ACEs: Understanding Trauma in Childhood

Foreign. I'd like to welcome everybody, today's presentation on adverse childhood experiences and trauma and how it impacts the person throughout their lifespan. I AM your host, Dr. Donnelly Snipes. In this presentation, we're going to explore the relationship between adverse childhood experiences, henceforth and forevermore referred to as ACEs, and trauma. We'll identify, identify the impact of ACEs and traumatic injury on mental, physical, and interpersonal health in adults. So we're looking at the lifespan perspective and explore risk factors for ACEs and subsequent prevention and intervention measures. And I am going to challenge you to think, when we get down to prevention and intervention and even the risk factors, think about ways that you can modify your current work environment or you can work with agencies within your community in order to make services more available to help create more preventative factors and buffer against those risk factors. So adverse childhood experiences, or ACEs, are stressful or traumatic events that children experience before age 18 years. Now, why before age 18 years? Well, that is the age of majority. In reality, the brain does not finish developing until about age 24. And the last part of the brain to develop is the frontal cortex, which is involved in all of our executive processing, our impulse control, our organization, our decision making. You know, so there's a lot of stuff that isn't formally matured until even after the age of 18. But we know that when the brain is developing, it's kind of like pottery that has not been yet been put into the kiln. It is much more susceptible or much more fragile when it. When. When it encounters insults. So this is why ACEs can be so detrimental before the age of 18. We're not saying that people do not experience trauma in their 30s, 40s and 50s. Of course they do. But when people are young, when their brain is still developing, the impact is often more extensive. Studies have linked exposure to ACEs and negative and negative health and. And developmental and behavioral outcomes. So these early childhood experiences, these ACEs, actually do cause problems physiologically, psychologically, behaviorally, and as a consequence, interpersonally. Now, traumatic events are those things that are. Can be defined as direct or indirect exposure to an event that involved the possibility of death or serious injury. If you've diagnosed PTSD before, you're familiar with this, now, it's direct. Either the person themselves was at risk of death or serious injury, or they saw it, you know, and that is the case in intimate partner violence, for example, when we see a child viewing their. Their parents in physical altercations or even verbal, verbally abusive altercations. So it is important to recognize that it doesn't have to be something that the person experienced themselves. Traumatic injury can happen after a traumatic event, but it doesn't always happen now in children. A lot of times it does. But it is important to recognize that there are people who've experienced ACEs, even multiple ACEs, who have had a sufficient support system and sufficient resources and mitigating factors that it didn't end up causing traumatic injury. Now, at this point, they are in the minority. The majority of people who experience multiple aces end up having some level of physiological and psychological injury. As a result, 61% of adults surveyed across 25 states reported that they had experienced at least one type of ACE, and nearly one in six reported that they had experienced four or more types of ACEs. And we're going to talk about what those ACEs are, but just kind of let that sink in for a minute. 61% of adults had experienced at least one, but nearly one in six had experienced four or more. You know, that's a huge leap from one to four in my opinion. Over 50% of adolescents have been exposed to ACEs, which can have detrimental effects on learning and behavior and is associated with increased suicidal ideation. We want to be aware of this. So when we're screening adolescents, when we're interacting with adolescents, it's important to be aware of and, and to kind of try to figure out if they've been exposed to ACEs. 68.1% of people who reported homelessness in childhood also reported experiencing four or more ACEs. Now, it's important to remember that homelessness is not just someone who is living in their car or living under a bridge. Homelessness is actually defined as someone who doesn't have a permanent shelter. So it can be a family who has lost their home and now they're living with family or friends. But that is not a permanent setting. That is not their home. Their, their residing with friends and family until they can get back on their feet. That still meets the definition of homelessness. Only 16.3% of people who were never homeless in childhood reported experiencing four or more ACEs. So we know that homelessness, even homelessness, that where the person still has some degree of shelter, significantly increases the likelihood of ACEs, which totally makes sense. ACEs have a different impact on the brain based upon the age of exposure, individual factors, and microsystem protective factors. What that means? Well, the strongest impacts are found for younger children ages 2 to 5. Okay, well, that totally makes sense. A 2 to 5 year old hasn't experienced much in life. They're still very egocentric, they still have very primitive Thought patterns, they still are extremely, like totally dependent on their parents. You know, they are in a position where they are extremely vulnerable. So when they experience these aces, what would be threatening or distressing to a 16 year old is just way overwhelming. It's a tsunami of emotion for a 2 to 5 year old. For a toddler under the age of 2, a lot of times children understand something's wrong, but they don't cognitively get it quite as much. So we do know that children who have experienced ACEs during their toddler years have the strongest impacts from the ACEs. And those living in households with incomes below 200% of the federal poverty level also have the strongest impacts. So we want to look at both the age of the child and understand that, you know, what, what might be a minor impact for an older child could be an extreme impact for a younger child. The same thing is true if the person is in a household that is struggling socioeconomically. Why? Well, because as you will see, poverty contributes to just about every single adverse childhood experience out there. Aces contribute to disturbances in cognitive and affective processing, including heightened attention toward threatening stimuli. So we have a child who becomes hypervigilant when they are, you know, awake. When they're hypervigilant, they are scanning, they are aware, they have heightened attention toward threatening stimuli, which leaves precious little time, attention and energy to notice non threatening stimuli. So what do you think their perception of the world is? You know, that is a terrifying kind of place to be. They have an increased experience of loneliness. Well, a lot of times when they experience ACEs, they have a hard time trusting others. It impacts their self esteem because it disrupts their attachment. Makes sense they would experience more loneliness. They have increased HPA axis dysregulation. Well, if they're hypervigilant all the time, if they're stressed out all the time, then their HPA axis is going to be upright regulated most of the time. I won't say all the time. And that is going to contribute to what we've talked about before with glucorticoid resistance, with HPA axis dysfunction and emotional dysregulation. So that, you know, again, it makes sense. When people have this HPA axis disregulation, we need to remember that that usually results in emotional dysregulation, which often results in reduced impulse control. When people go from being, you know, okay, kind of white knuckling it, holding it together, to feeling completely out of control, a lot of times their behaviors become very reactive. Again. Totally makes sense. So we need to start remembering that behavior is communication. When we are dealing with a child or even an adult. Because a lot of times the adults still have these symptoms. They've never learned how to address them. They haven't been, they've never felt safe. You know, they grew up recognizing or believing that the world is a dangerous place, that they are isolated, that they're not good enough, poor attachment. They grow up to be adult. That doesn't just magically fix itself. So unless they have done a whole lot of self help work or gone to a therapist, a lot of times we are going to be seeing adults with these same symptoms. So we want to look at their symptoms as information, as communication. People who experience ACEs as children evidence functional alterations in key stress and emotion associated brain regions, particularly the anterior cingulate cortex, the amygdala and the hippocampus. All right, we know the amygdala. If you've done any research at all on EMDR or trauma, you know, the amygdala is involved in threat and fear processing. So there are changes in the amygdala in people who experience ACEs. They've, they've done the brain scans, they've shown that people who experience them actually do have changes in volume. The hippocampus, remember, our hippocampus is so important. It's involved in the HPA axis. The hip, and, and I'm sorry, hypothalamus is in the HPA axis. But the hippocampus also shrinks. And the hippocampus is also involved in fear processing. Initially, when people are exposed to ACEs, the amygdala volume increases. Makes sense because the fear. Think about, as the fear grows, the amygdala grows. However, over time, those neurons start to die off because it becomes neurotoxic. The environment, there's too much glutamate in that, in that area, it starts killing off neurons. So with persistent distress over the course of years, the amygdala actually shrinks in volume. It doesn't mean that that alters people's fear or responsiveness. But we do need to understand that there are changes in, in, in the brain. These brain regions, the hippocampus, the anterior cingulate cortex and the amygdala are particularly susceptible to damage from trauma, which triggers the HPA axis. Because the HPA axis, remember, dumps glutamate, our main excitatory neurotransmitter. And when glutamate is present for too long and in too high of a concentration, it actually starts to, you know, kill off neurons so these areas that have high densities of glucorticoid receptors, you know, they are the ones that we know usually get flooded with glutamate. And so when these areas do get flooded and they stay, they flooded kind of like, you know, when an area floods, you know, a neighborhood floods, eventually, you know, the houses start to crumble and eventually the brain cells start to die off and the brain starts to adjust. Interestingly, exposure to specific types of ACEs selectively affect the sensory systems which were involved in perceiving the trauma. So they have found, for example, that if a child hears the, their, their parents fighting, if the child hears something that's traumatic to them, then their auditory processing and their hearing may actually become impacted, will be altered as opposed to, you know, other senses. Generally the hearing becomes a little bit more acute because now the, the brain is saying, okay, you know, I picked up on that threat by hearing it, so I need to make sure that I hear all threats henceforth and forevermore. Mental disorders in individuals with ACE exposure tend to have more severe symptomatology, increased risk of comorbidity, and are less likely to respond to standard treatments. So think about why that might be. If somebody, you know, has traumatic experiences when they're a child and they start to have brain changes as a result of glucorticoid resistance and hyper vigilance, HPA axis activation, whatever, you know, it's hard for them to, it's hard enough to grow up and deal with life on life's terms, but then put this albatross around their neck, so to speak, and it makes it even harder compound that when they have disrupted attachment, they don't feel safe, they feel lonely, they have poor self esteem. You can see how they may have more severe symptoms. They often remember we talked about increased HPA axis dysregulation. Because of that extended exposure to distress, we tend to see HPA axis dysregulation and emotional dysregulation, which is often perceived as more severe symptomatology. You see more self injurious behavior, more addictive behavior, more numbing, even more aggressive and violent behavior. Because the people go from a, a state of, you know, like I said, kind of holding it together to terrified or enraged. They tend to be less likely to respond to standard treatments. Because a lot of times our s standard treatments are singular in focus. We focus on cognitions, we focus on environments, we focus on self esteem. When we need to recognize that there have been physiological changes in this individual and there have been alterations in their developmental course over time because they were not able to flourish like youth who hadn't been exposed to ACEs in adults. ACE exposure is associated with a wide range of physical disorders, including obesity, dysregulation of the immune system, autoimmune disorders, abnormal pain perception with and without underlying causes. Stress itself, just the, the emotion stress or the physiological reaction. Stress can sensitize nociceptive neurons in the spinal cord, which result in comparable changes in pain perception and related behavior. Basically, that's saying that when people are under a lot of stress, there are actually changes in the perceptiveness of the neurons which make them more pain intolerant, that the, the pain is more palpable, more intense for people. So let's look at, let's think about why these physical disorders may occur going back to that HPA axis, the hypothalamic pituitary axis dumps glutamate, norepinephrine tells us that we need to, that we need to fight or flee. Also it, it dumps cortisol. And cortisol is a steroid. In the short term, cortisol is meant to suppress inflammation and suppress our immune system. It's not time to devote energy to repair and immunity. It's time to devote energy to fight or flee. So it makes sense that the immune system in, in short term would be suppressed. However, when that system goes wonky, when it becomes dysregulated, then it also causes subsequent dysregulation of the immune system. The person starts actually having increased levels of pro infla. Pro inflammatory cytokines are inflammatory molecules throughout the body. We know that stress increases pro inflammatory cytokines. We know that pro inflammatory cytokines increase auto. Are associated with autoimmune disorders and are also associated with increases in symptoms of clinical depression. They also have disruptions in the intestinal microbiota and the mucosal immune system. And I did a video on gut health. Oh gosh. About two years ago ago, where we talked about the impact of stress on the gut. And our gut is where a lot of our neurotransmitters are actually made. And interestingly, if you want to think about the gut as the factory, the gut communicates with the brain and vice versa through the vagus nerve when people are stressed. Think about what happens when you're stressed. A lot of times when people are stressed, it's not time to rest and digest. So what does the body do? It tries to expel that food as quickly as possible. So it's going to push the nutrients out the Alterations in the nutrients, the alterations in the neurotransmitters, cause alterations in the intestinal microbiota. And that can cause alterations in the body's ability to actually create the neurotransmitters that we need to feel happy and healthy. So it's, you know, it's all interconnected. People who have an unhealthy gut have more difficulty regulating some of their. Regulating some of their neurotransmitters. And actually, Pat, you're getting ahead of me because we're going to talk about COVID in just a minute. There is a 200 to 400% increase risk of heart disease and cancer, chronic lung disease, skeletal fractures, depression, diabetes, and prediabetes, which, by the way, they have started realizing or thinking that diabetes is actually in many cases an autoimmune issue, and liver disease. So it's important to recognize that the stress on the body, the free radicals caused by emotional distress, can really wreak havoc on everything. The alterations in hormone levels, gonadal hormones, thyroid hormones, stress hormones, all kinds of hormones, in addition to alterations in the neurotransmitters, also wreak havoc on the body. Serotonin, for example. It's not just your happy chemical. Serotonin is involved in blood pressure or heart rate, gastrointestinal motility. It's involved in pain perception. Our neurotransmitters are involved in so much more than just mood. It's important to recognize that when those things, neurotransmitters go offline, it's going to impact the person biopsychosocially. Experiences. Now, what we talk about when we're thinking about adverse childhood experiences include family violence, intimate partner violence, and child abuse or neglect. Those are the two that were screened for in the ACEs survey. Now, it doesn't mean that these are the only adverse childhood experiences we remember. In the beginning of the presentation. We defined adverse childhood experiences pretty broadly, but the ones that they tested or evaluated in the survey included intimate partner violence, child abuse or neglect, mental illness in the family members in, in a parent, addictive behaviors in a care parent or caregiver, and then family instability or parental separation that is caused by jail, death, divorce, job, you know, anything that takes a caregiver away, especially the primary caregiver for an extended period of time can contribute to adverse childhood experiences. Now, does that mean that every person who is a child of someone who is in the military or someone who travels a lot for work is going to experience this as an adverse childhood experience? No, because those people, while they may not be physically present. There are a lot of ways that, for example, soldiers still communicate with their family, still make sure that they stay in touch in connection with their loved ones while they're overseas, while they're deployed. Divorce is the same way. Not every divorce is equal. Some of them are very amicable, and the children have sufficient resources and sufficient supports to buffer against the negative impact of changes that are happening in their life. Now, as Pat pointed out, the rise of aces during COVID has been. We're expecting meteoric. We know, unfortunately, just by looking at the records to date that there have been significant increases in substance misuse. There have been significant increases in intimate partner violence and child abuse and neglect and mental illness in the caregivers. Okay, so what does that mean? You know, unfortunately, in some cases, a lot of people have been the opposite of separated during COVID and that has contributed to some of this distress because they've been kind of locked down together, which can cause stress among people, especially if there's crowding. There's been a lot of poverty, a lot of people who are out of work, a lot of people who aren't used to being home all day long. There's been a lot of frustration, and that all those all become risk factors for violence, abuse, neglect, anxiety, depression, addiction. So Covid has been just absolutely awful, in my opinion, on the future of a lot of the people, a lot of the youth of today, because this is the environment that they've grown up in or spent a year now. You think, well, it's only been eight months. And, you know, by the time we get the vaccine out, maybe it'll be a year, a year and a half. You know, what's the big deal? Well, when you're 10, that's a tenth of your life. When you're five, that's 20% of your life. You know, when you're a kid, that is a really freaking long time. Okay, so let's look at, you know, in what ways does this contribute to distress? How are these things adverse, if you will? And you know, obviously witnessing violence is going to be threatening for a lot of people. You know, if you see a caregiver abusing another caregiver, you know, that is anxiety provoking. You feel powerless to protect your caregiver. And you know that you can't survive without your caregiver. So that's, you know, really stressful. But it also impacts attachment. So let's think about attachment. Remember, we've talked before about the mnemonic device craves in order to form Healthy attachment relationships have to be characterized by consistency. You know the caregiver is there, you know is consistent in their responses. It's not one day it's going to make me mad, another day I won't care. One day I love you, the next day you know, I could take care or leave you. They're consistent, they're responsive. When the child is emoting, you know, good or bad, the parent or caregiver is responsive to the child. If the child is in distress, the caregiver is there to provide support and to model self soothing behaviors to help the child learn the skills that they need to de escalate. If the child is happy, of course, the caregiver is also being responsive, can be happy with the child, can, you know, mimic, can support the happiness. So responsiveness is important. Even with happy feelings, we don't want it. The person is not consistent and responsive if they only respond when the child's in distress and ignore the child the rest of the time. Which takes us to attention. Children need to feel like they are deserving of your attention. And when a person is struggling with mental health or addictive issues, a lot of times they have difficulty putting one foot in front of the other, let alone paying attention to the child. So a lot of times the child is emotionally neglected and, and or ignored. Validation is important. Remember the, the child's feelings are the child's feelings and they are normal and natural and we need to accept them. Just like we try to teach ourselves to do, accept our feelings non judgmentally and then figure out what's this feeling telling me and what should I do with it. But it's important to validate. A lot of times people who struggle with emotional dysregulation, who grow up in environments that are invalidating, develop shame and have difficulty coping with emotions because their caregivers were always saying, you know, just get over it or you're overreacting and dismissing their feelings. It is so important to validate the child's feelings and then to explore the child's feelings with them and help them again figure out what to do next, how to self soothe, validate and be responsive. Attachment also requires, and we'll put these two together, encouragement and support. And they're different. Support is a caregiver that's there to, you know, be there. If the child steps out of their comfort zone and you know, fails at something or it doesn't go the way they, they want it to. A supportive caregiver is there to welcome, welcome them back, say you know, you Got this. I love you, I'm here for you. Encouragement is when the caregiver is encouraging, kind of nudging the child outside of their comfort zone, going, you can do this. You know, first grade is going to be really exciting. High school is going to be really exciting. You know, try out for the cheerleading squad if that's what you want to do. So consistency, responsive responsiveness, attention, validation, encouragement and support are all essential for raising a happy, healthy child. But when there is family violence, when there is family mental illness, and I'm talking about in the nuclear family, or when there's family instability, this may not always happen. And remember, children, especially children under the age of 9 or 10, are very egocentric. So if they're not getting these needs met, they often perceive it as their fault. You know, what did I do? Why is my, why does my parent hate me? They also think in dichotomous terms. It's either love or hate. It's not, you know, why is mom a little off today? So it is important to recognize how adverse childhood experiences impact the youth's ability to develop their self esteem and to form later attachments. If they never experienced secure attachment, they're going to have a hard time forming secure attachment. We also have seen an increase in aces with technology, media and social media. The media is always, you know, bombarding people's houses and, and I'm not just talking about news, I'm talking about, you know, all different kinds of television shows and those sorts of things. But media and social media can contribute to mental health or mental illness, anxiety, depression in caregivers. Social media, unfortunately, I'm seeing a frustrating increase in families in which one or one or both caregivers is so involved in their social media that they, you know, they come home from work, they plop down on the couch and they ignore the family for the rest of the night because they are too busy scrolling. And you know, that contributes obviously to a lack of consistency, responsiveness, attention, validation, encouragement and support. So we do want to look broader, more broadly than just, you know, necessarily blaming the caregivers. You know, there is a lot of stuff. And I encourage you to look back at Broffen Brenner's model of socioeconomic, socioecological influences. And especially in that microsystem, there are a lot of factors that can contribute to stress that leads to violence, stress that leads to abuse or neglect, mental health or addictive behaviors, and even criminal acts, death. And, and I'm not talking about murder. I'm talking about, you know, somebody having a coronary because they're so stressed out and their blood pressure goes through the roof or their diabetes is uncontrollable because they have, they're under so much stress right now because stress impacts blood, your ability to control your blood sugar. We also want to recognize that unless there is intervention for the majority of people who experience traumatic injury from adverse childhood experiences, they will likely go on to have children and not be able to form those attachments. They will likely go on to have children. You know, if they have children and they will still have mental health issues that they're dealing with, they'll be at high risk for addictive behaviors. There may be family instability because they never resolved their own issues with which is going to end up causing aces in their children. So it's intergenerational unless we break the cycle. Risk factors in the child. And I'm not blaming the child. You don't get me wrong, children are, do the best that everybody does the best that they can. But we do recognize that there are certain characteristics in children that make them at higher risk for, for abuse. One of them proposed by Dr. Sears, and I can't remember his first name right now, is, is being a high needs child. And a high needs child generally, from the time they start breathing air, are intense and demanding. They don't just whine, they don't cry, they wail. And, and obviously we want to rule out any physiological causes. My son had gastric reflux when he was little and he would wail after. He would eat and you know, burp him and whatever until we realized that he had gerd. He would obviously have indigestion really bad and he would cry. And it wasn't just a cry, it was, I will every breath he would take in this big breath and just let it out until he was like perfect purple in the face. And then he'd take in another breath and do it again. It was heart wrenching. So obviously we want to make sure that parents who have high risk children are ruling out or high needs children are ruling out any physiological causes of the high needs ness, if you will. But these children tend to come out of the womb and intense and demanding. You know, they will cry, you know, and, and, and like I said, it's a whale. It's not just your normal, you know, baby cry. They tend to be inconsistent and unpredictable. What works to soothe them on Monday may not work on Tuesday. Heck, what works on Monday morning may not work on Monday, Monday afternoon. So that contributes to the parent having difficulty consoling the child. And we know that a crying baby can, you know, be very frustrating and stressful after a while. And the more stressed parents get, the baby picks up on it, the more stressed baby gets, so increases their crying. It's just this negative cycle. But it also contributes a lot of times to a sense of parental helplessness and hopelessness if they can't figure out how to soothe their child. And that often leads to distancing from the child. It's like, okay, I can't attach, I, I can't do it. I don't know what to do. Which takes us back to disrupted attachment. High needs children also tend to be extremely sensitive. Small noises will startle them. And it's not just a, you know, startle like this. When they're startled, they are freaked out. They go from 0 to 200. They emotionally dysregulate, if you want to think about it that way. But they also tend to be very sensitive to minute changes in temperature, lighting, sound, you know, not all of those things, but some of those things. And they are often unable to self soothe. Now it's important to recognize that a high, there are high needs children who are neurotypical, okay, but there are, there are also high needs children who are neuro atypical. Children with disabilities are at a higher risk for again experiencing adverse childhood experiences. So let's just talk before we go there. Let's think about this high needs child, thinking about how a highly demanding, inconsolable child that, you know, we have difficulty helping them, we have difficulty bonding with them. How might that contribute to violence between partners? You know, we see probably one parent getting frustrated with the other parent. You know, there's a lot of frustration and it can cause, you know, difficulty among the caregivers. How can it contribute to child abuse or neglect? Well, we talked about that. You know, it can contribute to unfortunately shaken baby syndrome. It can contribute to just putting junior in their crib and saying let them cry it out. And when, when Junior actually has a problem, when Junior doesn't know how to self soothe. So there are a lot of issues that may happen in there. It can contribute to depression and hopelessness in caregivers and it can contribute to addictive behaviors in caregivers who may feel like the only way that they can cope with this child is by self soothing themselves with substances of some sort. So there can be a lot of issues among the caregivers as a result of a high needs child. And so it's really important that parents who have high needs children have A lot of support in dealing with the unique needs of that child. So let's go down to children with disabilities. Unfortunately, children with disabilities, children who are not born quote perfect, may be at higher risk of abuse and neglect because the parents are angry. And that is just heart wrenching to think that that could be. But unfortunately the research plays it out that way. Autism spectrum disorders are unique because children with ASDs a lot of times are not diagnosed when they are infants. When they are really young, you know, they're older before they're diagnosed at least, you know, a lot of times toddler age or older. But a lot of times children who are on the autism spectrum are very sensitive. Just like a high needs child to touch to other, even caregiving behaviors and caregiving behaviors. You know, parents may be trying to, you know, swaddle the child to help them feel safer, so maybe they'll stop trying. They're trying everything. But what they don't realize is they're actually traumatizing the child because their, their, their touch, their sound, their rocking may be perceived, you know, at an intensity much greater than what the parent really realizes. So it feels aggressive, it feels painful to them in some ways. And so children with autism, autism spectrum disorders are actually at higher risk for what I call inadvertent adverse childhood experiences. Distress reactions, just like in the high needs child, distress reactions in caregivers of children with autism spectrum disorders may cause distancing and a sense of futility in a caregiver who doesn't understand what, why they can't help Johnny Self soothe, why they can't, you know, when they touch the child, the child cries. I mean, how rejecting must that feel if they don't understand what's going on? We do need to educate the public. You know, obviously if the caregivers don't know that the child is on the spectrum, then they probably haven't begun therapy and all that stuff yet. So it's important to educate the public about the early signs that a child may be neuroatypical. So they can get early intervention for one, but also so they can prevent the disrupted attachment and other adverse childhood experiences. There was also a significant association between ACE score, so the number of adverse childhood experiences, ADHD and moderate to severe, especially moderate to severe adhd, which makes sense. All of it makes sense when, when you step back from it. But children who have moderate to severe adhd, they have difficulty remembering. They may seem like they're being oppositional, they may seem distracted. That can be very frustrating for a parent who Again doesn't understand that, that it's not willful behavior, it is neurological behavior. And, and so early intervention, early identification of ADHD behaviors is really important to protect and, and buffer against the development of adverse childhood experiences. Risk factors for caregivers to perpetrate ACES so this is what we're looking at in, in caregivers who may become perpetrators. And I don't like the word perpetrators but I couldn't think of another one affectively. And these characteristics contribute to all of the adverse childhood experiences that we listed above. Family instability, Interpersonal violence, Addiction and mood disorders Low self esteem. All right, so we need to do some outreach psycho education. We need to do what we can to help people figure out how to increase their self esteem, why their self esteem is low and how to increase it. People with low self esteem tend to be at higher risk for depression, anxiety, fear of abandonment and even some personality disorders. Parental low academic achievement and low verbal iq. Well you know, that makes it harder to get a job that's actually going to pay the bills. So people who have low academic achievement and low verbal IQ often have difficulty getting or, or often are in a poor socio economic condition. Low verbal IQ also may contribute and this also goes along with low emotional intelligence may contribute to the person being unable or have having difficulty communicating their thoughts, feelings, wants and needs. So even if they feel they can, they may not be able to actually get it out which contributes to them feeling frustrated, powerless under misunderstood and angry and resentful. Mood disorders. Anger, anxiety and depression have all increased under Covid but they are risk factors for family instability, family violence and mood and addictive disorders. So prevention and early intervention services are essential. What can we do? What can we do with brief inter intervention services in doctor's offices, in pediatricians offices. What can the pediatric staff do to screen for mood and addictive disorders in parents? Where else can we screen for these things? How can we increase parents families health literacy so they actually may start recognizing mood disorders within themselves and understand the steps they can take to reach out for help. Most people don't. They've been depressed for as long as they can remember. They may not realize that oh hey, this isn't quote normal, you know, I can feel better than this. So making sure that people are aware of the signs and symptoms is important. But also making sure they know how to access help and making sure that help is available in your community with COVID Now one of the benefits of COVID has been people are are embracing or accepting of technology a lot more readily. So People who live in rural areas are actually being more willing or being, feeling more able to access behavioral health services. Borderline or antisocial personality traits and conduct problems make caregivers more likely to perpetrate aces. Well, people who grew up or people who develop borderline or antisocial personality, often, not always, but often grew up in a very traumatic environment. So, so they often were exposed to ACEs themselves, which their, their method of coping with life, their method of survival was to develop some of these personality disordered behaviors. When you look at the symptoms and you put yourself in the place of a five or a six year old and you look at those symptoms and you go, okay, I can see how that behavior might make sense. Sense. I can see how, for example, with borderline personality disorder, the ability to what they call turn on a dime, where it's either I love you or I hate you. Well, that's how little kids think. You know, they think in dichotomies. And people who experienced trauma at a very young age often have difficulty progressing past that without assistance, without intervention. So we do want to make sure that they have access to effective treatment. Marsha Linehan has done amazing things with dialectical behavior therapy and to help people with borderline personality disorder, lack of non violent social problem solving skills. Well, we need to make sure that from the time they're knee high to a grasshopper, you know, we add in the curriculum in daycare, in kindergarten, in elementary school, all the way up through that, we are integrating non violent social skills and problem solving skills into the curriculum, into the health curriculum, into, you know, whatever curriculum. Behaviorally, people who are aggressive or delinquent as youth tend to be more likely to be aggressive and, and be at risk of mood and addictive disorders as adults. People who are heavy alcohol or drug users tend to be more at risk of behavioral disinhibition, violence and mood and addictive disorders. Just because you use heavily doesn't mean you're addicted. But they are more at risk behavioral control and impulsive. Poor behavioral control and impulsiveness goes along with that dysregulation. We talked about a lot of people who have impulsivity and poor behavioral control. Excuse me, have been exposed to trauma as a child and or may also have some other issues going on. People who have ADHD tend to be much more impulsive and have difficulty with behavioral control and a history of being physically abusive. If you've done it in the past, you're more likely to do it in the present. Environmentally, poverty and I put unemployment and underemployment together because people can be employed and just still not making enough money to be able to rub two nickels together at the end of the week. What can we do? We need in our communities to have programs that teach financial literacy. How can I stretch my dollar as much as I can? What do I need to do so I don't end up under, you know, $40,000 of credit card debt at 20% interest? Literacy, literacy. If a lot of people who struggle with unemployment or underemployment or often, not often, but may have difficulty with actual literacy, they may have struggled in school, they may have difficulty filling out job applications. So we do need to make sure that people have access to literacy services, job opportunities, and education about job opportunities. A lot of people think of job opportunities the old way, which is you've got to go in and hand in your resume and, you know, interview and all that stuff. Well, that's true for a lot of jobs like restaurants and stuff. However, in today's day and age, there are also a lot of work from home opportunities. So caregivers who are living at home or who are obviously they're living at home. Caregivers who are at home with their children may be able to find some online legit work from home opportunities that they're able to engage in. And that has been another blessing of COVID I'm sorry, but a lot of organizations have figured out that, hey, this work from home thing might actually work for some of our people and then we can downsize our office and not spend as much there. Family friendly work policies are ideal, but you know, let's worry about getting jobs out there first. And people need access to their basic Maslovian needs. Nutrition, housing, medicine, medical res. Medical services and educational resources. We need to make sure those are available. I should have put dental there too, because dental is big. Free clinics are, are important for some people making sure that Medicaid is available. I am a strong proponent of the Medicaid expansion and you know, think what you will, but I think it is really important for a lot of people's health to be able to make sure that they actually can afford health care. Lack of institutions, relationships and norms that shape a community, social interactions. In rural areas, for example, there may not be much to do. There may not be community centers, There may not be places where people congregate, except for maybe one or two churches and you know, the grocery store parking lot, which means there's not a lot of connectedness, there's not a lot of interaction. And Supporting of one another, lacking access to those basic needs. You know, I. I did talk about. And that has become an issue as well as poverty as a result of COVID because a lot of people are in jeopardy of losing their housing and have had difficulty getting their basics. Poor neighborhood support and cohesion. When we have support, support is a great buffer against stress. If you've got neighborhood support, if you are feeling really stressed out, you may be able to have a neighbor, you know, watch your child for two hours so you can take a bath in peace and regroup. If you don't have support and cohesion where you're helping each other out, then you may feel like you're. You're very isolated. And that is. It's really hard to live in an isolated state. Weak community sanctions against interpersonal violence. You know, people knowing it goes on but not saying anything. So, you know, kind of condoning it. Easy access to alcohol or drugs. Cult cultural norms that support aggression and community violence. And we need to figure out the best way to address some of these things relationally. And I'm going to go through these last couple things really quick because I know we're heading the end of our. At the end of our hour. Isolation is a big one. Like I was just saying, it's important that people have social supports that can help buffer them when they're having difficulty dealing with life on life's terms. They may not even be angry at Junior or whatever. They may feel depressed or angry about something completely different, but that is going to impact their interactions with their significant others, including their children. A desire for power and control in relationships can lead to more conflict attitudes. Accepting or justifying violence can also increase risk. And we are seeing unfortunately, an increase in attitudes that are accepting or justifying of violence. If you. And it can be emotional, verbal violence. If you go online and you look at, you know, people who intentionally go around and flame different people's posts. Poor interpersonal skills that are characterized by many conflicts, fights, tension and other struggles. Jealousy, possessiveness and negative emotion within intimate relationships. Marital instability, Unhealthy family relationships and interactions. Witnessing interpersonal violence as a child. History of experiencing poor parenting as a child. Poor parenting usually means poor attachment. Usually means difficulty forming future attachments and difficulty with self soothing because they never learned those skills. Being a victim of physical or psychological abuse. So aces and association with antisocial or aggressive peers. So what can we do? We need to provide safe, stable and nurturing relationships to nurture health and mental health. We can do this with trauma, informed intergenerational practices in clinical settings, early childhood care, educational settings, and community contexts. We need to make sure that our current systems are adjusted to realize the widespread impact of trauma and the multiple paths of recovery. Recognize the signs and symptoms of trauma in clients, but also in their families, staff and others that they're involved with because they may not have experienced trauma, but if their caregiver did, then that may impact them and make them more at risk for ACEs. These systems need to respond by fully integrating knowledge about trauma into policies, procedures and practice and seek to actively resist re traumatization. We can do this by making sure that our services provide a sense of safety so the clients know they're respected, a sense of trustworthiness and transparency so clients feel informed peer support so clients feel connected, collaboration and mutuality in goal setting and program development so clients feel respected, empowerment, voice and choice in what they do and how they do it so they feel respected and informed and a reflection or a representation of cultural, historical and gender issues. Mindfulness based mind body approaches have been shown to reduce presenting symptoms by over 30 30%. Remember that mindfulness is the purposeful moment by moment presence and self awareness of one's breathing, body sensations, emotions and or thoughts in a non judgmental manner and it can be incorporated into approaches like biofeedback, yoga, Tai Chi, hypnosis and meditation. We also can seek to improve the parent child relationship with a which they found to be a great buffer against traumatic injury. When we help parents, parents and children share ideas and discuss things that matter, we help the parent recognize the importance of meeting most or all of the child's friends and participating in the child's events. We provide the parent with tools to manage stress and aggravation with parenting and tools and skills to help them cope well with parenting and to improve their own mental health. More than 60% of people have experienced adverse childhood experiences. It's believed that the rate of exposure to ACEs has increased significantly during COVID Not everyone who experiences ACES will develop traumatic injury, but many will. Injuries related to ACE trauma include borderline and antisocial personality disorder because they did experience significant trauma and those behaviors are often how they sought to survive. Mood disorders ptsd, addictions, autoimmune issues, heart disease, cancer, lung disease, liver disease, increased difficulty in interpersonal relationships due to any or all of the above issues and an increased risk of of becoming a perpetrator of ACEs in the future. Are there any questions? I know I went off off track a couple of times because I really do think this is a. Exciting topic or a important topic for for us to know about. And the research actually all the research that I cited and the PDF in your classroom, the hyperlinks in the PDF will take you to the studies. A lot of the research that I cited, most of it has actually come in the in the past three to five years. So you know, we're really just starting to understand the impact and and recognize yes, children are resilient but but they actually do experience more than more distress or more changes than we initially may have thought. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is at allce.com/podcastce. That's allce. Com podcastce. To sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to allce.com sponsor. Thank you.