There is no trust more sacred than the one the world
holds with children. There is no duty more
important than ensuring that their rights are
respected, that their welfare is protected, that their
lives are free from fear and want and that they grow
up in peace.
Kofi A. Annan
The “ACE” Study
&
Unaddressed Childhood Trauma
Presented by Ann Jennings Ph.D.
www.TheAnnaInstitute.Org
Anna’s Story
This is Anna at age one
and a half
This is Anna years
later – in a mental
institution
What happened?
Anna
Caroline
Jennings
1960 - 1992
The Adverse Childhood
Experiences Study
(ACE)
Collaboration between Kaiser Permanente’s Department of
Preventive Medicine in San Diego and the Center for Disease
Control and Prevention (CDC)
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)
What is the Adverse
Childhood
Experiences (ACE)
Study?
Decade long. 17,000 people involved.
Looked at effects of adverse childhood experiences
over the lifespan.
Largest study ever done on this subject.
ACE Study Findings
Childhood experiences are powerful
determinants of who we become as adults
Adverse Childhood Experience*
Categories
Abuse of Child
Recurrent Severe Emotional abuse
Recurrent Physical abuse
Contact Sexual abuse
Trauma in Child’s Household
Environment
Substance abuse
Parental separation or divorce Chronically depressed, emotionally
disturbed or suicidal household
member
Mother treated violently
Imprisoned household member
Loss of parent – (by death,
by suicide, - or by
abandonment)
Neglect of Child
Abandonment
Child’s basic physical and/or
emotional needs unmet
Impact of Trauma and Health
Risk Behaviors to Ease the Pain
Neurobiologic Effects of Trauma
Health Risk Behaviors
* Above types of ACEs are the “heavy
end” of abuse.
Disrupted neuro-development
Difficulty controlling anger-rage
Hallucinations
Depression
Panic reactions
Anxiety
Multiple (6+) somatic problems
Sleep problems
Impaired memory
Flashbacks
Dissociation
Smoking
Severe obesity
Physical inactivity
Suicide attempts
Alcoholism
Drug abuse
50+ sex partners
Repetition of original trauma
Self Injury
Eating disorders
Perpetrate interpersonal violence
Long-Term Consequences of
Unaddressed Trauma (ACEs)
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: rape, DV
compromised ability to parent
Intergenerational transmission of
abuse
Long-term use of health,
behavioral health, correctional,
and social services
Adverse Childhood Experiences
are Common
Of the 17,000 HMO Members:
1 in 4 exposed to 2 categories of ACEs
1 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.
The higher the ACE Score, the
greater the likelihood of :
Severe and persistent emotional problems
Health risk behaviors
Serious social problems
Adult disease and disability
High health and mental health care costs
Poor life expectancy
For example:
The following information and slides are from September 2003 Presentation at “Snowbird
Conference” of the Child Trauma Treatment Network of the Intermountain West, by
Vincent J. Felitti, MD. And from Lanius/Vermetten Book Chapter 6/2007
Emotional Problems
% With a Lifetime History of
Depression
Childhood Experiences
Underlie
Chronic Depression
80
70
60
50
40
30
20
Women
Men
10
0
0
1
2
ACE Score
3
>=4
Childhood Experiences
Underlie Suicide
25
4+
% Attempting Suicide
20
15
3
10
2
5
0
1
0
ACE Score
ACE Score and Hallucinations
Ever Hallucinated* (%)
12
10
Abused
Alcohol
or Drugs
8
No
Yes
6
4
2
0
0
1
2
3
4
5
6
ACE Score
*Adjusted for age, sex, race, and education.
>=7
Childhood Sexual Abuse and the
Number of Unexplained Symptoms
Number of Symptoms
Percent Abused (%)
45
40
0
1
2
3
4
5
6
7
8
35
30
25
20
15
10
5
0
History of Childhood Sexual Abuse
ACE Score and Impaired Memory
of Childhood
Percent With Memory
Impairment (%)
ACE Score
1
2
3
ACE Score
4
5
Health Risk Behaviors
Adverse Childhood Experiences
and Current Smoking
20
18
16
14
12
%
10
8
6
4
2
0
0
1
2
3
ACE Score
4-5
6 or more
Childhood Experiences and
Adult Alcoholism
18
16
4+
% Alcoholic
14
12
3
10
2
8
6
1
4
2
0
0
ACE Score
ACE Score and Intravenous
Drug Use
% Have Injected Drugs
3.5
3
2.5
2
1.5
1
0.5
0
0
1
2
3
4 or more
ACE Score
N = 8,022
p<0.001
Basic cause of addiction is experiencedependent, not substance-dependent
Significant implications for medical
practice and treatment programs
Serious Social Problems
Childhood Experiences Underlie
Rape
35
4+
% Reporting Rape
30
25
20
3
2
15
10
5
1
0
0
ACE Score
Adverse Childhood Experiences and
Likelihood of > 50 Sexual Partners
Adjusted Odds Ratio
4
3
2
1
0
0
1
2
ACE Score
3
4 or more
% have Unintended PG, or AB
ACE Score and Unintended
Pregnancy or Elective Abortion
80
Unintended Pregnancy
70
Elective Abortion
60
50
40
30
20
10
0
0
1
2
ACE Score
3
4 or more
Sexual Abuse of Male Children and Their
Likelihood of Impregnating a Teenage Girl
35
1.8x
30
1.3x
25
20
1.4x
1.0 ref
15
10
5
0
Not
abused
16-18yrs 11-15 yrs <=10 yrs
Age when first abused
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
35
30
25
Pink =self
Yellow =mother
20
15
10
5
0
Never
Once,
Twice
Sometimes
Often
Very
often
ACE Score and Indicators of
Impaired Worker Performance
25
Prevalence of Impaired
Performance (%)
ACE Score
20
0
1
2
3
4 or more
15
10
5
0
Absenteeism (>2
days/month
Serious Financial
Poblems
Serious Job
Problems
Adult Disease and Disability
Adverse Childhood Experiences and
History of STD
Adjusted Odds Ratio
3
2.5
2
1.5
1
0.5
0
0
1
2
ACE Score
3
4 or more
ACEs Increase Likelihood of Heart Disease*
•
•
•
•
•
•
•
•
•
Emotional abuse
Physical abuse
Sexual abuse
Domestic violence
Mental illness
Substance abuse
Household criminal
Emotional neglect
Physical neglect
1.7x
1.5x
1.4x
1.4x
1.4x
1.3x
1.7x
1.3x
1.4x
High Health and Mental
Health Care Costs
Poor Life Expectancy
Effect of ACEs on Mortality
Age Group
Percent in Age Group
60
19-34
35-49
50-64
>=65
50
40
30
20
10
0
0
2
ACE Score
4
ACE Study
www.cdc.gov/nccdphp/ace
www.acestudy.org
Other Studies on Childhood
Sexual and/or Physical
Abuse
Sarah
Joe,
Anna
John
Mary
Early Child Sexual Abuse (CSA) may especially
impair resiliency
Substance Abuse and Unaddressed
Childhood Sexual/Physical Abuse
2/3rds of men and women in SA treatment - physical
and/or sexual abuse
75% of the women - sexually abused.
SAMHSA/CSAT, 2000;
SAMHSA, 1994
Teenagers with alcohol and drug problems - 6 to 12 times
more likely physically abused ,
18 to 21 times more likely sexually abused .
Clark et al, 1997
Of AI/AN women in SA treatment – 86% report physical
abuse histories, 69% sexual abuse histories.
Of those with sexual abuse histories, 96.7% physically
abused . 96% of both (sa, pa) emotionally abused.
Saylors, 2003; 2004
Serious Mental Illness and Unaddressed
Sexual/Physical Abuse
51 – 98% of public mental health clients
with severe mental health diagnoses
Goodman et al, 1999, Mueser et al, 1998; Cusack et al, 2003
93% of psychiatrically hospitalized
adolescents
Ipschitz et al, 1999
Criminal Justice Problems and
Unaddressed Sexual/Physical Abuse
More than 75% of girls in juvenile justice
system
Calhoun et al, 1993
80% of women in prison and jails
100% of men on death row
Smith, 1998
Freedman, Hemenway,
2000
Boys who commit violence
van der Kolk, 1998
Self-Injury and Suicide and
Unaddressed Childhood Sexual Abuse
Childhood sexual abuse is significantly related to
adolescent and adult self-harm, including suicide
attempts, cutting, and self-starving.
Van der Kolk et al, 1991
One study found childhood sexual abuse to be
the single strongest predictor of suicidality
Read et al, 2001
Prevalence of Child Sexual Abuse
1/4th to 1/3rd of all children and as many as
42% of girls are sexually abused before age
18 – with 9% experiencing persistent, genital
assault. Males are underreported.
Saunders et al, 1992; Randall 1995; Epstein, 1998
79.8% of American Indian girls experience
sexual abuse . This abuse starts early.
National Center on Child Abuse and Neglect, 1999
One fifth of all sexually abused children
develop serious psychological disturbances
as adults .
Giller, 2007
Yet the Silence Continues
“They do not want
to hear what their
children suffer.
They’ve made the
telling of the
suffering itself
taboo”
From ACE Study Slides: Vincent Felitti
From Possessing the Secret of Joy,
Alice Walker
Lasting Alterations in
Self Perception
The sexual and physical violation of children
results in alterations in self-perception which
are immediate, last throughout the life-span,
and contribute to suicidality as a way to cope.
Judith Herman, 1992
Sense of helplessness, paralysis, captivity,
inadequacy, powerlessness, danger, fear
Continues over the lifespan
Sense of Shame, Guilt, Self-Blame, Being Bad
Continues over the lifespan
Sense of defilement, contamination, spoiled,
degraded, debased, despicable, evil
Continues over the lifespan
Sense of complete difference from others, deviance, utter
aloneness, isolation, non-human, specialness, unseen,
unheard, belief no other person can ever understand
Continues over the lifespan
In Summary
Childhood abuse and trauma:
Impacts brain and nervous system, perception
of self and others
Causes serious and chronic health, behavioral
health and social problems
Epidemic proportions. Major public health
issue
Often unrecognized , ignored or denied.
There are Many Faces of Trauma
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
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 $265,200 - (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.
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 = $33,101,302,133.00
Annual Indirect Costs: Special Education, Juvenile
Delinquency, Mental Health and Health Care, Adult
Criminal Justice System, Lost productivity to Society =
$70,652,715,359.00
Total Annual Cost: $103,754,017,492.00
Economic Impact Study. (September, 2007). Prevent Child Abuse America
Investing in Our Children
The issue is not are we going to pay - - it’s are we going to pay now, up front,
or are we going to pay a whole lot more
later on.
Marian Wright Edelman
What Can We Do as Individuals?
Break societal silence and end
the isolation of the child.
Ask “what happened” vs
whats wrong with you.
Listen. Pay attention. Believe.
Respond with compassion.
Be a safe place for the child.
A Public Health Approach
I.
Prevention
II. Detection and Early Intervention
III. Safe, Strengthening and Healing
Environments and Responses
“If you think you’re too small
to make a difference, try
sleeping in a room with a
mosquito.”
African Proverb
“The solution of adult
problems tomorrow
depends in large
measure upon the way
our children grow up
today”.
Margaret Mead
Thank You
www.TheAnnaInstitute.Org
