Trauma and Poverty

November 19, 2015

Dimitri TopitzesAssociate Professor, Social WorkU. of Wisconsin-Milwaukeetopitzes@uwm.edu

Acknowledgements

Joshua Mersky and David Pate Wisconsin Department of

Children and Families Health Services

Milwaukee Area Work Force Investment Board Funders:

Health Resources and Services Administration Chapin Hall Center for Children Wisconsin Partnership Program, UW-Madison,

School of Medicine and Public Health

Topic outline

Define trauma

Intersection of poverty and trauma

Implications for practice/policy

DEFINE TRAUMA

Psychiatric definition of trauma Threatened or actual sexual or physical violence

experienced directly or indirectly

Sudden or violent death of loved one

Results in symptoms that impair daily functioning re-experiencing avoidance numbing hyperarousal

Limitations

Doesn’t capture non-physical or non-sexual trauma, e.g., financial ruin, relational betrayal

Doesn’t capture childhood or developmental trauma, e.g., neglect and emotional abuse

Doesn’t recognize other symptoms that can arise from PTE exposure

Too constrictive

Expanded definition of trauma

An extremely upsetting event that at least temporarily overwhelms the individual’s internal resources, and produces lasting psychological symptoms.

Event can be emotional in nature

Accounts for children’s trauma experiences, e.g., bullying, emotional abuse, neglect

Symptoms that arise are not limited to PTSD clusters, e.g. depression anxiety substance abuse conduct related problems in children or adolescents

Limitations of Briere definition

Steeped in psychiatric and psychological language

Conceptualization of trauma limited to an event

Adverse childhood experiences (ACEs)

10 types of adversities experienced during childhood Abuse/neglect and household dysfunction

Framework recognizes milieu as important as opposed only to events

Findings: High prevalence Cluster

Accumulation of ACEs overwhelms developmental systems undermine adult well-being: Physical health Mental health Behavioral health

The Adverse Childhood Experiences Study

Study launched by Kaiser Permanente and CDC in the mid-1990s (Vincent Felitti & Robert Anda)

>17,000 patients in San Diego, CA responded to a survey documenting childhood experiences of: Abuse (physical; sexual; psychological) Neglect (physical; emotional) Domestic violence Household crime Household mental illness & substance abuse Divorce http://www.cdc.gov/ace/about.htm

Prevalence

ACEs High! Over ½ were exposed to at least 1 ACE

Chances of having a second ACE if you exposed to:Sexual Abuse: 65%Physical Abuse: 86%Psychological Abuse: 93%Household Substance Abuse: 69%Household Mental Illness: 74%Household Crime (Incarceration): 86%Household Domestic Violence: 86%

ACEs

Od

ds o

f H

eart

Dis

ease

0 1 2 3 4 5,6 7,8

1

1.5

2

2.5

3

3.5

Heart Disease

Depression

0 1 2 3 >=40

10

20

30

40

50

60

70

80

Women

Men ACE Score

% L

ife

tim

e D

ep

res

sio

n

Series10

2

4

6

8

10

12

14

16

18

20

% S

mokin

g

ACE Score

Early smoking Current smoking

Smoking

Limitations

Normed on middle class sample Ignores severity and chronicity of adversity Doesn’t account for protective factors Doesn’t account for stressors relevant to low-

income samples Community violence Homelessness Food insecurity Absence of parent

Toxic Stress

Multiple adversities, e.g., poverty, discrimination, CAN

Overwhelm small number protective factors

Particularly in early life Chronic toxic stress response, reflects

allostatic load

Result in poor lifelong health trajectories Extends ACE framework

additional stressors (poverty) and highlights neurophysiological mechanisms

POVERTY & TRAUMA

I. Poverty increases exposure Poverty increases exposure to index

trauma Low-income/high crime communities increase

likelihood of violence exposure Poverty increases chances child exposed

to trauma as defined by Briere and by ACEs: Neglect

Poverty increases risk of exposure to toxic stress Food insecurity

Home visiting study

Over 800 adults receiving home visiting services in WI

Completed an ACE-related survey over the last 9 months of 2014

Primarily low-income women just given birth

Abuse & Neglect

Adverse Childhood Experience

Prevalence (%)

WI Home Visiting ACE Study1

Physical Abuse 42.4 26.4

Sexual Abuse 26.5 21.0

Psychological Abuse 28.0 10.2

Physical Neglect 10.6 9.9

Emotional Neglect 17.8 14.81Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study. Pediatrics, 111(3), 564-572.

Household Dysfunction

Adverse Childhood Experience

Prevalence (%)

WI Home Visiting ACE Study

Substance Abuse 49.1 28.2

Mental Illness 39.2 20.3

Criminal Offending

37.1 6.0

Domestic Violence

38.1 13.0

Divorce/Separation

43.0 24.1

Cumulative Risk

Number of ACEs*

Prevalence (%)

WI Home Visiting ACE Study

0 15.3 32.7

1 15.5 25.6

2 13.4 15.5

3 11.5 9.9

4 13.1 5.9

5 or more 31.2 10.5

*Sum of 10 ACEs: Physical abuse, Sexual abuse, Psychological abuse, Physical neglect, Emotional neglect; Parent substance abuse; Parent mental illness; Household crime; Domestic violence; Parent separation or divorce.

MAWIB Study

199 men accessing employment services in Milwaukee

2013, four week period

Convenience sample collected in resource room

MAWIB Study

  ACE Study Men MAWIB _____________________ (N = 3,948) (N = 199)Abuse:

Verbal 7.8 38.2Physical 27.9 41.2Sexual 17.1 21.6  

Neglect:Emotional 12.5 38.2Physical 10.7 29.1

 Household dysfunction:

Domestic violence 12.0 29.6Substance abuse 25.5 48.2Mental illness 14.3 19.1Separation/divorce 22.6 60.8Incarcerated member 4.9 51.3

MAWIB Study

ACE Index Score, ACE Study* Current Study Prevalence (%) (N = 3,948) (N = 199)______________________________________________________________

0 34.2 15.71 27.3 11.62 16.4 17.23 9.3 8.14 4.8 8.6 ≥5 8.0 38.8

Poverty and Toxic Stress

Adverse Childhood Experience

Prevalence (%)

WI Home Visiting

Serious Financial Problems (often) 34.1

Food Insecurity 17.3

Homelessness 22.5

Peer Victimization (often) 25.6

Prolonged Absence of Parent 56.2

II. Poverty affects trauma symptoms

Lower access to treatment: External resources Poor receptive/expressive language: Internal resources

“Meaningful differences” Professionals talking 2000-3600 words/hour to child, ages 1-2 Non-professionals talking 400-1200 words/hour to children All talk same amount of business: do this, don’t do that, etc. But professionals add chit chat, affirmation, commentary,

stories Parents extra talk, correlates .78 to age 3 Stanford Binet. Parents extra talk, correlates .77 age 9 Vocabulary Test

Poorer health trajectories

III. Poverty as an index trauma

Ongoing adversity, chronic degradation, stress, shame

Financial hardship has direct, independent effect on CAN (Slack & Berger)

Results of childhood poverty similar to early trauma Low status attainments Poor health trajectories

Conclusion

See poverty and trauma inextricably connected

See services for poverty and trauma as co-offerings (false dichotomy)

Story of housing first Story of re-entry Evidence to show that job services

improved with mental health services

IMPLICATIONS

Trauma-Informed Practice

Assess

Educate

Regulate

Refer

Assess (adults or children)

Index trauma Original ACEs Additional ACEs relevant for low-income

types Effect of ACEs in present Resilience to ACEs

Discussing ACEs in assessment context led to positive impacts on healthcare utilization

Assessing ACEs in CW, HV, & CHC

Comfort Workers more uncomfortable than clients with questions: 20% 10% clients are uncomfortable with questions

Address Discomfort Giving client decision making power, when & if to talk about

ACEs Give client choice over paper and pencil format or discussion Allot plenty of time to talk about it if discussion format Workers develop comfort, language, and style with questions Know that discomfort generally manifests as internalizing

Educate and potentially refer Trauma, ACEs and Toxic Stress Extensive health effects Other outcomes Resilience What helps, regulate

Intervention to target coping or regulation strategies

Refer in order to resolve trauma if PTSD or other mental health related problems Mental health Trauma focused

Policy

Jack Shonkoff: Harvard Center on the Developing Child