Presentation on theme: "The “ACE” Study The Tragic Consequences of Unaddressed Childhood Trauma Thank you for this opportunity to speak with you today about the adverse childhood."— Presentation transcript:
1 The “ACE” Study The Tragic Consequences of Unaddressed Childhood Trauma Thank you for this opportunity to speak with you today about the adverse childhood experiences study and its implications for women and girls.The study demonstrates how childhood trauma, if unrecognized and unaddressed early on, can lead to significant adult difficulties and at times tragedy.It contains information of vital importance to health and human service systems across the country.I’m very grateful to be able to present it to you.Presented by Ann Jennings Ph.DFederal Roundtable on Women and TraumaApril 29, 2010
2 But first I’m going to start by telling you a story But first I’m going to start by telling you a story. The story of my daughter Anna. This is a picture of her in her early 20s . She had a great soul. And although she had no formal training, she was a fine artist. All artworks shown in this presentation are by her – as are the paintings and drawings shown……refer to.Anna’s Story
3 What happened? This is Anna at age one and a half What happened to her?This is Anna years later – in a mental institutionWhat happened?
4 Anna Caroline Jennings At less than 3 years old, Anna was sexually abused.The abuse was severe, sadistic, perpetrated by a trusted caregiver, occurred at an early developmental stage, and continued for nearly 4 years.None of us were aware of or intervened in what was happening to her. She did not have the language to tell us, and we did not recognize the signs. This was the 1960s, when sexual abuse was never spoken of or asked about.Numerous additional traumatic events (ACEs) occurred throughout her childhood and adolescence – overwhelming her already severely compromised resiliencyShe “broke” at age 13, was misdiagnosed schizophrenic, and at age 15 began psychiatric treatmentThru her childhood, adolescent and teenage years, she interacted with multiple health and human service systems, and many good individuals tried to help her.But no one asked or looked into what might have happened to her. Rather, the focus was on what was wrong with her. Was she learning disabled? Did she have a mental illness? What was her diagnosis? How can we control or manage her “symptoms” and behaviors?For 17 years she was in the mental health system – 11 of those years in mental institutions, - and sometimes homelessShe did not drink or drug, but did self-mutilate and made multiple suicide attempts. During periods of homelessness she would steal food and other items, or confront people in a threatening way, bringing her into contact with the correctional system.At times her rage and fear would overcome her. Though never physically violent to others, she would attack with words and destroy things. She was always suspicious that others were out to hurt her.For 17 years no psychiatric treatments, alternative therapies, mental health services or medications helped her. In fact, much of what passed for ‘treatment” retraumatized her and made her even sicker.When she was 23, she learned from other patients that she was not the only one in the world to be sexually abused.Throughout her long history in the mental health system, although she requested help for her trauma and diagnosed herself to have PTSD, she was never assessed or treated for trauma.When she attempted to communicate the awful things that had happened to her, there was no one at that time to listen, to understand, or to help her. No one had trauma training, and the system was not financially or otherwise structured to support that kind of care.As a result, she was continually misdiagnosed and considered to be “chronically mentally ill”. No hope of healing was held out for her.She took her life October 24, 1992, at the age of 32, on the back ward of a state mental hospital.I tell you her story because it is similar in many ways to the stories of others who have been wounded by childhood trauma and the accumulation of other traumatic adverse childhood experiences. The majority of people, children and adults, who are served by health and human service systems, can tell similar stories about their own childhood experiences.Though the lives of many do not end in the kind of tragedy my daughter’s life did, the impacts of childhood trauma – when not recognized or treated – can be severe and can last over the lifespan.This is what the ACE Study so clearly demonstrates.Anna Caroline Jennings
5 The Adverse Childhood Experiences Study (ACE Study)“In my beginning is my end.”T.S. Eliot, Four Quartets
6 What is the Adverse Childhood Experiences (ACE) Study? CDC and Kaiser Permanente CollaborationOver decade long. 17,000 people involved.Looked at effects of adverse childhood experiences over the lifespan.Largest study ever done on this subject.The Adverse Childhood Experiences study – otherwise known as the “ACE” study is a now 14 year collaboration between the CDC and Kaiser Permanente in San Diego. It the largest study of its kind ever done. Over 17,000 HMO Members – were interviewed and answered a series of questions about their childhood experiences. (The questions are in your handouts) The purpose of this study was to look at the possible health and social effects of adverse childhood experiences over the lifespan. The findings are groundbreaking, have vast public health implications, and are being discussed all over the world today.
7 ACE Study FindingsWhat the ACE study revealed was irrefutable evidence showing that childhood experiences are the most powerful determinants of who we become as adults.And that cumulative adverse childhood experiences – when unaddressed – have a significant graded relationship to the development of many of the most troublesome health, behavioral health and social problems of today.Childhood experiences are powerful determinants of who we become as adults
8 Adverse Childhood Experience* ACE Categories (Birth to 18) Abuse of ChildEmotional abusePhysical abuseContact Sexual abuseTrauma in Child’s HouseholdEnvironmentAlcohol and/or Drug UserChronically depressed, emotionallydisturbed or suicidal householdmemberMother treated violentlyImprisoned household memberNot raised by both biologicalparents(Loss of parent – best by deathunless suicide, - Worst byabandonment)Neglect of ChildPhysical neglectEmotional neglect* Above types of ACEs are the “heavy end” of abuse. *1 type = ACE score of 1Impact of Trauma and Health Risk Behaviors to Ease the PainNeurobiologic Effects of TraumaDisrupted neuro-developmentDifficulty controlling anger-rageHallucinationsDepression - other MH DisordersPanic reactionsAnxietyMultiple (6+) somatic problemsSleep problemsImpaired memoryFlashbacksDissociationHealth Risk BehaviorsSmokingSevere obesityPhysical inactivitySuicide attemptsAlcoholismDrug abuse50+ sex partnersRepetition of original traumaSelf InjuryEating disordersPerpetrate interpersonal violenceLong-Term Consequences of Unaddressed Trauma (ACEs)Disease and DisabilityIschemic heart diseaseCancerChronic lung diseaseChronic emphysemaAsthmaLiver diseaseSkeletal fracturesPoor self rated healthSexually transmitted diseaseHIV/AIDSSerious Social ProblemsHomelessnessProstitutionDelinquency, violence, criminalInability to sustain employmentRe-victimization: rape, DV, bullyingCompromised ability to parentNegative alterations in self percep-tions and relationships with othersAltered systems of meaningIntergenerational traumaLong-term use of multiple humanservice systemsThis is an overview of the ACE Study. You have this chart as one of your handouts. It captures the essence of the ACE study in one page.In column one are listed 10 categories of adverse childhood experiences or ACEs. All 17,000 participants answered specific questions to determine which of these 10 types of potentially traumatic events they had experienced. (Abuse of Child: Emotional abuse; Physical abuse; Contact sexual abuse. Trauma in Household: Alcohol/Drug use; Depressed, emotional disturbed or suicidal household member; Mother treated violently; Imprisoned household member; Loss of parent thru divorce, separation, death, suicide, abandonment. Neglect of Child: (Physical and/or Emotional)A person’s ACE Score is based on the number of CATEGORIES of adverse childhood experiences they identified in their childhood. So if as a child you were physically abused – that counts as ONE ACE – no matter how many times the physical abuse occurred.Column Two lists the impacts of these adverse childhood experiences on the brain or nervous system and identifies health risk behaviors that are developed to cope with and ease the pain caused by the emotional and neurological impacts of childhood trauma. Neurobiologic Effects of Trauma: disrupted neuro-development, difficulty controlling anger-rage; hallucinations; depression; panic reactions; anxiety; multiple somatic problems; sleep problems; impaired memory; flashbacks; dissociation.Health Risk Behaviors are understood by the ACE study as attempts to cope with, get release from or lessen the pain caused by childhood traumas NOT as symptoms, bad habits, self-destructive behavior, or public health problems. These behaviors include smoking, severe obesity; physical inactivity; suicide attempts; alcoholism; drug abuse; multiple sex partners (50+); repetition of original trauma; self injury; eating disorders; perpetration of interpersonal violence.In the third column are listed some of the long-term consequences of unaddressed childhood trauma. Disease and Disability: Ischemic heart disease; cancer; chronic lung disease; chronic emphysema; asthma; liver disease; skeletal fractures; poor self rated health; sexually transmitted disease; HIV/AIDS.Serious Social Problems: Homelessness, prostitution; delinquency violence criminal behavior; inability to sustain employment; re-victimization by rape, DV; compromised ability to parent; Negative alterations in self-perception and relationships with others; Alterations in Systems of Meaning; intergenerational transmission of abuse; and longterm use of health, behavioral health, correctional, and social services.
9 HMO Members in ACE Study 80% White, including Hispanic10% Black10% AsianAbout 50% men, 50% women74% had attended college62% age 50 or olderThe 17,000 HMO members who were interviewed for the ACE study were middle class people with jobs and medical insurance – not likely to have been exposed to street violence, extreme poverty, malnutrition, dislocation, homelessness, natural catastrophes or war terror. So they can’t be dismissed as atypical, aberrant, or “not in my practice”. They can’t be categorized as “at risk” populations. “They” are “us”.Of these HMO members: 80% were white including hispanic, 10% black, 10% Asian; About half were men, half were women; 74% had attended college; 62% were 50 or older.
10 Adverse Childhood Experiences are Common Of the 17,000 HMO Members:1 in 4 exposed to 2 categories of ACEs1 in 16 was exposed to 4 categories.22% were sexually abused as children.66% of the women experienced abuse, violence or family strife in childhood.Women were 50% more likely than men to have experienced 5 or more ACEsAmong this middle class HMO population, Adverse Childhood Experiences were found to be common.1 in 4 were exposed to 2 categories of ACE’s –which would equate to 1/4th of this audience1 in 16 were exposed to 4 categories22% were sexually abused as children. That’s over 20% of this audience. Over one in every 5 of us. Applies to men and women.66% of the women reported abuse, violence or family strife in childhood. (That’s two out of every 3 women in this audience)And women were found to be 50% more likely than men to have ACE scores of 5 or more.
11 The higher the ACE Score, the greater the likelihood of : Severe and persistent emotional problemsHealth risk behaviorsSerious social problemsAdult disease and disabilityHigh health, behavioral health, correctional and social service costsPoor life expectancyFor example:The higher a persons ACE score (the more TYPES of adverse childhood experiences he or she reported) – the more likely he or she was to developSerious emotional problemsHealth risk behaviorsSerious social problemsAdult disease and disabilityCumulative childhood traumas also led to -Higher health and human service costs from long term use of multiple services.And resulted in:Poor life expectancy or early death. For example:
12 Emotional ProblemsChildhood trauma underlies Serious and persistent mental health problems – often borne over the individuals entire lifespan.
13 Childhood Experiences Underlie Chronic DepressionACE Study found that adults with an ACE score of 4 or more were 460% more likely to be suffering from depression.It also found that Women are twice as likely as men to experience episodes of major depression over their lifespan.
14 Childhood Experiences Underlie Suicide 4+3The likelihood of adult suicide attempts increased 30-fold, or 3,000%, with an ACE score of 7 or more.Childhood and adolescent suicide attempts increased 51-fold, or 5,100% with an ACE score of 7 or more.This is hugely significant. Relationships of this magnitude are rare in epidemiology.You might think that attaining an ACE score of 7 is difficult to achieve. Not so. E.g. When you think of children sexually abused – it would not be uncommon to find also emotional and physical abuse, substance abuse, violence in the household like DV, someone emotionally disturbed, parental separation or discord, or missing parent, neglect, etc.As regards women: the ACE study found 54% of current depression and 58% of suicide attempts in women to be directly attributable to their traumatic childhood experiences.A cautionary note to suicide prevention programs: Whatever later factors might trigger suicide, childhood experiences cannot be left out of the equation.21
15 Childhood Adverse Experiences 2/3rd (67%) of all suicide attempts64% of adult suicide attempts80% of child/adolescent suicide attemptsAre Attributable toChildhood Adverse ExperiencesSo we see that 2/3rd of ALL suicide attempts; 64% of ADULT suicide attempts, and a startling 80% of child/adolescent suicide attempts have been found by the ACE study to be attributable to cumulative childhood traumas.And that the lifetime prevalence of having at least 1 suicide attempt was approximately 3 times higher for women than for men. (5.4% vs 1.9%)Women are 3 times as likely as men to attempt suicide over the lifespan.
16 Childhood sexual abuse is strongest most independent risk factor for suicidality As many as 42% of girls are sexually abused before age 1879.8% of American Indian Alaskan Native (AIAN) girls experience sexual abuse in early childhood.Young AIAN women are over 3 ½ times more likely to commit suicide than females in the general populationChild Sexual AbuseOf all the many types of childhood trauma, research shows CSA to be the strongest and most independent risk factor for suicidality; accounting by itself for between 9 to 20% of all suicide attempts.This is most strikingly demonstrated among young American Indian and Alaska Native girls and women.In general population studies we find between 1/3 to 42% of all girls are sexually assaulted before the age of 18.By comparison, nearly 80% of American Indian Alaska Native girls are sexually abused in early childhood.The relationship of CSA to suicide then becomes apparent in the fact that among all young females between the ages of 5 to 34, young AIAN women have the highest rate of suicide – over 3 ½ as high as in the general female population, including other minority groups.References: CSA: Being SA in childhood – Brown et al, 1999; Fergusson et al, 2000b in Book? CSA alone – the population attributable risk for child sexual abuse was 9 – 20% of suicide attempts. Brown et al, 1999; Fergusson et al, 1996; Molnar et al, Also Read et al, 2001As many as: 42% of girls are sexually abused before the age of 18 – with 9% experiencing persistent, genital assault Saunders et al, 1992; Randall 1995; Epstein, 199880% or 79.8% - of American Indian Alaskan Native girls experience sexual abuse in early childhood. National Center on Child Abuse and Neglect, 1999Among young (age 5 – 34) females, American Indians and Alaska Natives have the highest rate of suicide. Over 3/5 as high. Child Trends Databank. And IOM book p. 48
17 Childhood Experiences Underlie Serious and Persistent Mental Health Problems Traumatic experiences in childhood also underlie serious and persistent mental health problems. This is demonstrated by ACE Study analysis of the use of antidepressant, anti-anxiety and antipsychotic prescription drugs. Note the graded relationship between the more the ACE score – the more the need for and use of these drugs later in life – indicating as well, increased rates of depression, anxiety, and psychotic disorders later in life.
18 ACE Score and Hallucinations Are We Misdiagnosing?ACE Score and HallucinationsAbusedAlcoholor DrugsEver Hallucinated* (%)The ACE Score and hallucinationsAre we misdiagnosing? Hallucinations often get mistaken for symptoms of schizophrenia vs neurological response to trauma. And so ROOT causes are overlooked, misdiagnosis occurs and treatment is frequently ineffective.The ACE study found:Compared to persons with 0 ACEs, those with 7 or more ACEs had a five-fold increase in the risk of reporting hallucinations Whitfield et al 2005Bruce Perry of the National Child Traumatic Stress Network, notes that Abuse and trauma suffered in the early years of development result in a far greater likelihood of pre-psychotic and psychotic symptoms. Perry, B.D. (1994)ACE Score*Adjusted for age, sex, race, and education.
19 Health Risk BehaviorsA few examples of health risk behaviors which – although they help to calm the neurological impacts of cumulative traumas, they can lead to disabling health conditions and many social problems later in life.A common example of course is smoking…..
20 Adverse Childhood Experiences and Current Smoking %A child with 6 or more categories of adverse childhood experiences is 250% more likely to become an adult smoker .And with a score of only 4 categories of adverse childhood experiences – individuals are 260% more likely to have developed Chronic Obstructive Pulmonary Disease. (COPD) .
21 Childhood Experiences and Adult Alcoholism 4+32There is A 500% increase in adult alcoholism directly related to adverse childhood experiences. (note again the graded relationship) andChildhood traumatic events underlie 2/3rds of all alcoholism.Among youth:Teenagers with alcohol and drug problems are 6 to 12 times more likely to have been physically abused as children , and18 to 21 times more likely to have been sexually abused , in early childhood. Clark et al, 1997Of note from additional research is that 75% of women in Substance Abuse treatment have been sexually abused as children and as adults. SAMHSA/CSAT, 2000; SAMHSA, 19941
22 ACE Score and Intravenous Drug Use A male child with an ACE score of 6 has a 4,600% increase in the likelihood that he will become an IV drug user later in life78% of drug injection by women can be attributed to their experience of cumulative kinds of trauma in childhood. (ACES)Again - Relationships of this magnitude are rare in Epidemiology.What The ACE study demonstrates is that the basic cause of addictions (smoking, alcoholism, drug use, food, sex etc) is predominantly experience-dependent during childhood and not substance-dependent.The SAMHSA Women Cooccuring Disorders and Violence study – and others as well, found more positive results and less recidivism when women with cooccuring disorders were treated concurrently for both substance use and trauma.N = 8, p<0.001
23 Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners And finally, we see the graded relationship between higher ACE scores and the likelihood of multiple – more than 50 – sexual partners – leading of course to higher rates of STD and HIV.The ACE study found a consistently graded relationship between the higher ACE scores with increase in STD
24 Serious Social Problems A homeless mom and her child.By increasing vulnerability and weakening resiliency, Cumulative Adverse Childhood Experiences lead to difficult, heartbreaking and often revictimizing social problems.
25 Childhood Experiences Underlie Rape 4+32For example:Women with an ACE score of 4+ are almost 900% more likely to become victims of rape.1
26 They are also 500% more likely to become victims of domestic violence.
27 ACE Score and Unintended Pregnancy or Elective Abortion And to experience unintended pregnancy or elective abortion
28 ACE Score and Indicators of Impaired Worker Performance Prevalence of Impaired Performance (%)In addition, their ability to work is impaired. The higher their ACE score, the more they were abused or traumatized as children, the more absenteeism, serious financial problems and on the job problems they have..Keep in mind – this data is from employed and insured people. They have work. But they are experiencing considerable difficulty within the work environment...
29 Adult Disease and Disability And now we come to health issues
30 Higher ACE Score = significant rise in chronic health conditions: Sexually Transmitted DiseaseLiver DiseaseCOPDIschemic Heart DiseaseAutoimmune DiseaseLung CancerThe more adverse and traumatizing events experienced in childhood, - higher the ACE Score, - the more likely an individual will develop serious health conditions later in life.The ACE Study found Consistently graded relationships between higher ACE scores and the development of serious health conditions later in life, including Sexually Transmitted Disease; Liver Disease; COPD; Ischemic Heart Disease; Autoimmune Disease; and Lung Cancer.ACE data offers compelling evidence that behaviors known to increase the risk of chronic diseases have had their origins in childhood regardless of the changing influences of the 20th century.In heart disease – the study found a strong relationship of ACE score to coronary disease, after correcting for all the conventional risk factors like smoking, cholesterol, etc. Which illustrates how ACEs in childhood are related to adult disease by two basic etiologic mechanisms:Conventional risk factors – attempts at self help through use of agents like nicotine, drugs, alcohol, AND,2) the effects of chronic stress on the developing brain and body systems.This information challenges the disciplines of medicine and public health to address both the primary prevention and secondary prevention of ACEs in the 21st century.
32 Effect of ACEs on Mortality Age GroupThe ACE Study has found that those suffering substantial childhood trauma have double the risk for early death compared with adults who had not endured adverse childhood experiences.On average, Children exposed to 6 or more ACES died at age 60Whereas Children without ACES died at age 79.So – a traumatic childhood takes 20 years off an individuals life expectancy.0 ACE 60% live to ACE less than 3% live to 65
33 This is another way – besides the 3 column chart - of viewing the various connecting aspects of ACE study findings.(Go over steps of pyramid)
34 The Many Faces of Women and Trauma These are some of the many faces of women whose lives have been impacted by cumulative childhood abuse and trauma.Note: The veteran sexually assaulted as a child, raped again in service, now with PTSD and no insurance, the pregnant teen, the murderer on trial, the battered woman ,the homeless woman and her infant, the elderly victim of DV, the mental patient abused as a child and raped again in a mental hospital, the street rape victim, the young girl in juvenile detention, the mother of 4 who killed her children then took her own life, the IV drug user, the woman with HIV/AIDs, the teenage prostitute, the young woman with anorexia, another woman dying of AIDs, a runaway girl, another woman homeless -judged mentally ill from too much loss and too much grief…, a young mother sentenced to prison for possession of drugs, an alcoholic, a teenage IV drug user, a morbidly obese woman homeless with her children, another woman veteran homeless with PTSD, and a young woman who cuts herself.There are women less visible – as yet hidden from service systems - missing from this collage. Some of them – are us.Each one of these women is representative of thousands more . Each one has a story, and their stories are heartbreaking – their struggles and despair palpable.As children, like my daughter Anna, they were wounded, and no one saw – or no one intervened. And so they bear the scars – and the wounds beneath those scars sometimes hurt beyond bearing.We need to listen carefully to their stories. We need to ask them “What Happened?” We need to know - and accept as truth - what they tell us. We need to recognize the full implications of what we learn from them – for our services, our policies, our politics, our organizations, our communities, our families, our own personal lives, and for generations to come.And then we need to respond with our hearts – and with services and service systems that are knowledgeable about the dynamics of trauma and sensitive to the special needs of women whose lives, perceptions and actions have been shaped and mis-shaped by their childhood experiences.We need - at least - to offer them hope – and our friendship. As Tonier Cane – who will be speaking later - tells us: “Where There’s Breath, There’s Hope.”
35 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.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
36 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, (compared to $2,639,360)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.Intensive psychotherapy – note that today there are other even less expensive options – psychoeducational, groups, many models of treatment and healing which have been found effective.
37 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 = $33,101,302,133.00Annual Indirect Costs: Special Education, Juvenile Delinquency, Mental Health and Health Care, Adult Criminal Justice System, Lost productivity to Society = $70,652,715,359.00Total Annual Cost: $103,754,017, (Over $184 million dollars a day)Economic Impact Study. (September, 2007). Prevent Child Abuse AmericaThe financial burden to society of undiagnosed and untreated childhood trauma is staggering.Annual direct costs are over 22 billion dollars a yearAnnual Indirect Costs are over 70 billion, 600 million dollars a yearAnd the total annual cost comes to almost 104 billion dollars a year.That’s $184 million dollars a day!Its not a question of whether as a society – we pay. It’s a question of Do we pay now?, or do we pay later?
38 “The solution of adult problems tomorrow depends in large measure upon the way our children grow up today.Margaret MeadThe solution of adult problems tomorrow depends in large measure upon the way our children grow up today.And that – tho dads are more and more involved – still parenting depends primarily on women - moms – and the degree to which they have opportunities to learn good parenting and the degree to which they are supported and enabled by society to raise their children.
40 Handouts Chart of Adverse Childhood Experiences Study Finding Your ACE Score: A QuestionnaireACE Publications on Major findings by Health Outcomes“The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease”
41 SourcesACE Publications: For comprehensive list see CDC ACE Study website: Publications on Major Findings By Health Outcomes: This site was updated (March 1, 2010) and links to related articles on all subjects.The Damaging Consequences of Violence and Trauma: See Trauma-Informed Resources :Documents and articles on women and trauma: Presentation Bibliography in preparation. Available upon request: Ann Jennings,
42 ACE Study slides are from: 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“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)
43 Presentation ArtworkAll artwork in this presentation was created by Anna Caroline Jennings. Although she had no formal training, her work is stark, sophisticated and haunting. It has been exhibited at conferences across the country.Through her paintings and drawings she vividly and poignantly expresses her abuse at the hands of perpetrators and within the mental health system.Her work and story are displayed on the website:
44 Trauma Informed Resources SAMHSA National Center for Trauma-Informed CareThe Anna Institute Inc:ACE Study Section: Powerpoint presentation slides and notes; 41 full downloadable ACE Study articles; related materials; collection of ACE Study powerpoint slidesAnnotated list of Trauma WebsitesModels for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services, 2008Downloadable trauma-informed articles, powerpoints, educational materials; links; Anna’s story and art exhibit.