There is no trust more sacred than the one the world holds with children. There is no duty more important than ensuring that their rights are respected, that their welfare is protected, that their lives are free from fear and want and that they grow up in peace. There is no trust more sacred than the one the world holds with children. There is no duty more important than ensuring that their rights are respected, that their welfare is protected, that their lives are free from fear and want and that they grow up in peace. Kofi A. Annan

The “ACE” Study & Unaddressed Childhood Trauma Presented by Ann Jennings Ph.D.

Anna’s Story

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

Anna Caroline Jennings

Collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the Center for Disease Control and Prevention (CDC) The Adverse Childhood Experiences Study (ACE)

ACE Study slides are from: ACE Study slides are from: Robert F. Anda MD at the Center for Disease Control and Prevention (CDC) Robert F. Anda MD at the Center for Disease Control and Prevention (CDC) September 2003 Presentation by Vincent Felitti MD “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West September 2003 Presentation by Vincent Felitti MD “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West “The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare” Book Chapter for “The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease” Lanius & Vermetten, Ed) “The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare” Book Chapter for “The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease” Lanius & Vermetten, Ed)

What is the Adverse Childhood Experiences (ACE) Study? Decade long. 17,000 people involved. Decade long. 17,000 people involved. Looked at effects of adverse childhood experiences over the lifespan. Looked at effects of adverse childhood experiences over the lifespan. Largest study ever done on this subject. Largest study ever done on this subject.

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

Adverse Childhood Experience* Categories Abuse of Child Abuse of Child Recurrent Severe Emotional abuse Recurrent Severe Emotional abuse Recurrent Physical abuse Recurrent Physical abuse Contact Sexual abuse Contact Sexual abuse Trauma in Child’s Household Trauma in Child’s Household Environment Environment Substance abuse Substance abuse Parental separation or divorce - Parental separation or divorce - Chronically depressed, emotionally Chronically depressed, emotionally disturbed or suicidal household disturbed or suicidal household member member Mother treated violently Mother treated violently Imprisoned household member Imprisoned household member Loss of parent – (by death, Loss of parent – (by death, by suicide, - or by by suicide, - or by abandonment) abandonment) Neglect of Child Neglect of Child Abandonment Abandonment Child’s basic physical and/or Child’s basic physical and/or emotional needs unmet emotional needs unmet * Above types of ACEs are the “heavy end” of abuse. Impact of Trauma and Health Risk Behaviors to Ease the Pain Neurobiologic Effects of Trauma Disrupted neuro-development Disrupted neuro-development Difficulty controlling anger-rage Difficulty controlling anger-rage Hallucinations Hallucinations Depression Depression Panic reactions Panic reactions Anxiety Anxiety Multiple (6+) somatic problems Multiple (6+) somatic problems Sleep problems Sleep problems Impaired memory Impaired memory Flashbacks Flashbacks Dissociation Dissociation Health Risk Behaviors Smoking Smoking Severe obesity Severe obesity Physical inactivity Physical inactivity Suicide attempts Suicide attempts Alcoholism Alcoholism Drug abuse Drug abuse 50+ sex partners 50+ sex partners Repetition of original trauma Repetition of original trauma Self Injury Self Injury Eating disorders Eating disorders Perpetrate interpersonal violence Perpetrate interpersonal violence Long-Term Consequences of Unaddressed Trauma (ACEs) Disease and Disability Ischemic heart disease Ischemic heart disease Cancer Cancer Chronic lung disease Chronic lung disease Chronic emphysema Chronic emphysema Asthma Asthma Liver disease Liver disease Skeletal fractures Skeletal fractures Poor self rated health Poor self rated health Sexually transmitted disease Sexually transmitted disease HIV/AIDS HIV/AIDS Serious Social Problems Homelessness Homelessness Prostitution Prostitution Delinquency, violence, criminal Delinquency, violence, criminal behavior behavior Inability to sustain employment Inability to sustain employment Re-victimization: rape, DV Re-victimization: rape, DV compromised ability to parent compromised ability to parent Intergenerational transmission of Intergenerational transmission of abuse abuse Long-term use of health, Long-term use of health, behavioral health, correctional, behavioral health, correctional, and social services and social services

Adverse Childhood Experiences are Common Adverse Childhood Experiences are Common Of the 17,000 HMO Members: 1 in 4 exposed to 2 categories of ACEs 1 in 4 exposed to 2 categories of ACEs 1 in 16 was exposed to 4 categories. 1 in 16 was exposed to 4 categories. 22% were sexually abused as children. 22% were sexually abused as children. 66% of the women experienced abuse, violence or family strife in childhood. 66% of the women experienced abuse, violence or family strife in childhood.

Severe and persistent emotional problems Severe and persistent emotional problems Health risk behaviors Health risk behaviors Serious social problems Serious social problems Adult disease and disability Adult disease and disability High health and mental health care costs High health and mental health care costs Poor life expectancy Poor life expectancy For example: The following information and slides are from September 2003 Presentation at “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West, by Vincent J. Felitti, MD. And from Lanius/Vermetten Book Chapter 6/2007 The higher the ACE Score, the greater the likelihood of :

Emotional Problems

Childhood Experiences Underlie Chronic Depression

Childhood Experiences Underlie Suicide

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

Childhood Sexual Abuse and the Childhood Sexual Abuse and the Number of Unexplained Symptoms History of Childhood Sexual Abuse Percent Abused (%) Number of Symptoms Number of Symptoms

ACE Score and Impaired Memory ACE Score and Impaired Memory of Childhood of Childhood Percent With Memory Impairment (%) ACE Score ACE Score

Health Risk Behaviors

Adverse Childhood Experiences and Current Smoking %

Childhood Experiences and Adult Alcoholism

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

Basic cause of addiction is experience- dependent, not substance-dependent Basic cause of addiction is experience- dependent, not substance-dependent Significant implications for medical practice and treatment programs Significant implications for medical practice and treatment programs

Serious Social Problems

Childhood Experiences Underlie Rape

Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners

ACE Score and Unintended Pregnancy or Elective Abortion

Sexual Abuse of Male Children and Their Likelihood of Impregnating a Teenage Girl Not 16-18yrs yrs <=10 yrs abused Age when first abused Percent who impregnated a teenage girl 1.3x 1.4x 1.8x 1.0 ref

Frequency of Being Pushed, Grabbed, Slapped, Shoved or Had Something Thrown at Oneself or One’s Mother as a Girl and the Likelihood of Ever Having a Teen Pregnancy Never Once, Sometimes Often Very Twice often Percent who had a teen pregnancy Pink =self Yellow =mother

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

Adult Disease and Disability

Adverse Childhood Experiences and History of STD

High Health and Mental Health Care Costs High Health and Mental Health Care Costs

Poor Life Expectancy

Effect of ACEs on Mortality Age Group

ACE Study

Other Studies on Childhood Sexual and/or Physical Abuse

Early Child Sexual Abuse (CSA) may especially impair resiliency Sarah Joe, Anna John Mary

2/3rds of men and women in SA treatment - physical and/or sexual abuse 2/3rds of men and women in SA treatment - physical and/or sexual abuse 75% of the women - sexually abused. SAMHSA/CSAT, 2000; SAMHSA, % of the women - sexually abused. SAMHSA/CSAT, 2000; SAMHSA, 1994 Teenagers with alcohol and drug problems - 6 to 12 times more likely physically abused, Teenagers with alcohol and drug problems - 6 to 12 times more likely physically abused, 18 to 21 times more likely sexually abused. Clark et al, to 21 times more likely sexually abused. Clark et al, 1997 Of AI/AN women in SA treatment – 86% report physical abuse histories, 69% sexual abuse histories. Of AI/AN women in SA treatment – 86% report physical abuse histories, 69% sexual abuse histories. Of those with sexual abuse histories, 96.7% physically abused. 96% of both (sa, pa) emotionally abused. Of those with sexual abuse histories, 96.7% physically abused. 96% of both (sa, pa) emotionally abused. Saylors, 2003; 2004 Substance Abuse and Unaddressed Childhood Sexual/Physical Abuse

51 – 98% of public mental health clients with severe mental health diagnoses Goodman et al, 1999, Mueser et al, 1998; Cusack et al, – 98% of public mental health clients with severe mental health diagnoses Goodman et al, 1999, Mueser et al, 1998; Cusack et al, % of psychiatrically hospitalized adolescents Ipschitz et al, % of psychiatrically hospitalized adolescents Ipschitz et al, 1999 Serious Mental Illness and Unaddressed Sexual/Physical Abuse

Criminal Justice Problems and Unaddressed Sexual/Physical Abuse More than 75% of girls in juvenile justice system Calhoun et al, 1993 More than 75% of girls in juvenile justice system Calhoun et al, % of women in prison and jails Smith, % of women in prison and jails Smith, % of men on death row Freedman, Hemenway, % of men on death row Freedman, Hemenway, 2000 Boys who commit violence van der Kolk, 1998 Boys who commit violence van der Kolk, 1998

Childhood sexual abuse is significantly related to adolescent and adult self-harm, including suicide attempts, cutting, and self-starving. Van der Kolk et al, 1991 Childhood sexual abuse is significantly related to adolescent and adult self-harm, including suicide attempts, cutting, and self-starving. Van der Kolk et al, 1991 One study found childhood sexual abuse to be the single strongest predictor of suicidality Read et al, 2001 One study found childhood sexual abuse to be the single strongest predictor of suicidality Read et al, 2001 Self-Injury and Suicide and Unaddressed Childhood Sexual Abuse

Prevalence of Child Sexual Abuse 1/4 th to 1/3 rd of all children and as many as 42% of girls are sexually abused before age 18 – with 9% experiencing persistent, genital assault. Males are underreported. 1/4 th to 1/3 rd of all children and as many as 42% of girls are sexually abused before age 18 – with 9% experiencing persistent, genital assault. Males are underreported. Saunders et al, 1992; Randall 1995; Epstein, % of American Indian girls experience sexual abuse. This abuse starts early. 79.8% of American Indian girls experience sexual abuse. This abuse starts early. National Center on Child Abuse and Neglect, 1999 One fifth of all sexually abused children develop serious psychological disturbances as adults. Giller, 2007 One fifth of all sexually abused children develop serious psychological disturbances as adults. Giller, 2007

“They do not want to hear what their children suffer. They’ve made the telling of the suffering itself taboo” From Possessing the Secret of Joy, Alice Walker Yet the Silence Continues From ACE Study Slides: Vincent Felitti From ACE Study Slides: Vincent Felitti

The sexual and physical violation of children results in alterations in self-perception which are immediate, last throughout the life-span, and contribute to suicidality as a way to cope. Judith Herman, 1992 Lasting Alterations in Self Perception

Sense of helplessness, paralysis, captivity, inadequacy, powerlessness, danger, fear Continues over the lifespan

Sense of Shame, Guilt, Self-Blame, Being Bad Continues over the lifespan

Sense of defilement, contamination, spoiled, degraded, debased, despicable, evil Sense of defilement, contamination, spoiled, degraded, debased, despicable, evil Continues over the lifespan

Sense of complete difference from others, deviance, utter aloneness, isolation, non-human, specialness, unseen, unheard, belief no other person can ever understand Continues over the lifespan

In Summary Childhood abuse and trauma: Childhood abuse and trauma: Impacts brain and nervous system, perception of self and others Impacts brain and nervous system, perception of self and others Causes serious and chronic health, behavioral health and social problems Causes serious and chronic health, behavioral health and social problems Epidemic proportions. Major public health issue Epidemic proportions. Major public health issue Often unrecognized, ignored or denied. Often unrecognized, ignored or denied.

There are Many Faces of Trauma

The Costs Are High 1992 Analysis of Cost of Anna’s Care Over 17 years, Anna was hospitalized a total of 4,124 days. At $648 a day the cost was $2,639,360. Over 17 years, Anna was hospitalized a total of 4,124 days. At $648 a day the cost was $2,639,360. Other costs – entitlements, residential treatment, case management, legal, medical – were estimated to be over $1,000,000, bringing total cost to nearly $4,000,000. Other costs – entitlements, residential treatment, case management, legal, medical – were estimated to be over $1,000,000, bringing total cost to nearly $4,000,000. Adjusted for inflation (2005) total cost = $5,417,032 Adjusted for inflation (2005) total cost = $5,417,032

1992 Analysis of Cost of Anna’s Care Intensive trauma based psychotherapy, figured at $150 a session, 2 sessions a week, for 17 years, would have cost a total of $265,200 - (compared to $2,639,360) Intensive trauma based psychotherapy, figured at $150 a session, 2 sessions a week, for 17 years, would have cost a total of $265,200 - (compared to $2,639,360) Had trauma been recognized and treated at age 3, costs would have been significantly less. Had trauma been recognized and treated at age 3, costs would have been significantly less. If parents had been trauma-informed, the abuse may not have occurred. If parents had been trauma-informed, the abuse may not have occurred.

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

Investing in Our Children The issue is not are we going to pay it’s are we going to pay now, up front, or are we going to pay a whole lot more later on. The issue is not are we going to pay it’s are we going to pay now, up front, or are we going to pay a whole lot more later on. Marian Wright Edelman

What Can We Do as Individuals? Break societal silence and end the isolation of the child. Break societal silence and end the isolation of the child. Ask “what happened” vs whats wrong with you. Ask “what happened” vs whats wrong with you. Listen. Pay attention. Believe. Respond with compassion. Be a safe place for the child. Listen. Pay attention. Believe. Respond with compassion. Be a safe place for the child.

A Public Health Approach I. Prevention I. Prevention II. Detection and Early Intervention II. Detection and Early Intervention III. Safe, Strengthening and Healing Environments and Responses III. Safe, Strengthening and Healing Environments and Responses

“If you think you’re too small to make a difference, try sleeping in a room with a mosquito.” African Proverb

“The solution of adult problems tomorrow depends in large measure upon the way our children grow up today”. Margaret Mead

Thank You