Creating Trauma Informed Systems of Care for Human Service Settings What is Trauma and Why Must We Address It? Brian R. Sims, M.D. Senior Medical Advisor NASMHPD The Adverse Childhood Experiences Studies(ACEs) Tasneem Ismailji MD, MPH President Academy on Violence and Abuse Turning GOLD to LEAD How can we turn LEAD back into GOLD again 1
Take Home Messages! Adverse Childhood Experiences are common! ACEs exert cumulative lifelong effects on physical and behavioral health! There are additional traumas experienced in adolescence and adulthood that add to these effects! These effects can be transferred across generations! We can recover from the traumas we have experienced The Adverse Childhood Experiences Study (ACES)!!Largest study ever done examining effects of adverse childhood experiences over one s lifespan (>17,000 people)!!majority were >50 yo, white, and attended college!!original study done in California!!www.acestudy.org 2
ACES Categories!! Recurrent physical abuse!! Recurrent emotional abuse!! Contact sexual abuse!! An alcohol and/or drug abuser in the household!! 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 neglect!!two-thirds had at least one ACE score!!ace scores tend to occur in clumps! Positive, linear correlation between ACE scores and health problems!! ACEs influence the likelihood of the 10 most common causes of death in the U.S.!! With an ACE score of 0, the majority of adults have few, often none, of the risk factors for these diseases!! With an ACE score of 4 or more, the majority of adults have multiple risk factors for these diseases or the diseases themselves!! Smoking!! COPD!! Hepatitis Health problems # ACEs!! Cardiac disease!! Diabetes!! Fractures!! Obesity!! Alcoholism!! Other substance abuse!! Depression!! Attempted suicide!! Teen pregnancy and teen paternity!! Sexually transmitted diseases!! Occupational health!! Poor job performance 3
!Positive, linear correlation between ACE scores and Alcoholism!Positive, linear correlation between ACE scores and tobacco use Alcohol abuse & dependence!! High ACE score # ACEs predicts alcohol abuse!! Higher yet in people whose parents abused alcohol!! Self-perpetuating cycle over generations!! 20% of ACE respondents lived in families with alcoholism!! The presence of alcohol abuse in the family increases the likelihood of sexual and physical abuse Tobacco use # ACEs!!ACEs apparently maintain smoking behavior!!ace score of 4 or more results in 260% more likely to have Chronic obstructive pulmonary disease (COPD) 4
Prevalence of Individual ACES in Iowa 5
6
7
Prevalence of Trauma Child Mental Health/Youth Detention Population - U.S.!! Canadian study of 187 adolescents reported 42% had PTSD!! American study of 100 adolescent inpatients; 93% had trauma histories and 32% had PTSD!! 70-90% incarcerated girls sexual, physical, emotional abuse!! (DOC, 1998, Chesney & Sheldon, 1991) 5 30 Trauma in American Children!!! 3 million children were suspected of being victims of abuse and/or neglect in 1998 (Mazelis, 1999)!! 3.9 million adolescents have been victims of serious physical assault, and almost 9 million have witnessed an act of serious violence (Kilpatrick et al., 2001)!! In 1998, 92% of incarcerated girls reported sexual, physical or severe emotional abuse in childhood (DOC, 1998)!! Each year between 3.5 and 10 million children experience the abuse of their mother up to half are victims of abuse themselves (Edelson, 1999)! Persons with Intellectual Disabilities referred for Co-occurring Behavioral or Mental Health Issue! 8
Co-occurring Intellectual Disabilities and Behavioral/Mental Health Data Set!!! Sobsey, PhD, database statewide area, confirmed by samples from other states, provinces & countries!! Mean age 30, range 14 mo to 98 yrs!! Over 50% do not use speech!! Mean of moderate to severe cognitive challenge!! Most common referral is aggression/violence!! 60% institutionalized/re-institutionalized history!! 85% had untreated, undertreated or undiagnosed medical problems!! Over 50% on non-psychiatric meds that often cause psychiatric symptoms, used in ways meds were never intended and which are not safe, often used in unresearched combinations Prevalence of Trauma Substance Abuse Population U.S.!! Up to two-thirds of men and women in SA treatment report childhood abuse & neglect (SAMSHA CSAT, 2000)!! Study of male veterans in SA inpatient unit!! 77% exposed to severe childhood trauma!! 58% history of lifetime PTSD (Triffleman et al., 1995)!! 50% of women in SA treatment have history of rape or incest!! (Governor's Commission on Sexual and Domestic Violence, Commonwealth of MA, 2006) 6 34 Sexual Trauma and Addiction!! 208 African-American Women with histories of crack cocaine use!! Women with history of sexual trauma (n=134) reported being addicted to more substances than those who had not been sexually traumatized (n=74)!! Women with trauma histories reported more prior treatment failures than those without.!! (Young & Boyd, 2000) "#$%&'()!*+$+,'-.!*+$/0%$! Women in Substance Abuse Treatment Reporting Physical Abuse in Past 6 Months 12 35 9
"#$%&'()!*+$+,'-.!*+$/0%$! Women in Substance Abuse Treatment Reporting Psychological Abuse in Past 6 Months "#$%&'()!*+$+,'-.!*+$/0%$! Women in Substance Abuse Treatment Reporting Partner Abuse in Lifetime "#$%&'()!*+$+,'-.!*+$/0%$! Women in Shelter, Safe Homes or Receiving Outreach Domestic Violence Services Report of Substance Use "#$%&'($!"#)*%#+!,)-!.'#+$)&$!,%$!-'/$%$)*! -'0$)1'#)1!#2!-#0$1*'&!('#+$)&$! 10
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b!,*!+$,1*!#)$! 6,%*)$%!B1$1!('#+$)&$@!)$'*;$%!B1$1!&#$%&'($!&#)*%#+@!!!! "'#"3%#,)#,44&4"!3).562)b!#)$!6,%*)$%!B1$1!C#*;! ('#+$)&$!,)-!&#$%&'($!&#)*%#+@!*;$!#*;$%!6,%*)$%!'1! )#)('#+$)*@!!!!!-"&(,'#)4,!"!#%'*,).172)b!C#*;!6,%*)$%1!B1$!('#+$)&$@! #)+5!#)$!B1$1!&#$%&'($!&#)*%#+@!!!!!3$#$%()-"&(,'#)*&'#4&().8102)b!C#*;!6,%*)$%1!B1$! C#*;!('#+$)&$!,)-!&#$%&'($!&#)*%#+?!!! =! R#;)1#)@!F?8?!7OPP[<?!!)(-78#$#*7(#9(5#/%,-"'(:"#$%&'%;!_#1*#)>!K#%*;$,1*$%)!`)'($%1'*5!8%$11?!JB**#)@!F?\?@!,)-! W##-0,)@!Z?\?!7OPPY<?!"#$%&'#)!')!')*'0,*$!6,%*)$%!('#+$)&$>!I#9,%-!,!)$9!&#)&$6*B,+'4,*'#)?!<%=(>#$%,0(?2311@1240(a]HXaYa?! R#;)1#)@!F?8?!7OPP[<?!!)(-78#$#*7(#9(5#/%,-"'(:"#$%&'%;!_#1*#)>!K#%*;$,1*$%)!`)'($%1'*5!8%$11?! 11
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ntimate terrorism!89%!!!!!!!11c!![1 Violent Resistance 15% 85% 61 Situational Couple 55% 45% 167 Violence Mutual Violent 50% 50% 16 Control R#;)1#)@!F?8?!7OPP[<?!!)(-78#$#*7(#9(5#/%,-"'(:"#$%&'%;!_#1*#)>!K#%*;$,1*$%)!`)'($%1'*5!8%$11?! Gold into Lead!! Male child with an ACE score of 6 has a 4600% increase in likelihood of later becoming an IV drug user when compared to a male child with an ACE score of 0. Might heroin be used for the relief of profound anguish dating back to childhood experiences? Might it be the best coping device that an individual can find?!! ACE score of 4+ increases probability of depression 500%, suicide 1200%, and COPD 390% (Felitti et al, 1998) What does the prevalence data tell us?!! The majority of adults and children in psychiatric treatment settings have trauma histories!! A sizable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety!! A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories!!!!!! (Hodas, 2004, Cusack et al., Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998) 9 47 13 48 12
What does the prevalence data tell us?!! Growing body of research on the relationship between victimization and later offending!! Many people with trauma histories have overlapping problems with mental health, addictions, physical health, and are victims or perpetrators of crime!! Victims of trauma are found across all systems of care!!!! (Hodas, 2004, Cusack et al., Muesar et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998) Therefore!!We need to presume the clients we serve have a history of traumatic stress and exercise universal precautions by creating systems of care that are trauma-informed!!!!!! (Hodas, 2005) 14 49 15 50!"#$%&%'()!!! db0,)!3$)#0$!2,'%+5!&#)1*,)*!,)-!&;,)3$1!($%5! 1+#9+5!#($%!0'++'#)1!#2!5$,%1?!!! E)('%#)0$)*!,%#B)-!B1!&;,)3$1!,++!*;$!*'0$?!!!! E6'3$)$*'&1!&,)!*$++!B1!;#9!#B%!3$)$1!,-,6*!*#!*;$! $)('%#)0$)*!$($)!*;#B3;!,&*B,+!1*%B&*B%$!#2!*;$! 3$)#0$!-#$1!)#*!&;,)3$!!! M*B-5!#2!;$%'*,C+$!&;,)3$1!')!3$)$!$D6%$11'#)!*;,*!,%$! )#*!-B$!*#!&;,)3$1!')!*;$!JK\!1$NB$)&$!?+%.(0,9&3!@!A-+%(0,9&3!!! I'3;*+5!&#'+$-!JK\!'),&&$11'C+$!2#%!*%,)1&%'6*'#)@! 3$)$1!')!*;,*!&#'+!1'+$)&$-!!! d'1*#)$1!,%$!6%#*$')1!*;,*!1b%%#b)-!*;$!3$)$!,)-!&,)!,/$&*!3$)$!$d6%$11'#)!!! F$*;5+!0#+$&B+$1!7"dH<!,**,&;!*#!*;$!;'1*#)$1!,)-! *'3;*$)!*;$!JK\!&#'+1@!C+#&A')3!,&&$11!*#!*;$!3$)$1!!! \&$*5+!7"e"dH<!0#+$&B+$1!+##1$)!*;$!JK\!&#'+1@! $D6#1')3!3$)$1!2#%!*%,)1&%'6*'#)! 7R#,)!_#%51$)A#<! 13
BC,850+!DD!E/00(#3F!!! f-$)*'&,+!*9')1!b!_b++'$-!*9')!;,-!')&%$,1$-!jk\! 0$*;5+,*'#)!#2!MEgI!b!,!1$%#*#)')!*%,)16#%*$%!3$)$!!! g$1b+*')3!')!-$&%$,1$-!%$16#)1$!*#!&#%*'1#+!!! :;'&;!'1!+')A$-!*#!6##%!1*%$11!')3!1*%,*$3'$1! Z#B'1$!\%1$),B+*!$*!,+?! AF&/9!?#-+!G!H#'%0+!,3<!I,%+'0,3<J$! +C5+'#8+3%!!! \3#B*'!0'&$!#/16%')3!'-$)*'&,+!*#!6,%$)*1!b!5$++#9@!2,*@! &,)&$%!,)-!-',C$*$1@!-'$!5#B)3!!! J'-!)#*!,/$&*!JK\@!%,*;$%!2$-!0#*;$%1!,!-'$*!%'&;!')! 0$*;5+!7"dH<!-#)#%1!b!&;$0'&,+!&+B1*$%1!*;,*!&,)!,**,&;!*#!,!3$)$!,)-!*B%)!'*!#/!!! e/16%')3!b!c%#9)@!*;')@!)#!&,)&$%!#%!-',c$*$1@!+'($-!*#!,)!#+-!,3$?!!!! F$*;5+!-#)#%1!9#%A$-!*;$'%!9,5!#)*#!$0C%5#S1! &;%#0#1#0$1!,)-!#)*#!&%'*'&,+!,3#B*'!3$)$@!,--')3!*#! *;$!3$)$!,!&;$0'&,+!19'*&;!*;,*!-'00$-!*;$!3$)$S1! -$+$*$%'#B1!$/$&*! B5#F+3+9-$!@!B5#F+3&8+$!!! W$)$1!)$$-!')1*%B&*'#)1!2#%!9;,*!*#!-#!,)-!9;$)!*#! -#!'*!!! f)1*%b&*'#)1!,%$!)#*!')!*;$!jk\@!cb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
=3%+'F+3+',9&3!!! F,%&B1!8$0C%$5!2#B)-!')!,!10,++!*#9)!')!M9$-$)>!!! W%,)-2,*;$%1!9;#!+'($-!6%$*$$)!5$,%1!')!*'0$1!#2! 6+$)*'2B+!2##-!1B66+5!;,-!3%,)-1#)1!0#%$!+'A$+5!*#!C$! -',C$*'&!!! W%,)-0#*;$%1!9;#!9$%$!')!B*$%#!#%!')2,)*1!-B%')3! *'0$1!#2!6+$)*5!0#%$!+'A$+5!*#!;,($!3%,)--,B3;*$%1! 9;#!9$%$!-',C$*'&!!! E/$&*1!1$D!16$&'h&!,)-!C,1$-!#)!-'/$%$)*!&%'*'&,+! 6$%'#-1!!"#$%&%'(*+,-%.&)*,.%* /%0%.)#12%* Z#9!)B%*B%$-!%,*S1!C%,')!9,1!')i$&*$-!9'*;!,!-%B3!*;,*! %$0#($-!0$*;5+!3%#B61!,)-!'*!,&*1!+'A$!,!;'3;!)B%*B%$-! %,*! d'3;!)b%*b%$-!%,*s1!c%,')!')i$&*$-!9'*;!0$*;'#)')$! 0,-$!'*!0#%$!,)D'#B1! 15