Session # C4
October 29, 2011
10:30-11:15 AM
Childhood Adversity & Trauma
A Life Course Perspective for
Prevention & Healing
Roberta Waite, EdD, APRN, FAAN
Assistant Dean of Academic Integration and Community Programs
Patricia Gerrity, RN, PhD, FAAN
Associate Dean for Community Programs
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Need/Practice Gap & Supporting Resources
What is the scientific basis for this talk?
The experiences of abuse and family dysfunction in childhood
significantly shapes an individual’s future physical and mental
health. These cumulative experiences are referred to as
adverse childhood experiences (ACEs).
Empirical data confirms the important role that ACEs have in
increasing risk for many health conditions however public
health and clinical practice has not proactively implemented
evidence based interventions to address the problem.
Objectives
• Identify common adult health outcomes that are correlated
with adverse childhood experiences (ACEs)
• Describe the role health care providers play in recognition and
referral for treatment of person's affected by ACEs
• List patient treatment interventions that can be useful in
helping individuals affected by ACEs
• Identify how organizational culture influences response to
care among patients who have experienced ACEs
Expected Outcome
What do you plan for this talk to change in the
participant’s practice?
• Assess and recognize that ACES are preventable and treatable
• Address the life course and transgenerational effects of
trauma
• Treat root causes of many physical and mental illness and
destructive health behaviors
• Organizational trauma informed care
Understanding ACEs from a life-course perspective promotes
understanding how early-life experiences can shape health
across an entire lifetime and potentially across generations.
Eleventh Street Family Health Services of
Drexel University
in partnership with Family Practice and Counseling Network
An Overview About ACEs
WHAT ARE THEY?
What do we mean by ACEs?
Experiences that represent health or social problems of national
importance, such as:
•
•
•
•
•
•
•
•
•
Emotional/Physical Abuse
Sexual Abuse
Emotional/Physical Neglect
Domestic Violence – Battered Mother
Single Parent Homes – Due to Separation/ Divorce/Death
Substance Abuse - One or Both Parents
Incarcerated Parent(s)
Parent(s) Suffering From Mental Illness
Parent(s) Suffering From Chronic Illness
Chapman, Whitfield, Felitti, Dube, Edwards, & Anda , 2004
Why look at ACES?
They’re a strong influence on how we
develop and what we become as
individuals, as communities, and as a
nation
ACES can impact individuals
along this trajectory
Social
Social
Example: Children exposed to
violence often grow up to become
victims of violence. Some may
also inflict violence on others
Psycho
Bio
Preconception
Birth
Childhood
Adulthood
http://www.acestudy.org/
Kaiser Permanente Medical Group
Centers for Disease Control and Prevention (CDC)
 The largest scientific research project of its kind 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.
Adverse Childhood Experiences Score
Number of categories adverse childhood experiences
are summed …
ACE score Prevalence
0
48%
1
25%
2
13%
3
7%
4 or more
7%
More than half have at least one ACE
(Anda et al., 2009; Edwards, Holden, Felliti, & Anda, 2003; Felliti et al., 2002)
Health problems in Adults Increased with
Exposures to Adverse Experiences in Childhood
Alcoholism and Illicit
Drug Use
Smoking
Ischemic Heart
Disease (IHD)
Chronic Obstructive
Pulmonary Disease
(COPD)
Liver disease
STDs
Depression
Multiple Sex
Partners
Suicide Attempts
Risk for Intimate
Partner Violence
Unintended
Pregnancies
Fetal Deaths
The HEALing Project
Roxana Arango
Dr. Roberta Waite
Dr. Patricia Gerrity
Reeva Gupta
Women (n=647)
Category of ACE
Abuse
Neglect
Household Dysfunction
Men (n=154)
Total (n=801)
%
%
%
Emotional
16.7
16.8
16.7
Physical
35.1
45.8
37.2
Sexual
35.3
18.1
31.9
59
57.4
58.7
Physical
35.6
36.8
35.8
Battered Mother
25.5
28.2
26.1
Parental
Discord/Divorce
56.2
59.4
56.9
Mental Illness in
Household
36.7
37
36.7
Household Substance
Abuse
50.4
55.8
51.4
Incarcerated Household
Member
33.2
50.6
36.6
Emotional
Original Study vs 11th St Results
Number of
Adverse Childhood
Experiences
(ACE Score)
Women
Men
Total
11th
Street
Patients
Original
Study
0
6.8%
34.5%
3.9%
38.0%
6.3%
36.1%
1
12.5%
24.5%
9.9%
27.9%
12.0%
26.0%
2
18.5%
15.5%
14.5%
16.4%
17.8%
15.9%
3
14.6%
10.3%
16.4%
8.6%
14.9%
9.5%
4 or more
47.5%
15.2%
55.3%
9.2%
49.0%
12.5%
11th Street
11th Street
Original
Original
Patients
Patients
Study
Study
Adult health outcomes that are
correlated with ACEs from the
HEALing Project
WHAT ARE THEY?
ACE vs. Feeling Depressed or “Down in
the Dumps”
ACE vs. Ever Attempted Suicide
ACE vs. Ever Used Street Drugs
Death
Early
Death
Disease,
Disability
Adoption of
Health-Risk Behaviors
Social, Emotional, and Cognitive
Impairment
Birth
Adverse Childhood Experiences
The Influence of Adverse Childhood Experiences Throughout Life
ACE’s Major Determination of Health & Well Being (Felitti, 2003)
Health Care Providers
WHAT ROLE DO THEY PLAY IN RECOGNITION
AND REFERRAL FOR TREATMENT OF
PERSON'S AFFECTED BY ACES?
ACES: Implications for Clinical Practice
• Problems that come into the clinic are complex and providers
should be aware of the link between those problems and ACEs
– Redefine ‘resistence’ ‘non-compliant’
• In all stages of the encounter – assessment & evaluation,
treatment plan – providers must avoid easy answers
• If the problems are complex, why would the solutions be
simple?
Implications for Clinical Practice
How do I think broadly about
my patient(s)?
Can I put myself in my
patient’s shoes?
Do my interventions
empower?
Implications for Practice and
Interventions
These findings are particularly relevant to
integrated care and wellness programs and
practices. They reveal the need to address
trauma as central to the health and well-being
of people across a very wide spectrum of
problems.
WHAT CAN WE DO…….
 Pay attention
 Get out of our comfort zone and explore the possibility of
prevention
 Overcome lack of knowledge – our own and others
 Overcome our fear
 Speak out and end silence about the role of ACEs in serious
health, mental health, and social problems of all kinds.
 Stop treating symptoms and treat the cause
 Do a better job of routinely screening at the earliest point for
ACEs. Identify cases early and allow treatment of basic causes
rather than vainly treating the symptom.
Integrative Health Care
To create a seamless engagement by patients
and caregivers of the full range of physical,
psychological, social, preventive, and
therapeutic factors known to be effective and
necessary for the achievement of optimal health
throughout the lifespan.
Integrated Team
• Family nurse practitioner
• Primary behavioral health consultant
– Child & adult
– Couples & Family Therapist- energy psychology
•
•
•
•
•
Generalist social worker
Health educator/nutritionist
Complementary & integrated therapist
Physical therapist
Creative arts therapists
Traditional Care
• What is wrong with this person?
Integrated care
Who is this person?
What has happened to this person?
Ethical Imperative for Screening
• Many clinicians are reluctant
• Not disclosure by itself that results in harm,
but rather negative responses the person
receives when disclosing trauma
• Need to be prepared to provide referral
sources and respond in a supportive manner
• Individuals are grateful to know that others
care about these issues
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?
Yes / No
If yes enter 1 ________
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 ________
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.
The ACEs Scoring Method
• Exposure to one category (not incident) of ACE,
qualifies as one point.
• An ACE Score of 0 (zero) would mean that the person
reported no exposure to any of the categories of trauma
• When the points are added up, a total ACE Score is
provided.
• The ACE Score represents the cumulative effect of
multiple exposures.
http://www.acestudy.org/files/ACE_Score_Calculator.pdf
Patient Treatment Interventions
WHAT CAN BE USEFUL IN HELPING
INDIVIDUALS AFFECTED BY ACES?
Interventions to Treat Trauma
at 11th Street
• Outpatient behavioral health
• Primary behavioral health therapists
• Couples & Family Therapist
– EFT
– EMDR
• Creative Arts Therapies
Art
Music
Movement
• Trauma Recovery & Empowerment Groups
• Trauma informed yoga
EMDR
Art Therapy
Yoga
Life Course Perspective
• The life course approach to conceptualizing
health care needs and services evolved from
research documenting the important role
early life events play in shaping an individual’s
health trajectory. The interplay of risk and
protective factors, such as socioeconomic
status, toxic environmental exposures, health
behaviors, stress, and nutrition, influence
health throughout one’s lifetime.
Visit for Mother and Baby
Early Programming
• Early experience can program an individual's
future health and development
• Prenatal- exposure in utero
• Intergenerational-health of mother prior to
conception
• Adverse programing can directly result in a
condition or make one vulnerable or more
susceptible
Organizational Culture
HOW DOES IT INFLUENCE RESPONSE TO
CARE AMONG PATIENTS WHO HAVE
EXPERIENCED ACES?
Trauma Informed Care
• Dr. Sandra Bloom- international expert on trauma
• Trauma-informed cultures understand it has broad and
profound impacts‚ and the very diverse way in which people
cope with and recover from traumatic events impacting the
way that people think and act.
• Example: Safety‚ trustworthiness‚ choice‚ collaboration‚
and empowerment are core to TIC.
• Providers don’t’ ask “what is your problem or what is
wrong with you” instead ask “what has happened to you
and how have you dealt with it.”
• Providers don’t say‚ “Here’s what I can do to fix you‚”
instead ask‚ “How can you and I work together to achieve
your goals of recovery and healing?”
Trauma Informed Care
• All members of an organization must experience these same
core TIC concepts
• Staff can only create a setting of and offer relationships that
are characterized by safety‚ trustworthiness‚ choice‚
collaboration and empowerment only when they experience
these same factors in the organization as a whole.
– Example. Trustworthiness. Can staff trust each other and the program
supervisors and administrators?
– Do staff exert some control over how they accomplish their task? Is
creativity valued?
– Collaboration. Do administrators actively seek and take seriously staff
ideas about the program and empowerment? Do staff feel valued? Do
they have resources to do their jobs well?
Health center seen as a safe place
in the comunity
Implications - Research
Culture
Policy
Systems
Environment
•Asking the questions that will have
impact
•Importance of moving beyond the
clinic into the community 
community based research
•Transdisciplinary problems require
transdisciplinary partners and
teams
Individual
Programs
and
Outcome Measures
Hays-Grudo (2008)
Summary
• How we define ACEs– how we understand them  ultimately
impacts how we decide to ‘solve’ them
• For medical providers, 99% of effort in learning is oriented to
BIOLOGY, which is fine, however biology is LINKED to social
context and determinants
• It’s important to let go of the individualistic models of blame –
and widen our scope of analyses and treatment. Become a
part of the emerging future care for communities and patients.
• In a medical home model, such as 11th street, there is a team
of people – all with different areas of expertise and knowledge
that work collaboratively
“ You don’t have to know everything – just
accept different possibilities”
Resources
•
•
•
•
•
•
•
•
•
•
Chapman DP, Dube SR, Anda RF. Adverse childhood events as risk factors for negative mental health outcomes.
Psychiatric Annals. 2007; 37(5):359–364.
Corso, PS, Edwards, VJ, Fang, X, Mercy, JA.. Health-related quality of life among adults who experienced
maltreatment during childhood. Am J Public Health, 2008;98:1094-1100
Dong M, Anda RF, Felitti VJ, Williamson DF, Dube SR, Brown DW, Giles WH. Childhood residential mobility and
multiple health risks during adolescence and adulthood: the hidden role of adverse childhood experiences.
Archives of Pediatrics and Adolescent Medicine. 2005;159:1104-1110.
Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB. Cumulative childhood stress and autoimmune
disease. Psychom Med. 2009;71, 243-250.
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 1900. Preventive Medicine, 2003;37(3):268–277.
Edwards, VJ, Holden, GW, Anda, RF, & Felitti, VJ Relationship between multiple forms of childhood maltreatment
and adult mental health in community respondents: results from the adverse childhood experiences (ACE) study.
American Journal of Psychiatry. 2003;160(8):1453-60.
Edwards, VJ, Dube SR, Felitti VJ, Anda RF. It's OK to ask about past abuse. American Psychologist. 2007; 62(4):327–
328.
Felitti VJ, Anda RF, Nordenberg D et al. The relationship of adult health status to childhood abuse and household
dysfunction. This issue American Journal of Preventive Medicine, April 1998
Herman J. Trauma and Recovery. NY: Basic Books 1992.
Read, J & Fraser, A Abuse histories of psychiatric in-patients. To ask or not to ask? Psychiatric Services. 1998; 49,
355-359.
“The truth about childhood is stored up in our bodies
and lives in the depths of our souls. Our intellect
can be deceived, our feelings can be numbed and
manipulated, our perceptions shamed and
confused, our bodies tricked with medication, but
our soul never forgets. And because we are one,
one whole soul in one body, someday our body will
present its bill.”
Alice Miller
What society does to its children,
its children will do to society.
~Cicero, 106-43 B.C.E.
IF you don’t deal with trauma, trauma will
deal with you.
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!