1. Adverse Childhood Experiences
and Resiliency:
Pathways to Self-Care
Amy L. Griffith, LPC
Adrienne Gilbert, MPH
28th Judicial Bar CLE
November 7, 2014
What is an ACE Score?
Why is it important to know yours?
How does resiliency mitigate impact of ACEs?

3. ACE Study 1995 – 1997 Kaiser Permanente (San Diego)
Dr. Vincent Felitti
Weight loss clinic
17,000+ participants
Survey on childhood
maltreatment &
family dysfunction
ACE Study is one of the largest studies to investigate the associations of childhood maltreatment & later life health & well-being.
Collaboration between the Centers for Disease Control and Kaiser Permanente’s Health Appraisal Clinic in San Diego.
Dr. Vincent Felitti, a physician in southern California, ran a weight loss clinic for Kaiser Permanente.
He observed that a sub-set of the patients who physiologically should have been losing weight were not.
Dr. Felitti began conducting personal interviews and, to his surprise, discovered a theme of childhood traumas.
Kaiser Permanente began a study which included confidential questionnaires that were filled out by more than 17,000 patients and brought in at their annual exam.
This included questions about childhood maltreatment and family dysfunction, as well as current health status and behaviors in adulthood.

4. Adverse Childhood Experiences
Prior to your 18th birthday…
Based on the data, Dr. Felitti created 10 categories of adverse childhood experiences in the patient’s life before the age of 18.
Pass them out, take a moment to review items.
An ACE score is determined by adding 1 if a person experienced one of these categories at least once. [So, multiple exposures to domestic violence adds only “1”]

5. 65% more likely to have 1 additional ACE
ACE Categories
Percent
Emotional Abuse: recurrent threats, humiliation
11%
Physical Abuse: beating not spanking
28%
Sexual Abuse
28% women, 16% men
Mother treated violently
13%
Household member alcoholic or drug user
27%
Household member imprisoned 6%
Household member mentally ill, depressed, suicidal, psych hospitalization
19%
Not raised by biologic parents (including separation or divorce)
23%
Physical neglect
10%
Emotional neglect
15%
Dr. Felitti’s results showed the following total percentages. How many people in this room, based on percentage.
Middle class, white, insured popluation.
When separated by sex, women experience more of each category than men, with the exception of physical abuse.
Persons with 1 ACE are:
65% more likely to have 1 additional ACE
45% more likely to have 2 or more ACEs

6. ACEs have an impact on: Adolescent health Reproductive health Smoking
Obesity
Alcohol abuse
Illicit drug use
Sexual behavior
Mental health
Risk of victimization
Stability of relationships
Performance in the workplace & school
Working with Dr. Robert Anda’s (Co-Principal Investigator on the ACE Study), they linked ACEs with many physical, emotional, and behavioral outcomes.

7. ACEs increase health risk of:
Early Death
Heart Disease
Chronic Lung Disease
Lung Cancer
Liver Disease
Autoimmune diseases
Suicide
Injuries
HIV & STDs
The physical, emotional, and behavioral indicators were correlated with chronic disease and death.
The root cause of these outcomes appears to be tied directly to stress, secondary to # of ACEs.

8. National Scientific Council on the Developing Child, 2009
Levels of Stress
Moderate, short-lived stress responses that are normal part of life and healthy development. A child can learn to manage and control these experiences with support of caring adults in context of safe, warm, and positive relationships.
Stress responses that could affect brain architecture but generally occur for briefer periods which allow brain to recover and thereby reverse potentially harmful effects.
Stress happens! Positive stress, Tolerable stress, and Toxic stress– each impacts children in different ways, leading to specific coping strategies in adolescence and adulthood.
Learning how to cope with stress is an important part of a child’s healthy development, whether it’s the stress of meeting new people, learning to walk, or dealing with problems.
There is a range of physiological responses to stress, which most of us are familiar with: increased heart rate and fluctuations in stress hormone levels, such as cortisol.
When stress occurs to a young child within an environment of supportive relationships with adults, these physiological effects are buffered and brought back down to baseline. The result is a healthy stress response system.
For larger stressors -- such as the death or serious illness of a loved one, a frightening injury, the divorce of one’s parents, or a natural disaster -- these physiological responses are sustained for a longer period of time.
The buffering effects of supportive adult relationships allow the brain to recover from what might otherwise be damaging effects.
When situations of extreme stress are prolonged and unrelenting, in the absence of supportive adults, a child can be affected by toxic stress. These situations can include physical or emotional abuse, chronic neglect, severe maternal depression, substance abuse, or family violence. Without the support of a caring network of adults, toxic stress can disrupt brain architecture and lead to stress management systems that respond at relatively lower thresholds, thereby increasing the risk of stress-related physical and mental illness.
Refer to brain research for more info.
Strong, frequent or prolonged activation of body’s stress management system. Stressful events that are chronic, uncontrollable, and/or experienced without child having access to support from caring adults.
National Scientific Council on the Developing Child, 2009

9. Pyramid shows the mechanisms by which ACES influence health and well-being throughout life-span
Children with toxic stress become adults who live much of their lives in fight, flight or freeze mode. Some kids and adults do all three. They often find solace in food, alcohol, tobacco, methamphetamine, inappropriate sex, high-risk sports, and/or work and over-achievement. Consciously or unconsciously, they use them as solutions to escape from depression, anxiety, anger, fear and shame.
Many of these coping styles have an obvious connection to health problems and disease– i.e. alcohol = liver disease, smoking = heart disease, risky sex = STD’s.
On average, individuals with an ACE score of 6 or higher die 20 years earlier than those with no ACE score.

10. Let’s look at some outcomes tied to mental health and substance use and ACEs.
Based on the original ACE Study.

12. 16% of individuals with a score of 4+ ACEs answered YES to the following question, “Have you ever considered yourself to be an alcoholic?”
This is very different than a person endorsing behaviors that are consistent with problem drinking– this is about self-perception among individuals with high ACE scores.

13. Drastci increase between % using– 6+ ACEs = 4600% increased likelihood of later becoming in IV drug user.
Addiction is NOT the problem. ACEs lead to behaviors.

18. The roots of the problem…
How do you think this has affected you?
We want people to ask each other: How has this affected you?
Parents, friends, peers, doctors, counselors, clergy, etc.
If we are only addressing smoking, we are addressing the attempted solution rather than the problem
Not addressing the root of the issues

19. The ability to recover from or adjust to change
What is RESILIENCE?
The ability to recover from or adjust to change Or
The ability to survive a crisis and survive in a world of uncertainty and change
Generally speaking, resilience can be defined as:
The ability to recover from or adjust to change, or
The ability to survive a crisis or survive in a world of uncertainly and change

20. In the presence of significant adversity,
resilience is understood to be both the capacity of individuals to navigate their way to the psychological, social, culture and physical resources that sustain their well-being
& their capacity to individually and collectively negotiate for these resources to be provided and experienced in culturally meaningful ways.

21. Doctor Vincent Fellitti’s ‘BIG’ Question:
“I see that you have experience ___X___ as a child, how you think that this is affecting your life now….?”
-In the ACE Study, Filetti’s ‘BIG’ Question, for interviewing was, “I see that you experienced __X___, as a child, how do you think that this is affecting your life now”.
-Acknowledging that patients have coped with this experience, for a long time, without vocalizing it to anyone, changed their lives
-Helping patients acknowledge how far they have come while coping with their experiences, is a point of discussion for providers to demonstrate how strong they really are, to point out personal strengths
Ways that Individuals Can Build Resilience, or way that providers encourage patients to build or maintain or build resilience are:
Asking for help, by talking to a trusted friend, family member or professional
Learn how to take care of oneself, if you are a caregiver, so you can learn to take care of others, family members, etc.
Building Social Connections; build trusting relationships with others & strengthening your social network
Developing a positive attitude: find and focus on the good in every day
Maintain concrete supports in times of need
Preserving Social and Emotional Well-Being; identify and understand your feelings/emotions in order to express them in a healthy way

22. Three basic building blocks to success:
Attachment - feeling connected, loved, valued, a part of family, community, world
Regulation - learning about emotions and feelings and how to express them in a healthy way
Competence - acting rather than reacting, accepting oneself and making good choices
The Boston Trauma Center, a leading organization in the field of trauma work, has developed a scheme made up of three building blocks – Attachment, Regulation and Competence.
This model can be used in early childhood development settings to help children (and adults, in that case) with learning how to build resilience from a young age.
Adapted from the research of Dr. Margaret Blaustein

23. Community Resiliency Model
Key Concepts for the Community Resiliency Model:
People respond to stress in similar ways.
People are resilient by nature.
People can learn skills that will mitigate the impact of stress.
Master Community Resiliency Model Trainers in Buncombe County
MaryLynn Barrett, Director of Behavioral Health, MAHEC
Dr. Stephanie Citron, Independent Psychiatrist
The Community Resiliency Model comes from the Trauma Resource Institute in Loma Linda, California
TRI’s mission is to create trauma-informed and resiliency-informed communities
The Key Concepts for the Community Resiliency Model (CRM) are:
CRM teaches skills to help children and adults experiencing stress and traumatic stress reactions
CRM can be used as a wellness practice
Human Beings respond to stressful & traumatic experiences in similar ways
Human beings are resilient- most are able to bounce back to their best selves after difficult experiences
There is a biological reaction common to most of humanity after a traumatic experience. A person is having a common experience to an extraordinary life event
Current scientific research is demonstrating that the train can be changed
Master Trainers here in Buncombe County have trained, in a train-the-trainer model, about 30 trainers here in Buncombe County, who are teaching a set of 6 wellness skills to who can apply this directly to the clients, they work with, or use it in their own lives:
These trainers include:
social workers at Mission,
early childhood development consultants,
parent of children and youth with special health care needs,
Pastors
Public health/social service administrators
Buncombe County School social workers and counselors

24. Learn More on our local Website: www.buncombeaces.org
Local Initiative:
Buncombe County Innovative Approaches
Learn More on our local Website:
Buncombe County Innovative Approaches-Grant Funded Project through Health and Human Services
Convenes a Learning collaborative called ACEs, Adverse Childhood Experiences
Leaders work together to create systems changes for the prevention of trauma passed down in families, generation to generation
Leaders include:
primary health care & behavioral health from MAHEC
Buncombe County and Asheville City School leadership
Pediatric Physicians & Pediatric Psychiatrics
Director of mental Health intake services at BC Jail
Smoky Mountain Health Center Staff
Etc.
Current Projects Include:
Pilot of the ACE Screening tool at BC Jail intake assessment and intake assessment at RHA center
Pilot of the ACE Screening tool at MAHEC and Blue Sky Pediatrics to asses adverse childhood experiences & refer to resources
Including the development of an ACE Resource Guide for PCP, then human services and education community
Training of all BCS Counselors & Social workers on the CRM Model
County Wide Speaker’s Bureau on the Topic of ACEs to Different Audiences to education public on the topic
website for provider and public use as information sharing forum