the impact of adverse childhood experiences across the lifespan challenges and opportunities
TRANSCRIPT
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The Impact of Adverse Childhood Experiences Across the Lifespan
Challenges and Opportunities
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Special Acknowledgments
Vincent Felitti, MD, Kaiser Permanente
Robert Anda, MD, CDC and ACE Interface
Frank Putnam, MD, UNC at Chapel Hill, NC
William Harris, PhD, Children’s Research and Education Institute
& New School for Social Research, NYC, NY
Alicia Lieberman, PhD, UCSF, San Francisco, CA
Karen Putnam, PhD, UNC at Chapel Hill, NC
Lisa Amaya-Jackson, MD, Duke University, Durham, NC
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Adverse Childhood Experiences Study
How did it all start?
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Adverse Childhood Experiences Study
• >17000 patients
• Mostly White or Hispanic
• Insured
• Average age 57
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Study Questions
• Abuse: emotional, physical, or contact sexual
• Household dysfunction: substances, mental illness, or incarceration
• Neglect: emotional or physical
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ACES Prevalence (%) of Abuse and NeglectIn the Original Study 1
ACE Women Men TotalN=9367 N=7970 N=17337
AbusePhysical Abuse 27.0 29.9 28.3Sexual Abuse 24.7 16.0 20.7Emotional Abuse 13.1 7.6 10.6
NeglectEmotional Neglect 16.7 12.4 14.8Physical Neglect 9.2 10.7 9.9
1 http://www.cdc.gov/violenceprevention/acestudy/prevalence.html
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ACES Prevalence (%) of Household DysfunctionIn the Original Study 1
ACE Women Men TotalN=9367 N=7970 N=17337
Household DysfunctionHousehold Substance Abuse 29.5 23.8 26.9Parental Separation or Divorce 24.5 21.8 23.3Household Mental Illness 23.3 14.8 19.4Mother Treated Violently 13.7 11.5 12.7Incarcerated Household Member 5.2 4.1 4.7
1 http://www.cdc.gov/violenceprevention/acestudy/prevalence.html
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ACE, Larkin, U of Florida, Illinois BRFSS
How Common are ACEs?
• 2/3 of study patients reported at least 1 ACE
• In 2009, 85% of a homeless population reported at least 1 ACE, 55% reported 4 or more
• In 2013,50% of adult Illinois residents and 40% of children 17 had at least 1 ACE
• In 2014, Juvenile offenders in Florida had an average composite ACE score of 3.5-4.3
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Experiencing 1 ACE
Increases one’s risk for experiencing additional
ACES
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Percent of Cumulative Adverse Childhood Experiences ACES in the Original Study 1
Number of ACES Women Men TotalN=9367 N=7970 N=17337
0 34.5 38.0 36.11 24.5 27.9 26.02 15.5 16.4 15.93 10.3 8.6 9.5
4 or more 15.2 9.2 12.5
1 http://www.cdc.gov/violenceprevention/acestudy/prevalence.html
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• The original ACES (in red) are among the most commonly reported traumas in studies that look at additional traumas
• Over 40% of the children and adolescents served by the NCTSN experienced 4 or more different types of trauma and adversity
1Pynoos et. al (2014). Psychological Trauma: Theory, Research, Practice and Policy. 6:S9-S13
The ACES are Among Many Childhood Traumas and Adversities Measured by the National Child Traumatic Stress Network (N= 10,991)1
48.7
45.1
36.4
31.4
26.8
26.2
20.1
14.1
13.3
10.6
10.6
9.7
9.5
8.8
5
4.6
2
1.7
1
0.9
0 10 20 30 40 50 60
Traumatic Loss/Bereavement/Separation
Domestic Violence
Impaired Caregiver
Emotional Abuse
Neglect
Physical Abuse
Sexual Abuse
Community Violence
Sexual Assault/Rape
Serious Injury/Accident
School Violence
Other
Illness/Medical Trauma
Physical Assault
Natural Disaster
Extreme Interpersonal Violence
Kidnapping
Forced Displacement
War/Terrorism/Political Violence (Non-U.S)
War/Terrorism/Political Violence (U.S)
Percent % Reported
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Cumulative ACES Increase Risk for Poor Outcomes
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1 Data from the National Comorbidity Survey-Replication Sample (NCS-R) - Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013
Cumulative ACES & Mental Health1P
reva
len
ce
%
Mood Disorders Anxiety Disorders Substance Abuse Impulse Control Disorders
0
10
20
30
40
50
60
70
80
0 1 2 3 ≥ 4ACES
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1 Felitti et al., (1998) American Journal of Preventive Medicine, 14:245-258.
Cumulative ACES & Chronic Disease1P
reva
len
ce
%
Ischemic Heart Disease
Stroke COPD Diabetes Sexually Transmitted
Disease
0
2
4
6
8
10
12
14
16
18
0 1 2 3 ≥ 4ACES
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1 Anda et al., (2004) The Permanente Journal/Winter 8:30-38.
Cumulative ACES & Impaired Worker Performance1
Pe
rce
nt
% R
ep
ort
ed
Absenteeism Financial Problems Job Problems0
5
10
15
20
25
0 1 2 3 ≥ 4ACES
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ACEs are the Root Cause of Many Health and Social Problems
Disease and Disability• Major Depression,
Suicide, PTSD• Drug and Alcohol Abuse• Obesity• Diabetes• Heart Disease• Cancer• Chronic Lung Disease• Sexually Transmitted
Diseases
Social Problems• Homelessness• Prostitution• Criminal Behavior• Poor school outcomes• Unemployment• Parenting problems• High utilization of health
and social services• Intergenerational
transmission of abuse
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Washington State Family Policy Council
Contribution of ACEs
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Synergistic ACES in Females 1,2
• In females synergy occurs with 2 or more ACES
• For females the most potent ACE, sexual abuse, is synergistic with:
– Domestic violence
– Crime victimization
– Poverty
– Parental mental illness (anxiety/depression)
– Loss of a Parent
1 Data from the National Comorbidity Survey-Replication Sample (NCS-R)2 Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013
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Synergistic ACES in Males 1,2
• In males synergy occurs with 3 or more ACES
• For males, the most potent ACE, poverty, is synergistic with:
– Sexual abuse
– Parental substance abuse
– Loss of a parent
1 Data from the National Comorbidity Survey-Replication Sample (NCS-R)2 Putnam, Harris, Putnam, J Traumatic Stress, 26:435-442, 2013
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Synergy between ACES & Other Adversities (e.g., Environmental Pollution1)
• Childhood asthma affects lower income communities more where air pollution & ACES may be elevated
• When they corrected for other possible contributors, researchers found an increased risk between traffic-related air pollution and asthma (OR = 1.63, CI=1.14-2.33) solely among children exposed to violence
• ACES likely interact synergistically with many environmental pollutants and negative social experiences to increase risk for many costly illnesses
1Clougherty et al, (2007) Synergistic effects of traffic-related air pollution and exposureTo violence on urban asthma etiology. Environmental Health Perspectives 115:1140.
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Impact of Cumulative ACES & Social Dysfunction 1
• Lower educational, occupational attainment
• Increased social service costs
• Increased medical costs
• Shortened life span (ACE>6 by 20 years)
• Increased risk for HIV infection, teen pregnancy
• Intergenerational transmission of ACES to offspring
1 IOM (Institute of Medicine) and NRC (National Research Council). 2013. New Directions in child abuse and neglect research. Washington, DC: The National Academies Press.
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ACES and Toxic Stress
What’s the story????
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The Stress Response
• Positive—normal and essential part of healthy development with brief increase in heart rate and mild elevations of stress hormones which return to baseline, eg, the first day of school
• Tolerable—more and longer activation of the body’s alert systems as a result of more severe and longer lasting challenges like death of a loved one. The brain and body can recover fully if the activation is time-limited and buffered by relationships with caring adults
• Toxic—strong, frequent and/or prolonged activation of the stress response, like with ACES, without adequate adult support. Can disrupt the development of the brain and other organ systems, increasing the risk for stress-related disease and cognitive impairment across the life span.
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Attachment
• A special emotional relationship that involves an exchange of comfort, care, and pleasure.
• Early attachment styles are established in childhood through the infant/caregiver relationship.
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Effects of ACES in Childhood
• Impaired development in the first 3 years• > risk for failing a grade• Score lower on standardized tests• Have language difficulties• Be suspended or expelled• Be designated special ed• Have poorer health• Are at risk for incarceration
Anda, Blodgett, Burke-Harris
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Blodgett
ACEs and School
• The main reason that kids miss school or get in trouble
• The second highest predictor of academic failure after being in special ed classes
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http://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html
Individual Risk Factors
• Children younger than 4 years of age
• Special needs that may increase caregiver burden (e.g., disabilities, mental retardation, mental health issues, and chronic physical illnesses)
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Rates of Maltreatment by Age1
• Most maltreatment happens to younger children• Maltreatment has greater negative effects at younger ages
1 Child Maltreatment 2012. Washington, DC: US Department of Health and Human Services; 2014
Types of Child Maltreatment
PsychologicalMaltreatment
7%
0 1 2 3 4 5 6 7
0-3
4-6
7-9
10-12
13-15
16-17
Percent of Children
Age G
rou
p
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http://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html
Parental Risk Factors
• Parents' lack of understanding of children's needs, child development and parenting skills
• Parents' history of child maltreatment in family of origin• Substance abuse and/or mental health issues including
depression in the family• Parental characteristics such as young age, low education,
single parenthood, large number of dependent children, and low income
• Nonbiological, transient caregivers in the home (e.g., mother’s male partner)
• Parental thoughts and emotions that tend to support or justify maltreatment behaviors
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http://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html
Family Risk Factors
• Social isolation
• Family disorganization, dissolution, and violence, including intimate partner violence
• Parenting stress, poor parent-child relationships, and negative interactions
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http://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html
Community Risk Factors
• Community violence
• High poverty and residential instability
• High unemployment rates
• High density of alcohol outlets
• Poor social connections.
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Adverse Childhood Experiences•Abuse and Neglect (e.g., psychological, physical, sexual)•Household Dysfunction (e.g., domestic violence, substance abuse, mental illness)
Impact on Child Development•Neurobiologic Effects (e.g., brain abnormalities, stress hormone dysregulation)•Psychosocial Effects (e.g., poor attachment, poor socialization, poor self-efficacy)•Health Risk Behaviors (e.g., smoking, obesity, substance abuse, promiscuity)
Long-Term Consequences
Disease and Disability•Major Depression, Suicide, PTSD•Drug and Alcohol Abuse•Heart Disease•Cancer•Chronic Lung Disease•Sexually Transmitted Diseases•Intergenerational transmission of abuse
Social Problems•Homelessness•Prostitution•Criminal Behavior•Unemployment•Parenting problems•High utilization of health and social services
How the ACES Work
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ACEs and the Next Generation
Experiences that we have turn our genes on or off, making us healthier or sicker. Then we pass those modified genes on to our sons and daughters.
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The Great Rat Mother Switcheroo
• Rats born to anxious,non-nurturing mothers become anxious, non-nurturing adults
• Rats born to calm nurturing mothers become calm and nurturing adults
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What happens when you switch the
babies???
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How ACES Cross Generations
Child
Adolescent
Adult
ChildAbuse
ChildAbuse
AggressionConductProblems
DepressionPTSD
Anxiety
SchoolProblems
Revictim-ization
SchoolDropout
SubstanceAbuse
DepressionPTSD
Anxiety
ParentingProblems
DomesticViolence
MaternalDepression
PTSDPoverty
SubstanceAbuse
Generation 1
Generation 2
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Hurt People
Hurt Other People
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01.5
34.5
Second Hand Smoke & Lung Cancer2 Versus
Sexual Abuse & Drug Addic-tion1
Od
ds R
ati
o
0
1
2
3
4
5
6
Texting & Crash or Near Fatal Crash3Versus
Physical Abuse & PTSD1
Od
ds R
ati
o
0
1
2
3
4
ADHD & Lead Exposure ADHD with Exposure toDomestic Violence in
Females
ADHD with Exposure toDomestic Violence in
Males
Odds
Rati
o
Lead Exposure & ADHD4
VersusDomestic Violence & ADHD1
0
1
2
3
4
Melanoma Risk & TanningBeds
Conduct Disorder withExposure to Poverty in
Females
Conduct Disorder withExposure to Poverty in
Males
Odd
s Rati
o
Tanning Beds & Melanoma Risk5
VersusPoverty & Conduct Disorder1
1Putnam et. al. JTS, 26:435-442,2013 2Brennan et. al. Int J Cancer, 109:125-31,2004 3Klauer et.al. NEJM, 370:54-59,2014 4Froehlich et. al. Pediatrics, 124:1054-1063,2009 5Lazovich et, al. Cancer Epidemiol Biomarker Prev., 19:1557-1568,2010
Public Health Thresholds of Risk for
Legislation, Regulation or Recommendations
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Costs of Cumulative & Synergistic ACES
• Human suffering borne by victims & their families
• Economic costs borne by society
• Social costs borne by society
• Intergenerational transmission of childhood adversity borne by future society
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What does it cost to do nothing?Each 2014 First-Time Case of Child Maltreatment Costs U.S. Economy
Approximately $1.8 Million in Total Expenditures over their Lifetime1
1Suffer the Little Children: An Assessment of the Economic Costs of Child MaltreatmentThe Perryman Group, [email protected]
$1.8 Million per 2014 victim1
Graphic from Pew Issue Brief Jan 2011: Paying Later: High Cost of failing to Invest in Young children.
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Estimated Lifetime Costs for all 2014 First Time Maltreatment Victims = $5.9 Trillion1
1Suffer the Little Children: An Assessment of the Economic Costs of Child MaltreatmentThe Perryman Group, [email protected]
$5.9 Trillion
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Summary
• ACES are cumulative & synergistic
• ACES increase risk for major public health problems far in excess of the usual thresholds (i.e., ORs ≥ 1.4 – 1.8) for interventions
• ACEs may be synergistic with environmental exposures or social experiences, e.g., air pollution & childhood asthma
• ACEs are often transmitted from one generation to the next
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What Can We Do?
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Maslow’s Hierarchy of Needs
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Addressing ACES Offers Critical Public Health Opportunities1
• ACES are the most preventable cause of serious mental illness
• ACES are the most preventable causes of drug and alcohol abuse in women
• ACES are the most preventable causes of HIV high-risk behavior (IV drugs, promiscuity)
• ACES are a significant contributor to leading causes of death (heart disease, cancer, stroke, diabetes, suicide)
1 IOM (Institute of Medicine) and NRC (National Research Council). 2013. New Directions in child abuse and neglect research. Washington, DC: The National Academies Press.
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Adopt a Public Health/Systems approach to Child Maltreatment and other ACEs
1. Implement trauma-sensitive legislation and regulations
2. Build capacity in communities and systems to prevent & treat child trauma
3. Integrate trauma services across family-serving systems
4. Increase access to trauma-informed services for children & families
5. Screen for ACEs in systems that serve children and families
6. Integrate and enhance programs to target synergistic ACEs with highest cumulative risks
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• California resolution to encourage state policies that decrease exposure to ACEs
• Wisconsin bill encourages policies that attend to brain development, prevention of toxic stress and ACEs, and appropriate early intervention programs
• Massachusetts bill supports creating conditions for “safe and supportive schools
• Vermont bill plans for evaluation of whether ACE-informed medical practice should be part of the state’s health plan
Policy Examples
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Protective Factors for Primary Prevention and Treatment
Supportive family environment, social networks, and communities
– Basic family needs– Nurturing parenting skills– Stable family relationships– Household rules and child monitoring– Parental employment– Adequate housing– Access to trauma sensitive health care and social services– Caring adults outside the family who can serve as role models
or mentors– Communities that support parents and take responsibility for
preventing abuse
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Prevention, Screening, & Treatment Can Be Embedded In Existing Systems That Serve Children and Adults
• Child care• Education• Medical • Well-child• Home visitation• Military families• Foster Care
• Child welfare• Mental health• Drug and alcohol • Juvenile justice• Immigration• Faith based
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Prevention Starts with Parental and Adult Support
• High Quality Home Visiting (Nurse Family Partnership) 40-80% reduction in cases
• Evidence-based Parenting instruction (Triple P) reduced cases, placements and injuries
• Wrap-Around Services embedded in Schools
• Self-care Time and Opportunities for Parents and Staff
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• Many current problems faced by the people we serve may be related to traumatic life experiences
• To provide effective services we need to understand the life situations that may be contributing to the person’s current problems
• People who have experienced traumatic life events are often very sensitive to situations that remind them of the people, places or things involved in their traumatic event
• These reminders, also known as triggers, may cause a person to relive the trauma and view our setting/organization as a source of distress rather than a place of healing and wellness
Organizations Can Understand Trauma
SAMHSA/National Council on Behavioral Health 2013
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SAMHSA/National Council on Behavioral Health 2013
A program, organization or system that is trauma-informed
(1) realizes the prevalence of trauma and taking a universal precautions position;
(2) recognizes how trauma affects all individuals involved with the program, organization, or system, including its own workforce;
(3) responds by putting this knowledge into practice; and
(4) resists retraumatization.
ACEs and the Next GenerationACEs and the Next GenerationSAMHSA’s Concept of a Trauma-Informed
Approach (draft)
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• Invasive procedures • Removal of clothing • Physical touch • Personal questions that may be
embarrassing/distressing • Power dynamics of relationship • Gender of healthcare provider • Vulnerable physical position • Loss of and lack of privacy
Why medical settings may be distressing for people with trauma experiences
SAMHSA/National Council on Behavioral Health 2013
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SAMHSA
A. Train “all” staff about trauma, sensitive practice and sharing critical information
B. Screen and assess for trauma
C. Communicate a sensitivity to trauma issues
D. Create a safe and comfortable environment
E. Provide services in a trauma informed manner – some practical tips
Trauma Sensitive Care and Practices
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Neuroplasticity, also called brain plasticity, is the process in which your brain's neural synapses and pathways are altered as an effect of environmental, behavioral and neural changes.
Resilience is the ability to recover quickly from difficulties; toughness, bouyancy
Good News Definitions
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van der Kolk
4 Concrete Steps for Working with Trauma
• Start with Self-Regulation• Integrate the Senses Through
Rhythm• Help Your Patients Take Steps
Toward Self-Empowerment• Help Your Patients Learn to
Express Their Inner Experience
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• Sensitive acknowledgment of trauma– ACEs screening followed by compassionate listening to the story
• Healing Relationships– HCW’s, teachers, clergy, etc and patients
• Movement– Yoga, marching, martial arts
• Cultivating Awareness– Mindfulness
• Creative self-expression– Dancing, drumming, theater, journaling, COLORING
• Certain Psychotherapies– EMDR, EFT tapping, Ecotherapy, CBT
Treatment
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You don’t have to be a therapist to be therapeutic
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Treatment can restore normal biology in stress response
systems
Thank You Neuroplasticity!
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D. Longhi, Resilience Report, February 2015
Transformation of School Culture: Increasing trust, love, mutual respect, sense of control, clear expectations, pride in achievement allowed students at Lincoln High in Walla Walla to attain high levels of resilience.
Outcomes included better attendance, grades, and test scores even with
increasing ACE scores!!!
Silver Lining—Resilience Trumps ACEs
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Prevention & Treatment Cost Savings!
• Are prevention & treatment programs cost-effective?
• High quality home visiting child abuse prevention programs have been found to return ~ $3.00/dollar of cost1
• Evidence-based child trauma treatments such as Parent-Child Interaction Therapy (PCIT) return $3.64/dollar cost1
1http://www.wsipp.wa.gov/rptfiles/04-07-3901a.pdf
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What Are The Expected Outcomes?
• Reduced human suffering
• Decreased costly Mental & Medical Illness
• Reduction in health risk behaviors (e.g., smoking, substance abuse, poor diet)
• Improved population Health & Well-being
• Decreased intergenerational transmission of ACES
• Improved Educational & Occupation attainment
• Decreased Crime & Victimization
• Decreased Welfare & Social Services
• Increased Productivity & Life Expectancy