Adverse Childhood Experiences (ACEs):
What We Know Can Change the Future
Linda Chamberlain, Ph.D. MPH
State of Alaska Family Violence Prevention Project
Chronic Disease Prevention and Health Promotion, DPH, DHSS
www.ACEsconnection.com
Please follow our work by joining: “DV and ACEs in the Arctic” Group
What We’re Talking About
•Framework of Resilience and Hope
•Original ACE Study and Alaska ACE data
•Effects of ACEs start early
•Best practices and resources
–Key characteristics of evidence-based interventions
→Two-generation approach resources
→Self-regulation skills
Resilience Framework
• Resiliency buffers the effects of trauma
• Social support builds resilience across
the lifespan
• Trauma-informed care increases the
effectiveness of health services
• Helping parents to understand how
ACEs can affect their parenting and
children can prevent intergenerational
trauma
Capacity to adapt, cope and thrive during
tough times = RESILIENCE
– Resilience does not
happen all by
itself…
– Resilience happens
in the context of
systems—family,
schools,
community...
ACEs Can Be Overcome
Why Focus on Resilience?
• Protective factors can have stronger
influence on how children who grow up
with adversities do than specific risk
factors
– Remain consistent across different ethnic, social
class, geographical & historical boundaries
Rutter, 1987, 2000; Werner, 2001; Bernard, 2004
Children’s Response to Trauma is influenced by:
–Characteristics of child
–Frequency, severity, proximity of
trauma
–Community cohesion and
collective support, family access
to outside supports
–Quality of parenting, parents’
response to trauma
6
RESILIENCE
ACEs → ?
TOXIC STRESS
BRAIN
↓
STOP
Toxic Stress
Response
Depressed immune
system
Chronic
inflammation
Physical health
Mental
problems
health problems
Self- medicate
to cope
Adopt
risky behaviors
Insights about Trauma
• “Not realizing that children
exposed to inescapable, overwhelming stress may act out their
pain, that they may misbehave, not
listen to us, or seek our attention
in all the wrong ways, can lead us
to punish these children for their
misbehavior. The behavior is so
willful, so intentional. She
controlled herself yesterday, she
can control herself today. If we
only knew what happened last
night, or this morning before she
got to school, we would be
shielding the same child we’re
Playing a Poor Hand
reprimanding.”
Well, Mark Katz
Trauma through a Different Lens
Self-awareness is a key step in healing
It’s not about what’s wrong with me,
it’s about understanding what happened to me.
Show of Hands
• How many of you have
heard of the ACE Study?
• How many of you are
currently talking with
clients about ACEs?
10
The Original “ACE” Study
•Large, collaborative study at
Kaiser Permanente with CDC to
examine the medical, social, and
economic consequences of
childhood adversities over the
lifespan
•ACE questions integrated into
adult health history questionnaire
Felitti et al, 1998
What Are Adverse Childhood Experiences?
Positive
answer
to any
questions
for each
type of
ACE
counts as
one to
create
the ACE
Score
Based on Robert Wood Johnson Info-graphic at http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/05/Infographic-The-Truth-AboutACEs.html
Prevalence of Adverse Childhood
Experiences in “Original” ACE Study
Abuse, by Category
Psychological (by parents)
Physical (by parents)
Sexual (anyone)
Prevalence (%)
11%
28%
22%
Neglect, by Category
Emotional
Physical
15%
10%
Household Dysfunction, by Category
Alcoholism or drug use in home
Loss of biological parent < age 18
Depression or mental illness in home
Mother treated violently
Imprisoned household member
27%
23%
17%
13%
5%
ACEs Are Good Buddies
ACE Score Prevalence
0
33%
1
25%
2
15%
3
10%
4
6%
5 or more
11%
If any one ACE is present, there is an 87% chance at least one
other category of ACE is present, and 50% chance of 3 or >.
Based on Robert Wood Johnson Info-graphic at http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/05/Infographic-The-Truth-AboutACEs.html
Alaska ACE Data Sources
• Behavioral Risk Factor Surveillance System
(BRFSS)
• Telephone survey, 18 years or older
• Questions on neglect added in 2014
• National Survey of Children’s Health (NSCH)
• Telephone survey of households with at least
one child < 18 years old; one child randomly
selected as subject of parental interview
• State-level data on the prevalence of selected
ACEs among children
– Excludes child abuse & neglect
ACEs in Alaska (2013 BRFSS)
ACE Score Prevalence
0
35.6%
1
22.3%
2
14.7%
3
10.1%
4
6.5%
5 or more
10.8%
5 or More ACEs by Age Group
Age (Yrs)
Prevalence
18-24
10.0%
25-34
12.1%
35-44
15.2%
45-54
12.0%
55+
6.5%
Adverse Childhood
Experiences*
Alaska Native
Non-Alaska Native
Abuse
%
%
Emotional
37.8%
29.8%
Physical
23.9%
18.3%
Sexual
21.9%
13.6%
*Percentages in red are significantly different between Alaska Native and Non-Alaska Native.
Source: Alaska data from the 2013 Alaska Behavioral Risk Factor Surveillance System, Alaska Department of Health and Social Services, Division of Public
Health, Section of Chronic Disease Prevention and Health Promotion
Adverse Childhood
Experience*
Alaska Native
Non-Alaska Native
Household Dysfunction
%
%
Mental Illness in the Home
25.2%
21.3%
Incarcerated Family Member
19.5%
10.1%
Substance Abuse in Home
49.8%
31.0%
Separation or Divorce
39.4%
30.4%
Witnessed Domestic Violence
33.0%
16.2%
*Percentages in red are significantly different between Alaska Native and Non-Alaska Native.
Source: Alaska data from the 2013 Alaska Behavioral Risk Factor Surveillance System, Alaska Department of Health and Social Services, Division of Public
Health, Section of Chronic Disease Prevention and Health Promotion
National Survey of Children’s Health
2011/2012
Ace Question
U.S.
Statistically
Alaska Significant
Family's income hard to cover the basics like food or housing? Very often or Somewhat
25.7% 25.0%
often.
No
Did child ever live with a parent or guardian who got divorced or separated after he or
she was born?
20.1% 23.8%
Yes
Did the child ever live with a parent or guardian who died?
3.1%
3.1%
NA
Did ever live with a parent or guardian who served time in jail or prison after he/she was 6.9%
born?
9.6%
Yes
Did the child ever see or hear any parents, guardians, or any other adults in his/her
home slap, hit, kick, punch, or beat each other up?
7.3%
8.6%
No
Was the child ever the victim of violence or witness any violence in his/her
neighborhood?
8.6% 10.5%
No
Did the child ever live with anyone who was mentally ill or suicidal, or severely
depressed for more than a couple of weeks?
8.6% 11.0%
No
Did the child ever live with anyone who had a problem with alcohol or drugs?
10.7% 14.5%
Yes
Was the child ever treated or judged unfairly because of his/her race or ethnic group?
4.1%
No
http://childhealthdata.org/learn/NSCH
4.9%
Two or More Adverse Childhood Experiences
Highest Quintile
Second Highest Quintile
Middle Quintile
Second Lowest Quintile
25.8%
Lowest Quintile
Range: 16.3% (NJ)-32.9% (OK)
The Data Resource Center for Child and Adolescent Health is a project of the Child and Adolescent Health Measurement Initiative (CAHMI) supported by
Cooperative Agreement 1-U59-MC06980-01 from the U.S. Department of Health and Human Services, Health Resources and Services Administration
(HRSA), Maternal and Child Health Bureau (MCHB). With funding and direction from MCHB, these surveys were conducted by the Centers for Disease
Control and Prevention’s National Center for Health Statistics. CAHMI is responsible for the analyses, interpretations, presentations and conclusions
included on this site. Map created by Alaska Mental Health Board Staff
Age 0-5 Years Old by Number of ACES in Alaska
Zero ACEs
59.8%
One ACE
24.7%
Two or More ACEs
15.5%
Source: National Survey of Children’s Health 2011/2012, Graphic created by the Alaska Mental Health Board/Advisory Board on
Alcoholism and Drug Abuse Staff.
Age 6-11 Year Olds by Number of ACES in Alaska
Zero ACEs
48.1%
One ACE
24.9%
Two or More ACEs
27.0%
Source: National Survey of Children’s
Health 2011/2012, Graphic created by the Alaska Mental Health Board/Advisory Board on Alcoholism and Drug Abuse Staff.
Age 12-17 Year Olds by Number of ACES in Alaska
Zero ACEs
38.3%
One ACE
26.1%
Two or More ACEs
35.6%
Source: National Survey of Children’s
Health 2011/2012, Graphic created by the Alaska Mental Health Board/Advisory Board on Alcoholism and Drug Abuse Staff.
Alaskan Children with One or More Emotional, Behavioral or
Developmental Issues by ACE Score
30.0%
25.0%
Percentage
20.0%
15.0%
14.2%
10.0%
5.0%
0.0%
5.6%
2.5%
Zero
One
Two or More
ACE Score
Source : National Survey of Children's Health. NSCH 2011/12. Data query from the Child and Adolescent Health
Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Retrieved [08/24/2015] from
www.childhealthdata.org Slide Prepared by Alaska Mental Health Board and Advisory Board on Alcoholism and Drug
Abuse Staff
Alaskan Children with More, Less and No Complex Health Care
Needs by ACE Score
100.0%
90.0%
23.0%
28.4%
80.0%
46.5%
70.0%
Two or More
ACES
Percentage
25.3%
60.0%
24.9%
One ACE
50.0%
24.6%
40.0%
30.0%
51.7%
20.0%
No ACES
46.7%
28.9%
10.0%
0.0%
Children with No Special Health
Care Needs
Children with Less Complex Special
Health Care Needs
Children with More Complex
Special Health Care Needs
Source : National Survey of Children's Health. NSCH 2011/12. Data query from the Child and Adolescent Health Measurement
Initiative, Data Resource Center for Child and Adolescent Health website. Retrieved [08/24/2015] from www.childhealthdata.org
Slide Prepared by Alaska Mental Health Board and Advisory Board on Alcoholism and Drug Abuse Staff
Alaska Children's Medical Home Status by ACE Score
100
18.4
90
80
32.8
Percentage
70
26.1
60
Two or
more
One
24.4
50
40
Zero
30
20
55.5
42.9
10
0
Care does not meet all medical home
criteria
Medical home--all criteria are met
Source : National Survey of Children's Health. NSCH 2011/12. Data query from the Child and Adolescent Health Measurement
Initiative, Data Resource Center for Child and Adolescent Health website. Retrieved [08/24/2015] from www.childhealthdata.org
Slide Prepared by Alaska Mental Health Board and Advisory Board on Alcoholism and Drug Abuse Staff
Effects of ACEs Can Start Early
Increase risk of:
Childhood obesity
Early age at first
intercourse
Teen pregnancy
Bullying
Dating violence
Fighting and carrying weapon
to school
Early initiation of tobacco use
Early initiation of drug abuse
Early initiation of alcohol use
Self-mutilation and suicide
Anda et al, 2002; Anda et al, 1999; Boynton-Jarrett et al, 2010; Dube et al, 2006; Dube et al, 2003;
Duke et all, 2010; Hillis et al, 2001; Miller et al, 2011
School Readiness
Children with 3 or more ACEs are
nearly 4 times (OR=3.66) more
likely to have developmental
delays (Marie-Mitchell et al, 2013)
Children with 4 or more ACEs are
32 times more likely to have
behavioral problems in school
(Burke et al, 2011)
Children with 2 or more ACEs are
2.67 times more likely to repeat a
grade (Bethel et al, 2014)
ACEs and Childhood Obesity
•Young children with an ACE score
of 4 or greater are twice as likely
to have a body mass index (BMI)
≥85% (Burke et al, 2011)
•Children exposed to domestic
violence are 80% more likely to be
obese at age 5 years
(Boynton-Jarrett et al, 2010)
Prevalence of 2 or More ACEs among Children
with Selected Health/Health Risk Factors*
Health Factor
2 or more ACEs (%)
Asthma
33.4%
ADHD
45.2%
Autism spectrum disorder
34.4%
Behavior problem
61.4%
Who bully
55.4%
NCHS data which excludes abuse & neglect, includes exposure to
community violence, poverty and discrimination; Bethel et al, 2014;
*CSHCN SCREENER (Children with Special Health Care Needs); 5 domains
Childhood Adversities and Psychiatric Disorders
Among Adolescents
Among adolescents, childhood adversities
account for:
–15.7% of fear disorders
–32.2% of distress disorders
–34.4% of substance use orders
–40.7% of behavior disorders
Population attributable risk proportions (PARPs) were predictive
across DSM-IV disorder classes in this national sample ( n= 6483) McLaughlin et al, 2012
ACEs AND TEEN ALCOHOL USE
Teens exposed to ACEs are more likely to:
- to start drinking alcohol by age 14
-binge drink
-say that they drank to cope
during their first year of drinking
Dube et al, 2006
Suicide Prevention Must Address ACEs
• 80% of childhood and
adolescent attempted
suicides are attributable
to ACEs
*
Attributable Risk Fraction (ARF) calculated in
Study by Dube et al, 2001
Dube et al,2001
NATIONAL REVIEW OF BEST PRACTICES
www.promisingfutureswithoutviolence.org
Key Characteristics of Evidence-Based Practices for Children
Exposed to Violence and Other Trauma
• Caregiver involvement and support
– Emphasis on trauma-informed parenting skills
• Anxiety and stress management strategies for
child and parent
• Children’s social and emotional regulation skills
– Identify and express emotions in safe ways
– Construct trauma narrative/share story
• Empowerment training
www.promisingfutureswithoutviolence.org;
NCJFCJ TA Bulletin; Buffington et al, 2010
Key Findings
• Wide range of community-based interventions including some
services provided by non-clinical staff
– Domestic violence shelters (adapted TF-CBT)
– School-based ( ARC, CBITS)
– Homeless shelters (CARE)
• Innovative practices such as therapeutic play and art-based
interventions (PAL)
• Parenting interventions including mothering (MotherCraft)
and fathering after domestic violence (“Caring Dads”)
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
• Individual and joint sessions with child and parent
(usually 12-16 sessions) to address childhood PTSD
• Adapted for Native American and Alaska Native children
• 8-session adaptation evaluated with DV-exposed
children (Cohen et al, 2011)
– ↓ in children’s DV-related PTSD and anxiety
www.pittsburghchildtrauma.org
Kids’ Club and Mom’s Empowerment
• 10-week intervention with mothers & children (ages 6-12)
• Multi-component approach
– Parent training with behavior management
– Social skills training with children
• RCT results indicated 79%  clinical range externalizing
scores & 77% internalizing scores for children in
mother-child intervention group
• Pilots planned in Alaska
Graham-Bermann et al, 2007
Structured Psychotherapy for Adolescents Responding to
Chronic Stress (SPARCS)
• Skill-based, present focused group psychotherapy for teens
living with ongoing stress/trauma
• 16 one-hour sessions by therapists offered in variety of
community settings; adaptations include:
– Shorter 6-session
– Two peer-led curricula
• EB-practice pilots have shown decreased risk behaviors, reduced
trauma symptoms, and improved overall functioning
www.nctsnet.org
Collective Impact Framework
Opportunities to integrate and expand availability of
services, teach resilience-promoting skills:
– Trauma-informed schools (ARC [Attachment, SelfRegulation & Competency]; CBITS)
– Shelter-based programs (Kids’ Club, adapted TF-CBT,
CARE)
– Perinatal programs, home visitation, parenting classes
– Juvenile justice, DOC …
Collective Impact= structured approach to collaborative work across many
sectors to achieve significant and lasting change on complex issues
“Science tells us that interventions
that strengthen the capacity of families and
communities to protect young children from
the disruptive effects of toxic stress are likely to
promote healthier brain development and
enhanced physical and mental wellbeing.”
- American Academy of Pediatrics
Planting the Seed
•Many parents may not recognize how early trauma
can affect their parenting and how they react to
stressful situations
•Increasing parents’ awareness about the effects of
ACEs can help them to understand their own lives
and make healthier choices to protect their own
children from ACEs
When we reach out and support children and their parents together,
we see far greater results than the sum of their parts
Two Generation Approach, Aspen Institute
Is This Science?
•Lots of hugs and
affection
•Reading/telling stories
•Playing imaginary games
•Singing songs
•Helping child at
mealtime and bedtime
•Toys with movable parts
Suglia et al, 2009
5 Core Principles of Trauma-Informed Parenting
1. Meet parents where they are at in terms of their life
experiences and build on their strengths
2. Help parents/caregivers understand how experiences
they had as children can affect their well-being and how
they parent
3. Help parents/caregivers to recognize that ACEs can affect
children in many different ways
4. Coach parents on positive discipline and parenting
strategies that promote resilience
5. Offer tools to help parents/caregivers manage stress
Chamberlain L. in ACEs: Best Practices,
AVA, 2015
Caregiver Resource
• Positive, supportive approach to help parents understand how
trauma can affect their health, parenting & children
• Universal education with self-assessment
• Simple language to convey core concepts
• Practical strategies to reduce
stress and promote protective
factors for parents and children
(scannable QR codes)
Contact jo.gottschalk@alaska.gov for free copies or go to
www.healthfederation.org to download free PDFs of Amazing Brain Series
Two-Generation Approach
Meeting Parents Where They Are At and
Providing Tools to Down-Regulate and Manage Stress
Promoting Resilience
•Self-Regulation
•Attachment
•Empathy
•Competence
Self-Regulation with Children
“Neuroscience suggests that mediating the
impact of adverse childhood experiences
involves not only the education and emotional
and practice support but also the introduction
and application of neurological repair methods
such as mindfulness training.”
Bryck et al, 2012
Expanding Evidence Base:
Mindfulness Practices and Children
• Reductions in attention problems & anxiety (Lee et al, 2008; Semple
et al, 2010)
• Changes in brain activity (↓theta/beta ratios-EEG) and improved
ADHD symptoms after 3 months (Travis et al, 2011)
• Reduced anxiety, enhanced social skills and academic performance
among adolescents with learning disabilities (Beauchemin et al,
2008)
• Decreased aggressive behavior and bullying among students
diagnosed with conduct disorder (Singh et al, 2007)
Resilience Skills
Being able to stay calm and in control when faced
with a challenge mitigates the effect of trauma
among children with special health care needs who
had 2 or more ACEs
-1.5 times more like to be engaged in
school
-half as likely to repeat a grade compared
to those not exhibiting resilience
NSCH data, Bethel et al, 2014
Lessons from
Head Start, Trauma Smart
• Children need simple
strategies to calm their
amygdala
• Deep breathing helps
children to focus and
calm down
Juanita Cabrales: 3 year olds
Practicing mindful breathing
Progressive Relaxation for Children
Listen carefully and do what I say, even if it sounds silly. Pay attention
to your body—think about how your muscles feel when they are all
wound up and tight and when they are loose and relaxed.
1. You are a furry, lazy cat and you want to stretch…stretch your arms
out in front, now high above your head, higher and way back, now
drop your arms to the side, let’s try again and touch the ceiling
2.
Be a turtle and go in and out of your shell
3.
You have lemons in your hands, squeeze hard to get all the juice out,
now let go, squeeze again, now drop the lemon…--------
4.
Fly on your nose---no hands!
5.
Here come elephants and your tummy is the bridge! One elephant,
two elephants….
Adapted from www.yourfamilyclinic.com
“Sitting
meditation seems to be an effective
intervention in the treatment of physiologic,
psychosocial and behavioral conditions among
youth [ages 6 to 18 years old].”
Systematic evidence review by Black et al. published
In Pediatrics 2009
Seated meditation refers to sitting in a comfortable position,
closing your eyes and focusing on breathing or a specific word of choice.
MindUP Warm-UP:
Inner and Outer Stillness
•Sit in a comfortable position & make sure your shoulders are relaxed.
•Relax your jaw; let your eyelids get heavy; close your eyes if you want to.
•Notice your breath coming in and going out. Don’t try to change it!
•Feel your stomach rising and falling. Let your belly be soft and relaxed.
•Now see if you can breath a little more slowly and a little more deeply.
•If your mind gets distracted, go back to noticing your breath.
•Open your eyes slowly, take a deep breath and smile.
MindUP Curriculum, Grades 6-8;
Scholastic, 2011; lesson 3; pg 45.
Mindfulness-Based Parenting Interventions
•Parallel 8-week training for children (ages 8-12 y.o.) with
ADHD and their parents demonstrated reductions parentreported stress and overreactivity and teacher-reported ODD
behavior (Van Der Oord et al, 2012)
•8-week Mindfulness-Based Stress Reduction (MBSR)
randomized trial with parents of children with developmental
delays indicated significantly less stress and depression as well
as greater life satisfaction while children had improvement in
attention problems & ADHD symptoms (Neece, 2014)
Yoga Curricula for Self-Regulation
and Stress Management
Autism and Special Needs Curriculum
• Intentionally designed as CD so
children focus on how it feels vs. how
it looks
• Each movement followed by
breathing break
• Movement illustrated by Shanti the
Monkey Flip chart & coloring page
• Can be done seated or standing
http://greentreeyoga.org/programs/trauma-sensative-yoga/item/16trauma-sensitive-yoga-for-kids
Attachment
Attachment Can Be A Juggling Act
• Dysregulated child rarely communicates needs in clear, direct
manner
• Helping caregivers to look for the real meaning behind the
message—”I hate you!” → “I need a hug”
• Responding to what the child needs vs. “deserves” based on
behavior
• FOCUS ON THE RELATIONSHIP vs. THE BEHAVIOR
– →can go back to that after intense feelings have been calmed and
connection is re-established
Even the Small Stuff Changes -Terra Bovingdon
“There’s a bit difference between attention-
seeking behavior and children seeking
connection.”
Avis Smith, Head Start Trauma Smart
When the BRAIN feels “heard” it will naturally move towards adapting and
changing.
TAKE THE LEAD, LOOK PAST THE BEHAVIOR AND FIND THE HIDDEN NEED.
Tera Bovingdon, Attachment expert
Connected Kids:
Parent Video and Safety Card