The ACE Study The Tragic Consequences of Unaddressed

The “ACE” Study The Tragic Consequences of Unaddressed Childhood Trauma Presented by Ann Jennings Ph. D Federal Roundtable on Women and Trauma April 29, 2010

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 Study) “In my beginning is my end. ” T. S. Eliot, Four Quartets

What is the Adverse Childhood Experiences (ACE) Study? n CDC and Kaiser Permanente Collaboration n Over decade long. 17, 000 people involved. n Looked at effects of adverse childhood experiences over the lifespan. n Largest study ever done on this subject.

ACE Study Findings Childhood experiences are powerful determinants of who we become as adults n

Adverse Childhood Experience* ACE Categories (Birth to 18) Abuse of Child n n n Emotional abuse Physical abuse Contact Sexual abuse Trauma in Child’s Household Environment Alcohol and/or Drug User n Chronically depressed, emotionally disturbed or suicidal household member n Mother treated violently n Imprisoned household member n Not raised by both biological parents (Loss of parent – best by death unless suicide, - Worst by abandonment) n Neglect of Child n n Physical neglect Emotional neglect Impact of Trauma and Health Long-Term Consequences of Risk Behaviors to Ease the Unaddressed Trauma (ACEs) Pain Disease and Disability Neurobiologic Effects of n Ischemic heart disease Trauma n Cancer Disrupted neuro-development n Difficulty controlling anger-rage n Hallucinations n Depression - other MH Disorders n Panic reactions n Anxiety n Multiple (6+) somatic problems n Sleep problems n Impaired memory n Flashbacks n Dissociation n Health Risk Behaviors n n n n Smoking Severe obesity Physical inactivity Suicide attempts Alcoholism Drug abuse 50+ sex partners Repetition of original trauma n n n n Chronic lung disease Chronic emphysema Asthma Liver disease Skeletal fractures Poor self rated health Sexually transmitted disease HIV/AIDS Serious Social Problems Homelessness n Prostitution n Delinquency, violence, criminal n Inability to sustain employment n Re-victimization: rape, DV, bullying n Compromised ability to parent n Negative alterations in self perceptions and relationships with others n Altered systems of meaning n Intergenerational trauma n

HMO Members in ACE Study n 80% White, including Hispanic n About 50% men, 50% women n 10% Black n n 10% Asian 74% had attended college n 62% age 50 or older

Adverse Childhood Experiences are Common Of the 17, 000 HMO Members: n 1 in 4 exposed to 2 categories of ACEs n 1 in 16 was exposed to 4 categories. n 22% were sexually abused as children. n 66% of the women experienced abuse, violence or family strife in childhood. n Women were 50% more likely than men to have experienced 5 or more ACEs

The higher the ACE Score, the greater the likelihood of : n n n Severe and persistent emotional problems Health risk behaviors Serious social problems Adult disease and disability High health, behavioral health, correctional and social service costs Poor life expectancy For example:

Emotional Problems

Childhood Experiences Underlie Chronic Depression

Childhood Experiences Underlie Suicide 4+ 3 2 0 1

n 2/3 rd (67%) of all suicide attempts n 64% of adult suicide attempts n 80% of child/adolescent suicide attempts Are Attributable to Childhood Adverse Experiences Women are 3 times as likely as men to attempt suicide over the lifespan.

Childhood sexual abuse is strongest most independent risk factor for suicidality n As many as 42% of girls are sexually abused before age 18 n 79. 8% of American Indian Alaskan Native (AIAN) girls experience sexual abuse in early childhood. n Young AIAN women are over 3 ½ times more likely to commit suicide than females in the general population

Childhood Experiences Underlie Serious and Persistent Mental Health Problems

Ever Hallucinated* (%) Are We Misdiagnosing? ACE Score and Hallucinations Abused Alcohol or Drugs ACE Score *Adjusted for age, sex, race, and education.

Health Risk Behaviors

Adverse Childhood Experiences and Current Smoking %

Childhood Experiences and Adult Alcoholism 4+ 3 2 1 0

ACE Score and Intravenous Drug Use N = 8, 022 p<0. 001

Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners

Serious Social Problems

Childhood Experiences Underlie Rape 4+ 2 1 0 3

ACE Score and Unintended Pregnancy or Elective Abortion

Prevalence of Impaired Performance (%) ACE Score and Indicators of Impaired Worker Performance

Adult Disease and Disability

Higher ACE Score = significant rise in chronic health conditions: n n n Sexually Transmitted Disease Liver Disease COPD Ischemic Heart Disease Autoimmune Disease Lung Cancer

Poor Life Expectancy

Effect of ACEs on Mortality Age Group 0 ACE 60% live to 65 4 ACE less than 3% live to 65

The Many Faces of Women and Trauma

The Costs Are High 1992 Analysis of Cost of Anna’s Care n Over 17 years, Anna was hospitalized a total of 4, 124 days. At $648 a day the cost was $2, 639, 360. n Other costs – entitlements, residential treatment, case management, legal, medical – were estimated to be over $1, 000, bringing total cost to nearly $4, 000. n Adjusted for inflation (2005) total cost = $5, 417, 032

1992 Analysis of Cost of Anna’s Care n 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) n Had trauma been recognized and treated at age 3, costs would have been significantly less. n If parents had been trauma-informed, the abuse may not have occurred.

The financial burden to society of childhood abuse and trauma is staggering. n Annual Direct Costs: Hospitalization, Mental Health Care System, Child Welfare Service System and Law Enforcement = $33, 101, 302, 133. 00 n 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 n Total Annual Cost: $103, 754, 017, 492. 00 (Over $184 million dollars a day)

“The solution of adult problems tomorrow depends in large measure upon the way our children grow up today. Margaret Mead

Thank You www. The. Anna. Institute. Org

Handouts n Chart of Adverse Childhood Experiences Study n Finding Your ACE Score: A Questionnaire n ACE Publications on Major findings by Health Outcomes n “The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease”

Sources n ACE Publications: For comprehensive list see CDC ACE Study website: Publications on Major Findings By Health Outcomes: This site was updated (March 1, 2010) and links to related articles on all subjects. http: //www. cdc. gov/nccdphp/ACE/outcomes. htm n The Damaging Consequences of Violence and Trauma: See Trauma-Informed Resources : www. The. Anna. Institute. Org n Documents and articles on women and trauma: Presentation Bibliography in preparation. Available upon request: Ann Jennings, afj@gwi. net

ACE Study slides are from: n Robert F. Anda MD at the Center for Disease Control and Prevention (CDC) n September 2003 Presentation by Vincent Felitti MD “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West n “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)

Presentation Artwork n All artwork in this presentation was created by Anna Caroline Jennings. Although she had no formal training, her work is stark, sophisticated and haunting. It has been exhibited at conferences across the country. n Through her paintings and drawings she vividly and poignantly expresses her abuse at the hands of perpetrators and within the mental health system. n Her work and story are displayed on the website:

Trauma Informed Resources n http: //mentalhealth. samhsa. gov/nctic/default. asp SAMHSA National Center for Trauma-Informed Care n www. The. Anna. Institute. org: The Anna Institute Inc: n ACE Study Section: Powerpoint presentation slides and notes; 41 full downloadable ACE Study articles; related materials; collection of ACE Study powerpoint slides n Annotated list of Trauma Websites n Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services, 2008 n Downloadable trauma-informed articles, powerpoints, educational materials; links; Anna’s story and art