AcademyonViolenceandAbuse– 11YearsofWorktoImproveHealthandWellnessbyEducatingthe

HealthcareProfessionsandCommunities

DavidL. Corwin, MDPresident,AcademyonViolenceandAbuse (AVA)

Secretary, AmericanProfessionalSociety onthe Abuse of Childen

Professor ofPediatricsandDirector ofForensic ServicesUniversityofUtahSchoolofMedicine

david.corwin@hsc.utah.edu

Tulsa,OklahomaMay 20, 2015

AVA’sFirst10years

• Policy• Partners• People• Publications• Products

• Mission&Vision

• Initiatives• Research

Policy ImpetusforAVAFoundingInstituteOfMedicineReportReleasedSept10,2001

Calledfor:• MultidisciplinaryCenters

forEducationandResearch

• Organizationalguidance• Innovativetraining

models• Federalfunding

Partnership betweenAMAViolence&AbuseCouncilandFamilyViolence

PreventionFund

OtherKeyPartnerships• AMANationalAdvisoryCouncilonViolenceandAbuse/National

HealthCollaborativeonViolenceandAbuse• AmericanMedicalAssociation• FamilyViolencePreventionFund/FuturesWithoutViolence• T.BoonePickensFoundation• AHRQ• TraumaViolenceandAbuse• NationalChildTraumaticStressNetwork(NCTSN)• ChadwickCenterforChildrenandFamilies/SanDiego

InternationalConferenceonChildandFamilyMaltreatment• IVAT(InstituteforViolence,AbuseandTrauma)

PeopleNeverdoubtthatasmallgroupofthoughtful,committedcitizenscanchangetheworld.Indeed,it’sthe

onlythingthateverhas.MargaretMeade

AVA’sInauguralEvent- Sept.2005

AVABoard– April10,2015

AVA’scurrentsmallgroupof“thoughtful, committedcitizens”

AGlobal Interprofessional SocietyfocusedontheHealthImpactsofViolenceandAbuseacrossthe

Lifespan

AcademyonViolenceandAbuse(AVA)

AVAMission

Toadvancehealtheducationandresearchontherecognition,treatment,ofthehealtheffectsofviolenceandabuseacrossthelifespan.

AVAVisionTherecognition,treatment,andpreventionofthehealtheffectsofviolenceandabusearefullyintegratedintohealthcareandsocietysothatpeopleofallagesaresaferandhealthier.

Publications

• BuildingAcademicCapacityandExpertiseintheHealthEffectsofViolenceandAbuse

Publications

C O M P E T E N C I E S N E E D E D B Y H E A L T H P R O F E S S I O N A L S F O R A D D R E S S I N G E X P O S U R E T O V I O L E N C E A N D A B U S E I N P A T I E N T C A R E

• CompetenciesNeededbyHealthProfessionalsforAddressingExposuretoViolenceandAbuseinPatientCare

AVA’s1st Product- 2012ACEStudyDVD/OnlineVideos

• Felitti &Anda ACEStudyPlenaries

• Putnam– “ACEsChangedtheLandscape”

• IndividualInterviewswithVincentFelitti,RobAnda,andDavidWilliamson

• 4.5hoursofvideo• PPTs,ACEQuestionnaires

AVAACEsStudyDVD/Videos8MinutePolicyMakerSummary

2009– 2014AVAInitiatives2009– BeganpostingAVAvideosonwebsite2012– ScholarsPrograminitiated(AVAnowhas

sixAVAscholars)2013– UnitedStatesMedicalLicensure

Examination(USMLE)SiteVisit1st RegionalAcademies&Symposia2014– April- AshlandandAkron,Ohio

October- SaltLakeCity,Utah

Building Trauma-Informed and Resilient Communities

AVA MEMBERSHIP MEETING

NOVEMBER 2015

Ashland OH

u Population 54,000u Conservative Christian Community

u Brethren and Amish

u Agriculture and Manufacturingu Samaritan Regional Health Systemu Ashland Universityu Ashland Theological Seminary

Mental Health and Recovery Board

u Branch of local (county) Governmentu 18 Member Citizen Governing Boardu Plan, fund, monitor and evaluate u Contract provider network

u Clinical and Support Services

u Community Educationu Professional and Workforce Developmentu Advocacy

Three Legs of the Stool

uRecoveryu Trauma-Informed CareuMedication Optimization

How the AVA Supports Local Efforts

u ACEs DVDu Experts and Collaboration

u Regional Academy: April 2014 (Fellitti, Corwin, Ismailji, Alexander)

u Barbara Boat (April 2015)u Victor Vieth (March 2016)

u Affinity Groupsu Website Resources

Laying the Groundwork

uStaff and Board MembersuNetwork ProvidersuPublic and Private Social Service AgenciesuCommunity at Large

Pre-Conference Preparation

uLunch and Learn Series (AVA ACEs DVD)u Mental Health and Addiction Providersu Social Service Agenciesu Faith Communityu Hospitalu Educators

Recruit Partners

u Margaret Clark Morgan Foundationu Samaritan Regional Health Systemu Northeast Ohio Medical University (CMEs)u Visiting Nurse Association of Ohiou Mental Health Agenciesu Ashland University’s Center for Nonviolenceu Akron Partners Summa, Akron Children’s Hospital, others)

Regional Academy: April 2014

u Providing exposure to a wide body of knowledge, research and practice by subject experts

u Creating networking opportunity and helps to build a local learning community

u Promoting local leaders (individuals and organizations) who are seeking to address the impact of violence and abuse as well as to prevent its occurrence

Using the Media

uLocal NewspaperuLocal TV

Next Steps

u Faith Leaders Conference (March 2016)u Community Health Assessment TAGs

u Health and Wellnessu Opiate Addictionu Povertyu Violence Across the Lifespan

u Considering a Second Regional Academy

Resources

u AVAResourcesu ACEsDVD:

u https://avahealthorg.presencehost.net/ace_study/order_ace_dvd/

u RegionalAcademyPlanningGuideandRelatedResources:u http://www.avahealth.org/events/regional_academies/endorsements.html

u HealthFederationofPhiladelphiau Community Resiliency Cookbook:

u http://communityresiliencecookbook.org/

u ACEsConnectionNetworkResources:u Infographic:

u http://www.acesconnection.com/blog/roadmap-to-resilience-infographic

u RoadmaptoResilienceToolkit:u http://www.acesconnection.com/blog/roadmap-to-resilience-toolkit-v-1-0-1

u

ACEs:InformingBestPracticesOnlineCollaborativeLearninglivingDocument

2015AVAInitiativesRegionalAcademiesandSymposia– USA

May– Ft.PeckHealth&ResilienceSymposiumco-sponsorandoneAVAspeaker

October– Rochester,NYNovember– Tampa,FL

GlobalPartnershipsJuly– TraumaAwareness&SchoolMental

HealthSymposium– Seoul,KoreaOctober– HongKong/AVARegionalAcademy

AVAGlobalSummit– November5-7Jacksonville,FL

AVA’sEducationalToolsGoGlobal

ParadigmShifts

Mind-BodyDualism BiomedicalModel BiopsychosocialModel EcobiodevelopmentalModel

SlidebyTasneem Ismailji,MD,MPHusedwithpermission

Decartes (1596– 1650) RobertAnda,MD,MS VincentFelitti,MD

GeorgeEngel,MD(1913– 1999)

ECOBIODEVELOPMENTAL FRAMEWORK

Schonkoff JP,GarnerAS2012Pediarics129;e232SlidebyTasneem Ismailji,MD,MPHgraphiccopyrightedbyAAP

A collaborative effortof Kaiser Permanente and The Centers for DiseaseControl and Prevention

www.acestudy.org

Vincent J. Felitti, M.D. Robert F.Anda, M.D.

AdverseChildhoodExperiences(ACEs)&RelationshiptoAdultHealth

StatusandWell-Being

slide from Randell Alexander, MD, PhDandVincent Fel i t t i , MDusedwithpermission

•  The largest study of its kind ever done to examine the health, social, and economiceffects of adverse childhood experiences over the lifespan (17,337 participants)

•  Average age = 57 years old

slidesfrom RandellAlexander, MD, PhDandVincent Felitti, MDusedwithpermission

TheAdverseChildhoodExperiencesStudy

ACEStudyDesignSurveyWave171%response(9,508/13,454)

n=13,000

SurveyWaveIIn=13,000

Allmedicalevaluationsabstracted

PresentHealthStatus

MortalityNationalDeathIndexMorbidityHospitalizationDoctorOfficeVisitsEmergencyRoomVisitsPharmacyUtilization

Allmedicalevaluationsabstracted

vs.

17,337adults

Experiences that represent medical and social problems of national importance:• childhood abuse and neglect• growing up with domestic violence• substance abuse or mental illness in home• parental loss or incarceration

slide from RandellAlexander, MD, PhD, andVincent Felitti, MDusedwithpermission

WhatareAdverseChildhoodExperiences?

slidefromVincent Felitti, MD, usedwithpermission

FromRobAnda’s,MD,MSpresentationatFt.PeckIndianReservationMay27,2015- usedwithpermission

HistoricalTraumaandACEs

Prevalence of Adverse Childhood Experiences

Abuse, by CategoryPsychological (by parents) 11%Physical (by parents) 28%Sexual (anyone) 22%

Neglect, by CategoryEmotional 15%Physical 10%

Household Dysfunction, by CategoryAlcoholism or drug use in home 27%Loss of biological parent < age 18 23%Depression or mental illness in home 17%Mother treated violently 13%Imprisoned household member 5%

Prevalence (%)

slidesfromVincentFelitti,MD,usedwithpermission

Adverse ChildhoodExperiences Score

Number of categories of adverse childhood experiences are summed …

•  More than half have at least one ACE•  If one category of ACE is present, there is an 84% likelihood of

additional categories being present.slide from RandellAlexander, MD, PhDandVincent Fel i t t i , MDusedwithpermission

ACE score0

Prevalence48%

1 25%2 13%3 7%

4 or more 7%

Number ofAdverse ChildhoodExperiencesandTeenSexualBehaviors

0

35

30

25

20

15

10

5

40

45

Perc

entW

ithH

ealth

Prob

lem

(%

)

Number of adverse factors :

0 1 2 3 4 or more

slide from RandellAlexander, MD, PhDusedwithpermission

Intercourse byage 15

Teenpregnancy

Teenpaternity

ACE Score and HIV Risks

0

12

10

8

6

4

2

14

16

18

20Pe

rcen

tWith

Hea

lthPr

oble

m (

%)

Number of adverse factors:

0 1 2 3 4 or more

Slide from RandellAlexander,MD, PhDusedwithpermission

Ever injected drugs

Had 50 or more intercourse partners

Ever hadan STD

0

16

14

12

10

8

6

4

2

18

20

Perc

entW

ithH

ealth

Prob

lem

(%

)

Number of adverse experiences:

0 1 2 3 4 or more

Early smokinginitiation

Current COPD

Relationship Between Number of Adverse Childhood Experiences and Smoking Behaviors and Smoking-Related Lung Disease

Slide from RandellAlexander,MD, PhD - usedwithpermission

Childhood Experiences vs.Adult Alcoholism

6

41

20

ACEScore

8

12

3

14

16

18%

Alc

ohol

ic

2

4+

10

SlidebyVincentFelitti,MD– usedwithpermission

0

5

10

15

20

25

30

35

40

0 1 2 3 4 5 6 7

Series1

Series2

36.4%

1.1%

26.2%

2.2%

- LifetimeACEScore

- LifetimeHistoryofAttemptedSuicides

15.8%

5.6%

ormore

4.0%

9.5%

6.0%

8.4%

3.5%

13.8%

1.6%

21.8%

0.9%

35.2%

NumberofACEs

Percento

fPopulation

LifetimeACEs&SuicideAttemptsAdaptedfromKoplan &Chard– PsychAnnals,2014DatafromDube etal.– JAMA,2001

ACEScore vsInjection DrugUse

3.53

2.52

1.51

0.50%H

ave

Inje

cted

Dru

gs

0 1 2ACE Score

3 4 or morep<0.001

Health risks

SlidefromVincent Felitti,MDusedwithpermission

ACE Score and the Risk of Beinga Victim of Domestic Violence

0

10

5

15 Women Men

0 1 2 3 4 >5 0 1 2 3 4 >5

Ris

kof

Vic

timiz

atio

n(%

)

ACE Score

Well-being

Slideby Vincent Felitti,MD - usedwithpermission

Childhood Experiences Underlie Chronic Depression

80706050403020100

%W

itha

Life

time

Hist

ory

of

Depr

essi

on

0 1 2ACE Score

3>=4

Felitti, 2011

WomenMen

slidefromVincent Felitti,MDusedwithpermission

ACEs Increase Likelihood of Heart Disease*

*After correction for age, race, education, and conventional risk factors like smoking and diabetes. Circulation, Sept 2004.

SlidefromVincentFelitti,MDusedwithpermission

• • • 

Emotional abuse Physical abuse Sexual abuse

1.7x1.5x1.4x

•  Domestic violence 1.4x• • 

Mental illness Substance abuse

1.4x1.3x

•  Household criminal 1.7x• • 

Emotional neglect Physical neglect

1.3x1.4x

SlidebyMartinTeicher,MD,PhD–usedwithpermission

ACESTUDY FINDINGS•  AsACEscore goes up, sodoes risk for:–  Smoking–  Organicdisease–  Adult alcoholism–  Depressionandsuicideattempts–  Having50+lifetime sexualpartners–  STD’sandRape (from5% to33%)–  Hallucinations–  DomesticViolence–  Addictions–  Dying early–  Jobproblemsandlost time fromworkFelitti VJ, Anda RF, Nordenberg D,WilliamsonDF, Spitz AM, EdwardsV, KossMP, et alJS.The

relationship ofadult healthstatustochildhood abuse andhousehold dysfunction.

AmericanJournalofPreventiveMedicine.1998;14:245-258

ACEsDatafromThreeStudiesAdaptedfromKoplan &Chard– PsychiatricAnnals,2014

ACE Study CDCFiveStateBRFSSStudy

CDCTenStateBRFSSStudy

Year(s) 1995-1997 2009 2010

Samplesize 17,337 26,229 53,998

StudySite SanDiego,CA AR,LA,NM,TN,WA DC,HI,ME,NE,NV,OH,PA,UT,VT,WA,WI

Physical Abuse 28.3% 14.8 % 16.0%

SexualAbuse 20.7% 12.2% 10.9%

EmotionalAbuse 10.6% 25.9% 35.1%

ParentsSep./Div. 23.3% 26.6% 28.1%

HMwithalcohol ordrugproblem

26.9% 29.1% 21.7%(alcohol)9.4%(drug)

HMwithMental Illness 19.4 % 19.4% 16.4%

HMIncarceration 4.7% 7.2% 5.9%

HMDomestic Violence(IPV) 12.7%(Mothers only) 16.3% 15.0%

DiseaseBurdenofChildhoodAdversitiesGreaterthanallMentalDisorders

TYearsLivedwith

Disability

All ChildhoodAdversity 20.7AbuseandNeglect 15.8AllMentalDisorders 12.9

TheDiseaseBurdenofChildhood AdversityinAdults:APopulations-BasedStudy -Pim Cuijpers,Filip Smit,Froukje Unger,YvonneStikkelbroek,Margreet tenHave,RondeGraaf,ChildAbuse&Neglect,35(2011)937-945.

UtahWorkforceServicesDepartment

• Commitmenttotrainallemployeestobetrauma-resiliencyinformed

• ThreeTiers• TierOne

• Trauma– Health&Function• Resiliency• RolePlaying• Protocolsandnextsteps