The Adverse Childhood Experiences (ACE) Study, Substance Abuse, and Trauma Informed Care for Home

Visitors

Jennifer Stout, LICSW, MLADC

Goals

• 1. Describe the Adverse Childhood Experiences Study and why it is important.

• 2. Examine the relationship between adverse childhood experiences and substance abuse.

• 3. Talk about opportunities in home visiting to provide inter-generational trauma-informed care.

The ACE Study• Kaiser Permanente, San Diego• 17,000 volunteers• About 50/50 male/female participants• Almost half had college degrees• Mean age was 57

Adverse Childhood Experiences• 1. Recurrent physical abuse• 2. Recurrent severe emotional abuse• 3. Contact sexual abuse• 4. Physical neglect• 5. Emotional neglectGrowing up in a household…• 6. where someone was in prison• 7. where the mother was treated violently• 8. with an alcoholic or drug user• 9. where someone was chronically depressed, mentally ill,

or suicidal• 10. where at least 1 biological parent was lost to the

person during childhood, regardless of the cause.

According to the study, ACE’s:

• are vastly more common than recognized or acknowledged• have a powerful relation to adult

health and behaviors a half-century later.

ACE are more common that expected…

• 64%of study participants reported at least 1 ACE score.

• If you experienced 1 adverse childhood experience, you had an 80% chance of having at least 1 more.

• 20% had 3, 12% had 4 or more• 16% of men and 26% of women reported

childhood sexual abuse• 66% of the women in the sample experienced

abuse, violence, or household dysfunction in childhood. (Felitti, 2002)

ACE have a powerful relationship to adult health

As the number of adverse childhood experiences increased, the number of health and social outcomes

also increased:

Including obesity, diabetes, substance abuse, and mental illness

*********MAJOR PUBLIC HEALTH CRISES********

“Every adult was once a child”Robert Block

Types of Trauma

• Acute Trauma “is an emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical”• PTSD may develop.

• (American Psychological Association)

• Complex/Chronic Trauma + childhood=– Exposure to multiple traumatic events, that

are • Relational• Chronic• Long-term

These events begin early in life and can impact the very formation of self, interfere with the child having a primary source of safety and stability created through secure attachment.

• “Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life.” — Judith Herman, Trauma and Recovery

•HOW?

• The Stress Response

• “Young children cannot manage most dangers”- Patricia Crittendon, PhD

• Positive stress response

• Tolerable stress response

• Toxic stress response

Toxic Stress Response

• Toxic Stress in the Developing Child

TOXIC STRESS AND THE YOUNG CHILD• Toxic stress can disrupt the development of

neural circuits in the brain in early childhood. • High levels of stress hormones can suppress

the body’s immune system and impact physical health.

• Sustained high levels of cortisol can damage the hippocampus, an area of the brain responsible for memory and learning.

What does this look like?Biologically: problems with movement and sensation,

hypersensitivity to physical contact, difficulty with balance and coordination.

Physically: stomach problems, fast heart rates, difficulty sleeping. Socially: relationships can be characterized by boundary problems

or distrust. They can have difficulty empathizing with others. Intellectually: trouble focusing, completing tasks, understanding

their part in what happens to them, leaning difficulties.Emotionally: difficulty regulating mood, knowing their feelings,

low self esteem, not a clear sense of self. Behaviorally: poor impulse control, aggression, or becomes passive

and fearful, have a heightened awareness of potential dangers.

Aren’t we talking about substance abuse????

Trauma and Toxic Stress in Adolescence

• Prefrontal cortex development promotes:– Assessing behavioral consequences– Appraising of danger and safety– Meeting long term goals

THIS DEVELOPMENT IS IMPAIRED BY TOXIC STRESS

What does this look like?

• Behavioral: reckless, aggressive risk taking behavior, (danger of re-vicimization, sa)

• Emotional: feel angry, ashamed, low self esteem, anxious, depressed, over or underestimating danger

• Physical: poor sleep, disturbed eating• Social: feeling alone, childish”, expecting

maltreatment• Intellectual: underachievement at school

Adopting High Risk Behaviors

Alcohol abuseIllicit drug abuseObesity (overeating)Promiscuity Risk of pathologic gambling

Alcohol, Drugs, and ACE

• Maltreated children are at 1/3 greater risk for using drugs as teenagers (Kelley, Thornberry, and Smith, 1997)

• People with high ACE scored were more likely to initiate alcohol and illicit drug use at an earlier age.

• Participants with high ACE scores were more likely to identify as an alcoholic and marry an alcoholic.

• They were more likely to experience addiction.• They were more likely to have more than 30 sexual

partners & engage in sexual intercourse earlier.

(DHHS, 2008)

Alcohol, Drugs and ACE continued…

• One study estimates that as many as 75% of women in treatment for alcoholism have a history of sexual abuse.

• Approximately 50%-60% of women and 20% of men in chemical dependency programs report having been victims of sexual abuse, 69% of women and 80% of men report physical abuse. (Matsakis, 1994)

• Women who have an ACE score of 4 or more have are 78% more likely to inject drugs compared to women with an ACE score of 0.

• A male with an ACE score of 6 has a 46-fold (4,600%) increased risk of becoming an injection drug user later in life. (Miller, 2011)

• “Since no one injects heroin to get endocarditis or AIDS, why is it used? Might heroin be used for the relief of profound anguish dating back to childhood experiences? Might its psychoactive effects be the best coping device that an individual can find? Is intravenous drug use properly viewed as a personal solution to problems that are well concealed by social niceties and taboo? If so, is intravenous drug use a public health problem or a personal solution? Is it both? Is drug abuse self-destructive or is it a desperate attempt at self-healing, albeit while accepting a significant future risk? “- Felitti, 2002

How do home visitors help??

Powerful opportunity for intergenerational trauma-informed

intervention1. Using trauma informed interactions

with caregivers and children to promote healing.

2. Alleviating toxic stress for the child and caregiver

What is being Trauma Informed??

• “A trauma informed approach is based on the recognition that many behaviors and responses (often seen as symptoms) expressed by survivors and consumers are directly related to traumatic experiences that often cause mental health, substance abuse, and physical health concerns.”

• National Center for Trauma Informed Care• Substance Abuse and Mental Health Service Administration

TIC Guiding Values

• Understand the impact & prevalence of trauma

• Communicate with compassion• Promote safety• Earn trust• Embrace diversity

TIC guiding values continued

Harvard’s Center for the Developing Child says…

• The most effective prevention (of toxic stress) is to reduce exposure of young children to extremely stressful conditions…Programs or services can remediate the conditions or provide stable, buffering relationships with adult caregivers. Research shows that, even under stressful conditions, supportive, responsive relationships with caring adults as early in life as possible can prevent or reverse the damaging effects of toxic stress response.

The Pew Center on the States Says…

• “Evidence shows that when families volunteer to receive home based support in partnership with trained professionals, their children are born healthier and are less likely to suffer from abuse or neglect.”

Conclusions:• As home visitors, you are in the unique position

to CHANGE BRAINS!!– Offer support, information, and modeling to the

parent, child, and parent-child diad.– Your trauma-informed interactions help heal the

caregiver and offer an opportunity for children to increase experiences of safety so that their brains can go about the business of thinking and learning.

– This builds RESILIENCE for both caregiver and child- stress and danger may happen, but positive adaptation and coping can, too.

• jstout@familiesfirstseacoast.org

References:• Bloom, Sandra. “Doubls Trouble: The Perils of Substance Abuse and PTSD” (2000).• Ott, David. “Trauma Informed Care:Top 10 Tips for Caregivers and Case Managers”.• Barnes, Barbara, Claudia Meyer and Martha Williamson. “Trauma Informed Care”.• Cave, Cathey and Niki Miller. “Trauma and Its Impact”. • Carson, Kathy et al. “Adverse Childhood Experiences and Evidence Based Home Visiting”. (2011)• Center for Nonviolence and Social Justice (website)• Crittendon, Patricia M. “A dynamic maturation Model of Attachment”. (2006)• Lucenko, Barbara et al. “Adverse Childhood Experiences Associated with behavioral health Problems in Adolescents”.

(2012)• Middlebrooks, Jennifer and Natalie Audage. “The Effects of Childhood Stress on Health Across the Lifespan” (DHHS, CDC)• Jennings, AnnPhD. “The ACE Study and Unaddressed Childhood Trauma. • Felitti, Vincent. “The Relationship of Adverse Childhood Experiences to Adult Health, Turning Gold into Lead”. (2002)• McEwan, Bruce. “Brain on Stress: How the Social Environment gets under the Skin”. (2013)• Anda, Felitti et al. “The enduring effects of abuse and related adverse experiences in childhood”. (2006)

• www.acestudy.org• www.acesconnections.org