, No.1 http://xnet.kp.org/permanentejournal/winter02/goldtolead.html

21. Region V Focus on Trauma Vision: To equip every health and social service provider and institution with the knowledge, resources, and support to provide services that are gender responsive and trauma informed so as to provide the best possible care for trauma-affected individuals.

22. History Grew out of work focusing on incarcerated women Incarcerated women have a disproportionately high rate of trauma exposure. If we can understand and ideally prevent trauma or at least provide trauma-informed interventions, programs and services, the well-being of these women and their families could be improved.

23. Early Work Gender- responsive trauma-informed trainings for leadership and staff of women's prisons and jails Trauma-informed care trainings for health and social service providers Stephanie Covington, Center for Gender and Justice Curricula: Helping Women Heal, Beyond Trauma

24. Region V Trauma Initiatives Goal: To equip every health and social service provider and institution with the knowledge, resources, and support to provide services that are gender-responsive and trauma-informed.

25. The impact of violence, abuse, neglect, disaster, war, and other harmful experiences continues long after the traumatic event has ended. The Office on Womens Health has partnered with SAMSHA to host this a monthly webinar series that addresses the Impact of Trauma on Women and Girls Across the Lifespan. The series was launched on November 2, 2010 We invite renowned speakers from all over the nation to speak for 45 minutes and then answer questions for the remaining 15 minutes. Our trauma webinars are 1 hour in length and typically max out attendance at 2,400 individuals. After the live broadcast, the webinars are available via archive for one year.

26. Special Topics/Populations: Clinical Services for womens reproductive health Incarcerated Women and Re-Entry Dental Health Providers Women Vets Refugees & Immigrants Trauma-Informed Practices for the Community Setting Trauma-Informed Systems & Organizational Change The ACE study - Life course effects of childhood trauma Understanding the Importance of Sex and Gender in providing Trauma-Informed Services Trauma-Informed Best Practices: What EVERYONE needs to know

27. Trauma-informed Services These are services that are provided for problems other than trauma but require knowledge about violence against women and the impact of trauma thereby increasing their effectiveness.

28. Universal Precaution Approach Presume that every person in a treatment setting has been exposed to abuse, violence, neglect or other traumatic experiences. http://www.health.vic.gov.au/chiefpsychiatrist/creatingsafety/ntac/module6.pd f

29. Current Work with Sheela Raja The Office on Womens Health in Region V has partnered with Sheela Raja, PhD and Assistant Professor of Dentistry and Medicine at the University of Illinois at Chicago, to develop a new symposium. The symposium will bring together academics, teachers, community providers, clinical service providers, state and local legislators, researchers, survivors, and students to discuss ways to collaborate and integrate trauma-informed care across disciplines.

30. Trauma Stewardship The Office on Womens Health Region –V has co- hosted two Trauma Stewardship trainings with Laura Van Dernoot Lipsky The workshops explore the ways we reconcile the trauma we experience through our work. Lauras book is called Trauma Stewardship: An Everyday Guide to Caring for Self while Caring for Others More information can be found at TraumaStewardship.com

31. Incarcerated Women Re-Entry Activities JSI work -Advisory Council -Literature Review -Framework of Recommendations National Summit- Spring 2012

32. The Federal Partners Mental Health Transformation Committee on Women, Girls and Trauma Purpose: Raise awareness and expand the common knowledge base among Federal Partners and collaborators regarding the prevalence and behavioral impacts of trauma on the lives of women and girls

33. The Federal Partners Mental Health Transformation Committee on Women, Girls and Trauma Roundtable I Woman and Trauma Monograph Roundtable II- December 6-7, 2011

34. Intervention Models Addiction and Trauma Recovery Integration Model (ATRIUM) Essence of Being Real Risking Connection Sanctuary Model Seeking Safety Trauma, Addictions, Mental Health, and Recovery (TAMAR) Model Trauma Affect Regulation: Guide for Education and Therapy (TARGET) Trauma Recovery and Empowerment Model (TREM and M-TREM) http://www.samhsa.gov/nctic/trauma.asp

35. Resources The National Child Traumatic Stress Network http://www.nctsnet.org/ The Centers for Disease Control and Prevention on their website lists many of the publications that use the ACE study for their findings. (http://www.cdc.gov/ace/year.htm)http://www.cdc.gov/ace/year.htm The Substance Abuse and Mental Health Services Administration www.samhsa.govwww.samhsa.gov

36. 233 N Michigan Ave, Suite 1300 Chicago, IL 60601 312-353-8122 Michelle.Hoersch@hhs.gov