The Impact of Adverse Childhood
Experiences
LISC Chicago - Neighborhood Health Initiative
“Healthy Wednesday” Discussion
January 30, 2012

:
An overview of the pioneering work of Drs.
Robert Anda (CDC) & Vincent Felitti (Kaiser
Permanente), and Laura Porter (Family Policy
Council)
Presented by Elena Quintana, Ph.D.
Executive Director of the Adler Institute on Public Safety & Social Justice

– Anne Studzinski, Childhood Trauma Coalition
“The power to warn those downstream”
-- Laura Porter

• The ACE Study is ongoing collaborative research between the Centers for Disease Control and
Prevention in Atlanta, GA, and Kaiser Permanente in San Diego, CA.
• Data from over 17k participants reveals staggering proof of the health, social, and economic risks that result from childhood trauma.
Vincent Felitti, M.D., 2012

• Basic Science
• Brain Research
• Resilience Research
• Program & Intervention Development

A HISTORY OF THE FOLLOWING BY AGE 18 :
• Physical, Emotional, or Sexual Abuse
• Physical or Emotional Neglect
• Mental Illness
• Prison
• Domestic Violence
• Divorce or Parental Loss
• Substance Abuse

• Please be aware that there are trends that are discussed, and that NO INDIVIDUAL SCORE explains all.
• There are very high functioning high scorers, and low functioning low scorers.
• All can agree: ACEs are powerful forces that we want to prevent by whatever means possible.

Prevalence Percentiles of Adverse Childhood Experiences
Abuse, by Category
• Psychological (by parents)
• Physical (by parents)
• Sexual (anyone)
11%
28%
22%
Neglect, by Category
• Emotional
• Physical
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
15%
10%
27%
23%
17%
13%
5%
Vincent Felitti,
M.D., 2012

People with 6 ACES die, on average, 20 years sooner than those with zero.

• 2/3 experience at least one category of ACEs
• If any one ACE is present, there is an 87% chance at least one other category of ACE is present, and a 50% chance that there will be 3 or more.
• WOMEN ARE 50% MORE LIKELY TO HAVE A
SCORE OF >5.
Vincent Felitti, M.D., 2012

Population
Average:
43% have
3 or more
ACEs as compared with
26% of
WA Adults
OLDER CHILDREN – WA High School Sophomores and Seniors

12
10
8
6
4
2
0
20
18
16
14
0
1 2 3 4
Vincent Felitti, M.D., 2012

60
50
40
30
20
10
0
0
1
2
3
Vincent Felitti, M.D., 2012
4
Men
Women

15
10
5
0
0
1
2
3
Robert Anda, M.D., 2012
4
5
Men
Women

25
20
15
10
35
30
5
0
0
Vincent Felitti, M.D., 2012
1 2 3 4

Laura Porter, 2012
BEHAVIORAL HEALTH
12
10
8
6
4
2
0
30
25
20
15
10
5
0
10,4
0
Current Smoking
13,2
11,1
16,3
20,8
28,5
1 2 3
Number of ACE Categories
4 or 5 6,7, or 8
Risk for HIV
10,2
7,3
6
5,1
3,7
2
0 1 2 3 4 or 5 6,7, or 8
Number of ACE Categories
CHRONIC DISEASE
Diabetes
14
12
10
8
6
4
2
0
6,1
7,5
8
7,5
7,9
11,7
10
8
6
4
2
0
0
4,9
1 2 3 4 or 5 6,7, or 8
Number of ACE Categories
Cardio Vascular
Disease
9,4
8,1
6,7
5,6 5,6
0 1 2 3 4 or 5 6,7, or 8
Number of ACE Categories

Laura Porter, 2012
30
25
20
15
10
5
0
25
20
15
10
5
0
MENTAL HEALTH
5,8
>14 of 30 Unhealthy
Mental Health Days
20,6
17,6
12,6
10,6
6,6
0 1 2 3
Number of ACE Categories
4 or 5 6,7, or 8
Treatment for Mental
Health Condition
24,5
19,3
15,5
14
11
7,3
0 1 2 3
Number of ACE Categories
4 or 5 6,7, or 8
DISABILITY
10
8
6
4
2
0
Missed Work > 14 of 30
Days Due to Mental Health
8,5
1,1
1,8
2,5
3,2
5,5
0 1 2 3
Number of ACE Categories
4 or 5 6,7, or 8
20
15
10
5
0
Health Problems Require
Special Equipment
5,2 5,2
6,4
8,6
11,3
14,8
0 1 2 3
Number of ACE Categories
4 or 5 6,7, or 8

• Make people feel that they can not speak their truth
• Make providers feel it’s impolite to ask certain questions
• Lead us all to believe that this suffering is uncommon
• Paralyze us* from taking life-saving action
*everyone

POPULATION
ATTRIBUTABLE
RISK
A large portion of many health, safety and prosperity conditions is attributable to Adverse
Childhood Experience.
ACE reduction reliably predicts a decrease in all of these conditions simultaneously.

EARLY CHILDHOOD
HIPPOCAMPUS
CONTROLS EMOTIONAL
REACTIONS,
CONSTRUCTS VERBAL &
SPATIAL MEMORY
SENSITIVE TO ALL
FORMS OF
MALTREATMENT IN
FIRST 2-3 YEARS OF LIFE,
ESPECIALLY SEXUAL
ABUSE
ADAPTATION
*EMOTIONALLY
REACTIVE – BRAIN’S
BRAKING MECHANISM
FAILS
*POOR REGULATION OF
BEHAVIOR
*DIFFICULTY WITH
VERBAL & SPATIAL
MEMORY
*NET VOLUME LOSS
BECOMES EVIDENT IN
20S.
Laura Porter, 2011
TRAUMA IS HARD-WIRED INTO BIOLOGY
MIDDLE
CHILDHOOD
CORPUS COLLOSUM
INTEGRATES
HEMISPHERES &
FACILITIES
INCLUDING
LANGUAGE DEV.,
MATH ABILITY, AND
PROCESSING SOCIAL
CUES SUCH AS
FACIAL EXPRESSIONS
SENSITIVE TO
NEGLECT IN INFANCY
SEX ABUSE AT AGES
~9&10
ADOLESCENCE – THE CORTEX
CENTER FOR THINKING & JUDGEMENT, EXECUTIVE
FUNCTION, LONG TERM MEMORY, & VISION
SENSITIVE TO WITNESSING VIOLENCE, AND SEX ABUSE
ADAPTATION
*POOR EXECUTIVE FUNCTION * IMPULSIVENESS
*DIMINISHED ABSTRACT REASONING * DIMINISHED
HOPE * LIMITING FIELD OF VISION
ADAPTATION
* LANGUAGE DELAY
*DIMINISHED MATH
CAPACITY
*DIMINISHED
INTEGRATION &
COORDINATION
*DIFFICULTY WITH
SOCIAL CUES

Important factors for the walking wounded:
1) Have a trustworthy person you can talk to about your true situation and feelings
2) The ability to reframe your life (e.g. as a 9 year old I was not responsible for my parent’s drinking behavior)
3) Have hope for your future

• Intelligence
• Talent and Skill Mastery
• Creative Expression
• Physical Activity
• Positive Human Touch

Community Safety Formula
R+O (hp²)=CS
Where human potential is squandered communities are less safe

Schools, juvenile detention center, immigration detention and policy, imprisonment, security, mental health

Bradley C. Stolbach, PhD
Program Director, Chicago Child Trauma Center
La Rabida Children's Hospital
Lead Technical Advisor
Midwest Region Complex Trauma Training and Technical Assistance Center
NCTSN Complex Trauma Treatment Network
Associate Professor of Clinical Pediatrics
The University of Chicago Pritzker School of Medicine
LISC Chicago Healthy Wednesday
Mental Health - Violence Roundtable
Chicago, IL, January 30, 2013

Who is a Child Soldier?
A child soldier is any person under 18 years of age who is part of any kind of regular or irregular armed force or armed group in any capacity, including but not limited to cooks, porters, messengers and anyone accompanying such groups, other than family members. The definition includes girls recruited for sexual purposes and for forced marriage.
It does not, therefore, only refer to a child who is carrying or has carried arms.
Cape Town Principles and Best Practices on the Recruitment of Children into the Armed Forces and on Demobilization and Social Reintegration of Child Soldiers in Africa (Cape
Town, 27-30 April 1997).

The Power of a Lens
Criminal or Maltreated Child or Child Soldier
U.S. incarcerates more than twice as many youth per 100,000 than next highest youth incarcerator.
Many of these youth are classified by statute as adults.
Youth of color are much more likely than others to be incarcerated. In Cook County, Illinois, African American youth are 46 times more likely than White youth to be incarcerated.

Adverse Childhood Experiences Study (ACES)*
Physical abuse by a parent
Emotional abuse by a parent
Sexual abuse by anyone
An alcohol and/or drug abuser in the household
An incarcerated household member
Someone who is chronically depressed, mentally ill, institutionalized, or suicidal
Domestic violence
Loss of a parent
Emotional neglect
Physical neglect
Felitti et al. 1998

Adverse Childhood Experiences Study (ACES)*
Felitti et al. 1998

The Co-Occurring Nature of Trauma
“ Individuals with a trauma history rarely experience only a single traumatic event, but rather are likely to have experienced several episodes of traumatic exposure.
”
Cloitre et al., 2009
(Retrospective studies, e.g., Kessler, 2000; Stewart et al., 2008;
Coid et al., 2001; Dong et al., 2004 )
NCTSN Core Data Set (2012)
Children Served in the National Child Traumatic Stress Network (n=11,138)
Fewer than 24% had experienced only one type of trauma or ACE.
Over 40% had experienced 4 or more.
Chicago Child Trauma Center (FY12)
Among children receiving services in FY12, 86% of those exposed to
Domestic Violence were also exposed to Physical and/or Sexual Abuse.

 Attachment: an evolved behavioral system that functions to promote the protection and safety of the attached person
 Attachment system is activated strongly by internal and external stressors or threats.
 It is through healthy attachment (i.e., a behavioral system that effectively protects and comforts the infant or child) that a child develops the capacity for emotional and behavioral selfregulation, as well as a coherent self.

Some Basic Assumptions About
Psychological Traumatization
Traumatic experiences are those which overwhelm an individual ’ s capacity to integrate experience in the normal way. (e.g., Putnam,
1985)
Following exposure to trauma, if integration does not occur, traumatic experience(s) are split off and an individual alternates between functioning as if the trauma is still occurring and functioning as if the trauma never occurred. (e.g., Nijenhuis et al., 2004)
Although traumatic memories and associations remain inaccessible to consciousness much of the time, they have the power to shape an individual ’ s daily functioning and behavior. (e.g., Allen, 1993)

Exposure to multiple forms of violence and other potentially traumatic stressors in the context of attachment behavioral systems that are unable to provide protection, care, and comfort
Focus on cumulative trauma and the developmental context in which exposure occurs rather than on discrete episodes
Proposed Developmental Trauma Disorder Criterion A:
A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:
A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and
A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse

Key Developmental Capacities Affected by
Complex Trauma
Ability to modulate, tolerate, or recover from extreme affect states
Regulation of bodily functions
Capacity to know emotions or bodily states
Capacity to describe emotions or bodily states
Capacity to perceive threat, including reading of safety and danger cues
Capacity for self-protection
Capacity for self-soothing
Ability to initiate or sustain goal-directed behavior
Coherent self, Identity
Capacity to regulate empathic arousal

Reactive aggression entails impulsivity, anger, and intolerance for perceived provocation whereas instrumental aggression is motivated by material or social gain (Crapanzano et al., 2010).
In a study of juveniles convicted of committing violent crimes,
Silvern & Griese (2012) found that:
Multiple maltreatment positively predicted reactive aggression.
The significant relationship between multiple maltreatment and reactive aggression was fully mediated by dissociative symptoms and partially mediated by PTSD symptoms.

Trauma Exposure in CeaseFire Chicago
Violence Interrupters and Outreach Workers n = 9
Mean total traumatic stressors and other ACES = 10.33
Range = 4 -15
Mean age of first trauma = 9 years, 2 months
89% exposed to domestic violence
DV was first trauma exposure for 67%
100% experienced at least 4 forms of ongoing traumatic stress.
Bocanegra & Stolbach, 2012

CeaseFire Self-Reported Trauma Exposure
Physical Abuse
Witnessed Physical Abuse
Witnessed Community Violence
Witnessed School Violence
Witnessed Domestic Violence
Loss Through Violent Death
Witnessed Sexual Victimization
Motor Vehicle Accident
Witnessed Homicide(s)
100%
100%
100%
100%
89%
89%
78%
56%
44%
Other trauma types include fire, burn, dog attack
Bocanegra & Stolbach, 2012

Youth Self-Reported Trauma Exposure n = 8
Physical Abuse
Witnessed Physical Abuse
Witnessed Domestic Violence
Witnessed Community Violence
Witnessed School Violence
Witnessed Homicide(s)
100%
100%
100%
100%
100%
75%
Loss Through Violent Death
Witnessed Sexual Victimization
Motor Vehicle Accident
Victim of Extrafamilial Violent Crime
Dog Attack
75%
62.5%
50%
50%
37.5%
Burns 37.5%
Other trauma types include fire, natural disaster, torture
Bocanegra & Stolbach, 2012

100% experienced both family violence and community violence.
100% experienced at least one form of ongoing traumatic stress.
Average age of first trauma exposure = 6 years, 1 month
Mean # Types of Trauma Experienced = 10
Range = 7 - 13
Bocanegra & Stolbach, 2012

Youth Other Adverse Experiences
Impaired Caregiver
Exposure to Drug Use or Criminal Activity in Home
Exposure to Prostitution or other Developmentally
Inappropriate Sexual Behavior in Home
Substitute Care
75%
75%
37.5%
25%
Other ACEs include incarcerated significant other, homelessness, neglect
Mean # Types of Adverse Experiences = 2.75
Range # Types of Adverse Experiences = 0 – 5
Bocanegra & Stolbach, 2012

Youth
Mean Combined Total Types of Traumatic Stressors +
Other Adverse Childhood Experiences =
12.75
Range = 7 - 18
Bocanegra & Stolbach, 2012

Torture
Physical Abuse
Substitute Care
Witnessed Community Violence
Witnessed Physical Abuse
Impaired Caregiver
Extrafamilial Violent Crime Victim
Witnessed Domestic Violence
Witnessed Sexual Assault
Motor Vehicle Accident
Traumatic Loss
Witnessing Homicide (3)
School Violence
Dog Attack
Burn
Total Types of Traumatic Stress 13
Total Types of Adverse Other Experiences 2
5
5 - 13
7
8 – 13
9 - 13
9 - 13
9 - 13
10 - 13
10
12
12
12, 13
12 - 13
12
12
Bocanegra & Stolbach, 2012

Trauma History Timeline: “ Alfonso ”
Age at which Trauma/ACE Occurred In Years
Trauma/Adverse Experiences
Torture
Physical Abuse
Substitute Care
Witnessed Community Violence
Witnessed Physical Abuse
Impaired Caregiver
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Extrafamilial Violent Crime Victim
Witnessed Domestic Violence
Witnessed Sexual Assault
Witnessed School Violence
Witnessed Homicides (3)
Motor Vehicle Accident
Traumatic Loss
Burn
Dog Attack
BLACK LINE = AGE WHEN FIRST PERFORMED ACTIONS
ON BEHALF OF STREET ORGANIZATION

nd
Fire
Domestic Violence
Impaired Caregiver
Physical Abuse
Sexual Abuse/Assault
Community Violence
School Violence
Extrafamilial Violent Crime Victim
Motor Vehicle Accident
Incarceration
Traumatic Loss
Witnessing Homicide
Homelessness
Employment in Sex Industry
Burn
1
5
5 - 20
5, 15, 16
7, 15, 16
10
10 - 16
12 - 20
14, 19
17 - 21
18
18, 19
19, 20
19, 20
20
Total Types of Traumatic Stress
Total Types of Adverse Other Experiences
12
4

Trauma History Timeline: 20-Year-Old 2 nd Generation Latina
Age In Years
Trauma/Adverse Experiences
House Fire
Domestic Violence
Physical Abuse
Impaired Caregiver
Neglect
Drug Use or Criminal Activity in Home
Sexual Abuse/Assault
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
School Violence
Street Violence, Witnessing Homicide
Extrafamilial Violent Crime Victim
Motor Vehicle Accident
Incarceration
Traumatic Loss or Bereavement
Homelessness, Sex Trade Worker
Burn

Dr. Paul Farmer: “ Structural violence is one way of describing social arrangements that put individuals and populations in harm ’ s way… The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people … neither culture nor pure individual will is at fault; rather, historically given (and often economically driven) processes and forces conspire to constrain individual agency. Structural violence is visited upon all those whose social status denies them access to the fruits of scientific and social progress.
”

Urban Black and Brown families face a unique set of adversities and stressors. The massive historical traumas of attempted genocide and slavery have never been addressed, yet create the context in which present traumas occur and are dealt with.
Those of us working with children and families whose daily existence is shaped by the legacy of slavery and racial injustice cannot optimally intervene if we fail to understand and address the effects of the trauma of the past.

Societal Traumatization and the Legacy of
Imperialism, Attempted Genocide, & Slavery
Just as in cases of individual traumatization, avoidance of acknowledging and addressing the traumatic past makes it impossible for integration to occur.
As long as historical trauma remains taboo, the racial divisions that pervade every aspect of American life will persist.

Eddie Bocanegra,
Community Renewal Society
M.A. Candidate, University of Chicago
School of Social Services


Present 4 community-based interventions that I founded to address trauma as a result of participation/ exposure to community violence

Disclaimer: All of these programs were developed without funding and drawing upon volunteers from major universities as well as other professionals

Motivation behind developing these programs


2 Components:

Support group for parents who have lost children to violence (Spanish, started
June 2010)

Support group for surviving siblings of the homicide victims

Critical point of intervention


Community arts group that engages ganginvolved youth and uses art as a medium for processing trauma and identity exploration

Physical Abuse
Witnessed Physical Abuse
Witnessed Domestic Violence
Witnessed Community Violence
Witnessed School Violence
Witnessed Homicide(s)
Loss Through Violent Death
Witnessed Sexual Victimization
Motor Vehicle Accident
Victim of Extrafamilial Violent Crime
Dog Attack
Burns
100%
100%
100%
100%
100%
75%
75%
62.5%
50%
50%
37.5%
37.5%
Other trauma types include fire, natural disaster, torture

100% experienced both family violence and community violence.
100% experienced at least one form of ongoing traumatic stress.
Average age of first trauma exposure = 6 years, 1 month


Peer educator group bringing together combat veterans and young men to process trauma as a result of violence

12 Week Peer Educator Program that focuses in the following areas:

Mentorship

Identity Development

Empowerment

Self-Empathy

Protective Factors and Resources
Themes in the curriculum:
Combat and Survival
Reframing and Reshaping Personal Experiences of Violence


Coalition led by ex-offenders to create more opportunities for gainful employment by advocating for policy change

Addressing trauma through organizing for systems change

Kathryn Saclarides, LCSW
Director of Violence Prevention
Enlace Chicago





Children exposed to violence are more likely to have behavior problems
Children who witness violence are at increased risk for becoming victims themselves, suffering from PTSD, substance abuse, running away from home, or engaging in criminal activity
Males are more likely than females to be victims and witnesses of violent acts
African American and Latino youth have reported higher rates of exposure to violence


Trauma can occur often enough when it becomes part of the common human experience.
◦ Overt expressions of trauma: Violence, assault
◦ Insidious forms of trauma: discrimination, racism, oppression, and poverty

When experienced chronically, the cumulative impact can be life-altering


Social determinants of health and mental wellbeing at individual, community, and social system level



Case study of Derrion
Albert’s murder
Changing Places: How
Communities Will Improve the Health of Boys of Color
Ed: Christopher Edley, Jr and Jorge Ruiz de Velasco










Son of immigrant parents
Born in Little Village
Exposed to domestic violence and substance abuse within the household
Father left the family when Freddy was in 5 th grade, mother becomes sole provider for family
Academic difficulties
Bullying in school and from police
Gang initiation
Living in “opposition” territory
Freddy drops out of school
 Freddy gets out of the gang




Freddy’s death was 20 years in the making, just as was Derrion Albert’s
ACES as a crucial paradigm for who we target, why we target these youth with our resources, and how we advocate for them within multiple systems.
Programs and resources cannot just target the top of the pyramid- unless you want superficial results or none at all
 ksaclarides@enlacechicago.org