1. CUMULATIVE IMPACT OF TRAUMATIC EXPOsurES FOR VICTIMS OF DOMESTIC AND INSTRUSIVE VIOLENCE
Katherine A. Best, Ph.D., LCSW, MPH
Presentation for Loss, Grief, and End of Life Coalition
September 15, 2009

2. Learning Objectives
Understand the Prevalence of Cumulative Exposures to Domestic Violence
Understand the “Dose-Response” Relationship between the Burden of Adverse Exposures and the Risk of Depression and Suicide Attempts
Understand the Health Implications of Cumulative Exposures to Domestic Violence

3. World Health Organization (WHO)
Depression is ranked as the leading cause for disability and fourth leading contributor to the global burden of disease in the world.
Economic impact exceeds $63 billion per year in U.S.(DHHS,1999).
Evidence exists for the relationship between mental disorder and the leading health indicators:
Physical activity, overweight and obesity, tobacco use, substance abuse, sexual behaviors, injury and violence (NIH, 2000)

4. Findings from the Institute of Medicine Report
Depression: youth (14-19): Lifetime prevalence rate (20%).
Suicide: 3rd leading cause of death (11/100,000) for youth15-24.
Known risk factors for suicide are:
Mental illness
Family history of suicide
Economic insecurity
Hopelessness due to losses
Severe maltreatment and victimization
However, less is known about indicators for ideation.

5. Significant Public Health Problem
The link between exposure to DV in incarcerated adolescents who report higher levels of PTSD symptomatology is correlated with externalizing behaviors and delinquency.
The National Council on Crime and Delinquency report that 90% of female offenders report a history of abuse (Walrath, Ybarra, Holden, Manteuffel, Santiago, & Leaf, 2003).

6. Categories of Victimization:
Partner Violence
Marital Rape and Courtship Rape
Wife Beating
Gay and Lesbian Partner Violence
Parricide
Matricide
Patricide
Child Maltreatment
Infanticide/Filicide
Elder Abuse
Sibling Violence
Community Violence

7. Defining Risk Factors
Risk factors refer to antecedent events ranging from biological to environmental conditions that predispose, enable, or reinforce an onset of a problematic outcome (Kirby & Fraser, 1997; Kazdin, Kraemer, Kessler, Kupfer, & Offord, 1997).
Definitional ambiguity for related terms :
Risk Factors
Vulnerabilities
Resilience
Protective Factors
Protective Processes
Has resulted in inconsistent sets of variables being used to study the trajectories of children growing up under adversity.

8. Individual Risk vs. Cumulative Risk
Exposure to one risk factor does not necessarily lead to a poor outcome.
Assessing independent risk factors for mental disorder can lead to spurious prominence of a single factor (Kessler et al., 1997).
87% of adults reporting any single form of adverse childhood experience (ACE) reported at least one additional ACE suggesting the importance of understanding co- occurring traumas and the cumulative impact of stressful experiences (Dong et al., 2004).
The presence of four or more risk factors produces a 10- fold increase in psychological distress (Kazdin et al.,1997).

9. Rationale for Further Study of Cumulative Exposures
There is a graded or “dose-response” relationship between the burden of adverse exposures and the risk of depression and suicide attempts by 2-5 fold in adults.
For every increase in an ACE score there was an increased risk of suicide attempt by 60% (Dube et al., 2001).
There is evidence of multiple trauma exposures negatively affecting a youth’s brain development via repeated or chronic activation of the stress response (Dube et al., 2003).
Broad categories of adverse experiences include poverty, perceived deprivation, family disorganization, household dysfunction, victimization, and exposures to community violence (Cohen, 2002; Dong et al., 2005; Felitti, 1998; Gilman, Kawachi, Fitzmaurice, & Buka, 2003; Taylor & Turner, 2002).

10. Conceptual Model for Testing The Cumulative Impact of Adverse Childhood Exposures on Mental and Physical Health Outcomes
Adverse Childhood Exposures
Childhood
Victimization
Community
Violence
Household
Dysfunction + +
Changes in Distress
Mental Illness
Physical Illness

11. An Overview of the Adverse Childhood Experiences (ACE) Studies

12. The Adverse Childhood Experiences (ACE) Studies http://www. acestudy
The Adverse Childhood Experiences (ACE) Studies Kaiser Permanente Medical Group Centers for Disease Control and Prevention (CDC)
The largest scientific research project of its kind -
(49 ACE studies to date)
A decade long ongoing collaboration led by:
Vincent J. Felitti, MD
Robert F. Anda, MD, MS
Analyzing the relationship between multiple categories of childhood trauma and health and behavioral outcomes later in life.

13. Origins of the ACE Studies
In 1985, Dr.Felitti, a specialist in Preventive Medicine, studying obesity learned that weight was used as a shield against unwanted sexual attention, or a defense against physical attack, and that many of had been sexually and/or physically abused as children.
Dr. Robert Anda, of the CDC, was studying multiple health problems including smoking, alcohol abuse, obesity, and chronic diseases. His primary interests were the psychosocial origins of health-related behaviors.
They teamed up to develop a large-scale epidemiologic study of the influence of stressful and traumatic childhood experiences on the origins of behaviors that underlie the leading causes of disability, social problems, health related behaviors, and causes of death in the United States.

14. Purpose of the ACE Studies
Historically, research has assessed the contribution of independent risk factors on disorder.
The ACE studies have adopted cumulative analytic strategies given concerns that the study of independent factors fail to consider co-occurring and overlapping experiences of risk factors.
To assess the relationship between interrelated adverse experiences of childhood abuse and household dysfunction on health and behavioral outcomes in adults utilizing a cross-sectional lens.
(Chapman et al., 2004; Dong et al., 2005; Dube, Anda, Felitti, Chapman, Williamson, Giles, 2001; Felitti et al., 1998).

15. What is an ACE? 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

16. ACE Study Design
Two survey “waves” were conducted during 1995 to 1997.
Participants were predominantly well educated, middle-class members of the Kaiser Permanente Medical Care Program in San Diego, California.
The ACE study population included (total sample=17,337) :
9,367 (54%) women
7,970 (46%) men
Mean age was 56 years
75% were white
39% were college graduates
36% had some college education
18% were high school graduates
7% had not graduated from high school

17. Conceptual Model from the ACE STUDY

18. Finding Your ACE Score
While you were growing up, during your first 18 years of life:
1. Did a parent or other adult in the household often or very often…
Swear at you, insult you, put you down, or humiliate you? or
Act in a way that made you afraid that you might be physically hurt?
Yes / No If yes enter 1 ________
2. Did a parent or other adult in the household often or very often…
Push, grab, slap, or throw something at you? or
Ever hit you so hard that you had marks or were injured?
Yes / No If yes enter 1 ________
3. Did an adult or person at least 5 years older than you ever…
Touch or fondle you or have you touch their body in a sexual way? or
Attempt or actually have oral, anal, or vaginal intercourse with you?

19. Finding Your ACE Score continued….
4. Did you often or very often feel that …
No one in your family loved you or thought you were important or special? or
Your family didn’t look out for each other, feel close to each other, or support each other?
Yes / No If yes enter 1 ________
5. Did you often or very often feel that …
You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or
Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Yes / No If yes enter 1 ________
6. Were your parents ever separated or divorced?
Yes / No If yes enter 1 ________

20. Finding Your ACE Score continued….
7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or Ever repeatedly hit at least a few minutes or threatened with a gun or knife?
Yes / No If yes enter 1 ________
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes / No If yes enter 1 ________
9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
Yes / No If yes enter 1 ________
10. Did a household member go to prison?
Yes / No If yes enter 1 _______
Now add up your “Yes” answers: _____
This is your ACE Score.

21. The ACE Study Scoring Method
Exposure to one category (not incident) of ACE, qualifies as one point.  
When the points are added up, the ACE Score is achieved.  
An ACE Score of 0 (zero) would mean that the person reported no exposure to any of the categories of trauma. 
An ACE Score of 9 would mean that the person reported exposure to all of the categories of trauma. 
The ACE Score represents the cumulative effect of multiple exposures.

22. Findings from the ACE Studies
ACE Studies have demonstrated that disturbances [in neuron-development] resulting from early trauma at a critical time creates changes to areas of the brain that:
Creating conditions for depression and anxiety
Post-traumatic stress symptoms
Impact healthy bonding with other people
Memory
There is a graded or “dose-response” relationship between the burden of exposures and the risk of depression and suicide attempts by 2-5 fold in adults.
For every increase in an ACE score there was an increased risk of suicide attempt by 60% (Dube et al., 2001).

23. Health problems in Adults Increased with Exposures to Adverse Experiences in Childhood
Alcoholism and Illicit Drug Use
Smoking
Chronic Obstructive Pulmonary Disease (COPD)
Suicide Attempts
Depression
Unintended Pregnancies
Fetal Deaths
Risk for Intimate Partner Violence
Multiple Sex Partners
Liver disease
STDs
Ischemic Heart Disease (IHD)

24. Prevalence of Adverse Childhood Experiences

31. Adverse Childhood Exposures Associated With:
Eating Disorders & Chronic Pain
Fibromyalgia, Diabetes,
Irritable Bowel Syndrome
Personality Disorders
Violence and Substance Abuse
Depression
Suicidality
However, less is known about indicators for ideation.

32. Limitations of Study
We now know that “retrospective reports of childhood abuse [that was documented at the time of its occurrence] are likely to underestimate actual occurrence…”
In other words, the incidence of child abuse is probably much greater than is reported, and even greater than remembered and acknowledged by the victims themselves due to secrecy, shame, fear, and brain changes.

33. Implications of Findings from ACE Studies
It is important to remember that wrongly assuming that one single type of trauma is implicated misattributes the potency of one risk factor (i.e., child sexual abuse) as an antecedent event in the development of overall psychological distress.
This may lead to misdiagnoses, under assessment of distressing events, mistreatment of exposures, or mis-timed interventions by giving that event undue prominence while ignoring other factors.
(Chapman, Whitfield, Felitti, Dube, Edwards, & Anda, 2004; Felitti et al., 1998; Turner & Lloyd, 1995; Turner, Finkelhor & Ormrod, 2006; Menard, Bandeen-Roche, & Chilcoat, 2004 Whitfield, 1998).

34. What is the ACE Team up to now - According to the CDC
“The ACE Study ...prospective phase is currently underway.
Data are being gathered from outpatient medical records, pharmacy utilization records, and hospital discharge records to track the subsequent health outcomes and health care use of ACE Study participants.
In addition, an examination of National Death Index records will be conducted to establish the relationship between ACE and mortality among the ACE Study population.
Replications of the ACE Study:
In China, medical students are the subjects of an ACE investigation.
In Puerto Rico, the link between women’s cardiovascular health risks and ACE are under study.”

35. In 1845, Friedrich Engels observed, “the sufferings of childhood are indelibly stamped on the adults”
Contact Info: Katherine A. Best, Ph.D., LCSW, MPH, MSW, Encouragement Institute 8209 Natures Way, Suite 221 Lakewood Ranch, FL Phone: (941)

36. List of ACE STUDY Publications To Date
2007
Anda RF, Brown DW, Felitti VJ, Bremner JD, Dube SR, Giles WH. Adverse childhood experiences and prescribed psychotropic medications in adults. Am J Prev Med May;32(5):389–94.  
Edwards, VJ, Anda RF, Gu D, Dube, S R, Felitti, VJ. Adverse childhood experiences and smoking persistence in adults with smoking-related symptoms and illness*. Permanente Journal 2007;11:5–7.  
Brown DW, Anda RF, Felitti VJ. Self-Reported Information and Pharmacy Claims Were Comparable for Lipid-Lowering Medication Exposure. J Clin Epidemiol (5):525–529.  
Chapman DP, Dube SR, Anda RF. Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals (5):359–364.  
Edwards, VJ, Dube SR, Felitti VJ, Anda RF. It's OK to ask about past abuse. American Psychologist (4):327–328.
2006
Dube SR, Miller JW, Brown DW, Giles WH, Felitti VJ, Dong M, Anda RF. Adverse childhood experiences and the association with ever using alcohol and initiating alcohol use during adolescence. Journal of Adolescent Health. 2006;38(4):444.e1–444.e10.  
Anda, RF, Felitti, VJ, Brown, DW, Chapman, D, Dong, M, Dube, SR, Edwards, VJ, Giles, WH. (2006) Insights Into Intimate Partner Violence From the Adverse Childhood Experiences (ACE) Study. In PR Salber and E Taliaferro, eds. The Physician's Guide to Intimate Partner Violence and Abuse, Volcano, CA: Volcano Press; 2006.

37. Anda RF, Felitti VJ, Walker J, Whitfield, CL, Bremner JD, Perry BD, Dube SR, Giles WH. The Enduring Effects of Abuse and Related Adverse Experiences in Childhood: A Convergence of Evidence from Neurobiology and Epidemiology. European Archives of Psychiatry and Clinical Neurosciences, 2006; 56(3):174–86.  
2005
Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD, Dube SR, Giles WH. The enduring effects of abuse and related adverse experiences in childhood A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience. 2005; [Epub ahead of print]  
Dube SR, Anda RF, Whitfield, CL, Brown DW, Felitti VJ, Dong M, Giles WH. Long-Term Consequences of Childhood Sexual Abuse by Gender of Victim. American Journal of Preventive Medicine. 2005;28:430–438.  
Dong M, Anda RF, Felitti VJ, Williamson DF, Dube SR, Brown DW, Giles WH. Impact of residential mobility during childhood on health in adults: The hidden role in Adverse Childhood Experiences. Archives of Pediatrics and Adolescent Medicine. 2005;159:1104–1110.  
Edwards, V. J., Anda, R. F., Dube, S. R., Dong, M., Chapman, D. F., & Felitti, V. J. (2005). The wide-ranging health consequences of adverse childhood experiences. In Kathleen Kendall-Tackett and Sarah Giacomoni (eds.) Victimization of Children and Youth: Patterns of Abuse, Response Strategies, Kingston, NJ: Civic Research Institute.  
Whitfield CL, Dube SR, Felitti VJ, Anda RF. Adverse childhood experiences and hallucinations. Child Abuse and Neglect. 2005;29(7):797–810.
2004
Anda RF, Felitti VJ, Fleisher VI, Edwards VJ, Whitfield CL, Dube SR, Williamson DF. Childhood Abuse, Household Dysfunction and Indicators of Impaired Worker Performance in Adulthood. The Permanente Journal, 2004;8(1):30–38.  
Chapman DP, Anda RF, Felitti VJ, Dube SR, Edwards VJ, Whitfield CL. (2004). Epidemiology of Adverse Childhood Experiences and Depressive Disorders In a Large Health Maintenance Organization Population. Journal of Affective Disorders, 2004;82(2):217–225.

38. Dong M, Anda RF, Felitti, VJ, Dube SR, Williamson DF, Thompson TJ, Loo CM. Giles WH. The Interrelatedness of Multiple Forms of Childhood Abuse, Neglect, and Household Dysfunction. Child Abuse and Neglect, 2004;28(7):771–784.  
Dong M, Dube SR, Giles WH, Felitti VJ. Anda, RF. RE: “Adverse Childhood Experiences and Self-Reported Liver Disease: New Insights into the Causal Pathway.” Archives of Internal Medicine. 2004;164(4):460–461.  
Dong M, Giles WH, Felitti VJ, Dube, SR, Williams JE, Chapman DP, Anda RF. Insights into causal pathways for ischemic heart disease: Adverse Childhood Experiences Study. Circulation, 2004;110:1761–  
Dube SR, Williamson DF, Thompson T, Felitti VJ, Anda RF. (2004). Assessing the Reliability of Retrospective Reports of Adverse Childhood Experiences Among Adult HMO Members Attending a Primary Care Clinic. Child Abuse and Neglect, 2004;28(7):729–737.  
Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The Association Between Adolescent Pregnancy, Long-Term Psychosocial Outcomes, and Fetal Death. Pediatrics, 2004;113(2):320–327.  
Ye D, Yao J, Dong M. Progress on the adverse childhood experience study. Chinese Journal of Disease Control and Prevention, 2004;8(6):483–485. (Article in Chinese)
2003
Dong M, Anda RF, Dube SR, Felitti VJ, Giles WH. Adverse Childhood Experiences and Self- reported Liver Disease: New Insights into a Causal Pathway. Archives of Internal Medicine, 2003;163:1949–  
Dong M, Anda RF, Felitti VJ, Dube SR, Giles WH. The Relationship of Exposure to Childhood Sexual Abuse to Other Forms of Abuse, Neglect and Household Dysfunction during Childhood. Child Abuse and Neglect, 2003;27(6):625–639.  
Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood Abuse, Neglect and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experience Study. Pediatrics, 2003;111(3):564–572.

39. Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. The Impact of Adverse Childhood Experiences on Health Problems: Evidence from Four Birth Cohorts Dating Back to Preventive Medicine, 2003;37(3):268–277.  
Edwards, V. J., Anda, R. F., Felitti, V. J., & Dube, S. R. (2003). Adverse Childhood Experiences and Health-Related Quality of Life as an Adult. in K. Kendall-Tackett (ed.) Victimization and Health, American Psychological Association.  
Edwards, V. J., Holden, G. W., Anda, R. F., & Felitti, V. J. Experiencing Multiple Forms of Childhood Maltreatment and Adult Mental Health: Results from the Adverse Childhood Experiences (ACE) Study. American Journal of Psychiatry, 2003;160(8):1453–  
Felitti VJ. Ursprünge des Suchtverhaltens - Evidenzen aus einer Studie zu belastenden Kindheitserfahrungen . Praxis der Kinderpsychologie und Kinderpsychiatrie, 2003;52:547–559  
Whitfield CL, Anda RF, Dube SR, Felitti VJ. Violent Childhood Experiences and the Risk of Intimate Partner Violence in Adults: Assessment in a Large Health Maintenance Organization. Journal of Interpersonal Violence, 2003;18(2):166–185.
2002
Anda RF, Chapman DP, Felitti VJ, Edwards V, Williamson DF, Croft JP, Giles WH. Adverse Childhood Experiences and Risk of Paternity in Teen Pregnancy. Obstetrics and Gynecology, 2002;100(1):37–45.  
Anda RF, Whitfield CL, Felitti VJ, Chapman D, Edwards VJ, Dube SR, Williamson DF. Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression. Psychiatric Services, 2002;53(8):1001–  
Dube SR, Anda RF, Felitti VJ, Edwards VJ, Croft JB. (2002). Adverse Childhood Experiences and personal alcohol abuse as an adult. Addictive Behaviors, 2002;27(5):713–725.  
Dube SR, Anda RF, Felitti VJ, Edwards VJ, Williamson DF. Exposure to abuse, neglect and household dysfunction among adults who witnessed intimate partner violence as children. Violence and Victims, 2002;17(1):3–17.  
Felitti VJ. The relationship between adverse childhood experiences and adult health: Turning gold into lead. The Permanente Journal, 2002;6:44–47.

40. Felitti VJ. Belastungen in der Kindheit und Gesundheit im Erwachsenenalter: die Verwandlung von Gold in Blei. Z psychsom Med Psychother, 2002;48(4):359–369.  
Williamson DF, Thompson, TJ, Anda, RF,. Dietz, WH, Felitti VJ. Body Weight, Obesity, and Self-Reported Abuse in Childhood. International Journal of Obesity, 2002;26:1075–1082.
2001
Anda RF, Felitti VJ, Chapman DP, Croft JB, et al. Abused boys, battered mothers, and male involvement in teen pregnancy. Pediatrics, 2001;107(2), e19.  
Dube SR, Anda RF, Felitti VJ, Chapman D, Williamson DF, Giles WH. Childhood abuse, household dysfunction and the risk of attempted suicide throughout the life span: Findings from Adverse Childhood Experiences Study. Journal of the American Medical Association, 2001;286:3089–  
Dube SR, Anda RF, Felitti VJ, Croft JB, Edwards VJ, Giles WH. Growing up with Parental alcohol abuse: Exposure to Childhood Abuse, Neglect and Household Dysfunction. Child Abuse and Neglect, 2001;25(12):1627–1640.
Edwards, V.J., Anda, R.F., Nordenberg, D.F., Felitti, V.J., Williamson, D.F., Howard, N., & Wright, J.A. An investigation of response rate bias in an epidemiological study of child abuse. Child Abuse & Neglect, 2001;25:307–312.  
Edwards, Valerie J., Fivush, Robyn, Anda, Robert F., Felitti, Vincent J., and Nordenberg, Dale F. Autobiographical memory disturbances in childhood abuse survivors. In J.J. Freyd and A.P. DePrince (Eds.) Trauma and Cognitive Science: A meeting of minds, science, and human experience. Binghamton, NY: Haworth Press. Also published in Aggression, Maltreatment, and Trauma (2001).  
Hillis SD, Anda RF, Felitti VJ, Marchbanks PA. Adverse childhood experiences and sexual risk behaviors in women: a retrospective cohort study. Family Planning Perspectives, 2001;33:206–211.
2000
Hillis SD, Anda RF, Felitti VJ, Nordenberg D, Marchbanks PA. Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study. Pediatrics, 2000;106(1):E11.

41. 1999
Anda RF, Croft JB, Felitti VJ, Nordenberg D, Giles WH, Williamson DF, Giovino GA. Adverse childhood experiences and smoking during adolescence and adulthood. Journal of the American Medical Association, 1999;282:1652–  
Dietz PM, Spitz AM, Anda RF, Williamson DF, McMahon PM, Santelli JS, Nordenberg DF, Felitti VJ, Kendrick JS. Unintended pregnancy among adult women exposed to abuse or household dysfunction during their childhood. Journal of the American Medical Association,. 1999;282:1359–1364.
1998
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks, JS. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine, 1998;14:245–258.  
Foege WH. Adverse childhood experiences: A public health perspective (editorial). American Journal of Preventive Medicine, 1998;14:354–355.  
Weiss JS, Wagner SH. What explains the negative consequences of adverse childhood experiences on adult health? Insights from cognitive and neuroscience research (editorial). American Journal of Preventive Medicine, 1998;14:356–360.  
Whitfield CL. Adverse Childhood Experiences and Trauma (editorial). American Journal of Preventive Medicine, 1998;14:361–363.