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What Every Educator Should Know

About the ACE Study

Linda Chamberlain PhD MPH

State of Alaska Family Violence Prevention Project

Chronic Disease Prevention and Health Promotion

Trauma-Informed Schools Webinar Series: Part 2

Less is more and staying on course with the “Brain Rules of Learning”

◦Starting where we left off-Vicarious Trauma

Resilience Matters

The Original ACE Study and What We’ve Learned about ACEs in Alaska

We created choices in the

classroom for kids if they felt their emotions were starting to

get the best of them. They could put on headphones,

listen to some classical music, sit on a bean chair, take a

break, go for a walk.”

Principal Ryan Power,

Angelo Elementary School Brockton, MA

This is about changing the whole school environment. You

can have a great trauma-sensitive classroom but if the

child goes in the hall or cafeteria and gets yelled at, he can get

retriggered. It about creating a common context that keeps kids

feeling safe.

Susan Cole, Trauma Learning Policy Initiative (TLPI)

Have you seen the documentary, Paper Tigers, by Jamie Redford? ◦ YES

◦ NO

http://vimeo.com/37975761

Watch and discuss with at least one colleague

Having a prevention plan for vicarious trauma is the essential first step for trauma-informed practices

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Changes in our view of ourselves, others, and the world as a result of exposure to the suffering of others

Symptoms similar to PTSD but acquired through exposure to persons suffering the affects of trauma

Baird et al (2006)

When organizations become traumatized, they can get stuck in

toxic stress responses (crisis-oriented, unwelcoming,

disconnected, disrespectful…) that triggers toxic stress response in

students and families.

Widespread cynicism and pessimism

Lack of communication and frequent miscommunications

Increase in interpersonal conflicts

High rates of absences or tardiness

Ethical or boundary violations

Unexplained reductions in productivity/service delivery

Increase in client complaints

High rates of staff turnover

Negative atmosphere/low morale

Less energy & motivation..not willing to go extra mile

Killian KD. 2008. Helping till it hurts? Traumatology,14(2);41.

The industry needs to make a “paradigm shift” away from blaming helpers for developing compassion fatigue/vicarious trauma to where we see the solution in a larger organizational context rather than focusing solely on individual helpers’ responsibility for self-care.

There is a causal relationship between stress, exposure to trauma and staff turnover

Vicarious trauma can affect:

◦ your work, your colleagues, the overall functioning of the organization, and the quality of assistance being provided to those you are working to help.

◦Your physical, mental and behavioral health

◦The way you act and interact with people you care about

Addressing vicarious trauma and supporting staff will reduce staff turnover and absenteeism leading to improved quality, efficiency and reduced costs

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≠ individual trait

≠Being tough—bootstrap approach

≠“Just bouncing back”-our brains are not rubber balls

Common

Arises from ordinary resources & processes

Can be taught→skill-based

Buffers effects of trauma

Helps us to understand that despite

past and present adversities, cultures

have survived and even flourished.

Devereux Adult Resilience Survey (DARS)

Think about how to strengthen your protective factors

Self-reflective journal-Building Your Bounce

http://www.centerforresilientchildren.org/adults/assessments-resources/

Protective factors have stronger

influence on how children growing up

with adversities do than specific risk

factors or stressful events

Protective factors remain consistent

across different ethnic, social class,

geographical & historical boundaries

Rutter, 1987, 2000;Werner, 2001; Bernard, 2004

◦Characteristics of child

◦Frequency, severity, proximity of trauma

◦Cultural values & traditions

◦Community cohesion and collective support, family access to outside supports

◦Quality of parenting, parents’ response to trauma

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•Large, collaborative study at

Kaiser Permanente with CDC to

examine the medical, social, and

economic consequences of

childhood adversities over the

lifespan

The “ACE” Study

Felitti et al, 1998

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Based on Robert Wood Johnson Info-graphic at http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/05/Infographic-The-Truth-About-ACEs.html

Positive

response to any

category of trauma counts as “1 ACE” and are summed to create

“ACE Score”

Abuse, by Category 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%

Prevalence (%)

ACE Score Prevalence 0 33% 1 25% 2 15% 3 10% 4 6% 5 or more 11%

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 >.

State of Alaska Behavioral Risk Factor Surveillance System (BRFSS)

Telephone survey,18 years or older

National Survey of Children’s Health (NSCH)

Telephone survey of households with at least one child < 18 years old; one child randomly selected as subject of parental interview

Data on the prevalence of selected ACEs among children available on-line for each state

Excludes child abuse & neglect

ACE Score Prevalence 0 35.6% 1 22.3% 2 14.7% 3 10.1% 4 6.5% 5 or more 10.8%

5 or More ACEs by Age Group

Age (Yrs) Prevalence

18-24 10.0% 25-34 12.1% 35-44 15.2% 45-54 12.0% 55+ 6.5%

Adverse Childhood

Experiences*

Alaska Native Non-Alaska Native

Abuse % %

Emotional 37.8% 29.8%

Physical 23.9% 18.3%

Sexual 21.9% 13.6%

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Adverse Childhood Experience*

Alaska Native Non-Alaska Native

Household Dysfunction

% %

Mental Illness in the Home 25.2% 21.3%

Incarcerated Family Member 19.5% 10.1%

Substance Abuse in Home 49.8% 31.0%

Separation or Divorce 39.4% 30.4%

Witnessed Domestic Violence 33.0% 16.2%

Ace Question U.S. Alaska Statistically Significant

Family's income hard to cover the basics like food or housing? Very often or Somewhat often.

25.7% 25.0% No

Did child ever live with a parent or guardian who got divorced or separated after he or she was born?

20.1% 23.8% Yes

Did the child ever live with a parent or guardian who died? 3.1% 3.1% NA

Did ever live with a parent or guardian who served time in jail or prison after he/she was born?

6.9% 9.6% Yes

Did the child ever see or hear any parents, guardians, or any other adults in his/her home slap, hit, kick, punch, or beat each other up?

7.3% 8.6% No

Was the child ever the victim of violence or witness any violence in his/her neighborhood?

8.6% 10.5% No

Did the child ever live with anyone who was mentally ill or suicidal, or severely depressed for more than a couple of weeks?

8.6% 11.0% No

Did the child ever live with anyone who had a problem with alcohol or drugs? 10.7% 14.5% Yes

Was the child ever treated or judged unfairly because of his/her race or ethnic group? 4.1% 4.9% No

http://childhealthdata.org/learn/NSCH

Zero ACEs 59.8%

One ACE 24.7%

Two or More ACEs 15.5%

Source: National Survey of Children’s Health 2011/2012, Graphic created by the Alaska Mental Health Board/Advisory Board on Alcoholism and Drug Abuse Staff.

Zero ACEs 48.1%

One ACE 24.9%

Two or More ACEs 27.0%

Source: National Survey of Children’s Health 2011/2012, Graphic created by the Alaska Mental Health Board/Advisory Board on Alcoholism and Drug Abuse Staff.

Zero ACEs 38.3%

One ACE 26.1%

Two or More ACEs 35.6%

Prevalence of ACEs among 24 Alaskan Children

12-17 Years

Stand with feet

should distance apart, arms hanging at side

Breathe in deeply and raise arms upward towards sky, breathing in energy and cleansing cells

Bring arms down slowly, breathing out stress

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Physical health

problems

ACEs → ?

TOXIC STRESS BRAIN

Toxic Stress

Response

Mental

health problems

Self- medicate to cope

Adopt risky behaviors

Depressed immune system

Chronic inflammation

STOP

RESILIENCY

Heart disease

Cancer

Obesity

Smoking

Workplace problems

Mental health

problems

Sexual behavior problems

HIV

Depression

Drug use

Alcoholism

Suicide

Source: Alaska data from the 2013 Alaska Behavioral Risk Factor Surveillance System, Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion

Childhood obesity

Early age at first

intercourse

Teen pregnancy

Bullying

Dating violence

Fighting and carrying weapon

to school

Early initiation of tobacco use

Early initiation of drug abuse

Early initiation of alcohol use

Self-mutilation and suicide

Anda et al, 2002; Anda et al, 1999; Boynton-Jarrett et al, 2010; Dube et al, 2006; Dube et al, 2003; Duke et all, 2010; Hillis et al, 2001; Miller et al, 2011

Increase risk of: Young children with an ACE score

of 4 or greater are twice as likely

to have a body mass index (BMI)

≥85% (Burke et al, 2011)

Children exposed to domestic

violence are 80% more likely to be

obese at age 5 years

(Boynton-Jarrett et al, 2010)

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51.7% 46.7%

28.9%

25.3% 24.9%

24.6%

23.0% 28.4%

46.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Perc

enta

ge

Alaskan Children with More, Less and No Complex

Health Care Needs by ACE Score

Two or More

ACES

One ACE

No ACES

NO Complex HC Needs

Less Complex More Complex HC Needs

Health Factor 2 or more ACEs (%)

Asthma 33.4%

ADHD 45.2%

Autism spectrum disorder 34.4%

Who bully 55.4%

NCHS data which excludes abuse & neglect, includes exposure to community violence, poverty and discrimination; Bethel et al, 2014

*

ACE

SCORE

Developmental

Delay

O.D.D. or

Conduct Disorder

Autism Spectrum

Disorder

Zero 3.6% (4.4%) 0.6% (1.3%) 0.8% (1.7%)

One 4.0% (6.6%) 2.4% (3.3%) 2.1% (2.6%)

2-3 8.7% (8.6%) 4.5% (7.5%) 3.4% (3.3%)

4+ 19.1% (13.4%) 14.8% (16.8%) 8.1% (4.9%)

28.8% of children with 4 or more ACEs have a learning

disability compared to 6.6% of children with zero ACEs

Children with 4 or more

ACEs are 32 times more

likely to have behavioral

problems in school (Burke

et al, 2011)

Children with 2 or more

ACEs are 2.67 times more

likely to repeat a grade

(Bethel et al, 2014)

Children with 3 or more ACES were:

3X more likely to fail academically

5X more likely to have severe attendance problems

6X more likely to have severe behavioral problems

Compassionate Schools Data from Chris Blodgett, PhD October 28, 2014 Boise ID

“There’s a bit difference between attention-

seeking behavior and children seeking

connection.”

Avis Smith, Head Start Trauma Smart

When the BRAIN feels “heard” it will naturally move towards adapting and changing.

TAKE THE LEAD, LOOK PAST THE BEHAVIOR AND FIND

THE HIDDEN NEED.

Tera Bovingdon, Attachment expert

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Dysregulated child rarely communicates needs in clear, direct manner

Helping caregivers to look for the real meaning behind the message—”I hate you!” → “I need you to understand…”

Responding to what the child needs vs. “deserves”

FOCUS ON RELATIONSHIP vs. THE BEHAVIOR

◦ →can go back to address behavior after intense feelings have been calmed and connection is re-established

Even the Small Stuff Changes -Terra Bovingdon

What the science tells us about how stressed brains react to change, loss or threat is that children will often violate the rules because they feel profoundly out of control. It’s a survival reaction and it may actually be

intended to control the situation.

Chris Blodgett,

CLEAR Trauma Center Washington State University

Difficulty focusing

Poor emotional control

Unpredictable,

impulsive behavior

Over-reacting to noise,

physical contact, sudden

movement

NCTSN, 2008

ACE Score and Teen Sexual Risk Behaviors Looking for love

0

5

10

15

20

25

30

35

40

45

Perc

en

t W

ith

Healt

h P

rob

lem

(%

) 0 1 2 3 or more 4

ACE Score

Intercourse by 15

Teen Pregnancy

Teen Paternity

80% of childhood/adolescent attempted suicides are attributable (ARF*) to ACEs

Dube et al,2001

*ARF s(attributable risk fractions) of this magnitude are rarely seen in public health

Ongoing mental health screening survey of 6th and 9th grade students in Los Angeles Unified School District

Students report average of 5-8 potentially traumatic events in their lifetimes

One-half show signs of mild to severe Posttraumatic Stress Disorder (PTSD)

Proximity to trauma (family, person you are close to) increases the likelihood of impact of a potentially traumatic event

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Among adolescents, childhood adversities account for:

◦15.7% of fear disorders

◦32.2% of distress disorders

◦34.4% of substance use orders

◦40.7% of behavior disorders

Population attributable risk proportions (PARPs) were predictive across DSM-IV disorder classes in this national sample ( n= 6483) McLaughlin et al, 2012

Teens exposed to ACEs are more likely to:

- to start drinking alcohol by age 14

-binge drink

-say that they drank to cope

during their first year of drinking

Dube et al, 2006

•Each finger has a channel connected to an organ system & related emotions

•Strong feelings can block those channels

•Holding each finger while breathing deeply can release blockage and tension

Routine is even more important and preparing child for changes in routine/environment

◦How many transitions do we ask students to make before lunch?

Even small choices matter (trauma = loss of control/chaos)

Physically and emotionally safe place

Be sensitive to cues in environment that may be trauma triggers

Recognize that behavioral problems may be transient and related to trauma

National Child Traumatic Stress Network, 2008; www.nctsn.org

Resilience is primarily determined by the characteristics of an individual.

1. TRUE

2. FALSE

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Reduced version of 28-item CYRM which has been validated cross-culturally

12-item brief measure evaluated with multi-service using youth and school-based sample of youth (northern Canada)

www.resilienceresearch.org

Liebenberg et al, 2013

I am able to solve problems without harming myself or others

I know where to go in the community to get help

Getting an education is important to me

I try to finish what I start

I have people to look up to

My parents/caregivers know a lot about me

My family stands by me during difficult times

My friends stand by me during difficult times

I have opportunities to develop skills that will be useful later in life

I am treated fairly in my community

I feel I belong at my school

I enjoy my cultural and family traditions

Serving ~3000 low-income predominantly African American students

Partnering with social service agencies

◦Homeless shelter for students

◦Food bank and clothing for students

◦ Washers and dryers for families to use

Facilitates access to pediatricians & MH counselors

www.washingtonpost.com

“Some people think if you do all this other stuff, it takes

away from focusing on instruction, when really what it ensures is that you can take

kids further academically.”

Superintendent Tiffany Anderson, Joined Jennings S.D. 3 ½ yrs ago

“I’ve eaten more in the last two weeks than I’ve eaten in the last

two years.”

Senior staying at Hope House

BEFORE NOW

Running $2 million deficit

Music, dance & drama programs cut

One of lowest performing schools in State of Missouri

Budget balanced

New grants & philanthropic $

Arts programs restored

Saturday School-college prep program

2015, 92% of H.S. students graduated on time & 78% enrolled in post-secondary training

New teachers work with mentor for semester or more

Parents may not recognize how early trauma may affect parenting and their response to stressful situations

Increasing parents’ awareness of ACEs helps them to understand their own lives and make healthier choices to support their children

When we reach out and support children and their parents together, we see far greater results than the sum of their parts

Two Generation Approach, Aspen Institute

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Looks like “App”-uses QR codes

Avoid stigmatizing words

Trauma-informed parenting support & strategies

Promoting four core resiliency factors

◦Self-regulation

◦Attachment

◦Self-esteem

◦Competency

Free copies available from Jo Gottschalk: Call 907 269-3454 E-mail jo.gottschalk@alaska.gov

www.acestoohigh.com: network with

www.albertafamilywellness.org

http://developingchild.harvard.edu

www.fosteringresilience.orgdeos on brain

www.raisingresilientchildren.com resources

Trauma-informed practices for teachers and administrators

Resources for creating trauma-informed schools

Evidence-based programming and interventions that are being used nationwide