ACES and Kernels in Treatment Settings
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  • This presentation is a summation of evidence compiled by Dr. Robert Anda of the CDC and Dr. Vincent Filletti of Kaiser Permenente in Southern California, as well as research compiled by Dr. Dennis Embry.
  • Explain our goals for the day
  • Ask about the audience’s perception of the costs of child abuse and other adversity experienced during childhood. Most likely, many of the major ACE related outcomes will come up (but not all). That’s great, because we’re just trying verbalize here that we already know abuse is bad (many just don’t realize how comprehensively bad it is – and we’ll lead them to that).
  • When I work with parents and educators, I always ask them about the tools they want to pack into their children’s suitcase, and bricks they want to remove. The nature of your work means that by the time your clients have made it to you, the majority of them are carrying a suitcase full of bricks… you don’t have the luxury of proactively impacting their lives, but you’ll see that you can impact their future.
  • The ACE Study was developed by doctors at Kaiser Permanente in partnership with the Centers for Disease Control in the 1990’s. The need for a study became apparent when Kaiser Permanente’s nationally renowned weight loss program recognized that its most successful clients (in terms of weight loss) were the ones who were dropping out of the program prematurely. The quest for answers ultimately led the researchers to focus on abuse and dysfunction experienced by their clients as children.
  • Pass out the ACE Score calculator (if you haven’t already). This is the tool developed by Dr. Anda and his colleagues at the CDC to determine the ACE score. Each question is requires a “Yes” or “No” answer. Each “Yes” answer equals one point. Each “No” answer equals zero points. A person’s ACE Score is the sum of all the yes answers.A person’s ACE Score is private. Ask participants to keep their own score in mind as you walk them through the rest of the presentation. It could be that they are persons of great resilience and so will disbelieve the rest of the presentation. Those folks should be reminded that although they were protected, look at others in their lives or family who were not as resilient (or fortunate).
  • The intuition of a modern sage… This is exactly what the ACE Study found.
  • Kuelbs, 2009; Perry, 2001; Shore, 2001; Teicher et al, 2002
  • The Study established that ACEs lead to risk factors for the 10 most common causes of early death in the United States.
  • It was found that the higher ones ACE score, the more likely a person was to have clusters of issues.
  • It seems that clients with an ACE score of 4 or more are most drawn to use Heroin and other prescription Opiates.
  • The ACE Pyramid illustrates the momentum adverse childhood experiences have in a person’s life. If you begin life with a foundation of adversity, without intervention some form of social, emotional or cognitive impairment will develop to enable a person to adapt to their adverse environment. The ACE Study show this will lead to the adoption of health risk behaviors (or an individual’s personal solution) in childhood and adolescence, which are typically risk factors for disease, disability and social problems, which ultimately lead to an early death. This is not the foundation you want if you plan to send your kids to an ivy league school, or even to graduate from high school!
  • According to the initial ACE Study findings, average life expectancy is reduced by 19 years for a person with an ACE score of 6 or more.
  • This component of the presentation was adapted from the work of Dr. Dennis Embry at Paxis Institute. You can learn more at
  • If Americans reduced linoleicacid (e.g., soybean oil, cotton see oil, corn oil) intake to the same levels consumed in the UK, Canada or Australia, researchers believe homicides would drop from 30,000 to 2,000.
  • Mothers who eat NO fish during pregnancy, per US Government recommendations, have twice as many low IQ children as mothers who eat fish twice a week.
  • Ample research shows television viewing is directly linked to obesity, sexual promiscuity, teen pregnancy, violence and substance abuse.
  • American diets changed with all the grain-feed meats, packaged food, salad dressings, chips, prepared baked goods, snacks, fast food, etc., vastly increasing our consumption of omega-6 and reducing omega-3. This is bad, because omega-6 causes the brain to become inflamed and “leak” important brain chemicals like serotonin and dopamine. Essentially, the brain has little drug factories, and those factories work based on the raw materials the brain receives. If we eat lots of omega-6, that is what the brain’s chemical factories will use.

ACES and Kernels in Treatment Settings Presentation Transcript

  • 1. Supporting our client’s success intreatment and in the community Presented by Joe Neigel Snohomish County Human Services February 21, 2013
  • 2. Learn about the Adverse Childhood Experiences Study andhow early life trauma influences behavior and long-termadult health outcomes.Consider some additional factors that have becomesignificant contributors to the decline of wellness in oursociety, particularly among young people.Discover some low and no-cost strategiesyou can apply to significantly influence yourClient’s success in treatment, at home and inthe community.
  • 3. • ACES is the largest study ever completed that examines the health and social effects of traumatic childhood experiences throughout a person’s lifespan (more than 17,000 participants)  Middle class, average age of 57  80% white, 10% black, 10% Asian  74% some college  44% graduated college  49.5% men• Examines three forms of abuse and household dysfunction
  • 4. • Child physical abuse• Child sexual abuse• Child emotional abuse• Neglect• Mentally ill, depressed or suicidal person in the home• Drug addicted or alcoholic family member• Witnessing domestic violence against the mother• Loss of a parent to death or abandonment, including abandonment by divorce• Incarceration of any family member
  • 5. • The ACE Score is the number of categories of adverse childhood experiences to which a person was exposed.• The ACE Study found that the number of categories, not necessarily the frequency or severity of the experiences within a category, determine health outcomes across the population as a whole.
  • 6. ACEs are very common (what remainsuncommon is their recognition oracknowledgement).They are well-concealed by time, shame, bysecrecy and social taboo.ACEs are strong indicators of what happenslater in life, in terms of health risks, diseasesand premature death.
  • 7. “My greatest failure was in believing that the weight issue was just about weight. It’s not. It’s about not handling stress properly. It’s about sexual abuse. It’s about all the things that cause other people to become alcoholics and drug addicts.” — Oprah Winfrey
  • 8. Like you, Oprah didn’t need research to tell herthat a child’s environment and experiences shapetheir long-term health.We intuitively know that our environment shapesbrain development, which by design prioritizessurvival.To ensure survival, our brain produces ahormone called Cortisol that is released duringtimes of intense stress or danger – it triggers our“flight or fight” response.
  • 9. Prolonged exposure to Cortisol is toxic, andmakes permanent changes to the brain.This means a person may be perfectly suited tosurvive in their home environment, but they maynot know how to act in normal situations.Toxic Stress Hormone exposure even changes theDNA of a person, allowing for Mothers or Fathersto pass on their “survival characteristics” fromgeneration to generation.
  • 10. AGE OF TYPE OF ABUSE MALTREATMENT Different types ofThe brain develops maltreatment over time. The activate different effects of processes that maltreatment shape the brain, correspond to the such as chemicals region and/or & hormones, function that is electrical activity, developing at the cell growth, & time of specialization of maltreatment. cells. GENDER Although both boys & girls are affected by maltreatment, the effects of sexual abuse are more profound in girls while the effects of neglect are more profound in boys.
  • 11. The Temporal Lobes regulate emotionand receive input from the senses
  • 12. Hypervigilance - “Always on the ready;”Development of trauma induced ADHD symptoms;Early onset of sexual activity;More impulsive, aggressive behaviors;Less able to tolerate stress; and Increased risk of physical and mental health problems,including development of health risk behaviors likeaddiction.
  • 13. • There is a strong “dose/response” relationship between a person’s ACE score and their number of resulting outcomes and health problems.• Dose/Response is a measure of “cause and effect.”
  • 14. • We can see the cause and effect relationship ACEs create in people and in populations.
  • 15. • We can see the cause and effect relationship ACEs create in people and in populations.
  • 16. • We can see the cause and effect relationship ACEs create in people and in populations.
  • 17. • We can see the cause and effect relationship ACEs create in people and in populations. 80 Women% With a Lifetime History of 70 Men 60 Depression 50 40 30 20 10 0 0 1 2 3 >=4 ACE Score
  • 18. • We can see the cause and effect relationship ACEs create in people and in populations.
  • 19. Partial List of ACE Dose/Response OutcomesAlcoholism & alcohol abuse Liver diseaseChronic obstructive pulmonary Obesitydisease & ischemic heart diseaseDepression Sexually transmitted diseaseFetal death SmokingHigh risk sexual activity Suicide attemptsIllicit drug use Unintended pregnancyIntimate partner violence Early DeathThree or more marriages Increased Emergency Room UseIncreased Pharmacy Use Significant Financial Problems
  • 20. With an ACE score of 0, the majority of adults havefew, if any, risk factors for diseases leading to earlydeath With an ACE score of 4 or more, the majority ofadults have multiple risk factors for these diseases,or the diseases themselves. Prepare yourself for this – The things we identify as risk factors (obesity, illicitdrug use, promiscuity) are, in fact, effective short-term devices – coping mechanisms – for the trauma experienced as a child
  • 21. This is an important idea. Framing thisanother way, many of the things termedpublic health problems are actuallypersonal solutions. “What is conventionally viewed as a problem is actually a solution to an unrecognized prior adversity.” Dr. Vincent Felitti, co-principal investigator of ACE Study
  • 22. To put it simply, childhood experiences arethe most powerful determinants of who webecome as adults.
  • 23. PAR = The difference in rate of a conditionbetween an exposed population and anunexposed population.In this case, it is a calculation used by theCDC to estimate the proportion of a healthoutcome that is attributable to ACEsIMPORTANT: PARS are not predictors offuture behavior; rather, they evaluate theimpact of a causal factor (ACEs) on existingbehavior.
  • 24. Current Smoking Smoking Not Attributable to 21.7% Ace Smoking 78.3% Attributable to ACERisk data from Felitti, et. Al: PAR analysis: RE Voorhees
  • 25. Ever Using Illicit Drugs 32.1% not attributable to 32.1% ACE 67.9% 67.9% attributable to ACERisk data from Felitti, et. Al: PAR analysis: RE Voorhees
  • 26. Alcoholism 3.2% 3.2% of self- reported alcoholism not attributable to 96.8% ACE 96.8% of self- reported alcoholism attributable to ACERisk data from Felitti, et. Al: PAR analysis: RE Voorhees
  • 27. Reporting Having Attempted Suicide 0% of attempted suicide not 100% attributable to ACE 100% of attempted suicide is attributable to ACERisk data from Felitti, et. Al: PAR analysis: RE Voorhees
  • 28. Less than 1 of 100 people with 0 ACEs attempt suicide10 of 100 people with 3 ACEs attempt suicideNearly 20 of 100 people with 4 or more ACEs attempt suicide
  • 29. Client ACE Scores 9% 14% 56% 21%0 ACEs 1 ACEs 2 or 3 ACEs 4 or More ACEs
  • 30. Client Drug of Choice 14% 36% 15% 35%Heroin & Other Opiates Alcohol Meth All Others
  • 31. # of ATR Clients by Drug of Choice and ACE Score605040302010 0 Heroin & Alcohol Other Meth Opiates All Others* 0 ACEs 1 ACEs 2-3 ACEs 4 or More ACEs
  • 32. “PersonalSolution”
  • 33. 60Percent in Age Group 50 19-34 35-49 40 50-64 >=65 30 20 10 0 0 2 4 ACE Score
  • 34. Consider the impact ACES have on your work. Ifyou are supporting a client with a high ACEscore, they may not be successful without atailored or coordinated services. Follow throughon referrals!Share what you’ve learned so far. If you knowothers who would benefit from thisinformation, let’s organize a training for them.Reflect on the contributing factors and strategieswe’ll be talking about next.
  • 35. Adversity is not our destiny. Every person can heal.
  • 36. Our culture is killing our kids.
  • 37. Depression, bipolar disorder, anxiety and suicidality are increasing in youth.
  • 38. ADHD, conduct disorders and self mutilation (cutting behaviors) are increasing in youth.
  • 39. Younger kids are committing more serious crimes.
  • 40. Obesity has become epidemic in youth.
  • 41. Bullying and aggression continue to grow.
  • 42. Serious addictions are happening at younger ages.
  • 43. Our youth are suffering from majordevelopmental deficiencies unrecognizedby the majority of our culture, including:Essential brain nutrient deficienciesMovement deficienciesReinforcement deficiencies
  • 44. • Brain nutrient deficiencies lead to serious problems for youth, and the people who interact with them. • They are specifically known to cause: Increases Decreases Illness and Death in… in… from…Impulsivity Self-Control Heart diseaseBipolar disorder I.Q. StrokeDepression Academic achievement ObesitySuicide DiabetesADHD Alzheimer’sAggression & Homicide CancerSubstance abuse** Domestic Violence**
  • 45. • While our bodies consist mostly of water, our brains are 60% fat, fat that makes the neurons keep their shape and separation from each other.• Our neurons are mostly one kind of fat — something called Omega-3, which is specifically a fatty acid.• Humans do not create Omega-3 alone. We have to eat it, and it comes from just a few things in our diet.
  • 46. Many people in the United States exhibitsome form of Omega-3 deficiency. Omega-6 Omega-3 (soybean, corn, cotton seed oil) (fish and range-fed stock)
  • 47. • The alterations in brain chemistry that have resulted from our changing diet during the last 50 years contributes to trends of depression, bipolar disorder, autism, violence and academic problems.
  • 48. • Movement deficiencies also lead to serious problems for youth. • These deficiencies are specifically known to cause: Increases Decreases Illness and Death in… in… from…Depression Academic achievement Heart diseaseSuicide Social Competence StrokeADHD ObesityAggression DiabetesBullying Bone fracturesTobacco Use
  • 49. • Some national trends: 82% of mothers do not let their children play outside because of fear of crime. Many parents do not let their children roam with other children because of “stranger danger” fears. Parks, playgrounds and sidewalks for children are not being built. From 1981 to 1997, play time for young children declined from 15 hours to 11 hours. 70% of US mothers played outside as children, but only 31% of their children do today.
  • 50. • Ample research shows television viewing is directly linked to obesity, sexual promiscuity, teen pregnancy, violence, ADHD symptoms, decreased academic achievement and substance abuse.• It leads to vicarious trauma exposure and can create PTSD symptoms in youth, which may include having difficulty controlling emotions and reactions.  Having trouble beginning and maintaining relationships and friendships.  Having low self-esteem.  Having problems keeping up in school.
  • 51. • Reinforcement deficiencies lead to serious problems for youth and society • These deficiencies are specifically known to cause: Increases Decreases Illness and Death in… in… from…Depression Academic achievement Intentional injuriesADHD Social Competence Unintentional injuriesAggression Infectious diseasesBullying Stress-related illnessLegal and illicit drug use
  • 52. • What are the social reinforcers in your agency for this behavior?
  • 53. • What are the social reinforcers for this?
  • 54. • Attention is a reward, and our culture tends to give big and frequent rewards for bad things done by teens and adults today.• Every child has an “attention” gas tank. They need it filled in order to be whole people.  Praise and positive attention are like premium gasoline: they make children run at their best.  Negative attention is like regular unleaded gasoline: it will do.• Criticism and punishment reinforce negative behaviors, while praise and recognition reinforce positive behaviors. A child will behave in the manner that gets him the most attention!• Think about how video games influence youth: young people spend hours in front of a screen for nothing more than electronic “atta boy” or a “you go girl.”
  • 55. • No – its actually a Synergistic Pandemic, or “Syndemic!”• Syndemics are multiple-related afflictions, disorders and disruptions in American society that cause:  Rises in delinquency, crime, car crashes, violent injuries, and white-collar crimes  Mental illness, child-maltreatment, domestic violence, sexually transmitted diseases, and addictions of all types  Higher health-care and social-security costs  Lower economic productivity and global competitiveness  Vulnerability to terrorism and social instability
  • 56. • All of these problems seem big and messy.• Many of us feel too overwhelmed by our current work to try something that may be ineffective.• But we need to remember that these big problems are really a combination of many smaller problems spread across a lot of people.• What if we could use small solutions to make just as big of an impact?
  • 57. • A kernel is the smallest unit of scientifically proven behavioral influence.• They are the “active ingredients” of evidence-based programs.• A kernel is indivisible; that is, removing any part makes it inactive.• Kernels produce quick easily measured change that can grow into much bigger change over time.• They can be used alone OR combined with other kernels to create new programs, strategies or policies.• Combinations of Kernels are considered “behavioral vaccines.”• “Planted” Kernels create a culture.
  • 58. There are over 100 evidenced-based kernels you can plant for agency and community-level change.
  • 59. • Omega 3 has no harmful effects• Documented evidence for Reducing aggression, violence, depression, bipolar disorder, post partum depression and borderline personality disorder• Early evidence for reducing symptoms of developmental disorders and for reducing Cardio Vascular Disease and asthma.• In 2006, the American Psychiatric Association recommend that all psychiatric patients receive at least 1 gram of omega-3 per day to reduce symptoms of mental illness.
  • 60. • Notes of praise written from one peer to another, then read aloud or posted on a public display is widely shown to: – Increase positive friendships; – Reduce neighborhood disorganization and crime; – Increase sense of safety; – Increase volunteerism; and – Increase behaviors you want to see more of.
  • 61. • When any person receives specific, spoken recognition for engagement in a target act or behavior, it is widely demonstrated to: – Improve performance; – Improve personal interactions; – Improve organizational functioning; and – Increase the frequency of the target behavior.
  • 62. • This attention kernel works for youth and adults. It results in immediate reduction in transition time, increased engagement, reduced disruptive behavior, reduced aggression and bullying, and reduced trauma response in traumatized people.• Cost: Harmonica• Steps: – Blow the Harmonica – Raise hand in peace sign • Praise clients who quickly train their eyes on you • Make sure 95% of all clients eyes on you BEFORE you give your next instruction• Give transition instruction – Recognize success and occasionally reward quick transitions
  • 63. • Based on the “Premack Principle,” variations are known as voucher-based reinforcement, contingency management, or in classrooms - Granny’s Wacky Prizes. Results in a reduction in deviant behavior across the lifespan, relapse, other problem behaviors, and increases desirable behavior in all age groups• Motivates youth and adults to do their best and improve;• Builds “intrinsic” motivation; and• Fosters self-regulation instead of excitement.
  • 64. • Twelve studies by the National Institute on Drug Abuse show the Prize Bowl creates powerful, fast, low cost results in reducing the hardest drug addictions, including methamphetamine, cocaine and heroin.• Agencies participating in this system reward Clients with prize tickets for engaging in recovery behaviors, engaging in weekly goal-oriented activities, and not having dirty UA’s.• Research shows total rewards worth about $195 per client produce reliable results many times better than other therapies or strategies.• Prizes can even be donated from the community.
  • 65. 1. Over a period of 3 months, urine and breath samples are collected two or three times a week for at least the first 6 weeks, then once or twice a week thereafter.2. For each sample that tests negative, clients get to draw slips of paper or plastic chips from a bowl for the chance of winning a prize valued from $1 to $100. Clients may also receive draws from the prize bowl for attending counseling/group therapy sessions or completing weekly goal-related activities.3. The number of draws from the prize bowl increases from 1 to as many as 15 with consecutive negative test results and/or attendance at consecutive sessions. A drug- positive sample or an unexcused absence resets the number of draws to one.4. It’s okay to use client ideas and behaviors as prizes.
  • 66. • Also known as “handshakes.”• Frequent friendly physical and verbal greetings impact social status and perceptions of safety and harm.• It also affects behavior streams of aggression, hostility or politeness.• Greetings are also a key to positively influencing agency and even group culture.
  • 67. • Motivational Interviewing• Progressive muscle relaxation• Nasal breathing• Say/Do and Do/Say (Correspondence Training)• Choral responding• Paragraph shrinking• Public commitment• The list goes on…
  • 68. • Meaningful change for our client’s begins with you.• If you need it, I personally give you permission to do what’s in your heart.• Create a network of protection by sharing these strategies with your colleagues and others who couldn’t be here today, and encourage them to share this information with others they know.