2. Understanding the Effects of Adverse Childhood Experiences on HIV Prevalence and Treatment: What Providers Need to Know
Raul Almazar, RN, MA
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Senior Consultant
SAMHSA’s National Center for Trauma Informed Care
National Association of State Mental Health Program Directors
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3. What is Trauma? Definition (NASMHPD, 2006)
The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disasters
DSM IV-TR (APA, 2000)
Person’s response involves intense fear, horror and helplessness
Extreme stress that overwhelms the person’s capacity to cope
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4. Working Definition
A definition of individual trauma includes three key elements:
1) an external cause (event or circumstances)
2) an individual experience, and
3) measureable effects.
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5. Events and Circumstances
Events and circumstances may include
extreme or chronic stress,
the withholding of material or nonmaterial resources essential to healthy development or well-being,
persistent small psychological or physiological injuries that accumulate over time,
events that occur before or during birth, or historical events and circumstances that affect the primary group with whom the individual identifies (e.g., genocide, extreme violence against a racial or ethnic group, or persistent community violence.)
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6. Individual Experience
Helps to explain why the same event may be traumatic for one individual and not for another. The context, expectations, and meaning assigned to an event or circumstance may determine how it is experienced.
Trauma often includes a threat to life, bodily integrity or sanity and/or the feeling of being overwhelmed and unable to cope. Even interventions that are necessary or life-saving may be experienced as traumatic (e.g., medical interventions or removal from an abusive home.)
Humiliation, betrayal or silencing may compound the traumatic experience.
The individual’s experience of trauma is not necessarily conscious or recognized either by the individual or by others, and it may include physiological as well as cognitive experiences.
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7. Effect/Impact
The effect of trauma on an individual can be conceptualized as a normal response to an abnormal situation.
Trauma can have both short term and long term effects, and the impact may not be immediately recognized.
Trauma can affect an individual’s coping responses or ability to engage in relationships, or it can interfere with mastery of developmental tasks.
It may affect an individual’s physiological responses, psychological well-being, social relationships, and/or spiritual beliefs.
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8. Prevalence of Trauma Mental Health Population
90% of public mental health clients have been exposed
(Muesar et al., in press; Muesar et al., 1998)
Most have multiple experiences of trauma
(Ibid)
34-53% report childhood sexual or physical abuse
(Kessler et al., 1995; MHA NY & NYOMH, 1995)
43-81% report some type of victimization
In terms of our public mental health system, one study done by Muesar identified that 90% of clients in the public mental health system had been exposed to trauma and that most of these people had had multiple episodes of trauma. 34% - 53% reporting childhood sexual or physical abuse and 43% - 81% reporting some type of victimization.
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9. DEFENDING CHILDHOOD PROTECT HEAL THRIVE
REPORT OF THE ATTORNEY GENERAL’S NATIONAL TASK FORCE ON CHILDREN EXPOSED TO VIOLENCE
NOV 2012
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10. Prevalence
80% of child fatalities due to abuse and neglect occur within the first 3 years of life and almost always in the hands of adults responsible for their care.
In the US, we lose an average of more than 9 children and youths ages 5 to 18 to homicide or suicide per day.
According to the National Survey of Children Exposed to Violence, an estimated 46 million of the 76 million (61%) of children currently residing in the US are exposed to violence, crime and abuse each year.
1 in 10 children in this country are polyvictims.
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11. Effects
Their fear, anxiety, grief, guilt, shame, and hopelessness are further compounded by isolation and a sense of betrayal when no one takes notice or offers protection, justice, support, or help.
Exposure to violence in the first years of childhood deprives children of as much as 10% of their potential IQ, leaving them vulnerable to serious emotional, learning and behavior problems by the time reach school age.
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12. National Child Abuse Statistics 2010
More than five children die every day as a result of child abuse
Approximately 80% of children that die from abuse are under the age of 4
More than 90% of juvenile sexual abuse victims know their perpetrator in some way.
About 30% of abused and neglected children will later abuse their own children.
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13. National Child Abuse stats cont.
14% of men and 30% of all women in prison were abused as children
Children who experience child abuse and neglect are 59% more likely to be arrested as a juvenile, 28% more likely to be arrested as an adult, and 30% more likely to commit violent crime.
Children whose parents abuse alcohol and other drugs are three times more likely to be abused and four times more likely to be neglected than children from non-abusing families.
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14. Almazar Consulting

15. Almazar Consulting

16. Prevalence of Trauma Substance Abuse Population
Up to two-thirds of men and women in SA treatment report childhood abuse & neglect (SAMSHA CSAT, 2000)
Study of male veterans in SA inpatient unit
77% exposed to severe childhood trauma
58% history of lifetime PTSD
(Triffleman et al, 1995)
55-99% of women with substance use disorders have a lifetime history of trauma; 50% of women in treatment have history of rape or incest
(Najavits et. al., 1997; Gov. Commission on Sexual and Domestic Violence, Commonwealth of MA, 2006)
Similarly in substance abuse treatment programs ... (read slide) ....
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17. Sexual Trauma and Addiction
208 African-American Women with histories of crack cocaine use
Women with history of sexual trauma (n=134) reported being addicted to more substances than those who had not been sexually traumatized (n=74)
Women with trauma histories reported more prior treatment failures than those without.
(Young & Boyd, 2000)
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18. What does the prevalence data mean?
The majority of adults and children in psychiatric treatment settings have trauma histories as do children and adults served in a variety of other behavioral and justice settings
There appears to be a strong relationship between victimization and later offending
(Hodas, 2004; Frueh et al, 2005; Mueser et al, 1998; Lipschitz et al, 1999; NASMHPD, 1998)
Traumatic exposure is epidemic among adults and children in the mental health system. And as Gilligan and Garbarino’s work illustrates, there appears to be a relationship between being a victim and victimizer.
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19. What does the prevalence data tell us?
Many people with trauma histories have overlapping problems with mental health, substance abuse, physical health and are victims or perpetrators of crime
Victims of trauma are found across all systems of care (violence causes trauma…trauma causes violence)
(Hodas, 2004; Frueh et al, 2005; Mueser et al, 1998; Lipschitz et al, 1999; NASMHPD, 1998)
Many clinicians in the US see PTSD as the only trauma-related diagnosis. Increasingly, we are appreciating that a range of other disorders can be directly related to trauma exposure or individuals might suffer from such co-occurring such as substance abuse, affective illness, personality disorders and psychotic disorders.
The literature tells us that trauma is widespread – it is found across care settings and does not “play favorites” ...
Often professionals consider trauma to be a tangential issue to someone’s mental health or social problems ... but newer thinking indicates that trauma is not a “side issue” – it should be seen as a central issue in the care and treatment of individuals we serve.
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20. Prevalence in the General Population
90% of public mental health clients have been exposed to trauma.
In the general population, 61% of men and 51% of women reported exposure to at least one lifetime traumatic event, but majority reporting more than one traumatic event.
(Kessler, et al, 1995)
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21. ACE Study
Compares adverse childhood experiences against adult status, on average, a half century later
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22. 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)
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23. ACE Questions:  
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?
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? 
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?
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?
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24. ACE Questions:  Con’t
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?
6. Were your parents ever separated or divorced?
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?
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
10. Did a household member go to prison?
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25. Emotional Problems
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26. Childhood Experiences Underlie
Chronic Depression
Adults with an ACE score of 4 or more were 460% more likely to be suffering from depression .
The bargraph may underestimate chronic depression in men. Men tend to be covert (rather than overt) in disclosing feelings of depression. A recent study of men found 85% to be suffering from “Alexathymia” – a new DSM category of Depression for men.
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27. Childhood Experiences Underlie Suicide4+
The 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.
Suicidality may be triggered (by one more event – cumulative) but is not usually Caused by “mental illness”, drugs, rejection by peer groups, school pressure, failures, etc.
Rather, it is an attempt to cope – a way to manage or escape from the overwhelming impacts of adverse childhood experiences and/or adult trauma.
Its easier to get to 7 ACEs than you might think……(Anna’s ACE’s – sexual abuse; physical abuse; emotional abuse; my substance abuse, abandonment (temporary); bitter separation and divorce; my depression to 1 suicide attempt; attachment/nurturance issues….)
In a family where there is domestic violence for example – there often exists additional problems or ACE categories such as substance abuse, drug use, separation/divorce, abandonment, physical abuse, sexual abuse, someone in correctional system, serious emotional problems e.g. depression, emotional abuse, neglect………..
Once an individual experiences 1 significant ACE – it opens him or her to more – creates fragility, compromises resiliency. Like an immune system gets compromised. This is part of the story of what happened to my daughter.
We may keep ourselves socially or even professionally safe or acceptable by not looking at childhood experiences when we address suicide. 3 2 1
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28. ACE Score and Hallucinations
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 2005
Abuse and trauma suffered in the early years of development resulted in a far greater likelihood of pre-psychotic and psychotic symptoms. Perry, B.D. (1994)
In an adult inpatient sample, 77% of those reporting CSA or CPA had one or more of the ‘characteristic symptoms’ of schizophrenia listed in the DSM-IV: hallucinations (50%); delusions (45%) or thought disorder (27%) Read and Argyle 1999
Ever Hallucinated* (%)
ACE Score
*Adjusted for age, sex, race, and education.
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29. ACE Score and Impaired Memory of Childhood
Percent With Memory
Impairment (%)
Amnesia, usually considered a theatrical device of Hollywood movies of the 1940s, is in fact alive and well, though unrecognized, in everyday medical practice. In Kaiser’s Weight Program, they found 12% of the participants were partially or sometimes totally amnesiac for a period of their lives, typically the few years before weight gain began. In the ACE Study, they found that there was a distinct relationship of ACE Score to impaired memory of childhood, and understand this phenomenon to be reflective of dissociative responses to emotional trauma.
ACE Score
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30. Health Risk Behaviors Almazar Consulting
Developed in response to neurological impacts and pain of childhood adverse experiences.
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31. ACE Score and Smoking

32. Problem w/alcohol or consider self alcoholic
ACE Score and Alcoholism
Began drinking <=14 years
Problem w/alcohol or consider self alcoholic

33. ACE Score and Drug Abuse
Ever used drugs

34. “Male child with an ACE score of 6 has a 4600% increase in likelihood of later becoming an IV drug user when compared to a male child with an ACE score of 0. Might drugs be used for the relief of profound anguish dating back to childhood experiences? Might it be the best coping device that an individual can find?” (Felitti, 1998)
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35. Is drug abuse self-destructive or is it a desperate attempt at self-healing, albeit while accepting a significant future risk?” (Felitti, 1998)
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36. Significant implications for medical practice and treatment programs
Basic cause of addiction is experience-dependent, not substance-dependent
Significant implications for medical practice and treatment programs
ACE study data Suggests the basic cause of addiction is predominantly experience-dependent during childhood and not substance-dependent. ACE study also demonstrates MANY adult conditions may be experience dependent during childhood. This challenge to the usual concept of the cause of addictions – and other disorders - has significant implications for medical practice and for treatment programs.
Existing practice commonly asks “What is wrong with the person?”, vs “What happened to this person?” Existing practice observes symptoms, develops diagnoses, and treats symptoms instead of underlying causes.
To treat symptoms while not treating underlying causes, is like attending to smoke, instead of fire. It may be – in fact the research indicates – that when substance abuse is treated concurrently with trauma, relapse rates decrease.
These kinds of public health problems, while indeed that, are often also unconsciously attempted solutions to major life problems harkening back to the developmental years. The idea of the problem being the solution, while understandably disturbing to many, is certainly in keeping with the fact that opposing forces routinely co-exist in biological systems.
Understanding that it is hard to give up something that almost works, particularly at the behest of well-intentioned people who have little understanding of what has gone on, provides us a new way of understanding treatment failure in addiction programs where typically the solution rather than the core problem is being addressed.
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37. Serious Social Problems
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38. Childhood Experiences Underlie Rape4+ 3 2 1
Repetition of original trauma. Victims of cumulative early childhood traumas that have never been addressed - are much more highly vulnerable than others to being revictimized by rape or by domestic violence.
Women with an ACE score of 4+ are 500% more likely to become victims of domestic violence.
They are almost 900% more likely to become victims of rape.
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39. ACE Score and Age at Initiation of
Sexual Intercourse
Percent (%)
ACE Score
Hillis et al., Family Planning Perspectives, 2001;
Edwards, Valerie

40. The more adverse experiences as a child, the higher the risk of becoming a victim of domestic violence. This is the case for both women and men.
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41. Just as the risk of becoming a VICTIM of domestic violence rises with the number of ACES – So does the risk of perpetrating domestic violence. Also true for women and men.
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42. Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners
Higher # of ACEs more likelihood of the adult having had 50 or more sexual partners and being at risk for unwanted pregnancy, socially transmitted diseases, HIV/AIDs.
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43. ACE Score and Unintended Pregnancy or Elective Abortion
Higher ACE score leads to increased unintended pregnancy (red) or Elective Abortion (yellow)
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44. Adverse Childhood Experiences and History of STD
There is a significant graded relationship between Adverse Childhood Experiences and the rate of STDs. (Sexually Transmitted Diseases)
(Info: STDs include Chlamydia, gonorrhea, Genital Herpes, HPV (Human Papillomavirus Infection), PID (Pelvic Inflammatory Disease), Syphilis, Trichomoniasis), HIV/AIDS (Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome.
Some above STDs Can lead to infertility.)
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45. Sexual Abuse of Male Children and Their
Likelihood of Impregnating a Teenage Girl
1.8x
1.4x
1.3x
1.0 ref
Percent who impregnated
a teenage girl
Boys who were sexually abused are more likely to impregnate a teenage girl.
The earlier the age when the boy was sexually abused – the greater the likelihood that he will impregnate a teenage girl
Not yrs yrs <=10 yrs
abused Age when first abused
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46. Pink =self Green =mother
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
Pink =self
Green =mother
Percent who had a
teen pregnancy
This is about the relationship of violence (to self or to mom) and getting pregnant.
The more frequently girls are pushed, grabbed, slapped, shoved, or had something thrown at themselves or at their mothers – the greater the likelihood the girls will have a teen pregnancy.
Never Once, Sometimes Often Very
Twice often
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47. ACE Score and Indicators of Impaired Worker Performance
Prevalence of Impaired Performance (%)
The higher the ACE score the harder time an individual may have in making a living. Here there is a graded relationship between ACE scores Absenteeism, Serious Financial Problems and Job Problems
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48. Adult Disease and Disability
Adult Disease and Disability are often an outcome of ACEs. One example of note is that in a study of Native American women in a primary care setting, 77% reported childhood physical or sexual abuse or severe neglect. (2004, Duran et al)
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49. The higher the ACE score the greater the prevalence of Liver Disease
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50. The same relationship is seen with Chronic Obstructive Pulminary Disease
So one can assume that the total relationship of ACE to later biomedical disease lies in the observation that stressful early life experience leads to a coping behavior like smoking, which becomes the mechanism of biomedical damage.
While this hypothesis is true, it is incomplete; the actual situation is more complex. (next slide)
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51. High Health and Mental Health Care Costs
High health and mental health care costs are Reflected in the following graphs showing the higher the individuals ACE Score – the higher the use of costly prescription drugs
Now in its 14th year point, study researchers have begun to analyze pharmacy data.
This means they are looking at prescription drug use fifty to sixty years after the fact.
Prescription costs are an increasingly significant portion of rapidly rising national healthcare expenditures in the US.
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52. The relationship of ACE Score to antidepressant prescription rates is shown here. The following 2 slides show the relationship of adverse childhood experiences to the decades-later use of anti-psychotic and anxiolytic medications
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53. Antipsychotic prescriptions
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54. Pronounce: An zeeo lytic. Anti-anxiety prescriptions
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55. Poor Life Expectancy
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56. Effect of ACEs on Mortality
Age Group
Cummulative adverse childhood experiences lead to early death.
The bars represent the percentage of people of different ages (Pink: 65; Blue: 50-64; Green: age and Yellow: age 19 – 34) coming in for comprehensive medical evaluations. Age distribution for ACE Score 0 individuals is what one would expect old people are more likely to come in for comp medical evals than are young people – intermediate age quantiles have the expected relative proportionality.
However, at ACE score 2, its reversed. And at ACE score 4 the age group of 65 has almost disappeared while all the other age groups coming in for comprehensive evals have dwindled significantly.
This is one indicator – and the study anticipates – when their prospective analysis of death rates is completed, it will find an increasing death rate as the ACE Score increases.
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57. Aoife O’Donovan, Thomas C. Neylan, Thomas Metzler, Beth E. Cohen
Aoife O’Donovan, Thomas C. Neylan, Thomas Metzler, Beth E. Cohen. Lifetime exposure to traumatic psychological stress is associated with elevated inflammation in the Heart and Soul Study. Brain, Behavior, and Immunity, 2012
In the first study to examine the relationship between cumulative traumatic stress exposure and inflammation, the scientists found that the more traumatic stress a patient was exposed to over the course of a lifetime, the greater the chances the patient would have elevated levels of inflammatory markers in his or her bloodstream.
"This may be significant for people with cardiovascular disease, because we know that heart disease patients with higher levels of inflammation tend to have worse outcomes," said lead author Aoife O'Donovan, PhD, a Society in Science: Branco Weiss Fellow in psychiatry at SFVAMC and UCSF.
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58. “What’s wrong with you?”
“What happened to you?”
instead of
“What’s wrong with you?”
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59. All behavior has meaning Symptoms are ADAPTATIONS
Issues of self-regulation
Prevention
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60. I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.
~ Maya Angelou