Expanding The Adverse Childhood Experiences Model

8/19/2019Expanding the AdverseChildhood Experiences ModelSocial Conditions and Historical TraumaLINDA DOUGLAS M .ED.CERTI FI E D TRAUM A SERVI C E S SPECI A LI S TNH COALITIO N AGAINST DOM ESTI C AND SEXUALVIOLENCEWhy is Understanding Trauma Important? To provide effective services we need to understand the lifesituations that may be contributing to the person’s currentproblemsMany current problems faced by the people we serve maybe related to traumatic life experiencesPeople who have experienced traumatic life events areoften very sensitive to situations that remind them of thepeople, places or things involved in their traumatic event.These reminders, also known as triggers, may cause aperson to relive the trauma and view the supportive agencya source of distress rather than a place of healing andwellness.1

8/19/2019The ACE Study is an ongoing collaborationbetween the Centers for Disease Control andPrevention and Kaiser Permanente.Led by Co-principal Investigators Robert F. Anda, MD,MS, and Vincent J. Felitti, MD, the ACE Study is perhapsthe largest scientific research study of its kind, analyzingthe relationship between multiple categories of childhoodtrauma(ACEs), and health and behavioral outcomes later in life.The ACE conditions:Before the age of 18 Recurrent physical abuse Recurrent emotional abuse Contact sexual abuse An alcohol and/or drug abuser in thehousehold An incarcerated household member Someone who is chronically depressed,mentally ill, institutionalized, or suicidal Mother is treated violently One or no parents Emotional or physical neglectA Public Health ParadoxWhat are conventionally viewedas Public Health problems are often personalsolutions to long-concealedadverse childhood experiences.2

8/19/2019Adverse Childhood Experiences Study:Impact Across the LifespanAdverseChildhoodExperiencesNeurobiological Long-termImpacts andHealth andHealth RisksSocial ProblemsThe more typesof adversechildhoodexperiences The greater theneurobiologicalimpacts andhealth risks,and The more seriousthe lifelongconsequences tohealth and wellbeingFelitti, V.J., Anda, R. F., et. al., 19987Factors contributing for likelihood of PTSD Genetic factors account for one-third of the overall risk Severity of the trauma Being female Being younger Having a history of childhood abuse Other psychiatric problems Belonging to a minority group Lower socioeconomic status Lower education levelShaili Jain, 2019Prevalence Lifetime prevalence in general population is 7% Prevalence in veterans in the current wars inAfghanistan and Iraq is twenty per 100. The longerthe deployment and the more intense the exposure,the higher the rate climbs. Higher rates are found in police officers, firefighters,and other first responders. Similar statistics show high rates in low-incomewomen and teenagers living in high-crime inner-cityareas.Shaili Jain, MD 20193

8/19/2019Genogram of Trauma/Case StudyMaternal GrandparentsFrench -------IndigenousGrandmotherInstitutionalized in 40s fordepressionGrandfatherPlaced in Indian BoardingSchool at age 10AlcoholicRaised 5 children duringthe Great DepressionPaternal GrandparentsIrish/French Canadian --IrishGrandmotherRaised 11 children duringthe Great DepressionMarried twice – bothalcoholicsGrandfatherAbandoned family duringGreat Depression alcoholicGenogram of TraumaMotherAt least 2 brothers whowere alcoholicsAt least two werephysically abusive tochildren and wivesOne brother was apedophileHad four children – onedied before the age of 22 had medical traumasAnxiety/DepressionFatherHad ten siblings – anumber of whom werealcoholicsKorean War VeteranFood addictionPTSDAnger issuesThis GenerationMultiple addictions including alcohol, food, shopping,and gamingSexual assault victimsDepression, anxietyEtc., etc.ACEs not considered high but . . . . .4

8/19/2019Expanding the ModelS O C I A L C O N D IT IO N S AN D H IS T O R I C A L T R AU M A5

8/19/2019Social Location and Local ContextSafety and access to quality health care, economicopportunities, social connections, and social capitalare all key determinants of the health over time.NH Social and Economic FactorsChild PovertyBelow 200% PovertyFood InsecuritySocial Determinants of Health6

8/19/2019Abraham Maslow, 1954“Until we are willing to acknowledge that wecollectively have not fulfilled the needs ofdeveloping humans throughout our evolution, andtherefore as adults we are not operating at ouroptimal capacity as human organisms, we willcontinue to perpetuate the social conditions thathinder optimal development, all the whilepretending that we adults are unaffected andtraumatic childhoods are normal.”Elizabeth Perry7

8/19/2019Historical and Cultural Trauma“The collective experience of violence perpetrated againsta group in the process of colonization that results in ahumanitarian crisis for that community.”Brockie, Heinzelmann & Gill 2013“Living under such difficult, oppressive circumstances canlead parents to formulate fear based ‘survival messages’that they pass on to their children and grandchildren –ideas like “Don’t ask for help – it’s dangerous.”Elena Cherepanov 2019(Quoted by Methot)Shared StressDue to ongoing discrimination and micro-aggressions.Causes hyperarousal, feelings of alienation, worriesabout future negative events and perceiving others asdangerous.The feeling that you have to manage everything inyour own community because you don’t know whatyou will encounter in society at large.Monnica Williams, 2018(Quoted by Methot)Loss of Cultural Control Altered sense of identity and self-perception Lack of personal agency A lack of faith in the value and meaning of their ownlivesThese structures were broken by the oppressivesystems that dismantled their societies.Suzanne Methot8

8/19/2019Intergenerational Trauma First identified in the children of Holocaust survivorsand descendants of Japanese people interred duringthe Second World War. Also identified in the children of American veteransof conflict including Korea, Vietnam, and the GulfWars. 45% of American veterans’ children exhibited“significant” signs of PTSD with 83% “elevatedhostility” scores and more dysfunctional social andemotional problems.SUZANNE METHOTWhat is Epigenetics?Epigenetics and Culture Some Indigenous peoples refer to this as “bloodmemory.” Carried through generations through psycho-spiritual-biological processes that encompass thecultureSuzanne Methot9

8/19/2019Epigenetic Modifications from ACESThe ACE most linked to epigenetic differences andvulnerability for health disparities in that of child abuse.Labonte 2012Direct physical abuse and observing the abuse of a motherhave also been associated with great methylation level in thepromoter region of the glucocorticoid receptor gene inleukocytes.Tyrka, Price, Marsit, et. al. 2012Similar methylation profiles are also reported in the peripheralblood of babies whose mothers were depress during the thirdtrimester of pregnancy.Oberlander, et al. 2008Survivors ExperienceMultiple Types of Trauma Childhood victimization increases risk for abuse asadolescent or adult Coping strategies may increase risk for being harmed Not learn have right to protect oneself from harm. Survivors also experience social, political, cultural,historical, & immigration-related trauma* Cultural and historical trauma can impact individualsand communities across generations Protective factors and resilience can mitigate Can also be diminished, resulting in increasedvulnerability and fewer opportunities to heal*Fabri: Triple Trauma Paradigm; Root: Insidious trauma; Packard: Cultural and Historical TraumaLearning Brain Vs. SurvivalVideo10

8/19/2019Trauma Framework Normalizes human responses to trauma Recognizes that trauma is not the exception Shift understanding from symptoms to adaptations Shift from seeing symptoms to understanding survivalstrategies as coping mechanisms are overwhelmed An injury modelWhat’s wrong with you? VS What happened to you?NCDVTMH31The importance of a trauma-informedapproach to health care With appropriate supports and intervention, people canovercome traumatic experiences. A trauma-informed approach reduces the ways thatservices may unintentionally exacerbate trauma-relatedissues. Staff (in all capacities) are less likely to experience issuesrelated to vicarious trauma. The impact of the trauma-informed approach expands tothe family of the person seeking services and then onto thegreat community.Resiliency Building BlocksCompetencySelf RegulationAttachmentAdolescent Health Working Group 201311

8/19/2019Trauma-informed Approaches Use empowerment-based approach tocounteract the experiences of abuse Focus on strengthsSupport empowerment through skill-building Help create stability and supports Empathic engagement that provides: Information & choicesRespect, connection, and hope Access to tools, resources, and skills 34Harris and Fallot 2001; Saakvitne et al. 2000; Warshaw 2009ReferencesMethot, Suzanne, Legacy: Trauma, Story, and Indigenous Healing, 2019, BCWPress, ie, Heinzelmann, and Gill, A Framework to Examine the Role ofEpigenetics in Health Disparities among Native Americans, 2013, HindawjPublishing, Nursing Research & PracticeAngelis, Tori, The Legacy of Trauma, APA, February 2019, Vol 50, No. 2B. Labonte, “Genome-wide epigenetic regulation by early-life trauma,”Archivesof General Psychiatry, vol. 69, no. 7, pp. 722– 731, 2012.R. Tyrka, L. H. Price, C. Marsit, O. C. Walters, and L. L. Carpenter,“Childhood adversity and epigenetic modulation of the leukocyteglucocorticoid receptor: preliminary findings in healthy adults,” PLoSONE, vol. 7, no. 1, Article ID e30148, 2012.T. F. Oberlander, J. Weinberg, M. Papsdorf, R. Grunau, S. Misri, and A. M. Devlin,“Prenatal exposure to maternal depression, neonatal methylation of humanglucocorticoid receptor gene (NR3C1) and infant cortisolJain, Shaili, M.D. The Unspeakable Mind – Stories of Trauma and Healing from theFrontlines of PTSD Science, Harper Collins, 2019Resources National Center on Domestic Violence, Trauma andMental Healthhttp://www.nationalcenterdvtraumamh.org/ Family Homelessness Resource onal-centeron-family-homelessness-39.aspx ACES Connection http://acestoohigh.com/ Trauma and Justice Center of SAMHSAhttp://www.samhsa.gov/traumaJustice/ Open Doors NHCADSV Bloghttp://opendoorsnh.blogspot.com/ National Childhood Traumatic Stress Networkhttp://www.nctsn.org/12

A trauma-informed approach reduces the ways that services may unintentionally exacerbate trauma-related issues. Staff (in all capacities) are less likely to experience issues related to vicarious trauma. The impact of the trauma-informed approach expands to the family of the p