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November 2016

The ACE Study; the 3 E’s, 3R’s plus 4 th R; 5 components; Attraction, not promotion


In August this year, I presented at the Detroit Wayne Mental Health Authority’s 2nd Annual lnterdisciplinary Conference, “Raising the Bar”. One of the side benefits of my work is to be able to listen to other conference speakers for free! It is always satisfying to hear a  topic from the “horse’s mouth.”  This is what happened when I heard Robert Anda, M.D. present on the Adverse Childhood Experiences (ACE) Study.
Dr. Anda played the “principal role in the design of the ACE Study, served as its Co-Principal Investigator, and authored or co-authored more than 70 publications from the Study.” (  It was a treat to hear it from the person there from the start and who made it all happen. (When I train on The ASAM Criteria, I let people know that on that  topic, I have been there from the start too.  As Chief Editor that work was commenced in the 1980’s.  When people hear an ASAM Criteria presentation from me, they too are hearing it from the “horse’s mouth”, preferably that part of the anatomy, not another part!)
Dr. Anda shared a fascinating anecdote about how the term “Adverse Childhood Experiences” got its name.  He was with a colleague at McDonald’s (he must eat at the same gourmet restaurants as I do.) They were discussing what to call this study on trauma. “ Trauma” seemed too easily confused with physical accidents because this study was all about emotional trauma and its profound impacts on development and health.

“Childhood” as part of the terminology was easy, he said.  This was all about what happened in one’s childhood.  “ Adverse” was also fairly easy too, as traumatic experiences certainly caused many negative effects.  The “ Experiences” part took a bit of brainstorming – “environments” popped up in their conversation back and forth. However, they thought, that term could be confusing, since it focuses attention on  where a person lives. Was it about the family or significant others in the environment? or the cultural environment? or poverty? or inner city or suburban?  or what environment?
Then they happened on “ Experiences” and liked it. Why?  This term focused the attention back on the person affected and not the external “environments”.  This allowed them to study and quantify on the ACE score how many childhood  experiences the person had had, without having to make the person delve into the emotion and details and pain of the actual trauma.

So there it is: That’s how it became to be known as the Adverse Childhood Experiences (ACE) Study.

Here are some interesting and meaningful nuggets I was furiously scribbling down listening to Dr. Anda speak.  They are in no particular order of importance.
Ponder how important hope is in health and well-being
Dr. Anda opened his presentation referencing a 1993 paper he had written on “Depressed affect, hopelessness, and the risk of ischemic heart disease (IHD) in a cohort of U.S. adults.” He found that hopelessness significantly predicted who would die from a heart attack and even predicted the increased risk of nonfatal IHD. This was in a group of more than 2,800 initially healthy men and women from the National Health Examination Follow-Up Survey (NHEFS).

  • This study indicates that depressed affect and hopelessness may play a causal role in the occurrence of both fatal and nonfatal IHD.
As we counsel with clients who have had ACEs, Dr. Anda stressed that being trauma-informed in our work is to create a different path of hope, meaning and purpose for the people we serve. The message to clients, he said, should encompass:

  • It is not what is WRONG with you.
  • It is what HAPPENED to you.
  • Create a different story of your life by getting an accurate accounting of adverse childhood experiences through your ACE score.
  • You can shift from shame, confusion and hopelessness to hope, meaning and purpose. 
What is an ACE Score ?
“Dr. Anda created The ACE Score Calculator, allowing individuals to calculate their own ACE Scores, based on the original scoring criteria of the ACE Study.

To use this survey, add up all of the YES responses. The sum is the ACE Score. The ACE Score can range from “0”, meaning no exposure to the ten categories of child abuse and trauma investigated by the Study, to “10”, meaning exposure to all ten categories. The Study found the higher the ACE Score, the greater the risk of experiencing poor physical and mental health, and negative social consequences later in life.” 

Finding Your ACE Score
While you were growing up, during your first 18 years of life:
1. Did a parent or other adult in the household often or very often…Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
If yes enter 1 ________
2. Did a parent or other adult in the household often or very often…Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
If yes enter 1 ________
3. Did an adult person at least 5 years older than you ever…Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
If yes enter 1 ________
4. Did you often or very often feel that …No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
If yes enter 1 ________
5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
If yes enter 1 ________
6. Were your parents ever separated or divorced?
If yes enter 1 ________
7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or threatened with a gun or knife?
If yes enter 1 ________
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
If yes enter 1 ________
9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
If yes enter 1 ________
10. Did a household member go to prison?
If yes enter 1 _______
Now add up your “Yes” answers: _______ This is your ACE Score.
Review how persistent stress changes brain architecture
Dr. Anda referenced the Harvard University Center on the Developing Child.
“Extensive research on the biology of stress now shows that healthy development can be derailed by excessive or prolonged activation of stress response systems in the body and brain.  Such toxic stress can have damaging effects on learning, behavior, and health across the lifespan……When we are threatened, our bodies prepare us to respond by increasing our heart rate, blood pressure, and stress hormones, such as cortisol. “
  • Stress of severe and chronic childhood trauma releases hormones (adrenaline and cortisol) that physically damage the developing brain.
  • These flight, fight or fright (freeze) hormones in the Limbic system work well if there is a vicious dog chasing you (flight); or if cornered, to help you fight; or stop breathing and freeze in fright if a predator is nearby and you are trying not to be detected.
  • The adrenaline and cortisol shuts off the thinking prefrontal cortex of the brain to focus on the immediate need to run, fight or freeze.
  • But if the stress is now a daily event (witnessing or experiencing violence, belittling or verbal abuse, sexual and boundary issues etc.) not a one-time, unusual event like facing a bear or vicious dog, then the emergency response system activates over and over again every day.
  • The stress hormones, when turned on for too long day after day become toxic. When a child is always ready to fight or flee the prefrontal cortex that is needed to form a sentence or do a math problem becomes stunted. Emergencies take precedence over doing math or writing an essay.
  • With this overstimulation of the limbic system, the brain begins to dissociate and disengage in the state of hyperarousal survival mode. This affects learning and adaptive coping functions.
Take a look at “Resilience- The Biology of Stress & The Science of Hope”
This film was an official selection of the Sundance Film Festival. “Resilience chronicles the promising beginnings of a national movement to prevent childhood trauma, treat toxic stress, and greatly improve the health of future generations.”
See the trailer for the film:
Dr. Anda highlighted the importance of building resilience and hope in schools, prisons and the creation of self-healing communities.  He referenced work that is being done in Washington state.
1. Anda R, Williamson D, Jones D, Macera C, Eaker E, Glassman A, Marks J. (1993): “Depressed affect, hopelessness, and the risk of ischemic heart disease in a cohort of U.S. adults.”  Epidemiology Jul;4(4):285-94.
2. Center for Disease Control and Prevention. (2010): “Adverse Childhood Experiences Reported by Adults – Five States, 2009,” Morbidity and Mortality Weekly Report 2010 No. 59, pp 1609-1613.
3. Felitti & Anda (2010): “The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders, and sexual behavior: Implications for healthcare,” in R. Lanius and E. Vermetten, Eds., The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease. Cambridge University Press, 2010.
4. Porter L, Martin K, and Anda R (2016): “Self-Healing Communities- A Transformational Process Model for Improving Intergenerational Health” June 2016 Publisher: The Robert Wood Johnson Foundation.


In September, I presented at the Mental Health Recovery Summit 2016 Moses H. Cone Memorial Hospital, in Greensboro, North Carolina. Kelly Graves, Ph.D., Associate Professor, North Carolina A&T State University also presented on trauma and shared some succinct definitions and guidelines.
Understand the 3 E’s of trauma
Event – There is an Event or series of Events that trigger the emergency response system of the individual.
Experienced – Those Events or series of Events are Experienced by the person as harmful and threatening.
Effects – The Effects on the person are adverse on the individual’s functioning physically, emotionally, mentally, socially and spiritually.
Facilitate Trauma-informed care and trauma-specific services – The 3 R’s + 4th R of trauma-informed cultures

Trauma-informed: “A trauma-informed approach to the delivery of behavioral health services includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic.
In May 2012, the Substance Abuse and Mental Health Services Administration (SAMHSA) convened a group of national experts who identified three key elements of a trauma-informed approach:
(1)  Realize the prevalence of trauma and its widespread impact.
(2)  Recognize the signs and symptoms of trauma and how trauma affects all individuals involved with the program, organization, or system, including its own workforce.
(3)  Respond by putting this knowledge into practice and update policies, procedures, and practices in all settings. (SAMHSA, 2012, p 4).
(“Trauma-Informed Care in Behavioral Health Services” Treatment Improvement Protocol ( TIP) Series 57. Page xix, 2014).
4th R:  Resist Retraumatization e.g., heavy confrontation in a Therapeutic Community; male nurse coming into a female client’s room at night for routine bed checks triggers the trauma-affected client – inform clients with trauma histories about routine procedures; ensure female staff enters the room.
Promote 5 core components for healing in all services
Dr. Graves identified a common core of conditions across different lists of services that promote healing. She summarized this common core into five components:
1. Safety – the client must have a sense of safety in any counseling relationship. This can be a challenge for people who have been exposed to daily adverse experiences and are living in a state of hyperarousal.
2. Trust – when parents, relatives or other neighborhood acquaintances have repeatedly abused the client and violated boundaries, trust does not come easily.
3. Collaboration – creating hope and healing communities requires collaboration across systems and disciplines, but most importantly collaboration between the client and clinician.
4. Choice – clients should have real choice in the pacing and planning of treatment; and even in more mundane things like the date and time for the next appointment.
5. Empowerment – for too long, clients with significant ACEs have had to endure the memories, pain and limitations of past trauma by themselves. Empowerment upholds hope and healing.
1. Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women” Treatment Improvement Protocol ( TIP) Series 51. DHHS Publication No. (SMA) 09-4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.
2. Center for Substance Abuse Treatment. “Trauma-Informed Care in Behavioral Health Services” Treatment Improvement Protocol ( TIP) Series 57. DHHS Publication No. (SMA) 14-4816. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.


Although I am not a member of any 12 Step program, there is much wisdom in so many of the sayings and slogans. One in particular that is so meaningful in general as well as in the work of  motivational enhancement and stages of change is: “Attraction, not Promotion.”
You cannot push, pressure, persuade, prescribe and pester someone into real and lasting change. Only as you inspire and attract people to think and act differently will you initiate a process of change.
I broke my long held rule and belief in “attraction, not promotion” in last month’s pre-election SOUL section. I spoke out about my political views on the election in hopes of persuading  undecided voters and readers of  Tips and  Topics.  In my defense, I did warn readers that if they had already decided to vote for President-elect Trump, they should stop reading as I didn’t want to argue or alienate them (But of course saying that is like telling a child not to shake or touch the Christmas presents under the tree until Christmas Day.)  
*  One reader wrote me: “I think you should not have voiced your political opinion here, in your monthly newsletter“and in retrospect I think I agree. It distracted from my mission and purpose of  Tips and  Topics.
*  Another reader said: “ I have been a faithful reader of your tips and topics. I don’t appreciate your views on politics and now It makes me question your abilities.
That got my attention. Were my views on politics actually a reflection on my abilities as a trainer/consultant?  It made me think about the role and responsibilities in leadership and public discourse.
I responded to those who wrote to me, however I won’t share my responses as I deleted the emails! (That’s a joke – OK enough of election rhetoric).
Here is something I did say in my response and say again now:
The bottom line for me as regards writing this in Tips and Topics is that I am sure everyone who bothers to read Tips and Topics are all people of good will who want the best for the people we serve in our work; and the best for our country.  While we may differ on a number of things, there is much more that binds us together in the values and vision we have for America. I am sad that this election seems only to have drawn us further apart both within the Republican party and across parties.  I hope that once the election is over that everyone will rally to bring us together for the greater good of the country.”
Incidentally, the “faithful reader of  Tips and  Topics” who questioned my abilities ended her response to my message to her with: “ So I thank you for allowing me to share my thoughts and have a good discussion.  I look forward to your tips and topics in the future.”
I may have done too much political “promotion” for the preferences of some readers, but I’m glad we can move on together.
Happy Thanksgiving everyone!
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