1. Adverse Childhood Experiences, Complex Trauma, and Community Responses
Christopher Blodgett, Ph.D.
Washington State University

2. Five Takeaways for Today
Quality relationships fix many things
Adverse Childhood Experiences, are the public health problem facing America
Understanding trauma can guide what we do to make things better
Trauma is the least interesting thing you can know about another person
We have to look to each other and unusual partners for a problem this big

3. Understand Trauma but Build Resilience
Resilience- positive adaptation despite adversity
In early childhood, successful secure attachment
In later childhood, mastery of school and establishing meaningful peer and adult relationships
In adults, meaningful intimate and loving relationships
A virtuous cycle- Reduces exposure to vulnerability and increase access to protective resources
(Luthar & Cicchetti, 2000) content adapted from this article

4. Building Resiliency as the Positive Health Goal
Focus on positive growth in addition to reduction of risk
Harm reduction as the goal
Adopt a developmental and an ecological approach to assessment and provision of interventions
Commit to persistent efforts with high risk families
Build community capacity as the principal resource
(Luthar & Cicchetti, 2000) content adapted from this article

5. Relationship is the Evidence-Based Practice
Trauma results primarily from disrupted relationships
Focus on relationship as the vehicle for life success
Attachment key to well-being across the life span
Critical role of core caregiver-infant relationships
Early learning creates persistent but potentially modifiable responses
Progressive role of extended caregivers and intimate relationships

6. Attachment: Can I Depend on You When I Need You?
Attachment is the maintenance of a desired distance to a caregiver both physically and emotionally. The desired distance depends on the situation.
The caregiver as a safe haven soothes and comforts activation and creates readiness to explore in the child
Child may be ‘activated’ (seek closer proximity due to fear or uncertainty) by internal/external cues
Ideally, activation stops when the child’s desired distance is exceeded by the actual distance
The belief that the caregiver will be available as a secure base if needed provides a child the safety to explore their world
When something happens that is outside of my comfort zone and my ability to cope, I am wired to find you and come closer.
What we are talking about here is a person’s ability to modulate on their own. Modulation means “the ability to maintain a comfortable level of arousal.” Another word for modulation is “emotional regulation” but since the ARC model used the term modulation, we’re using it also for consistency.
So when a person can modulate on their own, they can stand a larger distance from their caregiver. When they can’t modulate on their own, they need that distance to shrink. It shrinks based on the amount of distress that person is feeling.

7. 4 Core Principles of Attachment
Attachment is an innate motivating force
In order to learn, you have to feel safe and free to explore
Fear and uncertainty activate attachment needs
Attachment offers a safe haven
Attachment offers a secure base
You build bonds by being accessible and responsive
Isolation and loss are inherently traumatizing
Developed by Susan Johnson who created EFT. She uses attachment theory to help create health with couples. Her model is one of only two counseling models for couples endorsed by the APA. It has a 70% effectiveness rate (most are closer to 20%).
Some of these are review, but you can take this list as a way to sum up attachment in 10 sentences.
We won’t go into great depth on these, but if there are any you’d like more information on, please include that in your eval so we get an idea of what we should cover in the future.

8. Directions of Attachment
View of Self is positive
Dismissing-avoidant-I can’t rely on you, so I only rely on me.
Secure Attachment- I can rely on me and I can rely on you
Disorganized- I’m not okay with you and I’m not okay without you. My fear is unsolvable.
Preoccupied Ambivalent- I can’t rely on me, so I rely on you
View of others
is negative
View of others
is positive
5 styles of attachment
There is a gradient with these- most people have a predominant style, but it’s not “which box do you fit in?” You can have a mostly secure attachment with one or two moments that feel ambivalent, but you’re mostly secure.
It’s a fluid process where we as helping professionals find opportunities to help another feel secure and build on it.
This process is not something we outgrow. It continues all throughout our lifetime.
Earned secure attachment- where a person’s primary caregiver can’t meet those attachment needs and the child forms an insecure attachment style. But, someone else at another point in their life gives them the opportunity to experience secure attachment and they use that other person to heal attachment wounds and move to a secure attachment.
Can be a teacher, coach, relative, etc.
Also is often what takes place in adult friendships, relationships, marriages.
This doesn’t mean that you’re substituting what a parent does. A secure attachment is just to another human being, not necessarily your parents. You, as the helper, can provide a place where, for 6 hours a day, this child gets to feel safe and be responded to in a way that meets those attachment needs of secure base/safe haven. It also means, for the parents you work with, that you can begin to give them a sense of safety that they’ve never had before, and even model to them how to respond to their children as a secure base/safe haven.
You guys are powerful!!!
So all this means that what attachment suggests is that if you as a helping professional work with a child or a parent with a mindful intention, it can be powerful enough to help a child develop secure attachment.
We can talk about this in much more depth in the future. Just remember it is NEVER TOO LATE to heal attachment.
Nearly 40% of the US population has an insecure attachment style. About 10% is somewhere on the Disorganized gradient. Isn’t that interesting when we also consider that 35-40% has experienced complex trauma?
View of Self is Negative

9. User’s Manual for Your Brain
Principle 1: Our brains are designed to benefit from rich and supportive intimate social relationships.
Principle 2: Brain function is hierarchical. We feel and then we think.
Principle 3: Brain systems change with use throughout life.
Adapted from Bruce Perry:

10. Toxic Stress Places Health at Risk
Persistent, unpredictable, overwhelming
Adverse Childhood Experiences as the origins of toxic stress
Complex trauma as adaptation and survival

11. Toxic Stress Places Brain Development at Risk
Access to adequate stimulation at key times
Elevated stress hormone levels can change brain structure
Functional immaturity of the threat-arousal management system
Brain development follows use
Survival trumps learning
Applying findings from animal experimental studies with supporting human clinical studies (correlation evidence)
Dunedin longitudinal studies suggest more direct causal association.
Catecholamines include dopamine, epinephrine, and norepinephrine
From Bruce Perry:
Principle 1: Brain function is hierarchical. Our first responses are based in non-conscious, reflexive, and conditioned responses.
Principle 2: The brain develops in a sequential fashion.
Principle 3: The brain develops most rapidly early in life.
Principle 4: Brain systems change with use throughout life.
Principle 5: Our brains are designed to benefit from rich and supportive intimate social relationships.
Principle 6: We feel and then we think.
Principle 7: Neural systems can be changed, but some systems are easier to change than others.
Principle 8: Stress can change brain development.

12. Complex Trauma and ACEs
The process of exposure to ACEs and the process of adjustment.
The ‘complex’ in complex trauma risk:
Early exposure at times of critical development
Multiple risks
Unpredictable and persistent
Who you love is who you may not be able to count on
Natural responses to extraordinary circumstances.
Complex trauma involves common challenges and responses that can be understood and guide our actions.
Knowing that loss and injury has occurred offers little to guide intervention. Knowing how development is disrupted and the nature of trauma behavior consequences can provide a focus for mitigation and recovery provides the framework for intervention.
The concept of complex trauma lets us focus on the responses to be managed and the capacities to build.

13. Natural Responses to Extraordinary Circumstances
Sense of self and ability to influence the world
Not feeling worthy of love, not trusting love
Feel incapable of having a positive impact on the outside world
Diminished sense of self worth = diminished persistence in effort, giving up on or distorting relationships
Self-regulation
Arousal and hyper-vigilance
Survival and automatic behaviors- aggression, withdrawal, dissociation
Poor impulse control
Trauma impairs emotional learning- constricts response and ability to form relationships
Feel incapable of having a positive impact on the outside world
Hopelessness
Difficulty in initiating play or having safety with imagination and exploration
Low self-esteem--diminished sense of self worth
Disturbances of body image
Shame and guilt; self blame
Unsure of own needs and often lack capacity to get needs met

14. We Swim in Adversity The Adverse Childhood Experiences Study
Substance Abuse 27%
Parental Separation/Divorce 23%
Mental Illness 17%
Battered Mother 13%
Criminal Behavior 6%
Psychological Abuse 11%
Physical Abuse 28%
Sexual Abuse 21%
Emotional Neglect 15%
Physical Neglect 10%

15. ACEs Have a Dose Effect on Health
(ACE Score)
Women %
Men
Total 35 38 36 1 25 28 26 2 16 3 10 9
4 or more 15 13
With four or more categories of childhood exposure, compared to adults with no ACEs
4- to 12-fold increased alcoholism, drug abuse, depression, and suicide attempt
2- to 4-fold increase in poor self-rated health
3- to 4-fold increase in chronic illness (heart disease, liver disease)
Earlier death with >6 ACEs

16. Impact-ACE Risk Pyramid

17. We don’t know much of what we need to know right now
Copyright WSU AHEC 2012 Reproduction with attribution permitted

18. How Do We Move to Community Responses to ACEs and Trauma?
Each of us has to name the problem
Trauma compromises our universal systems caring for children
Common need builds alliances
Education, primary health care, youth development
Helping professionals understand their role -appropriate response to trauma
Awareness, trauma informed planning, surveillance and referral, role of natural relationships in repair
Our initial experiences in early learning and K-12 education- Building the case, moving to action

19. Spokane Study ACEs Exposure in Elementary Aged Children
2,100 randomly selected children in 10 elementary schools
>200 teachers, counselors, and building administrators provided knowledge of children’s risk
5 Title I and 5 Non-Title I schools
Risk is greater as poverty increases
First study of its kind

20. Complex Trauma Risk in the Spokane Students
Lifetime
ACE Exposure
Past 12 Month
None
55%
81%
One
23%
12%
Two
10% 4%
Three or More 2%

21. Odds for Academic and Health Problems with Increasing ACEs in Spokane Children
Academic Failure
Severe
Attendance Problems
Severe School
Behavior Concerns
Frequent Reported
Poor
Health
Three or More ACEs N =248 3 5 6 4
Two ACEs
N=213
2.5
One ACE
N=476
1.5 2
No Known ACEs =1,164
1.0

23. Readiness to Learn and ACEs
RTL program
Adapting other assessment information in an adverse framework
Challenged data still produces powerful effects
Data entered by more than 100 different service providers
Data based on establishing a relationship to collect optimal data
 RTL ACEs Scale =
Basic Need
Legal Problems
Parenting Concerns
Single Parent/Living Away from Parents
CPS/Abuse Concerns
Homeless/Homeless Risk
Family Safety/Family Violence
Family Substance Abuse 
Copyright WSU AHEC 2012 Reproduction with attribution permitted

24. Copyright WSU AHEC 2012 Reproduction with attribution permitted

25. Behavioral Health Problems
RTL- ACEs and Odds Ratios for Academic Risk
Academic
Failure
Poor Attendance
School Behavior
Behavioral Health Problems
Four or More ACES
N=663
2.0
5.3
3.1
6.5
Three ACEs N=756 1
3.0
1.5
Two ACEs N=1,141
2.5
1.6
1.8
One ACE N=1,612
1.2
No Reported ACES
N=1,020
---
Copyright WSU AHEC 2012 Reproduction with attribution permitted

26. RTL-ACEs and academic success
Copyright WSU AHEC 2012 Reproduction with attribution permitted

27. RTL students and social emotional distress
Copyright WSU AHEC 2012 Reproduction with attribution permitted

28. Screening for ACEs in Head Start Children
Parent report
Adaptation of original ACE screen (0-9 items)
Average ACEs
Child M= 2.6
Parent M=4.0
44% of children and 75% of parents have 3 or more ACEs
Copyright WSU AHEC 2012 Reproduction with attribution permitted

30. Why There is Reason for Hope- Trauma Informed Practice in Education
Social support and resources build resiliency at any age. Resiliency buffers the effects of trauma.
Creating safety and predictability creates opportunity for new learning.
Understanding trauma creates opportunities for new behaviors.
Teachers can create powerful relationships.
Managing trauma’s effects may result in increasing success for systems.

31. A Roadmap for Change in Education as One Example
Response to Intervention as a public health principles adapted into education settings
Universal adoption of social emotional learning and trauma informed actions to guide decision-making
Trauma informed assessment and tailored response to children and families most in need
Sustainable interventions to prepare children to benefit from universal education and supports
Coordination of more intensive supports when required