1. Trauma and Poverty November 19, 2015 Dimitri Topitzes
1/17/14
Trauma and Poverty
Dimitri Topitzes
Associate Professor, Social Work
U. of Wisconsin-Milwaukee
November 19, 2015

2. Acknowledgements Joshua Mersky and David Pate Wisconsin Department of
Children and Families
Health Services
Milwaukee Area Work Force Investment Board
Funders:
Health Resources and Services Administration
Chapin Hall Center for Children
Wisconsin Partnership Program, UW-Madison, School of Medicine and Public Health

3. Topic outline Define trauma Intersection of poverty and trauma
Implications for practice/policy

4. Define Trauma

5. Psychiatric definition of trauma
Threatened or actual sexual or physical violence experienced directly or indirectly
Sudden or violent death of loved one
Results in symptoms that impair daily functioning
re-experiencing
avoidance
numbing
hyperarousal

6. Limitations
Doesn’t capture non-physical or non-sexual trauma, e.g., financial ruin, relational betrayal
Doesn’t capture childhood or developmental trauma, e.g., neglect and emotional abuse
Doesn’t recognize other symptoms that can arise from PTE exposure
Too constrictive

7. Expanded definition of trauma
An extremely upsetting event that at least temporarily overwhelms the individual’s internal resources, and produces lasting psychological symptoms.
Event can be emotional in nature
Accounts for children’s trauma experiences, e.g., bullying, emotional abuse, neglect
Symptoms that arise are not limited to PTSD clusters, e.g.
depression
anxiety
substance abuse
conduct related problems in children or adolescents

8. Limitations of Briere definition
Steeped in psychiatric and psychological language
Conceptualization of trauma limited to an event

9. Adverse childhood experiences (ACEs)
10 types of adversities experienced during childhood
Abuse/neglect and household dysfunction
Framework recognizes milieu as important as opposed only to events
Findings:
High prevalence
Cluster
Accumulation of ACEs overwhelms developmental systems undermine adult well-being:
Physical health
Mental health
Behavioral health

10. The Adverse Childhood Experiences Study
Study launched by Kaiser Permanente and CDC in the mid- 1990s (Vincent Felitti & Robert Anda)
>17,000 patients in San Diego, CA responded to a survey documenting childhood experiences of:
Abuse (physical; sexual; psychological)
Neglect (physical; emotional)
Domestic violence
Household crime
Household mental illness & substance abuse
Divorce

11. Prevalence
ACEs High!
Over ½ were exposed to at least 1 ACE
Chances of having a second ACE if you exposed to:
Sexual Abuse: 65%
Physical Abuse: 86%
Psychological Abuse: 93%
Household Substance Abuse: 69%
Household Mental Illness: 74%
Household Crime (Incarceration): 86%
Household Domestic Violence: 86%

12. Heart Disease Odds of Heart Disease ACEs 3.5 3 2.5 2 1.5 1 1 2 3 4 5,61 2 3 4
5,6
7,8
ACEs

13. Depression

14. Smoking

15. Limitations Normed on middle class sample
Ignores severity and chronicity of adversity
Doesn’t account for protective factors
Doesn’t account for stressors relevant to low-income samples
Community violence
Homelessness
Food insecurity
Absence of parent

16. Toxic Stress Multiple adversities, e.g., poverty, discrimination, CAN
Overwhelm small number protective factors
Particularly in early life
Chronic toxic stress response, reflects allostatic load
Result in poor lifelong health trajectories
Extends ACE framework
additional stressors (poverty) and
highlights neurophysiological mechanisms

17. Poverty & Trauma

18. I. Poverty increases exposure
Poverty increases exposure to index trauma
Low-income/high crime communities increase likelihood of violence exposure
Poverty increases chances child exposed to trauma as defined by Briere and by ACEs:
Neglect
Poverty increases risk of exposure to toxic stress
Food insecurity

19. Home visiting study
Over 800 adults receiving home visiting services in WI
Completed an ACE-related survey over the last 9 months of 2014
Primarily low-income women just given birth

20. Abuse & Neglect Adverse Childhood Experience Prevalence (%)
WI Home Visiting ACE Study1
Physical Abuse
42.4
26.4
Sexual Abuse
26.5
21.0
Psychological Abuse
28.0
10.2
Physical Neglect
10.6
9.9
Emotional Neglect
17.8
14.8
1Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study. Pediatrics, 111(3),

21. Household Dysfunction
Adverse Childhood Experience
Prevalence (%)
WI Home Visiting ACE Study
Substance Abuse
49.1
28.2
Mental Illness
39.2
20.3
Criminal Offending
37.1
6.0
Domestic Violence
38.1
13.0
Divorce/Separation
43.0
24.1

22. Cumulative Risk Number of ACEs* Prevalence (%)
WI Home Visiting ACE Study
15.3
32.7 1
15.5
25.6 2
13.4 3
11.5
9.9 4
13.1
5.9
5 or more
31.2
10.5
*Sum of 10 ACEs: Physical abuse, Sexual abuse, Psychological abuse, Physical neglect, Emotional neglect; Parent substance abuse; Parent mental illness; Household crime; Domestic violence; Parent separation or divorce.

23. MAWIB Study 199 men accessing employment services in Milwaukee
2013, four week period
Convenience sample collected in resource room

24. MAWIB Study
ACE Study Men MAWIB _____________________ (N = 3,948) (N = 199) Abuse: Verbal Physical Sexual Neglect: Emotional Physical Household dysfunction: Domestic violence Substance abuse Mental illness Separation/divorce Incarcerated member

25. MAWIB Study
ACE Index Score, ACE Study* Current Study Prevalence (%) (N = 3,948) (N = 199) ______________________________________________________________ ≥

26. Poverty and Toxic Stress
Adverse Childhood Experience
Prevalence (%)
WI Home Visiting
Serious Financial Problems (often)
34.1
Food Insecurity
17.3
Homelessness
22.5
Peer Victimization (often)
25.6
Prolonged Absence of Parent
56.2

27. II. Poverty affects trauma symptoms
Lower access to treatment: External resources
Poor receptive/expressive language: Internal resources
“Meaningful differences”
Professionals talking words/hour to child, ages 1-2
Non-professionals talking words/hour to children
All talk same amount of business: do this, don’t do that, etc.
But professionals add chit chat, affirmation, commentary, stories
Parents extra talk, correlates .78 to age 3 Stanford Binet.
Parents extra talk, correlates .77 age 9 Vocabulary Test
Poorer health trajectories

28. III. Poverty as an index trauma
Ongoing adversity, chronic degradation, stress, shame
Financial hardship has direct, independent effect on CAN (Slack & Berger)
Results of childhood poverty similar to early trauma
Low status attainments
Poor health trajectories

29. Conclusion See poverty and trauma inextricably connected
See services for poverty and trauma as co-offerings (false dichotomy)
Story of housing first
Story of re-entry
Evidence to show that job services improved with mental health services

30. Implications

31. Trauma-Informed Practice
Assess
Educate
Regulate
Refer
Struggle with experience of trauma in oneself or another: cognitive rumination (reflection)
Can lead to growth
Not psych comfortable and may not result in comfort, but will result in growth
Growth: worldview richer; lifestyle more enhanced, compassion is deeper
Improved relationships
Deeper appreciation of life
Greater sense of personal strength
Philosophy is more meaningful/realistic
Not psychological comfort or happiness in the emotional sense

32. Assess (adults or children)
Index trauma
Original ACEs
Additional ACEs relevant for low-income types
Effect of ACEs in present
Resilience to ACEs
Discussing ACEs in assessment context led to positive impacts on healthcare utilization

33. Assessing ACEs in CW, HV, & CHC
Comfort
Workers more uncomfortable than clients with questions: 20%
10% clients are uncomfortable with questions
Address Discomfort
Giving client decision making power, when & if to talk about ACEs
Give client choice over paper and pencil format or discussion
Allot plenty of time to talk about it if discussion format
Workers develop comfort, language, and style with questions
Know that discomfort generally manifests as internalizing

34. Educate and potentially refer
Trauma, ACEs and Toxic Stress
Extensive health effects
Other outcomes
Resilience
What helps, regulate
Intervention to target coping or regulation strategies
Refer in order to resolve trauma if PTSD or other mental health related problems
Mental health
Trauma focused

35. Policy
Jack Shonkoff:
Harvard Center on the Developing Child