Adverse childhood experiences and hope among caregivers seeking investigation for their child’s abuse Academy on Violence & Abuse 2015 Global Scientific Summit Jacksonville, FL November 6th, 2015 Michael Baxter, DO University of Oklahoma, Tulsa Health Sciences Center School of Community Medicine Department of Pediatrics

3.9 Million 678,932 “Abused children need Hope.” - Me, Today. 3.9 million- That is the estimated population of Oklahoma. It is also the number of Child abuse and Neglect investigations in the US in 2013. Just under Seven-Hundred thousand of those investigations were substantiated by Child Welfare. That is a lot of children who have had their lives impacted by abuse and neglect. And based off of our research, Abused Children need Hope. US 3,838,352/678,932 PAB 124,544/ (OK)5,589 SAB 62,936/ (OK)611 3.9 Million 678,932 Adverse childhood experiences and hope

Adverse childhood experiences and hope Study Aim To examine the connection between caregiver’s level of Hope and their Adverse Childhood Experiences (ACEs), among caregivers of children receiving abuse and neglect exams. Our question was, Of caregivers who brought children to the local Child Advocacy center, is there a connection with their level of Hope and ACE scores, specifically those with physical and sexual abuse? Although neglect is the most common form of child maltreatment, The National Children’s Alliance shows that year after year, physical abuse and sexual abuse are the two most common forms of child maltreatment seen at CACs. (next slide) Adverse childhood experiences and hope

Adverse childhood experiences and hope “Hope is defined as the perceived capability to derive pathways to desired goals, and motivate oneself via agency thinking to use those pathways.” In 1991 Dr. Snyder first described Hope Theory. After several years of research he and his colleagues developed validated measures of Hope based off the Theory. They defined Hope as “the perceived capability to derive pathways to desired goals, and motivate oneself via agency thinking to use those pathways.” Dr. C. R. Snyder Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., Sigmon, S. T., et al.(1991). The will and the ways: Development and validation of an individual-differences measure of hope. Journal of Personality and Social Psychology, 60, 570-585. Snyder, C.R. 2002. Hope Theory: Rainbows in the Mind. Psychological Inquiry Vol 13. No 4, 249-275 Adverse childhood experiences and hope

Adverse childhood experiences and hope Hope Theory The two key tenets of Hope Theory are Pathway and Agency processes. If an individual can conceive a way out of a problematic situation, using Pathway Processes, and also has a strong belief that s/he is capable of getting out of it, Agency Processes, that individual will have a higher sense of hopefulness. Research has shown an association between parental stress, hope, and the quality of the parent-child relationship in child abuse-prevention settings. Snyder, C.R. 2002. Hope Theory: Rainbows in the Mind. Psychological Inquiry Vol 13. No 4, 249-275 Adverse childhood experiences and hope

Adverse childhood experiences and hope Hope Theory This diagram attempts to take the complex theory and simplify it. As the diagram shows Hope thoughts begin as pathway and agency thoughts and they move along a continuum with positive and negative feedbacks, (Stressor Event) toward an ultimate Goal. Those with High hope are able to overcome the negative feedback and utilize the positive feedback (the Emotions) to strengthen their hope. Agency and Pathways are two different processes and one can have high Agency Hope, but low Pathway Hope and vice-versa. Snyder, C.R. 2002. Hope Theory: Rainbows in the Mind. Psychological Inquiry Vol 13. No 4, 249-275 Adverse childhood experiences and hope

Adverse childhood experiences and hope Goal Pathway and Agency “One of the first things I realized after taking office is that pediatricians must recognize change and we must manage that change in order to succeed in our advocacy for children,” said Dr. Block. “Our work on early brain and child development, epigenetics, and a science-based economic approach is so important to protect children as they follow the path of adult life. I am so proud of the work accomplished by the AAP during the past year that emphasizes our commitment to the importance of quality, comprehensive pediatric care for all children.” Adverse childhood experiences and hope

Adverse childhood experiences and hope “What we recognize as common disorders in adult medicine and psychiatry are likely the result of what we fail to recognize or address in childhood.” Adverse Childhood Experiences compose 10 events that occur during childhood described by Drs. Felitte and Anda. After observing that many of their adult patients seemed to have a common theme of problems from childhood, they asked 17,000 adults to complete a 10 question survey indicating “yes” or “no” to adverse events during their childhood. The events are divided into 3 main categories, Abuse, Neglect, and Home environment. Dr. Vincent Felitti Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults Felitti, Vincent J et al.American Journal of Preventive Medicine , Volume 14 , Issue 4 , 245 - 258 Adverse childhood experiences and hope

Adverse childhood experiences and hope What the ACE study found was that Adverse Childhood Experiences had an impact on ones life. Common adult illnesses, such as heart disease, diabetes, high risk activity (drug use and sexually activity) are more likely to occur as ones ACE score increases. ACEs may result in poor mental strategies for parenting skills (pathways) as well as the willpower to be a protective parent for their children (agency). We wanted to know how ACEs impacted Hope. Adverse childhood experiences and hope http://acestudy.org

Adverse childhood experiences and hope Methods Primary caregivers of children brought for child abuse and neglect exams at Tulsa County Advocacy Center Caregivers completed a Hope scale for validated measure of Hope and an ACE questionnaire Authors were blinded to results We recruited primary caregivers from amongst those who brought their children to the local Child Advocacy Center for medical evaluation of possible child abuse or neglect. The anonymous questionnaire was provided with validated measures of dispositional hope and ACEs. Ultimately, 151 non-offending adults completed the survey. Most were female (82.3%) and report an average age of 30.61 (SD = 7.15) years ranging from 19 to 55 years respectively. Respondents report 37.6% were employed full time with 32.0% being unemployed. Education levels included less than 12th grade (17.9%), HS/GED (27.6%), technical school (4.1%), some college (27.6%), and college degree (14.6%). Just over one-half (54.4%) of the caregivers were white, with the remaining reported as black (20.0%), Native American (9.6%), Hispanic (5.6%). Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., Sigmon, S. T., et al.(1991). The will and the ways: Development and validation of an individual-differences measure of hope. Journal of Personality and Social Psychology, 60, 570-585. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults Felitti, Vincent J et al.American Journal of Preventive Medicine , Volume 14 , Issue 4 , 245 - 258 Adverse childhood experiences and hope

Adverse childhood experiences and hope Instrument Questionnaire given to consecutive caregivers presenting to the Tulsa County Advocacy Center ANOVA used to test if ACEs predicted Hope scores between two groups, those who reported both physical and sexual abuse, and those who reported no abuse. We asked about the 10 ACEs as well as the Dispositional Hope Scale (Snyder et al., 1991) is an 8-item survey that measures both the mental energy and pathway cognitions toward goal attainment. Item responses are on an 8-point Likert scale, ranging from 1 (definitely false) to 8 (definitely true). The Dispositional Hope Scale is divided into two subscales: 1) agency, which captures motivation to obtain said goals, and 2) pathways, which captures ones thinking in regards to goal attainment. Together, the two subscales derive a total hope score with a potential range of 8 (low) to 64 (high). For the current study, total score reliability estimates were adequate (α = .97; M = 41.07; SD = 18.31). We also collected basic demographic information. We used statistical analyses to compare HOPE and ACE score of the caregiver. Adverse childhood experiences and hope

Adverse childhood experiences and hope Results 151 (82.3% female) caregivers given survey 86 respondents fully completed both Hope Scale and ACE questionnaire 15.5% reported both physical and sexual abuse Caregivers who experience both sexual AND physical abuse have significantly less Hope than caregivers who did not experience both types of abuse. ANOVA (F (1, 84) =5.28; p<0.05) We compared the prevalence of ACE of our sample to the national study reported by the U.S. Center for Disease Control. Our sample (81%) was significantly (χ2 = 7.23; p < .05) more likely to report any ACE (1+) compared to the CDC national sample (64%).However, when comparing the prevalence of physical abuse (χ2 = 1.75; p > .05) and sexual abuse (χ2 = 0.45; p > .05) our sample did not differ significantly from the national sample. What we found was caregivers who self reported both sexual AND physical abuse during childhood, would have LOWER dispositional HOPE than caregivers who self reported no abuse. Adverse childhood experiences and hope

Adverse childhood experiences and hope This is a graphic representation of our findings. The two bars on the left represent those caregivers reporting both physical and sexual abuse. The mean HOPE score was just over 29 and ACE of 6.6. ACE are categorical vs HOPE continuous HOPE scores range from 8 to 96. Average ACE scores are 36.1%-0 ACE, 26%-1 ACE, 15.9% 2-ACEs, 9.5% 3 ACEs, and 12.5% - 4 or more Of the primary caregivers that participated (n=151, 82.3% female), 19.7% reported childhood experiences of physical abuse only, 24.8% of sexual abuse only, and 15.5% of both physical and sexual abuse. After testing for the assumptions we computed an Analysis of Variance to determine if caregivers who have experienced both sexual and physical abuse (M=29.67; SD=15.96) have lower hope scores compared to those caregivers who have experienced neither physical nor sexual abuse (M=42.64; SD=18.44). Of those who completed the hope scale and ACE (n=86), the ANOVA (F (1, 84) =5.28; p<0.05) shows that caregivers who experienced both physical and sexual abuse report lower levels of hope compared to their counterparts. Hope Scores Range from 8 (least hopeful) to 96 (most hopeful). ACE distributions 36.1%-0 ACE, 26%-1 ACE, 15.9% 2-ACEs, 9.5% 3 ACEs, and 12.5% - 4 or more Adverse childhood experiences and hope

Adverse childhood experiences and hope Conclusions Caregivers experiencing both physical and sexual abuse: have significantly less hope than caregivers who do not experience both types of abuse. have higher risk for more stress, which is intrinsically tied to child abuse and neglect. The hopefulness of a caregiver may be an important factor in preventing child abuse and neglect. Children being evaluated for abuse and neglect in this study have caregivers who have experienced abuse and neglect as children. When caregivers reported experiencing their own childhood physical and sexual abuse, they also reported significantly less hope compared to caregivers who had not experienced abuse. Other research has shown that parental stress is intrinsically tied to child abuse and neglect, the hopefulness of a parent may be an important factor in preventing child abuse and neglect. limitations (e.g., geographic location, non random sampling, cross sectional design, lack of experimental control), the use of retrospective recall by the caregivers of their ACEs. Another limitation is the caregivers situation bias as they are asked to measure their hope during a period of increased stress. Although the numbers of participants are small compared to other large scale studies, this study did show a statistical significant finding between caregivers hope and ACEs. Hellman C, Robinson-Keilig R, Dubriwny N, Hamill C, Kraft A. 2012. p.31 Parental Hope and Well-Being Within Child Abuse and Neglect Prevention Services. Under review at: Child Abuse & Neglect: The International Journal. Adverse childhood experiences and hope

“Our children’s future and the world’s future are one.” Results of our study suggest that those who have higher ACE scores are less likely to develop successful pathways to their goals as well as dedicating the mental energy to pursuing these pathways. While campaigns to prevent child maltreatment deserve needed resources and attention, intervention programs should pay attention to strategies that promote the important future orientation of hope.  More specifically, interventions that develop and clarify goals, establish specific and measurable strategies to goal attainment warrant attention.  Higher hope individuals have elevated capacity for pathways and agency, have a more positive emotional state and focus on success.  Comparatively, low hope individuals recognize their deficiency in goal setting capacity, have a more negative disposition and focus on failure.  Given the empirically supported benefits of hope on a meaningful and purposeful life, we argue that this research opens a new and potentially beneficial line of inquiry for the study of child maltreatment. –Dr. C. Henry Kempe Adverse childhood experiences and hope

Adverse childhood experiences and hope Thoughts or questions? Adverse childhood experiences and hope

Adverse childhood experiences and hope Acknowledgement Co-Authors Sarah Passmore, DO Eden Hemming, MA Heather McInthosh, MS Chan Hellman, Ph.D Mentor Robert Block, MD I would like to thank my co-authors, particularly Dr. Hellman, our senior author. Also, Dr. Robert Block who encouraged me to begin my own journey into the field of Child abuse pediatrics. Adverse childhood experiences and hope