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SEE ALSO: Ann Jennings, Ph.D.: On Being Invisible in the Mental Health System (COMMENTARY) Published in The Journal of Mental health Administration 21(4): 374-387, 1994. Editor’s Note: The reader is forewarned that, to provide a realistic account of Anna’s experience and her attempts to communicate it to others, explicit language and graphic descriptions of her behavior are included. [PDF] http://www.annafoundation.org/OBI.pdf Comments Posting comment... Premium member Presentation Transcript Slide 1: The Story of A Child’s Path to Mental Illness and Suicide Presented by her mother Ann Jennings Ph.D. www.TheAnnaInstitute.Org: There is no trust more sacred than the one the world holds with children. There is no duty more important than ensuring that their rights are respected, that their welfare is protected, that their lives are free from fear and want and that they grow up in peace. Kofi A. AnnanSlide 3: This is me, Ann Jennings This is my daughter Anna She is the artist. She took her life at the age of 32.Slide 4: Two intersecting life journeys, my own and my daughters: How did this happen to my daughter? Why did I miss what happened? How did we all miss it? What could we have done differently?Today’s presentation: Today’s presentation Snapshot of Anna’s life Damaging consequences: Research findings The story of Anna’s early childhood and sexual abuse Cumulative trauma: making of a broken heart Becoming Trauma-Informed - a personal and professional challenge Reflection and DiscussionHandouts and Resources: Handouts and Resources ACE Chart Website: www.TheAnnaInstitute.Org Slide Presentation(s); Information and Articles; Art Gallery List of Websites and Resources Article: Retraumatizing the Victim Annotated List of Books for young children. Books on DisplayA Snapshot of Anna’s Life: A Snapshot of Anna’s LifeSlide 9: Anna Caroline Jennings (1960–1992) At less than 3 years old, my daughter Anna was sexually abused. The abuse was severe and continued for nearly 4 years. Additional trauma occurred. None of us recognized what was happening to her. For the story of Anna’s institutional years, see www.theannainstitute.orgSlide 10: Anna Caroline Jennings (1960–1992) She “broke at age 13, was diagnosed schizophrenic and at age 15 began psychiatric treatment. For 17 years she was in the mental health system – 11 of those years in mental institutions. Many medications and treatment approaches. Nothing helped. For the story of Anna’s institutional years, see www.TheAnnaInstitute.orgSlide 11: Anna Caroline Jennings (1960–1992) She took her life October 24, 1992, at the age of 32, on the back ward of a state mental hospital. For the story of Anna’s institutional years, see www.TheAnnaInstitute.orgThe damaging consequences of childhood trauma: Research Findings : The damaging consequences of childhood trauma: Research FindingsCollaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the Center for Disease Control and Prevention (CDC): Collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the Center for Disease Control and Prevention (CDC) The Adverse Childhood Experiences Study (ACE)What is the Adverse Childhood Experiences (ACE) Study?: What is the Adverse Childhood Experiences (ACE) Study? Decade long. 17,000 people involved. Largest epidemiological study ever done. Revealed health and social effects of adverse childhood experiences over the lifespan.ACE Study Findings: ACE Study Findings Childhood experiences are powerful determinants of who we become as adultsACE Study Findings and the Centrality of Trauma: ACE Study Findings and the Centrality of Trauma Adverse Childhood Experiences are the most BASIC cause of most health risk behaviors, morbidity, disability, mortality, and health and behavioral health care costs. Which means trauma is a crucial public health issue – at the ROOT of and CENTRAL to development of health and mental health problems – and to recovery.Slide 17: Adverse Childhood Experiences* Abuse of Child Recurrent Severe Emotional abuse Recurrent Physical abuse Contact Sexual abuse Trauma in Child’s Household Environment Substance abuse Parental separation or divorce - Chronically depressed, emotionally disturbed or suicidal household member Mother treated violently Imprisoned household member Loss of parent – (best by death, unless suicide, - worst by abandonment) Neglect of Child Abandonment Child’s basic physical and/or emotional needs unmet * Above types of ACEs are the “heavy end” of abuse. Impact of Trauma and Health Risk Behaviors to Ease the Pain Neurobiologic Effects of Trauma Disrupted neuro-development Difficulty controlling anger-rage Hallucinations Depression Panic reactions Anxiety Multiple (6+) somatic problems Sleep problems Impaired memory Flashbacks Dissociation Health Risk Behaviors Smoking Severe obesity Physical inactivity Suicide attempts Alcoholism Drug abuse 50+ sex partners Repetition of original trauma Self Injury Eating disorders Perpetrate interpersonal violence Long-Term Consequences of Unaddressed Trauma (ACEs) Disease and Disability Ischemic heart disease Cancer Chronic lung disease Chronic emphysema Asthma Liver disease Skeletal fractures Poor self rated health Sexually transmitted disease HIV/AIDS Social Problems Homelessness Prostitution Delinquency, violence, criminal behavior Inability to sustain employment Re-victimization: rape, DV compromised ability to parent Intergenerational transmission of abuse Long-term use of health, behavioral health, correctional, and social servicesSlide 18: ACE study views health risk behaviors as attempts to cope with impacts and ease pain of prior trauma, NOT as symptoms, bad habits, self-destructive behavior, or public health problems.Existing Practice: : Existing Practice: Existing practice commonly asks “What is wrong with the person?” vs “what happened to the person?” Existing practice develops diagnoses, and treats symptoms instead of underlying causes. Adverse Childhood Experiences (ACEs) are Common: Adverse Childhood Experiences (ACEs) are Common Of 17,000 HMO members: 72% had attended college 77% were white 62% were 50 or older Adverse Childhood Experiences are Common: Adverse Childhood Experiences are Common Of the 17,000 HMO Members : 1 in 4 exposed to 2 categories of ACEs 1 in 16 was exposed to 4 categories. 22% were sexually abused as children. 66% of the women experienced abuse, violence or family strife in childhood. What is uncommon is: What is uncommon is recognition acknowledgement action: health risk behaviors adult diseases disabilities severe social problems severe mental health problems For example: The following information and slides are from September 2003 Presentation at “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West, by Vincent J. Felitti, MD. The higher the ACE Score, the greater the likelihood of :Slide 24: Adverse Childhood Experiences and Current Smoking %Slide 25: A child with 6 or more categories of adverse childhood experiences is 250% more likely to become an adult smoker . A person with 4 categories of adverse childhood experiences is 260% more likely to have Chronic Obstructive Pulmonary Disease (COPD) . Current SmokingSlide 26: Childhood Experiences and Adult Alcoholism 0 1 2 3 4+Adult Alcoholism: Adult Alcoholism A 500% increase in adult alcoholism is directly related to adverse childhood experiences. 2/3rds of all alcoholism can be attributed to adverse childhood experiencesACE Score and Intravenous Drug Use: ACE Score and Intravenous Drug Use N = 8,022 p<0.001Intravenous Drug Use: Intravenous Drug Use A male child with an ACE score of 6 has a 4,600% increase in the likelihood that he will become an IV drug user later in life. 78% of drug injection by women can be attributed to ACEsChildhood Experiences Underlie Rape: Childhood Experiences Underlie Rape 0 1 2 3 4+Rape: Rape Women with an ACE score of 4+ are 500% more likely to become victims of domestic violence . They are almost 900% more likely to become victims of rape.Slide 32: ACE Score Ever Hallucinated* (%) Abused Alcohol or Drugs *Adjusted for age, sex, race, and education. ACE Score and HallucinationsThe making of madness…..: The making of madness….. There is a significant and graded relationship between a history of multiple childhood traumas (ACE’s) and hallucinations . Compared to persons with 0 ACEs, those with 7 or more ACEs had a five-fold increase in the risk of reporting hallucinations Whitfield et al 2005Slide 34: Abuse and trauma suffered in the early years of development resulted in a far greater likelihood of pre-psychotic and psychotic symptoms . Perry, B.D. (1994) In an adult inpatient sample, 77% of those reporting CSA or CPA had one or more of the ‘characteristic symptoms’ of schizophrenia listed in the DSM-IV: hallucinations (50%); delusions (45%) or thought disorder (27%) Read and Argyle 1999Slide 35: Childhood Experiences Underlie Chronic DepressionChronic Depression: Chronic Depression Adults with an ACE score of 4 or more were 460% more likely to be suffering from depression .Slide 37: Childhood Experiences Underlie Suicide 1 2 0 3 4+Suicide : Suicide The likelihood of adult suicide attempts increased 30-fold, or 3,000%, with an ACE score of 7 or more. Childhood and adolescent suicide attempts increased 51-fold, or 5,100% with an ACE score of 7 or more.Slide 39: Suicidality is not usually caused by “mental illness”, drugs, rejection by peer groups, school pressure, failures, etc. Rather, it is a coping device – a way to manage or escape from the unbearable impacts of adverse childhood experiences and/or adult trauma.ACE Score and Serious Job Problems: ACE Score and Serious Job ProblemsMuch of what causes time to be lost from work is actually predetermined decades earlier by the adverse experiences of childhood.: Much of what causes time to be lost from work is actually predetermined decades earlier by the adverse experiences of childhood.Slide 42: Adverse Childhood Experiences and Likelihood of > 50 Sexual PartnersSlide 43: Adverse Childhood Experiences and History of STDSlide 44: Frequency of Being Pushed, Grabbed, Slapped, Shoved or Had Something Thrown at Oneself or One’s Mother as a Girl and the Likelihood of Ever Having a Teen Pregnancy Never Once, Sometimes Often Very Twice often Percent who had a teen pregnancy Pink =self Yellow =motherSlide 45: Sexual Abuse of Male Children and Their Likelihood of Impregnating a Teenage Girl Not 16-18yrs 11-15 yrs <=10 yrs abused Age when first abused Percent who impregnated a teenage girl 1.3x 1.4x 1.8x 1.0 refACE Score and Unintended Pregnancy or Elective Abortion: ACE Score and Unintended Pregnancy or Elective AbortionEffect of ACEs on Mortality: Effect of ACEs on Mortality Age Group 0 ACE 60% live to 65 4 ACE less than 3% live to 65Many chronic diseases in adults are determined decades earlier, in childhood.: Many chronic diseases in adults are determined decades earlier, in childhood.Slide 50: Other Studies on Childhood Sexual and/or Physical AbuseSlide 51: In my experience, early child sexual abuse (CSA) especially impairs resiliency My other children experienced multiple ACE’s. They coped. Anna experienced early CSA and ACEs. She broke. Sarah Joe, Anna John MarySlide 52: A number of studies suggest that severe sexual and/or physical violation early in childhood appear to have the greatest impact and to be associated with the most serious disabilities later in life.Slide 53: 2/3rds of men and women in substance abuse treatment report childhood physical and/or sexual abuse. 75% of women in treatment programs for drug and alcohol abuse report having been sexually abused . SAMHSA/CSAT, 2000; SAMHSA, 1994Slide 54: 51 – 98% of public mental health clients with severe mental illness, including schizophrenia and bipolar disorder , have been exposed to severe childhood physical and sexual abuse. Most have multiple experiences of trauma. Goodman et al, 1999, Mueser et al, 1998; Cusack et al, 2003Slide 55: There is a significant relationship between childhood sexual abuse and various forms of self-harm later in life, including suicide attempts, cutting, and self-starving . Van der Kolk et al, 1991 One study found childhood sexual abuse to be the single strongest predictor of suicidality regardless of other factors. Read et al, 2001Slide 56: “They do not want to hear what their children suffer. They’ve made the telling of the suffering itself taboo” From Possessing the Secret of Joy, Alice Walker Yet the Silence Continues Prevalence of the Problem: Prevalence of the Problem 1/4 th to 1/3 rd of all children and as many as 42% of girls are sexually abused before age 18 – with 9% experiencing persistent, genital assault. Saunders et al, 1992; Randall 1995; Epstein, 1998 93% of psychiatrically hospitalized adolescents had histories of physical and/or sexual and emotional trauma. 32% met criteria for PTSD. Lipschitz et al, 1999: Teenagers with alcohol and drug problems are 6 to 12 times more likely to have a history of being physically abused and They are 18 to 21 times more likely to have been sexually abused than those without alcohol and drug problems. Clark et al, 1997 Among juvenile girls identified by the courts as delinquent, more than 75% have been sexually abused . Calhoun et al, 1993The sexual and physical violation of children results in alterations in self-perception which are immediate, last throughout the life-span, and contribute to suicidality as a way to cope. Judith Herman, 1992 : The sexual and physical violation of children results in alterations in self-perception which are immediate, last throughout the life-span, and contribute to suicidality as a way to cope. Judith Herman, 1992 Lasting Alterations in Self PerceptionSlide 60: Sense of helplessness, paralysis, captivity, inadequacy, powerlessness, danger, fear Continues over the lifespanSlide 61: Sense of Shame, Guilt, Self-Blame, Being Bad Continues over the lifespanSlide 62: Sense of defilement, contamination, spoiled, degraded, debased, despicable, evil Continues over the lifespanSlide 63: Sense of complete difference from others, deviance, utter aloneness, isolation, non-human, specialness, unseen, unheard, belief no other person can ever understand Continues over the lifespanLasting Alterations In Relations With Others: Lasting Alterations In Relations With Others The sexual and physical violation of children results in alterations in relations with others, which often last throughout the life-span. Judith Herman, 1992Slide 65: Isolation, Withdrawal Disruption in Intimate Relationships Repeated Search for Rescuer Persistent Distrust Repeated Failures of Self-ProtectionSo, what do our children ask of us?: So, what do our children ask of us?Slide 67: That we: Pay attention Overcome our lack of knowledge Ask “What Happened?” Overcome our fear Speak out and break the silenceSlide 69: Anna’s Early Childhood What happened to her as a child? What clues that she was being abused and traumatized were not recognized? What opportunities for prevention or early intervention and healing were missed? What might we do differently today?Context: Context One thing I have learned is how important it is to be aware of the context we are raised in and in which we are raising our children.Some of my context: Some of my context Ideal was the nuclear family model vs village – isolating. Gender roles were prescribed. Racial/Class/ Income/other cultural separation Rise of consumer culture The 1950s – 1960sMore of my context: More of my context Women married young, not encouraged to complete education or pursue career. Women deviating from norm - suspect, stigmatized, marginalized. Greatest goal - to be a wife and mother. Me, Married at Age 19Slide 73: For me as a Catholic girl, great stress on sexual “purity”, skewed knowledge of sex. Sense of self worth through husband’s success, personal, home, children’s appearances. Motherhood idealized, but no education in child development or parenting. Me, Married at Age 19Anna’s Parents’ Family Backgrounds: Anna’s Parents’ Family Backgrounds My family upper class professional; Anna’s father’s working class I was first of 9 siblings; Anna’s father first of 7. Both raised (Irish) Catholic – attended all Catholic schools.Slide 75: Anna’s ancestry – combination of Irish Catholic and German. One great-grandparent Irish immigrant. The rest rooted for generations in mid-west. Interfamilial conflict may go back generations to civil war. Substance abuse, depression, Alzheimer’s, physical violence, divorce, my great aunt’s suicide at age 16 in Germany. Secrets kept in both families of origin. Many things one did not talk about - ever. : Substance abuse, depression, Alzheimer’s, physical violence, divorce, my great aunt’s suicide at age 16 in Germany. Secrets kept in both families of origin. Many things one did not talk about - ever. Intergenerational Spare the Rod, Spoil the Child: Spare the Rod, Spoil the Child Anna’s dad and I raised in authoritative, punitive parenting model . Blame, shame, criticism, put-down, spanking, “whipping”, and removal of privileges used as discipline. Model same in schools. Anna’s father’s dad physically and emotionally violent to him as a child. My dad occasional intense emotional rage and negative judgment which conveyed sense of innate “wrongness” to us as children. My mother had difficulty nurturing. In both our “families of origin”, wives kept house, kept “peace”, and kept secrets.The model couple: The model couple Cover for record produced by Catholic organization - of Anna’s parents giving advice to other young married couplesThings are not always as they seem: Things are not always as they seem We continued in the punitive parenting model with our own children. Stress: I felt economic insecurity, fear of husband’s anger, fear of church’s and other’s judgment, dependency, low self-esteem, and lived in “nightly terror of getting pregnant again”. Stress: Anna’s dad had work and money problems, low self-esteem, and released his stress through anger directed toward me and children, especially oldest son.Anna – pre-natal environment: Anna – pre-natal environment Anna’s dad and I both smoked and drank. At times I drank to excess . I was prescribed amphetamines during pregnancy to keep weight gain under 20 lbs. Religion forbade us the use of contraceptives: Anna not a planned or wanted child – I tried to abort pregnancy.Anna: Birth to Age 2 ½ - 3: Anna: Birth to Age 2 ½ - 3 A major city in the Midwest Anna’s Birth: October 20, 1960 : Anna’s Birth: October 20, 1960 Birth and medical records: healthy birth; full term, 7 lbs., 14 oz; pregnancy uncomplicated; Pediatric records: no problems; healthy normal baby and toddler Nursing discouraged by medical profession; formula and bottle-feeding seen as preferable.Anna – a few days old: Anna – a few days old Me, Anna’s mom: “I remember being struck by how exquisitely beautiful she was, even as a tiny new born baby. A perfectly healthy and cuddly little baby girl, Anna snuggled in my arms, took to nursing and then to bottle feeding with ease, napped and slept abundantly, seemed content and trusting of the world.”Slide 84: Anna’s godmother Aunt Genevieve: “I never remembered anything unpleasant. She was a wonderful child. I babysat for her for six weeks after she was born, when you first had her – when she was a little tiny, brand new baby. She was delightful. And I saw her often after that.” Her Aunt Caroline: “I remember her as a tiny baby, being real sweet and quiet, lying in her crib in the dining room next to the kitchen. She was such a little sweetheart, such a quiet, easy going baby .”Slide 85: Her grandmother J: “I remember her as a very pretty and loving little girl, receptive to love and giving it in return. I’m a hugger and she hugged me in return.”Slide 86: Her Aunt Caroline: “She was fun. As a toddler I remember her being very active and outgoing. She was a little girl with a big mouth and big eyes. She would giggle, and that mouth was always open!”Slide 87: Her Aunt Alice: “ I remember feeling she was just the prettiest little girl I’d ever seen in my whole life, kind of sparkly, a big smile, bright eyes. You could really see in her eyes her soul. An incredible kind of spirit would come through in her eyes and smile.”Me, her mom: “…. I remember her gurgling laughter – how much fun she was. She was exuberant, active, assertive, determined and adventurous. I had my hands full with her once she was up and walking!” : Me, her mom: “…. I remember her gurgling laughter – how much fun she was. She was exuberant, active, assertive, determined and adventurous. I had my hands full with her once she was up and walking!”Sudden intense change occurred in Anna when she was about 2 ½ to 3 years old. : Sudden intense change occurred in Anna when she was about 2 ½ to 3 years old. Self Portrait by Anna in art therapy age 25Slide 90: All of a sudden, for seemingly no reason, she began to cry and scream inconsolably with unusual intensity and for prolonged periods of time – different than “terrible twos” She had frequent “temper tantrums”; screamed at siblings and friends; expressed extreme terror; withdrew from others; cut off her hair; ate mud; threw her feces at walls; had trouble sleeping; would not obey me….Slide 91: Her Grandmother J: “I remember her as a very pretty and loving little girl, and then just all of a sudden, whatever it was crept in and just changed her entire personality.” “For no apparent reason she would have temper tantrums.” “It came on rather suddenly.”Slide 92: Her Aunt Genevieve : “It was when she was about 2 ½ or 3 when I noticed that she, instead of being sociable with other people, would go into hiding, like she did not want to be seen.” “And she would not sing ‘Edelweiss’ anymore, when John and Mary would.”Medical: Medical Me, Anna’s mom – re Pediatrician : I thought Anna’s upset was due to her constantly raw sore bottom which seemed like a bad diaper rash. But it was unusual compared to the other children. Her pediatrician examined her several times and prescribed Desitin ointment for diaper rash.Medical: Medical Emergency Room and dental records: ER: She became accident prone . Between age 2 yrs 10 mo to 3 yrs 4 mo, was treated surgically on 3 occasions for lacerations on her face and head. Dentist : Anna noted as “completely unmanageable” – several visits. They could not work on her. For both ER and Dentist she was forcibly restrained .Slide 95: Anna: “I fell out of the crib when I was about two and a half or three years old, and I still got this ball on my head where I bumped myself. Then I remember going to the hospital and they put a sheet over my head.” “You were there, and dad, and I was screaming and screaming while they did the stitches.”Slide 96: Housekeeper: “When she was a little girl, if she go outside to play, she’d come back screamin and hollerin, nobody never could figure out why she was cryin. She used to go out your side door and she used to just cry, poor little thing, she used to scream.” “Always thought somethin was gonna get her out there. She used to say “It’s going to get me, it’s gonna get me daddy, it’s gonna get me mommy – it’s going to get me. She was a little girl then, a little bitty child.”Slide 97: Anna: “When I was about 2 ½ or 3 I used to go by the swings in the back yard and eat mud. And I used to throw my shit at the walls when I was in my crib in the bedroom upstairs. I would bump my crib across the floor and throw everything out of the drawers.”Slide 98: Neighborhood mom : “She used to come over to my house and play with the kids – dolls, blocks… but there was something that was a little bit different about her.” “She would grab a toy and run off with it and laugh – a strange laugh for a little kid – kind of crazy, almost like a squeal – more like yelling than laughing. And she used to scream, and became difficult for you to handle….”Slide 99: Anna’s dad: “I remember around three or four she became over-reactive, real loud, and particularly angry. Her friend would come over to play with Anna in the sandbox – the slightest thing that would happen, Anna would yell at the top of her voice at her friend – who would then leave. She would literally drive her away.” “She was very stubborn and difficult to discipline compared to the other kids.”I was overwhelmed: I was overwhelmed Me, Anna’s mom: Around this time I began drinking more heavily – always in the evenings. At one point I had 4 children under the age of 6, two in diapers and a 5 th child on the way. I had a wringer washer and wire clotheslines in the basement, no diaper service, and tub fulls of dirty diapers. The drinking added to my exhaustion.Slide 101: Me, Anna’s mom: “There were times I could hear Anna upstairs crying to get up from her nap, and I couldn’t get to her. Finally I would drag up the stairs, blurred in fatigue, and there she would be , totally a mess - - with tears in her eyes and down her face, sobbing for me to come and pick her up and take her out of her crib where she was all alone. I felt so bad for her. Poor Anna, sobbing to get out of her crib and nobody responding.”Slide 102: Anna: “Spiders. I started to be scared of spiders when I was two or three years old, in a bunk bed on the top bunk. I had thought there were tarantulas creeping along the bed or something.” “I hated mushrooms, I wouldn’t eat them, from about three years old on.”Slide 103: What happened to Anna? What caused – “all of a sudden, whatever it was – to creep in and just change her entire personality??”Multiple Instances of Childhood Sexual Abuse (revealed to me years later): Multiple Instances of Childhood Sexual Abuse (revealed to me years later) Age 2 ½ to 3 by teenage male relative Age 3 ½ to 6 by male babysitter Indeterminate age by older neighborhood boy Child without arms – encapsulated – no way out Age 2 ½ to 3: By teenage male relative: Age 2 ½ to 3: By teenage male relative Revealed to me by housekeeper 27 years later. *(Anna had no memory of this reported abuse). “Somethin happened to her when she was small….. She tried to tell me about the man, she say a man played with her where he wasn’t supposed to. She told me that man hurted her, and that’s what happened to the poor little child.” “That shut her off you know. She seemed like that kept on her mind, you know how little children do. They don’t tell you exactly what’s goin on. They keep on thinkin about it. That’s a shame though, it’s sad you know.”Slide 106: Housekeeper goes on to tell me …. “All along I had knowed that was X because that’s why when that child used to go outside she used to scream so hard. She was scared X was gonna come.” “And your mother knowed that. Yep, she sure did. Cause we had discussed it a lot of times, me and her did… she used to talk about that was a shame because X was family…” “And she didn’t want to say nothin.”Age 3 ½ to 6 by male babysitter Revealed to me by Anna 20 years later: Age 3 ½ to 6 by male babysitter Revealed to me by Anna 20 years later At age 23, Anna described to me the sadistic sexual abuse she experienced as a child. Her disclosure came after she participated in a therapy group at a psychiatric hospital and learned for the first time from the stories of other patients - that she “was not the only one in the world ” to have had such experiences…: This is what she told me: “He took me upstairs away from Mary and John and Joe and Sarah and told them to go outside and play.” “He tied me up and put my hands over my head so that I couldn’t move, blindfolded me with my little t-shirt, pulled my t-shirt over my head with nothing on below, opened my legs and was examining and sticking things up me. It hurt me. I would cry and he wouldn’t stop.”: “To do that when I was a little kid was like… uh… I don’t know, I don’t know. It made me feel pretty bad.” “I thought I was the only one in the world . It never happened to Mary or Sarah so I thought I was a bad seed …..”Slide 110: “I remember after he did that I was walking toward the door out of the room and I was feeling like I was bad . And why not Sarah and Mary, and why just me ??”Indeterminate age by older neighborhood boy: Indeterminate age by older neighborhood boy Me, Anna’s Mom: “The only abuse I remember Anna’s telling me about as a child was of being “fooled with” by a young teenage boy who lived across the street from us. Anna’s dad spoke to his parents and I then took Anna to a doctor for a physical examination.” “I thought of the “fooling” as child’s play, and inadvertently, when I took her to the doctor, I subjected Anna to another invasive procedure…. compounding the abuse.”Physical Examination by doctor: a “re-traumatization”: Physical Examination by doctor: a “re-traumatization” Anna: “Then I remember the doctor you took me to when I told you. He did things to me that were disgusting (pointing to her genital area).” Me, Anna’s mom: I can see now so many ways in which we retraumatized Anna as a child. The above is just one example of many. This kind of inadvertent re-traumatization continued all through her life.Intergenerational Impacts: Intergenerational Impacts Me, Anna’s mom: Its possible I was numb to Anna’s experience because of my own. At the age of about 60 I began having memories and one very severe flashback to an episode of sexual abuse by an aunt when I was around 6 or 7 years old. And I have experienced great discomfort and at times rage with some priests, for no “reason”…. I have always gone “numb” in the face of unexpected sexual aggression, in effect losing my ability to protect myself.Screams, Tears, “Obstinacy” Met with Discipline – Punishment - Spanking: Screams, Tears, “Obstinacy” Met with Discipline – Punishment - Spanking Her dad: “I still have guilt feelings. I can still picture me smacking her on the bottom going up the stairs. I was so frustrated that I could not control or communicate or get through to Anna like I could the other kids – that I felt myself out of control Sometimes I would give her a swat and she would just look at me, and wouldn’t even react.”Slide 115: Me, her mom : “I remember her screaming and crying with such piercing intensity and for such long periods of time that I would scream at her and spank her out of total frustration to try to make her stop. Since she had so many accidents, with all the scratches and bruises on her body there were times she looked to me like an abused child.”Slide 116: “I felt helpless – nothing seemed to work. If you wanted her to do something she would do the opposite. I would attribute it to obstinacy. I know now she must have been in terror, but I didn’t see what was happening to her then. I just knew something had to be wrong...”Examination by child psychiatrist: Examination by child psychiatrist Me, and Anna’s dad: We finally took Anna to see a well-known child psychiatrist when she was about 4 1/2. After observing her twice in play therapy, he said he thought that the heart of her problem was that she was very uncoordinated. She was left handed, left footed and right eyed. He said that she would get coordinated in time and would be OK. To just treat her with lots of love and ease up on the discipline. He suggested she needed a more structured environment, such as a nursery school. We were greatly relieved to be informed there was nothing seriously ‘wrong with her’.Slide 118: Anna – about her visits with the child psychiatrist: “I remember being in a doctor’s office – some doctor with some toys. I was sitting in a room and then he came in to the room and he said “Hi”, and I played with the toys. He said I was ambidextrous or whatever…..”Slide 119: Me, Anna’s mom: “We belonged to a Catholic group for married couples – a peer support group to help each other with our relationships and our children. It was moderated by a priest. We met every month. Most of us were new parents.” “We never talked about child abuse, and certainly not sexual abuse, as it was taboo to talk about sex at all.”Anna was telling her story: Anna was telling her story While we were all ignorant about sexual abuse and missed what was going on, Anna was conveying her experience through her behaviors - and her artwork . 25 years later her childhood drawings were interpreted by a well known art therapistChildhood Art: Childhood Art “Anna’s childhood drawings consistently contained numerous indicators typically seen in the drawings of children who have been sexually abused …..” Director Pediatric Play Therapy Program; Clinical Instructor, Department of Psychiatry UCSF (1991) *Notes accompanying each picture are the art therapist’s.Child without arms – encapsulated – no way out: Child without arms – encapsulated – no way outSlide 123: Phallic imagery Wedge shapes Rainbow colors Missing eyes: Rain in abundance - Disorganization or chaos (purple part) – Tears - Random chaotic scribbling Distorted body parts (short arms)Slide 125: Wedge ShapesMissing arms on all four figures – something overhead figures, theme of need for protection – both pictures have 2nd figure less prominent – wedge shapes - rain: Missing arms on all four figures – something overhead figures, theme of need for protection – both pictures have 2 nd figure less prominent – wedge shapes - rainSlide 127: Phallic images Line penetrates girls genital area Wedge shapes Disorganized/ Chaos Body part distortions Body part omissions Body part exaggeration Bizarre imagery that is very sexualized These pictures are very typical of sexual abuse seen in imageryHouse colored in – wedge shapes – no windows: House colored in – wedge shapes – no windowsBody parts missing – wedge shapes: Body parts missing – wedge shapesRed House – Windows filled in: Red House – Windows filled inNo arms – Faces crossed out – Distortions – Figures in big square except one to right - overdrawing abdominal parts: No arms – Faces crossed out – Distortions – Figures in big square except one to right - overdrawing abdominal partsBody fragmentation – missing body parts – rain – wedge shapes – splitting up torso: Body fragmentation – missing body parts – rain – wedge shapes – splitting up torsoSlide 134: Geometric body shape; overdrawing abdomen; body part distortions Themes of ProtectionNursery School Age 4 yrs 9 mo to 5 yrs 10 mo: Nursery School Age 4 yrs 9 mo to 5 yrs 10 mo Anna, far left in pictureTwo perspectives of Anna: Two perspectives of Anna Anna’s Nursery School Teacher : “She was a nice little girl, quiet. Nothing really stands out. She wasn’t a real outgoing little girl, yet she wasn’t withdrawn either, like others who… would not get up and play… or cried when their mother left them…. Basically not a sad child, but a happy child.” “It seemed that things were OK, no problems that we could see on the outside….”: Another nursery school mother: “When I took my daughter Stacey and Anna to the zoo, Anna seemed to be a little negative - ‘Stacey has more potato chips than I do’, and when asked to do something would be defiant and do the opposite. When I asked her to stay a certain place, she deliberately turned and walked and stood someplace else, defying me.”Slide 138: “She didn’t cooperate with me and she didn’t cooperate with you. It bothered me that she didn’t seem happier. I remember I thought she was a keen child, bright and intelligent. It was just her attitude.” “I could see that she had a problem, that she was ‘within’ herself, that she was a little against the world.” Con’tSlide 139: “On the way home, she got very excited when she saw a car with her (male relatives) in it, they were teenagers, three or four boys in a car.” “Then when we came home to your house, she climbed up on the top of your station wagon and would not get off. Your husband and you had to pull her off.”Slide 140: “She did not mind you. She seemed determined to do what she wanted to do and she was not going to get off that car to come in for dinner.” Anna recalls another car incident with perpetrator: “One day afterwards he came over with somebody else in a car and pulled up to our house. I screamed and cried and held on to you, then you talked to them and they drove off.” Con’tHer spirit fought to survive: Her spirit fought to survive Although the abuse continued, her spirit fought to survive and Anna carried on. The flip side of her resiliency is that it masked the impacts of the continuing abuse.Slide 142: Anna recalls: “I remember wearing nice clothes. I had a pretty nice life, playing with April-May Smith, going to nursery school. The public pools were fun… I was a good swimmer – jumped in the six feet part.” “Once I jumped in the shallow water of 3 feet and bumped my head. The baby pool was fun, and running out in the sprinklers, and getting ice cream cones” Anna, middle of front rowSlide 143: Anna: “Happiest time I remember was when we went sleigh riding on Art Hill and I got to have a Baby Ruth candy bar at the end. Then we went to visit Grandma J. She knit me a real beautiful sweater – hand knitted it herself. She said I was her favorite granddaughter…” Phallic imagery; Rain/Snow; Wedge shapesSlide 144: Anna: “I remember playing out in the backyard with the sprinkler. We were all running around in our underwear. I remember thinking ‘Oh god, we’re all running around in our underwear’.” “I was about 5 years old. I thought, “I’m not letting anybody give me a bath anymore. I’m not going to show myself to anybody anymore.” Red house; Scar on TreeKindergarten: Age 5 yrs 10 mo to 6 yrs 8 mo: Kindergarten: Age 5 yrs 10 mo to 6 yrs 8 moSlide 146: Sometimes high achievement can fool people into missing signs of continuing abuseSlide 147: Records show Anna scored in the 99 th percentile in the Metropolitan Achievement test Anna’s kindergarten teacher: “The test was given toward the end of the school year to all kindergarten students. Its a national comprehensive standardized and graded assessment of a child’s general strengths and weaknesses in a variety of different areas of aptitude. I can’t recall who Anna was all that many years ago, but I do know if she scored in the 99 th percentile, that you can’t get higher than that!” Hope persisted – along with love of family celebrations : Hope persisted – along with love of family celebrationsSlide 149: Anna: I was like, “Mommy, mommy, mommy” you know. And Dad, you and him would put all the Christmas presents out and it was so great! We would get up in the morning and all those Christmas presents would be there!!… and with love of artwork: … and with love of artworkAnna: “What stands out is doing art work. I was drawing all kinds of things. I was learning how to use my favorite materials and colors.”: Anna: “ What stands out is doing art work. I was drawing all kinds of things. I was learning how to use my favorite materials and colors.”Slide 152: Collage of yarn, paper cutouts, drawingSlide 153: Collage flower of colored or painted paper cut outs and yarn Cut out crayoned house with no windows.Her Aunt Jane remembered…..: Her Aunt Jane remembered….. “ Anna drew detailed, I mean beautifully detailed, pictures. I taught kindergarten and I thought, ‘This isn’t ordinary, her ability to draw is not ordinary’.”Slide 155: Anna titled this picture “A four year old Chinese girl next to a bush of bell flowers”. November 1966Slide 156: Christmas. Created by Anna at her Aunt Dorothy’s house. Age 5 ½- 6Slide 157: Anna: “ I remember how much I loved to draw! I remember drawing something that was kind of like an egg. It was all different colors… It was one of my favorite pictures back then…”Sexual Abuse continued through nursery school and kindergarten: Sexual Abuse continued through nursery school and kindergarten Sarah, Anna’s younger sister: Anna’s younger sister has one vivid memory of when she was about 2 and Anna was around 6. It was of “going upstairs, “there was a guy baby-sitter there with Anna in her room, and he said to get out, leave us alone, go do something else. Like he was doing something to Anna or something.”Sexual Abuse continued through nursery school and kindergarten: Sexual Abuse continued through nursery school and kindergarten Sarah, Anna’s younger sister: “I was only about two, but somehow that memory stuck. I was feeling worried for Anna. I felt bad for her. The memory impressed itself on me. It was out of the ordinary, there was something not right about the situation, it was not normal and that’s why somehow I remember that….”Then our family moved to the East Coast : Then our family moved to the East CoastSummary of following 7 years: Summary of following 7 years From age 6 yrs 8 mo to break at age 13 yrs 6 mo: Note numerous categories of “adverse childhood experiences” (ACEs) which further overwhelmed Anna’s already severely compromised capacity for resiliency.Slide 164: Multiple family relocations Increase in our (parent’s) problems – rage, physical violence, substance abuse, depression In my escape from traditional roles and determination to become self-sufficient – shifted childcare to oldest daughter Marriage disintegration – affairs – seek lifestyle change.Slide 165: Enroll children and live in alternative school communal setting Exposure to troubled children and teenagers alcohol and drug use, self-injury sexual harassment by other students sexual permissiveness and promiscuity Anna witnessing of sadistic physical and sexual abuse by adult male neighbor of 2 year old sonSlide 166: Frequent absence of parents – geographically and emotionally, including 1 suicide attempt Bitter divorce and subsequent disruption for children – new schools Legal custody of children to Anna’s father with limited visitation by me. Abandonment by additional trusted adultsAnna breaks. Hides herself. Withdraws completely. : Anna breaks. Hides herself. Withdraws completely.Slide 168: I thought I could fix it. Assumed full time legal custody of all children - while working full time and dealing with educational, mental health and social systems. Anna’s acting out escalates at school and home – sexual abuse still unknown to all of us. Trauma not asked about.Slide 169: Many treatments: “Brain-bio”; outpatient psychiatric treatment; medications; counseling. No one asked about trauma. Nothing helped. I struggled to keep Anna out of residential MH settings. Family stress overwhelming. Family Network community approach used as intervention. Aunt and Uncle volunteered temporary custody.Anna moves to Midwest: Anna moves to Midwest It was here that formal psychiatric treatment began, including 3 hospitalizations; medication; insulin and shock treatments. The story of her 17 years in the mental health system and eventual suicide, “Anna’s Institutional Years” , can be seen at: www.TheAnnaInstitute.orgSlide 171: Anna’s Adverse Childhood Experiences* Abuse of Anna Contact Sexual abuse Trauma in Anna’s Household Environment Substance abuse Parental separation and divorce - Depressed suicidal household member Loss of both parents by temporary abandonment Neglect of Anna Abandonment, partial, temporary Anna’s basic emotional needs unmet Other not in ACE Study: Expulsion from family MH Treatment Forced Medication Seclusion and Restraint Shock Treatment Impact of Trauma and Health Risk Behaviors to Ease the Pain Neurobiologic Effects of Trauma Disrupted neuro-development Difficulty controlling anger-rage Hallucinations Depression Panic reactions Anxiety Sleep problems Flashbacks Dissociation Health Risk Behaviors Smoking Suicide attempts Repetition of original trauma Self Injury Eating disorders Long-Term Consequences to Anna of Unaddressed Trauma Disease and Disability Poor self rated health Social Problems Homelessness Prostitution Delinquency Inability to sustain employment Re-victimization: rape, DV compromised ability to parent Long-term use of mental health and social servicesThe Costs Are High 1992 Analysis of Cost of Anna’s Care: The Costs Are High 1992 Analysis of Cost of Anna’s Care Over 17 years, Anna was hospitalized a total of 4,124 days. At $648 a day the cost was $2,639,360. Other costs – entitlements, residential treatment, case management, legal, medical – were estimated to be over $1,000,000, bringing total cost to nearly $4,000,000 . Adjusted for inflation (2005) total cost = $5,417,0321992 Analysis of Cost of Anna’s Care: 1992 Analysis of Cost of Anna’s Care Intensive trauma based psychotherapy, figured at $150 a session, 2 sessions a week, for 17 years, would have cost a total of $265,200 Had trauma been recognized and treated at age 3, costs would have been significantly less. If parents had been trauma-informed, the abuse may not have occurred.Anna’s story not unusual: Anna’s story not unusual 1/3 of girls – 1/5 of boys sexually abused Countless numbers of children exposed to multiple categories of adverse experiences Many live with their wounds in silence – When not addressed early on the consequences can be severe and lifelong… and may lead to early death, or suicide.There are Many Faces of Trauma: There are Many Faces of Trauma: At the heart – the core – the center of each - is unaddressed cumulative trauma most often occurring in childhood: What can we do today to help prevent child abuse and trauma? How can we recognize and respond to children who have been traumatized? How might we better understand and respond to adults with histories of such trauma? Anna’s early childhood community: Anna’s early childhood community Anna’s mom and dad Her extended family Neighbors Housekeeper Priests Couples’ group Obstetrician ER personnel Dentist and assistant Pediatrician Child Psychiatrist Nursery school teacher Kindergarten teacher: Any one of the adults in Anna’s early childhood community could have saved her life…… had they been trauma-informed – had they broken the silenceSlide 180: Becoming Trauma-Informed A Personal and Professional ChallengeSome personal steps to take: Some personal steps to take Become trauma-informed Bear Witness: Break the silence Work to prevent childhood trauma Intervene early when it occurs Empower young children with knowledge and language. Undertake our own healing process: One simple strategy: Give Young Children Language Children’s BooksSome professional steps to take: Some professional steps to take Develop trauma-informed organizations - where all interactions, services and service settings are safe, respectful and non re-traumatizing Basic trauma training for ALL staff, from janitorial to administrative Adoption of 5 principles of safety, trustworthiness, choice, collaboration, empowerment Modification of policies, procedures, physical settings, hiring practices, clinical guidelines Support for direct care staff Universal trauma screening Trauma-specific servicesSlide 184: Do Something !!Slide 185: “If you think you’re too small to make a difference, try sleeping in a room with a mosquito.” African ProverbSlide 186: In the context of your role, be it personal or professional, how might what you’ve seen alter the way you do your work?Slide 187: Presentation created by Ann Jennings Ph.D. For further information contact: email@example.com www.TheAnnaInstitute.Org You do not have the permission to view this presentation. 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