The SP Care Project on Adverse Childhood Experiences

HOPE on the Other Side Episode 29 Program Notes:

This podcast series aims to be informative, helpful, and also a community building space for those living with Schizophrenia and especially for their caregivers.

In this episode an additional explanation or cause for psychosis is presented. For a review, psychosis is the hallmark of the diagnosis of Schizophrenia. This disorder, or mental illness is a collection of signs and symptoms, but not a single clearly defined underlying disease. The research continues, and yet in the meantime Schizophrenia is a major global illness affecting many patients and families around the world.

Psychosis is a word for 5 different things. It is like the word “fever,” in that it describes something very real, but that word does not tell you the cause of the fever or in our case, the cause of the psychosis. The five parts are hallucinations, delusions, disorganized speech & thought, disorganized behavior, and lastly, so called “psychotic negativism.” The hallucinations can be in any one of the five physical senses, and the psychotic negativism refers to the absence of things; things such as speech / the person is mute, or absence of regular facial expressions that match one’s emotional state, or absence of self-care / such as bathing, or grooming.

To define or diagnose the disorder of Schizophrenia one needs psychosis for at least 6 months, a notable functional decline, no know medical disease, medication or street drug causing the psychosis. There are a number of features which are not part of the diagnosis. Here are some examples: Social and occupational problems are present in the lives of many folks with Schizophrenia. Suicide risk is prominent, and there are some completed suicides as well. This all makes the social impact of the condition known as Schizophrenia a major world health priority.

There is an educational free report available at DrKenCampos.com which describes psychosis and how psychiatrists make the diagnosis of Schizophrenia.

The idea of Adverse Childhood Experiences is introduced next. These traumas are called ACEs by medical doctors, the mental health field, psychologists, and counselors. ACEs were first identified in the 1980’s at a Kaiser doctor working at a weight control / obesity clinic in San Diego, California. The doctor who brought his work to clinical attention, is Dr Felitti. Since that time, the research has grown considerably.

ACEs, the Adverse Childhood Experiences, are things that happen in a child’s life that are potentially traumatic. These events and experiences may have negative, long-lasting effects of the person’s bodily health and mental / emotional well-being. Some of these experiences, things, or events range from physical, emotional or sexual abuse on the one hand to family dysfunction such as parental divorce, or to a parent or guardian going to jail or to prison.

There are basically 10 primary things or events that have been studied. This list is as follows:

• Physical abuse
• Sexual abuse
• Emotional Abuse
• Physical neglect
• Emotional neglect
• Exposure to Domestic Violence
• Household substance abuse
• household mental illness
• Parental separation or divorce
• Incarcerated household member

In order to investigate the ACEs in the life of a person, there are questionnaires, paper and pencil tools, or interviews used to assess the ACE’s.

The physical abuse questions cover items such as being pushed, slapped or grabbed by a parent or an adult in the household when the interviewee was a child or early teenager. The person is also asked if something were thrown at them. They are asked if they were ever hit so hard that there were marks, bruises or were injured. Additionally, they are asked if ever threatened for over a few minutes with a gun or a knife.

Regarding parental separation, loss or divorce and incarceration of a household member: these items includes the premature death of a parent, a divorce which of course could be amicable or full of anger and resentment or a divorce full of negative emotion, also there is the case of losing a parent in wartime. Criminal behavior in a parent or in a brother or other family member resulting in jail time or prison time is an ACE. The prison time could be with or without any letters or contact with the absent parent or family member. One scenario here is the case of an older sibling, say a brother who was involved in street gang activity who ended up in prison.

Emotional abuse for the person shows up as follows: feeling unloved, feeling unsupported, made to feel that he or she was unimportant. There could have been a lack of closeness in the family, or a feeling that the family members did not look out for each other. Other questions involve whether the person was frequently or very often humiliated, insulted or put down.

Sexual abuse can range from the inappropriate touching or fondling by a sibling that is 5 years older, by an adult family member, or by another adult person. Was the child touch the perpetrator in a sexual manner. At the far end, was there either oral, anal or vaginal sexual activity between the child and that other person. This can be a difficult area to examine because of so many social and cultural taboos. This can result in secrecy and hiding the truth. So, this ACE may be a big secret, and it is possible for self-deception on the part of one parent or adult to pretend that this has not happened.

The association between Adverse Childhood Experiences and physical illness in adulthood is well established. However, the epidemiological association between ACE’s and psychosis had been controversial and doubted in some circles for about 20 years. Finally in 2012 in a well researched study which has been referenced over 1000 times by other researcher the answer was clear. It was a rigorously designed and executed meta-analysis of other sound research on this topic. The studies reviewed used a variety of methodologies.

Those studies usually looked at the effect of a set of several traumatic events grouped together rather than just one alone. The score is one point for each type of event prior to age 18. Typically it is the total number or score on ACE tests, Adverse Childhood Experience test score that are meaningful.

The 2012 study published in Schizophrenia Bulletin reports strong epidemiological associations with long lasting problems in adulthood. Both the Maltreatment of children and household dysfunction is a risk factor for these problems.

The resulting problems appear in two main areas: adulthood high-risk health behaviors and ill physical health. The high-risk behaviors include cigarette smoking, drug abuse, sexual promiscuity and severe obesity. The ill-health medical problems include depression, heart disease, cancer, chronic lung disease and overall shortened life-span. The higher ACE score, the greater the risk for certain problems compared to an ACE score of zero. With an ACE score of four (4) Alcoholism shows an seven-fold increase; emphysema shows a 4 fold increase, and a doubling of cancer risk. Dramatically, an ACE of 6 or more correlates with a 30 – fold increase in attempted suicide.

Psychosis is a brain condition, and like fever is usually time limited. In the multi-national paper from 2012 there was careful review and analysis of scientific and mental health research studies of childhood trauma, published in peer reviewed journals. There were prospective studies, large population based cross-sectional studies and case controlled studies. The reports and studies were from a variety of nations, mostly European and from the USA and Canada, but also some from Japan and Korea, and also Israel and Australia. The published studies were screened by two or three researchers include in the analysis and over 27,000 articles were screened yielding 41 research studies to be included in the analysis. The main outcome measure was a kind of risk defined as the odds ratio, called the OR.

The odds ratio is defined as a ratio of two things. It is the ratio of the likelihood that an event will occur compared to the likelihood that the event will not occur. In both cases there is the outcome, but one case has an exposure to something and the other case does not have that exposure. So, for our example, the event or the outcome is the appearance of psychosis, that is psychotic symptoms and signs present in a group of people. In our case, the exposure is the exposure to the above ACE’s or adverse childhood events. Again, The outcome is psychosis. This gives a sense of the magnitude or the power of exposure to a thing with the outcome.

The punchline here is that the Odds Ratio has a value of 2.8 and in this case the two groups both have the outcome of psychosis. One group was exposed to ACE’s and the other group was not exposed to ACE’s. The Odds Ratio of 2.8 means that the set of people with psychosis who have a history of ACE’s were 2.8 times more likely to have psychosis than those with psychosis who were not exposed to ACEs in childhood.

The result was that all types of ACEs, Adverse Childhood Experiences are associated with an increase in psychosis, or psychotic symptoms. There are some fine tuning issues under question. Even with studies using different designs and methods, the association of psychosis with ACE was still clear. Most of the studies in the meta-analysis focused on hallucinations and delusions, the false beliefs, and not so much on the other parts of psychosis.

Lastly, what to do about this? When your loved one is in the acute psychiatric hospital with the first or with an early episode of psychosis, here is some advice. Be honest with yourself, the mental health professionals involved in your loved one’s care, and stay involved in treatment planning as much as possible.

Trauma informed care is a professionally organized treatment framework that included several factors and areas. There is an understanding and recognition of the effects of all types of trauma. This model of care involves the physical, mental health, and emotional safety of the people involved. Those people include the main person suffering with psychosis, the family members, and the care providers. After that, the next goal is to help the trauma survivor get and build or re-build a sense of control and empowerment. This will be the topic of a future podcast, too.

©2019 Dr. Ken Campos