The Story of A Childs Path to Mental Illness and Suicide

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• The Story of A Childs Path to Mental Illness and
  Suicide
• Presented by her mother
• Ann Jennings Ph.D.
• www.TheAnnaInstitute.Org

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• 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. Annan

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This is me, Ann Jennings This is my
daughter Anna She is the artist. She took her
life at the age of 32.
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• Two intersecting life journeys,
• my own and my daughters

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• 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?

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Todays presentation

• Snapshot of Annas life
• Damaging consequences Research findings
• The story of Annas early childhood and sexual
  abuse
• Cumulative trauma making of a broken heart
• Becoming Trauma-Informed - a personal and
  professional challenge
• Reflection and Discussion

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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 Display

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A Snapshot of Annas Life
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Anna Caroline Jennings (19601992)

• 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 Annas institutional years, see
www.theannainstitute.org
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Anna Caroline Jennings (19601992)

• 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 Annas institutional years, see
www.TheAnnaInstitute.org
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Anna Caroline Jennings (19601992)

• 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 Annas institutional years, see
www.TheAnnaInstitute.org
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The damaging consequences of childhood trauma
Research Findings
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Collaboration between Kaiser Permanentes
Department of Preventive Medicine in San Diego
and the Center for Disease Control and Prevention
(CDC)

• The Adverse Childhood Experiences Study
• (ACE)

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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.

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ACE Study Findings

• Childhood experiences are powerful determinants
  of who we become as adults

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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.

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• 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.

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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.

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Adverse Childhood Experiences (ACEs) are Common

• Of 17,000 HMO members
• 72 had attended college
• 77 were white
• 62 were 50 or older

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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.

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What is uncommon is

• recognition
• acknowledgement
• action

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• The higher the ACE Score, the greater the
  likelihood of

• 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.

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Adverse Childhood Experiences and Current Smoking

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Current Smoking

• 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) .

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Childhood Experiences and Adult Alcoholism
4
3
2
1
0
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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 experiences

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ACE Score and Intravenous Drug Use
N 8,022 plt0.001
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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 ACEs

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Childhood Experiences Underlie Rape
4
3
2
1
0
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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.

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ACE Score and Hallucinations
Abused Alcohol or Drugs
Ever Hallucinated ()
ACE Score
Adjusted for age, sex, race, and education.
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The making of madness..

• There is a significant and graded relationship
  between a history of multiple childhood traumas
  (ACEs) 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 2005

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• 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
  1999

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Childhood Experiences Underlie Chronic
Depression
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Chronic Depression

• Adults with an ACE score of 4 or more were 460
  more likely to be suffering from depression .

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Childhood Experiences Underlie Suicide
4
3
2
1
0
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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.

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• 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.

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ACE Score and Serious Job Problems
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Much of what causes time tobe lost from work is
actuallypredetermined decades earlierby the
adverse experiencesof childhood.
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Adverse Childhood Experiences andLikelihood of
gt 50 Sexual Partners
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Adverse Childhood Experiences andHistory of STD
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Frequency of Being Pushed, Grabbed, Slapped,
Shoved or Had Something Thrown at Oneself or
Ones Mother as a Girl and the Likelihood of Ever
Having a Teen Pregnancy
Pink self
Yellow mother
Percent who had a teen pregnancy
Never Once, Sometimes Often
Very Twice
often
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Sexual Abuse of Male Children and Their
Likelihood of Impregnating a Teenage Girl
1.8x
1.4x
1.3x
Percent who impregnated a teenage girl
1.0 ref
Not 16-18yrs 11-15 yrs
lt10 yrs abused
Age when first abused
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ACE Score and Unintended Pregnancy or Elective
Abortion
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Effect of ACEs on Mortality
Age Group
0 ACE 60 live to 65 4 ACE less than 3 live
to 65
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Many chronic diseasesin adults are
determineddecades earlier, in childhood.
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• Other Studies on Childhood Sexual and/or Physical
  Abuse

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Sarah Joe, Anna John Mary

• In my experience, early child sexual abuse
  (CSA)
• especially impairs resiliency
• My other children experienced multiple
  ACEs. They coped.
• Anna experienced early CSA and ACEs. She
  broke.

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• 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.

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• 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, 1994

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• 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, 2003

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• 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, 2001

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Yet the Silence Continues
They do not want to hear what their children
suffer. Theyve made the telling of the
suffering itself taboo From
Possessing the Secret of Joy, Alice Walker
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Prevalence of the Problem

• 1/4th to 1/3rd 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

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• 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, 1993

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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 Perception

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Sense of helplessness, paralysis,
captivity,inadequacy, powerlessness, danger, fear
Continues over the lifespan
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Sense of Shame, Guilt, Self-Blame, Being Bad
Continues over the lifespan
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Sense of defilement, contamination, spoiled,
degraded, debased, despicable, evil
Continues over the lifespan
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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 lifespan
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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, 1992

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• Isolation, Withdrawal
• Disruption in Intimate Relationships
• Repeated Search for Rescuer
• Persistent Distrust
• Repeated Failures of Self-Protection

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So, what do our children ask of us?
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• That we
• Pay attention
• Overcome our lack of knowledge

• Ask What Happened?
• Overcome our fear
• Speak out and break the silence

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Annas 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?
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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.

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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 1960s
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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 19
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• For me as a Catholic girl, great stress on
  sexual purity, skewed knowledge of sex.
• Sense of self worth through husbands success,
  personal, home, childrens appearances.
• Motherhood idealized, but no education in child
  development or parenting.

Me, Married at Age 19
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Annas Parents Family Backgrounds

• My family upper class professional Annas
  fathers working class
• I was first of 9 siblings Annas father first of
  7.
• Both raised (Irish) Catholic attended all
  Catholic schools.

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• Annas 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.

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Substance abuse, depression, Alzheimers,
physical violence, divorce, my great aunts
suicide at age 16 in Germany.Secrets kept in
both families of origin. Many things one did
not talk about - ever.
Intergenerational
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Spare the Rod, Spoil the Child

• Annas 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.
• Annas fathers 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.

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The model couple
Cover for record produced by Catholic
organization - of Annas parents giving advice to
other young married couples
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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
  husbands anger, fear of churchs and others
  judgment, dependency, low self-esteem, and
  lived in nightly terror of getting pregnant
  again.
• Stress Annas dad had work and money problems,
  low self-esteem, and released his stress through
  anger directed toward me and children, especially
  oldest son.

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Anna pre-natal environment

• Annas 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.

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AnnaBirth to Age 2 ½ - 3

• A major city in the Midwest

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Annas 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.

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Anna a few days old

• Me, Annas 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.

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• Annas 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.

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• Her grandmother J
• I remember her as a very pretty and loving
  little girl, receptive to love and giving it in
  return. Im a hugger and she hugged me in
  return.

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• 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!

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• Her Aunt Alice
• I remember feeling she was just the prettiest
  little girl Id 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.

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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!
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Sudden intense change occurred in Anna when she
was about 2 ½ to 3 years old.
Self Portrait by Anna in art therapy age 25
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• 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.

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• 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.

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• 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.

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Medical

• Me, Annas mom re Pediatrician
• I thought Annas 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.

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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.

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• 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.

96

• Housekeeper
• When she was a little girl, if she go outside to
  play, shed 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 Its going to get me,
  its gonna get me daddy, its gonna get me mommy
  its going to get me. She was a little girl
  then, a little bitty child.

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.

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.

99

• Annas 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.

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I was overwhelmed

• Me, Annas 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 5th 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.

101

• Me, Annas mom
• There were times I could hear Anna upstairs
  crying to get up from her nap, and I couldnt 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.
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 wouldnt eat them, from
  about three years old on.

103

• What happened to Anna?
• What caused all of a sudden, whatever it was
  to creep in and just change her entire
  personality??

104
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
105
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 wasnt supposed to. She
  told me that man hurted her, and thats 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 dont tell you exactly whats goin on.
  They keep on thinkin about it. Thats a shame
  though, its sad you know.

106

• Housekeeper goes on to tell me .
• All along I had knowed that was X because thats
  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 didnt want to say nothin.

107
Age 3 ½ to 6 by male babysitterRevealed 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

108

• 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 couldnt 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 wouldnt stop.

109

• To do that when I was a little kid was like uh
  I dont know, I dont 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..

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??
111
Indeterminate age by older neighborhood boy

• Me, Annas Mom
• The only abuse I remember Annas telling me
  about as a child was of being fooled with by a
  young teenage boy who lived across the street
  from us. Annas dad spoke to his parents and I
  then took Anna to a doctor for a physical
  examination.
• I thought of the fooling as childs play, and
  inadvertently, when I took her to the doctor, I
  subjected Anna to another invasive procedure.
  compounding the abuse.

112
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, Annas 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.
  

113
Intergenerational Impacts

• Me, Annas mom
• Its possible I was numb to Annas 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.

114
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 wouldnt even
  react.

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.

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
  didnt see what was happening to her then. I
  just knew something had to be wrong...

117
Examination by child psychiatrist

• Me, and Annas 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.

118

• Anna about her visits with the child
  psychiatrist
• I remember being in a doctors 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..

119

• Me, Annas 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.

120
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 therapist

121
Childhood Art

• Annas 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
  therapists.

122
Child without arms encapsulated no way out
123

• Phallic imagery
• Wedge shapes
• Rainbow colors
• Missing eyes

124

• Rain in abundance - Disorganization or chaos
  (purple part) Tears - Random chaotic scribbling
• Distorted body parts (short arms)

125

• Wedge Shapes

126
Missing arms on all four figures something
overhead figures, theme of need for protection
both pictures have 2nd figure less prominent
wedge shapes - rain
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 imagery

128
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129
House colored in wedge shapes no windows
130
Body parts missing wedge shapes
131
Red House Windows filled in
132
No arms Faces crossed out Distortions
Figures in big square except one to right -
overdrawing abdominal parts
133
Body fragmentation missing body parts rain
wedge shapes splitting up torso
134
Geometric body shape overdrawing
abdomen body part distortions
Themes of Protection
135
Nursery School Age 4 yrs 9 mo to 5 yrs 10 mo
Anna, far left in picture
136
Two perspectives of Anna

• Annas Nursery School Teacher
• She was a nice little girl, quiet. Nothing
  really stands out. She wasnt a real outgoing
  little girl, yet she wasnt 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.

137

• 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.

138
Cont

• She didnt cooperate with me and she didnt
  cooperate with you. It bothered me that she
  didnt 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.

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.

140
Cont

• 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.

141
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.

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 row
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 shapes
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, were
  all running around in our underwear.
• I was about 5 years old. I thought, Im not
  letting anybody give me a bath anymore. Im not
  going to show myself to anybody anymore.

Red house Scar on Tree
145
Kindergarten Age 5 yrs 10 mo to 6 yrs 8 mo
146

• Sometimes high achievement can fool people into
  missing signs of continuing abuse

147

• Records show Anna scored in the 99th percentile
  in the Metropolitan Achievement test
• Annas 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 childs general strengths and
  weaknesses in a variety of different areas of
  aptitude. I cant recall who Anna was all that
  many years ago, but I do know if she scored in
  the 99th percentile, that you cant get higher
  than that!

148
Hope persisted along with love of family
celebrations
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!!

150
and with love of artwork
151
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.
152
Collage of yarn, paper cutouts, drawing
153
Collage flower of colored or painted paper cut
outs and yarn
Cut out crayoned house with no windows.
154
Her Aunt Jane remembered..

• Anna drew detailed, I mean beautifully
  detailed, pictures. I taught kindergarten and I
  thought, This isnt ordinary, her ability to
  draw is not ordinary.

155
Anna titled this picture A four year old Chinese
girl next to a bush of bell flowers. November
1966
156
Christmas. Created by Anna at her Aunt Dorothys
house. Age 5 ½- 6
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

158
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159
Sexual Abuse continued through nursery school and
kindergarten

• Sarah, Annas younger sister
• Annas 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.

160
Sexual Abuse continued through nursery school and
kindergarten

• Sarah, Annas 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
  thats why somehow I remember that.

161
Then our family moved to the East Coast
162
Summary of following 7 years
From age 6 yrs 8 mo to break at age 13
yrs 6 mo
163

• Note numerous categories of adverse childhood
  experiences (ACEs) which further overwhelmed
  Annas already severely compromised capacity for
  resiliency.

164

• Multiple family relocations
• Increase in our (parents) 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.

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 son

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 Annas father with
  limited visitation by me.
• Abandonment by additional trusted adults

167
Anna breaks. Hides herself. Withdraws
completely.
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.
• Annas acting out escalates at school and home
  sexual abuse still unknown to all of us. Trauma
  not asked about.

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.

170
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, Annas
  Institutional Years, can be seen at
• www.TheAnnaInstitute.org

171
(No Transcript)
172
The Costs Are High1992 Analysis of Cost of
Annas 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
  5,417,032

173
1992 Analysis of Cost of Annas 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.

174
Annas 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.

175
There are Many Faces of Trauma
176

At the heart the core the center of each - is
unaddressed cumulative trauma most often
occurring in childhood

177

• 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?

178
Annas early childhood community

• Annas 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

179

• Any one of the adults in Annas early childhood
  community could have saved her life
• had they been trauma-informed
• had they broken the silence

180

• Becoming Trauma-Informed
• A Personal and
• Professional Challenge

181
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

182

• One simple strategy
• Give Young Children Language
• Childrens Books

183
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 services

184

• Do Something!!

185

• If you think youre too small to make a
  difference, try sleeping in a room with a
  mosquito.
• African Proverb

186

• In the context of your role, be it personal or
  professional, how might what youve seen alter
  the way you do your work?

187

• Presentation created by
• Ann Jennings Ph.D.
• For further information contact
• afj_at_gwi.net
• www.TheAnnaInstitute.Org