Misty McIntyre Goodsell LCSW Chris Adams Hill LCSW wwwsouthvalleytherapycom South Valley Therapy Objectives Background of ACES Study ACES Questionnaire ACES Outcomes Implementing in practice ID: 200491
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Slide1
Using the Adverse Childhood Experiences Scale (ACES)
Misty McIntyre Goodsell, LCSWChris Adams Hill, LCSW
www.southvalleytherapy.com
South Valley TherapySlide2
ObjectivesBackground of ACES Study
ACES QuestionnaireACES OutcomesImplementing in practiceMacro
www.southvalleytherapy.com
South Valley TherapySlide3
ACES Background
Collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the Center for Disease Control and Prevention (CDC)Dr. Vincent Felitti & Dr. Robert F. Anda
South Valley Therapy
www.southvalleytherapy.comSlide4
ACES Background
10 year study17,000 participantsCorrelated ACES score to health and behaviors occurring over participants’ lifespansLargest study of its kind
South Valley Therapy
www.southvalleytherapy.comSlide5
DemographicsSouth Valley Therapy
www.southvalleytherapy.com
Gender
Male
46%
Female
54%
Race
White
74.8%
Hispanic (Latin/Chicano)
11.2%
Asian/Pacific
Islander
7.2%
African-American
4.6%
Other
1.9%
Age
19-29
5.3%
30-39
9.8%40-4918.6%50-5919.9%60 and over46.4%
Education
Less than HS
7.2%
High School
17.6%
Some
College
35.9%
College Grad or Higher
39.3%Slide6
Questionnaire
South Valley Therapywww.southvalleytherapy.com
Additional questions:
Have you ever been a combat soldier?
Have you ever lived in a war zone?
Have you ever been physically abused as a child?
Have you ever been sexually molested as a child or adolescent?
Have you ever been raped?
Who in your family has been murdered?
Who in your family has had a nervous breakdown?
Who in your family has been a suicide?
Who in your family has been an alcoholic or drug user?Slide7
Outcomes
Number of categories (not events) is summed ACE Score Prevalence
0 33%
1 25%
2 15%
3 10%
4 6%
5 or more 11%
2 out of 3 experienced at least one
category of ACE
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 more
Women are 50% more likely than men to have a Score of 5<
South Valley Therapy
www.southvalleytherapy.comSlide8
Prevalence of Adverse Childhood Experiences
Abuse, by Category Prevalence (%) Psychological (by parents) 11%
Physical (by parents) 28% Sexual (anyone) 22%
Neglect, by Category
Emotional 15%
Physical 10%
Household Dysfunction, by Category
Alcoholism or drug use in home 27%
Loss of biological parent <age 18 23%
Depression or mental illness in home 17%
Mother treated violently 13%
Imprisoned household member 5%
South Valley Therapy
www.southvalleytherapy.comSlide9
Adverse Childhood Experiences Are Common
Of the 17,000 HMO Members:1 in 4 exposed to 2 categories of ACES1 in 16 was exposed to 4 categories22% were sexually abused as children66% of the women experienced abuse, violence or family strife in childhood
South Valley Therapy
www.southvalleytherapy.comSlide10
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
Disrupted
neuro
-development
Difficulty controlling anger-rage
Hallucinations
Depression
Panic reactions
Anxiety
Multiple (6+) somatic problems Sleep problems Impaired memory Flashbacks DissociationHealth Risk Behaviors Smoking Severe obesity Physical inactivity Suicide attempts Alcoholism Drug abuse 50+ sex partners Repetition of original trauma Self Injury Eating disorders Perpetrate interpersonal violenceLong-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/AIDSSerious 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
Slide11
ACEs Background
The higher the ACE score, the greater the likelihood of:Severe and persistent emotional problemsHealth risk behaviorsSerious social problemsAdult disease and disability
High health and mental health care costsPoor life expectancy
South Valley Therapy
www.southvalleytherapy.comSlide12
ACES Background Big Finding:
Childhood experiences are POWERFUL determinants of adult health outcomesSouth Valley Therapy
www.southvalleytherapy.comSlide13
The following information and slides are being used with permission from three sources:
September 2003 Presentation of the Child Trauma Treatment Network of the Intermountain West, by Vincent Felitti, MD Powerpoint presentation of Ann Jennings, Ph.D. of The Anna Institute
Felitti & Anda
(2010). The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: implications for healthcare. In Ruth
Lanius
, Eric
Vermetten
& Clare Pain (Eds.),
The Impact of Early Life Trauma on Health and Disease:
77-87.
Massachusettes
: Cambridge University Press.
South Valley Therapy
www.southvalleytherapy.comSlide14
Emotional Problems
South Valley Therapywww.southvalleytherapy.comSlide15
Childhood Experiences Underlie Chronic Depression
South Valley Therapywww.southvalleytherapy.comSlide16
Childhood Experiences Underlie Suicide
South Valley Therapywww.southvalleytherapy.comSlide17
ACE Score and HallucinationsSouth Valley Therapy
www.southvalleytherapy.com
Ever Hallucinated* (%)
Abused
Alcohol
or DrugsSlide18
ACE Score and Impaired Childhood Memory
South Valley Therapywww.southvalleytherapy.com
Percentage With Memory Impairment (%)Slide19
Social Issues
South Valley Therapywww.southvalleytherapy.comSlide20
ACE vs. Smoking as an AdultSouth Valley Therapy
www.southvalleytherapy.comSlide21
ACE vs Adult Alcoholism
South Valley Therapywww.southvalleytherapy.comSlide22
ACE vs IV Drug Use
South Valley Therapywww.southvalleytherapy.comSlide23
Childhood Experience Underlie Rape
South Valley Therapywww.southvalleytherapy.comSlide24
ACE and Likelihood of >50 Sexual Partners
South Valley Therapywww.southvalleytherapy.comSlide25
Sexual Abuse of Male Children and Their Likelihood of Impregnating a Teenage Girl
South Valley Therapywww.southvalleytherapy.com
Percentage Who Impregnate A Teenage Girl
Not Abused 16-18 Years 11-15 Years <=10 Years
Age When First AbusedSlide26
Frequency of a girl being physically abused or witnessing one’s mother being abused and the likelihood of ever having a teen pregnancy
Percent who had a teen pregnancy
Never Once, Twice Sometimes Often Very
Self
Mother
rSlide27
Health Outcomes
South Valley Therapywww.southvalleytherapy.comSlide28
ACE vs. History of STDSouth Valley Therapy
www.southvalleytherapy.comSlide29
ACEs vs. ObesitySouth Valley Therapy
www.southvalleytherapy.comSlide30
Effect of ACEs on MortalitySouth Valley Therapy
www.southvalleytherapy.comSlide31
What changes were seen?
35% reduction in doctor office visits was found in the year following the assessment (compared to the year before)11% decrease in ER visits3% reduction in hospitalizationsThese changes returned to baseline after two years when medial staff returned to previous medical
model without asking about ACEs or including treatment for the identified trauma
Felitti
&
Anda
, 2010
South Valley Therapy
www.southvalleytherapy.comSlide32
Power of the ACE Study
SimplicityThe Data Tell A Simple StoryACEs are commonACEs are highly interrelatedACEs pile up and have a cumulative impact
ACEs account for a large percentage of health and social problemsBiologic Plausability
South Valley Therapy
www.southvalleytherapy.comSlide33
What presents as the PROBLEM may in fact be an attempted solution
South Valley Therapywww.southvalleytherapy.comSlide34
AssessmentACES is an assessment tool
24 Hour HotlineYour ACE score never changesHow do we track progress?BDI, BAI, OQ, YOQ, Suicide Assessments, PCL-CResiliency: Empowerment Scale, Youth Self-Efficacy Scale
South Valley Therapy
www.southvalleytherapy.comSlide35
ApproachUse a Trauma Lens
Shifting from What is wrong with this person? to What has this person been through?Routinely seek a history of adverse childhood experiences from ALL patients
Acknowledge their reality by asking, “How has this affected you later in life?”Transparency
South Valley Therapy
www.southvalleytherapy.comSlide36
Intergenerational Impact
Children of Parents with ACE scores are secondary victimsHistorical TraumaParents with ACE scores will often lack coping and resilience that fosters effective parentingWhat does this mean for the extended family of our adult patients?
South Valley Therapy
www.southvalleytherapy.comSlide37
Therapy
There is no SINGLE recommended approachTrauma Based Therapies:Trauma Based CBTEMDRDBTEFT (Tapping)
MindfulnessMindfulness CBT (MCBT)
Family Therapy
South Valley Therapy
www.southvalleytherapy.comSlide38
TherapyDepression
Psycho-Educationi.e. DBT Skills, Communication, Stress ManagementWhole-Person ApproachReferrals
South Valley Therapy
www.southvalleytherapy.comSlide39
Strength Building
South Valley Therapy
www.southvalleytherapy.comSlide40
Micro Recommendations
Implementation Private PracticeHealth FacilitiesSenior LivingCorrectionsEducation System
Make Personal Connections to MDs and NursesConnect Children to Resiliency Activities
Mind-Body Connections
South Valley Therapy
www.southvalleytherapy.comSlide41
Macro Recommendations
ACEs becoming a primary assessment tool in mental and physical health agencies and organizationEncourage clinical research on trauma and its treatmentProviding funding to treat trauma should become a priority for Insurance, business, government etc.
Good for individuals, families and communitiesHigh Economic Impact
Whitfield, 1998
South Valley Therapy
www.southvalleytherapy.comSlide42
Macro Recommendations
Effective parenting programsParenting education starting as part of K-12 EducationRecognition of ACES/trauma and appropriate treatment should be a mandatory component of education for all health professionalsCreate and Endorse Primary Prevention
Efforts Whitfield
, 1998
South Valley Therapy
www.southvalleytherapy.comSlide43
ConsiderationsBaby Boomers and Older
Persons are a population that didn’t access or talk about mental health (cultural norm)South Valley Therapy
www.southvalleytherapy.comSlide44
Local ResourcesTrauma Informed Care Network
www.ticn.orgRape Recovery CenterUCASA40 Hour TrainingUtah Domestic Violence Council
uuadvt.orgUtah Department of HealthBRFSS Study
South Valley Therapy
www.southvalleytherapy.comSlide45
National ResourcesACEs Connection
Online Community of Researchers, Clinicians and Policy MakersThe Anna Institutewww.theannainstitute.orgACE Response
www.aceresponse.org
South Valley Therapy
www.southvalleytherapy.comSlide46
References
Anda RF, Butchart A, Felitti VJ, Brown DW. (2010). Building a Framework for Global Surveillance of the Public Health: Implications of Adverse Childhood Experiences.
Preventive Medicine, 39 (1
): 93
-
98.
Felitti
&
Anda
(2010). The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: implications for healthcare. In
Ruth
Lanius
, Eric
Vermetten
& Clare Pain (
Eds.),
The Impact of Early Life Trauma on Health and Disease:
77-87.
Massachusettes
: Cambridge
University Press.
Whitfield CL.
(1998). Adverse Childhood Experiences and Trauma (editorial). American Journal of Preventive Medicine, 14:361–363. South Valley Therapywww.southvalleytherapy.com