PPT-developmental-psychology-Wk1

Trauma and Aces

00:03
This mini lecture is focused on providing you with an introduction to trauma and adverse
childhood experiences. The learning in this lecture is going to provide you with some
important foundational knowledge for completing both your first assessment tasks and your
upcoming placements. trauma impacts on participation through all life stages. And we're
going to be exploring that in greater detail today. In this mini lecture, we are going to look at
the impact of trauma. We will be reviewing some types of childhood exposures that can have
long term mental and physical health consequences in adulthood, as well as possible
strategies to mitigate the effects of these exposures. The nature of our work means that we'd
need to work in spaces that don't always feel comfortable, we always encourage you to you
to utilize self care when working in this space. If you find this content difficult to engage with,
we would encourage you to seek further support from the University's counseling support
service. Reminder that you may also choose not to participate in discussions with your peers
relating to this content.

We begin our mini lecture by exploring what's meant by the term aces. If you do find yourself
working in the area of trauma informed care, it's highly likely you're going to come across
this term. So it's important that you have a really sound understanding of what's meant by
the term ACS, adverse childhood experiences or ACEs, or potentially traumatic events that
can have negative lasting effects on health and well being. These experiences ranged from
physical, emotional or sexual abuse, to parental divorce or the incarceration of a parent or
guardian. Other example of ACEs include enduring or being exposed to abuse or neglect,
familial violence, mental illness or substance abuse. While there are a multitude of
definitions of aces, the definition wave used captures the critical elements of these
exposures and potential impact. It forces us to consider biological changes that may occur in
response to toxic stress in childhood, and contemplate how outcomes that have traditionally
been thought of as a problem in the patient before us, may in fact, be the downstream
results of a process that began much earlier in life. As we begin to explore how stress even
experience prenatally can influence future stress responsiveness after birth, we can see a
potential cascade of events that can manifest in both outward behavioral changes, as well as
internal changes, resulting in permanent alterations in brain structure and function. We will
touch on a few of these ideas as we move ahead today. Now, I think it's really important that
once we recognize that there's not only tremendous potential within each person at birth, but
also a risk to derail, impair or alter a person's mental and physical health trajectory. As allied
health professionals, we have an obligation to do our best to intervene and change this
trajectory. This is what we hope that you walk away from this lecture experiencing and what
we're going to be exploring today through this presentation.

03:27
The first ACE study was conducted by Dr. Vincent Felitti. from Kaiser Permanente, and Dr.
Robert anda from the Centers for Disease Control and Prevention. They teamed up and did
a retrospective study of early childhood exposure to adverse experiences and subsequent
health consequences. The participants were Kaiser patients who were generally have middle
and upper middle class background. The majority were white and had attended some or
graduated from college. The survey was sent out to over 13 and a half 1000 Kaiser
members with a 70% response rate. seven categories of exposure were explored. Three
included abuse and four exposures related to household dysfunction. Interestingly, more
than half of all respondents had at least one ACE exposure, suggesting that these are very
common occurrences. Now at this point, it is important to recognize the individuals who have
wildly varied physiological and psychological responses to categories of exposure, so that
the exposure itself may not be nearly as critical to outcomes as how the individual him or
herself experiences the trauma ascribes meaning to this experience and internalizes the
adverse experience itself. Interestingly, from the study, they found that individuals with
higher ACE score, defined as a score of four or more adverse childhood exposures had
significant increases in risk for the 10 risk factors, we're going to be having a look at some of
the health impacts of exposure to adverse childhood experiences in the coming slides.

05:16
The next 11 graphs demonstrate a clear and convincing dose response relationship between
childhood exposures and adult health outcomes. Clearly, there is a very likely relationship
between alcohol, alcoholism, and risk of having liver disease as well as rates of depression
and antidepressant use. Whilst both men and women appear to be impacted by increasing
risk for depression as scores increase, women seem to be more affected than men. The
slope of the curve for suicide attempts is extremely steep, with almost one in five persons
with a higher ACE score, making a suicide attempt at some point in their lifetime. In addition
to being victims of abuse, both men and women with increasing ACE scores are more likely
to become perpetrators of domestic violence or intimate partner violence as adults. Smoking
in adulthood and the diagnosis of chronic obstructive pulmonary disease, previously known
as emphysema also increased with increasing ACE scores. In addition to health behaviors,
risk factors and health status, Aces appear to directly impact work performance and
potentially productivity in the workplace. The higher one's a score, the more likely one is to
face serious financial problems, poor job performance and increased absenteeism in the
workplace. The statistics that we just looked at on the previous slides came out of Felitti and
Anders study. Now some in part may have dismissed the results of the study because it was
based on retrospective recall by individuals. It turns out that there was a parallel prospective
study looking at a cohort of individuals from New Zealand born in the early 1970s 1000.
Children born between April of 1972 and March of 1973. From New Zealand were enrolled in
a prospective real time study, childhood trauma was recorded using the same a scoring
system. Except parental alcoholism was not included in the study, and maternal neglect was
added to the survey. The study was published in 2009, more than 30 years after the initial
enrollment, and it not only confirmed that aces were common, but also identified a
relationship between physical or sexual abuse or maternal neglect, which was not included
in the original Felitti study, and the chances for depression and heart disease in adulthood.

07:55
So how do we start to understand some of the connections between the experiences of
adverse childhood experiences and long term health outcomes? Before we get into the
description of what that connection is, I just want to review some of the neuroscience that
you learned about in your first year of study. The amygdala and hippocampus are part of the
limbic system, with the amygdala helping us to respond to certain stimuli, particularly our
fear response. It influences how we respond to an event in our lives that elicits strong
emotions. The hippocampus helps us process long term memories and emotional responses
to the world around us. The prefrontal cortex is critical to planning and complex cognitive
behaviors, encompassing expression of one's personality, decision making, as well as
modulating social behavior. All of these functions fall under the broad category of executive
functioning. And finally, the cerebellum helps us with coordination and voluntary movements,
and assists with balance and clear speech. Intuitively, any significant changes in these
critical brain structures might have substantial impact on emotional, physical and cognitive
function, potentially explaining some of those long term consequences of aces. But let's
have a look at what the research is suggesting. A review of studies looking at brain
development in children experiencing family maltreatment, and others enduring psycho
psycho logical deprivation in institutional settings suggested that global volumetric changes
in the brain can be seen in children experiencing maltreatment, emotional neglect and
physical abuse may be associated with smaller amygdala volumes PTSD, depression, and
emotional neglect may be associated with smaller hippocampal volumes. Volumetric
changes in the prefrontal cortex and cerebellum have been associated with maltreatment
related In Post Traumatic Stress Disorder aces have also been shown to impact immune
functioning in the growing child, as well as brain growth, neuronal connections and neuronal
responsivity. children experiencing maltreatment, who also exhibit PTSD or depression have
also been shown to have a lesser ability to fight infection with changes in T cell numbers,
which serve a critical role in immune function by attacking bacteria, viruses and even cancer
cells. High a scores have been shown to be associated with poor performance on
standardized behavioral and socialization surveys and have increased chances to have a
critical medical condition. Early animal studies on maltreatment and neglect have served as
a catalyst for scientists to look closely at brain development in children experiencing
maltreatment to assess assess potential impact on brain connectivity, volume and function.
So what's happening when we try and understand the link between aces and adult health
outcomes? Research has shown that high ace exposure significantly increases risks for a
multitude of adverse adult health outcomes, including two of the leading causes of death,
type two diabetes and cardiovascular disease. Whilst we do not have time today to explore
each of these adverse health outcomes in depth, I'll briefly show you the results from a few
studies on the relationship between diabetes cardiovascular disease, inflammatory gene
expression, and premature mortality and aces. There have been multiple research studies
that have begun to elucidate interactions between genes, genetic predicted predisposition
and ecology, exposures in the social and physical environment and their impact on
development. These interactions begin prenatally and continue throughout infancy childhood
and into adulthood. Although transient exposure to stress with release of stress home and
hormones is well tolerated, chronic exposure to stress can be toxic to the developing brain
and organs. Intergenerational perpetuation of adverse exposures may be further
exacerbated by poor educational achievement and poverty. unhealthy lifestyles as a means
of coping with stress, as well as sub optimal medical care are likely contributors to increase
morbidity and mortality in at risk individuals.

12:55
We've covered a lot, I'm just going to summarize it. Some of the adult consequences of
exposure to adverse childhood experiences include increased risk for diabetes and
cardiovascular disease, as well as substance abuse smoking, high risk behaviors and
mental health problems. Child consequences include altered immunity, brain development,
volume and connectivity, as well as increases in chronic illness and behavioral problems.

13:31
Now that we have more clearly defined the problem, what are we to do? A study study
published in 2016, looking at systematic inquiries about adverse childhood experiences in
pediatric primary care settings, demonstrated that almost 1/3 of pediatricians never asked
about ace exposures for the patients. Whilst only 7% asked about all of the seven original
ace exposures. Although pediatricians are in a position to identify and respond to ice
exposures in their vulnerable patients, all healthcare providers need to be aware of the
potential impact of ACEs in patients and to be able to ask and act on these risk factors.
Once patients have been identified to be at risk, providers have an obligation to provide
arrange for appropriate counseling and be able to provide patients and parents with
community resources including intimate intimate partner violence prevention, parenting
classes, home visiting services, teen pregnancy prevention and preschool enrichment
programs. Access for children to a consistent medical home is associated with higher levels
of child well being for patients with their ace exposures. Group attachment have a place in
the care of patients and families suffering the consequences of adverse childhood
experiences The Substance Abuse and Mental Health Service Administration has outlined
their concepts about trauma informed approach to patients. This does not simply include
training for individual health care providers, but encompasses a programmatic or
organizational initiative that can be defined as trauma informed recognition of how trauma
impacts individual patients is the first step towards helping them. Once the trauma is
acknowledged or uncovered, providers need to be informed about resources within the
organization, as well as in the community that can address these events and help the
patients move towards recovery. Although the patient may be the most impacted by their
adverse exposures, those caring for these patients are also affected by the sharing of these
stories, and subsequent unburdening of traumatic events. A system needs to be in place that
can enable all members of the healthcare team to work collaboratively to provide support
and guidance for patients, which includes anyone who has any contact with the patients and
families, from the front desk staff and billers to medical assistants, nurses and physicians. As
patients begin to reveal very difficult experiences that may be tied to early childhood pain,
and closely held secrets. All efforts need to be made to prevent retraumatization. In addition
to the concepts highlighted here, the Substance Abuse and Mental Health Services
Administration has defined six key principles of a trauma informed approach. These are
safety, trustworthiness and transparency, peer support, collaboration and check, mutuality,
empowerment, voice and choice and cultural, historical and gender issues. And so we can
start to think about how we might embed those six key principles in our daily practice.

17:09
The importance of safe spaces support, collaboration and empowerment are the cruxes of
trauma informed care. By providing safe spaces, we can avoid retraumatization. This
includes understanding that certain health related and interpersonal behaviors that appear
disordered can be reflections of the patient's coping strategies to chronic stress. When
patients are empowered, their voices are heard, and they collaborate in their care, they're
more likely to follow providers recommendations. For patients exposed to toxic stress. Their
providers may be some of the few people in their lives who provide support and bolster their
self confidence and self efficacy. This can be a powerful positive force in their lives, and can
help patients identify sources of resilience. Additionally, recognizing Cultural Historical,
gender and other issues are important for understanding the outside influences that put
patients at risk of stigmatization and marginalization.

18:16
Now the question often arises as to why some individuals with ace exposures are more
impacted by others given similar exposures in childhood. As it turns out, the quality of
resilience in a child offers some protection from the impact of aces. So in this study, by
Sage, Bethel and looking back, children were assessed by their teachers whether or not they
exhibited the quality of resilience and then assess for their score performance. comparisons
were then made among children who had scored 01, or two plus points on the a survey.
increasing risks for emotional mental health or behavioral issues were noted with increasing
a scores across the board. However, for each ACE score, whether it be 01, or more than two
resilient children demonstrated less absenteeism, more classroom engagement, and less
need to repeat a grade. Based on this study, the quality of resilience in childhood may help
to decrease the impact of ACEs and subsequently may affect academic performance. In
addition, positive childhood experiences appear to potentially mitigate the effects of
increased aces in adulthood. High risk adults who had a scores of four or more, were asked
about four positive possible positive childhood experiences in addition to their adverse
experiences. Participants were also assessed for for adult health consequences, obesity,
smoking, depression and generally poor health for each health consequence. Having at least
one of these positive childhood experiences was shown to correlate with a low rate for
smoking. It was a sense of belonging in high school for poor health and obesity. It was
feeling supported by friends and having fat family support that mitigated these
consequences for depression, or for positive experiences, including enjoying community
traditions, was somewhat protective. For patients who are identified as high risk based on
high ACE scores, it may be useful to assess their personal strengths, resilience, and positive
childhood experiences. On the slide, I've shared an example of a resilient survey developed
to assess someone's positive childhood experiences, it may be useful in the clinical setting
to help a high risk patient focus on some positive experiences in childhood. Here's an
example of an adult resilient survey that can be used in parallel with a child survey to assess
current beliefs and functioning. This too can establish a foundation upon which to foster
hope, build bridges and make positive plans for future actions. We've covered a lot in this
mini lecture, so I'm going to provide you with a really brief summary. Aces are potentially
traumatic events that can have negative lasting effects on health and wellbeing across the
lifespan. providers within the medical home can use knowledge about ACEs to better care
for patients who have significant exposures and mitigate the risk for disease. trauma
informed care focuses on recognizing the impact of trauma, and avoiding retraumatization
with a safe, trustworthy clinical environment that encourage self efficacy, collaboration and
empowerment. Resilience can mitigate the potential impact of aces, and as more evidence
accumulates about the power of resilience, additional resources may become available.
Finally, I'll share the reference list. This is also available in in the copy of the PowerPoint
slides. It's available on my uni