Friday, June 2, 2017

Moore Center Sex Abuse Symposium: Part Four: Adverse Childhood Experiences And Causes Of Sexual Offending

In case you missed the other parts for this series, please see part one, two, three, or five.
As a refresher...
So, What Is This Symposium?

The Moore Center Symposium is a "meeting of the minds" on the prevention of child sexual abuse. It  offers professionals (and advocates) an opportunity to learn more about the issue of child sexual abuse and how it can be prevented. The Moore Center for the Prevention of Child Sexual Abuse is a subset of Johns Hopkins' Bloomberg School of Public Health, which is a major educational institution in Maryland that is well-known for its work in the public health sector (as its name should indicate). The Moore Center is currently being directed by Dr. Elizabeth Letourneau, who used to be the president of The Association for the Treatment of Sexual Abusers (ATSA), and is a researcher that studies a myriad of topics within the realm of sexual abuse prevention. I am watching these admittedly dry and boring speeches to pull the essential parts out and communicate them to you. If you want to view them yourself, by all means, just be forewarned that they are dry and can be triggering. 

Beginning Introductions

The symposium starts with an introduction by Johns Hopkins' President, Ronald Daniels, regarding some of the reasons for the symposium and the keynote speaker at the symposium, Patrick McCarthy, who is the president and CEO of the Annie E. Casey Foundation, an organization that focuses on improving the lives of children in a variety of ways.  Other speakers at the symposium were Dr. Elizabeth Letourneau, Dr. Bruce Taylor (an expert in criminology), and Jill Levenson (expert in sociology and social work), followed by a showing of the film Untouchable, which I have talked about on this blog before. Following the film, there is a panel discussion about the film and closing remarks by Stephen and Julia Moore, the founding donors of the Moore Center.

Jill Levenson's Speech

Her speech focuses on early adverse childhood experiences and the causes of sexual offending. She starts with a handy little comic to illustrate the need to move beyond myth and current policy practices around prevention, and suggests that we need to start thinking about prevention differently. 

She then gives a disclaimer that she does not want to minimize the pain done to sexual violence victims, but that it helps to have an understanding of how sexual violence happens and inform interventions. She states that there are no sides, there is no contest, and that sexual abuse victim organizations and advocates and sex abuse preventionists are not on opposing sides: Everyone is on the same team, trying to stop sexual violence. I would hope that advocates for the primary prevention of child sexual abuse, who have either been victimized by abuse, perpetrated abuse and lament it, or of any background really, are included in her team. 

Public Health Model Of Primary Prevention

She starts by showing a graphic from the CDC about primary prevention where there are five areas that the CDC suggests to stop sexual violence: Promote social norms of protection, support victims/survivors, create protective environments, provide opportunities to empower and support women, and teach skills to prevent sexual violence.

She then asks what is missing from the model: Perpetrator prevention, or preventing someone from becoming a perpetrator. That is the focus of her speech. She then gives a handy demonstration of the public health model, which has three focuses: On primary prevention of universal precautions first, on secondary prevention of at-risk populations, and lastly on tertiary prevention of reacting when the problem presents itself.

Note: A handy way to think of this would be the flu: It is best to handwash and cover your mouth/nose (primary prevention - before the flu), and barring that, it is best to stay away from those that might be sick or getting flu shots to those who are vulnerable (secondary prevention - focusing on at-risk populations). The last thing you would want to do with the flu is just do nothing and wait for it to happen and then take steps (tertiary prevention).

She then points out that our resources and policies are currently aimed the polar opposite from what you would expect: Rather than focusing on primary, secondary, and tertiary prevention in that order, we "flip the pyramid" by focusing on tertiary prevention first, secondary second, and primary prevention last. In other words, we focus first on foster care, delinquency programs, incarceration, and sex offender registries/policies, we focus second on programs for at-risk youth and families, and improving parenting, and lastly we focus on primary prevention like changing cultural messages, reducing social problems, and reducing adverse childhood experiences (ACE's).

Overviewing The ACE Study

The Adverse Childhood Experiences study was a collaboration with the CDC and other researchers looking at family dysfunction and its causes. They originally were looking at obesity, and were noticing that many with issues with obesity had early harmful experiences in their childhood, so they did a study of over 17,000 participants to look at background challenges like abuse, family conflict, or neglect.

The survey looked at abuse, household challenges, and neglect: In abuse, they found that 21% experienced sexual abuse, 28% experienced physical abuse, and 11% experienced emotional abuse. In household challenges, they found that 13% dealt with violence towards their mother, 27% dealt with substance abuse, 19% had mental illness in the family, 23% dealt with a separation or divorce, and 5% had an incarcerated family member. In neglect, they found that 15% experienced emotional neglect and 10% experienced physical neglect.

They found that 36% of their sample had zero ACE's, 26% had one ACE, 16% had two ACE's, 9% had three ACE's, and 12% had at least four ACE's. Those numbers are about to be very important, but notice that in the original ACE study, they found that the higher number of participants had lower ACE scores, and that percentage drops as you increase the ACE score.

In other words, at least 64% of the population had some sort of adverse childhood experience of some kind. These experiences seemed to be correlated with social issues like a disordered social environment or caretakers who are not equipped to protect them from harm.

The ACE's that people experience as evidenced in the study are just a small representation of what people actually deal with in their life. She discusses the two kinds of ACE's that people can suffer: Disadvantaged communities (discrimination, poverty, bullying, crime, and violence) and unexpected events (accidents, injuries, illness, death of loved ones, a natural disaster).

She discusses the three different kinds of issues that are correlated with various mental health problems: Chronic events, multiple events, and cumulative events. She goes on to talk about the lasting effects that ACE's can have on people: Health issues (diabetes, obesity, depression, STD's, heart disease, cancer, stroke, COPD, broken bones), behaviors (smoking, alcoholism, drug use), and life potential (graduation, academic achievement, lost time from work). The ACE study found that the higher the ACE score, the more issues that come up.

Dr. Levenson's Study: Looking At ACE's and Sex Offenders

Dr. Levenson was interested in these effects, and what the backgrounds of sex offenders might look like with the ACE study in mind. So she and a few others did a study on that (Adverse Childhood Experiences in the Lives of Male Sex Offenders, Levenson, Willis, and Prescott, 2014). What they found was that sex offenders had a much higher number of ACE's in their background than general population males in every single category they studied.

When they broke down how many ACE's the male sex offenders reported, they found that 15.6% of sex offenders had zero ACE's, 13.7% had  one ACE, 12.8% had two ACE's, and 12.3% had three ACES, which so far is in keeping with the original ACE study: Higher ACE scores are associated with lower percentages. However, instead of finding a lower percentage than 12.3% for sex offenders with an ACE score of 4+, they found a whopping 45.7% did... compared to 9% for general (non-sexual) offenders.

She then looked at specific states, such as Texas (Obstacles to Help-Seeking for Sexual Offenders, Levenson, Willis, and Vicencio, 2017), which generally found very similar results to the original 2014 study. She also looked at the ACE scores of female sex offenders (Adverse Childhood Experiences in the Lives of Female Sex Offenders, Levenson, Willis, and Prescott, 2015), which again found similar results to the original 2014 study..

She looked in two other studies (Levenson and Socia, 2015, Levenson and Grady, 2016) studies at the correlations between ACE's and five areas: Criminal versatility (different types of arrests), persistence (quantity of arrests), sexual deviance, sexual violence, and substance abuse. She wanted to know which ACE's correlated with which of the five areas, finding that more sex crime arrests correlated with domestic violence, child sexual abuse, and emotional neglect, and that more general arrests were associated with substance abuse, unmarried parents, and an incarcerated family member.

She also overviews a study that featured in the OJJDP Journal of Juvenile Justice (The Prevalence of Adverse Childhood Experiences (ACE) in the Lives of Juvenile Offenders, Baglivio at al, 2014, p. 6-23) looking at the prevalence of ACE's in juvenile offenders. They surveyed over 64,329 juvenile offenders in Florida  finding that the lower the ACE score, the fewer offenders (male or female) who reported having them, and the higher the score, the more offenders report them, maxing out at three ACE's for males and four ACE's for females, dropping back down. This finding was again consistent with the previous three studies overviewed.

She goes on to describe the results of a new, not-yet published study, looking at a variety of demographics: Original CDC ACE study sample (pink), adult sex offenders (gray), juvenile sex offenders (orange), and juvenile non-sex offenders (blue) and found a similar trend to the previous studies. As the results are not yet published, I drew a proportionate graph:

Sex Offenders Had It Rough. So What?

The point to all this is that both adult and juvenile sex offenders have some sort of childhood trauma, in many cases multiple traumas, that may serve as the backdrop for sexual offending. That being the case, how can we form interventions to help children with these traumas to prevent abuse, prevent maladaptive behavior, and also begs the question... what effect does this trauma have on children, and how to children react? She proposes three basic responses: Fight, flight, or freeze. When this happens, there are multiple internal reactions within the brain.

She says that these ACE's can change the architecture of the brain to create stress hormones, and they become conditioned psychologically, socially, and behaviorally to be ready for the next stressor or threat, and this limits the growth in essential processing skills areas. In other words, these events start a domino effect in the brain that, if not interfered with, can have lifelong consequences for those with ACE's in their background.

These can form beliefs and themes that are unhealthy and can lead to cognitive distortions, mental illness, and damaging patterns of thinking. Those beliefs and themes affect behavior through internal impacts that lead to impeded self-regulation and relational skills, two essential areas to developing appropriate behaviors that do not hurt others.

No Excuses, But Understanding For Interventions

She emphasizes that prior trauma is no excuse for sexually violent behavior, and that the presence of ACE's can help understand how sexually violent behavior develops and thus how we can intervene. She suggests that these effects on children and the child's brain can lead to using sexual assault to meeting emotional and social needs.

In other words, ACE's that are chronic and continuous can lead to factors like distorted boundaries, distorted skills, reenacting trauma on others, turn to children that are less threatening, getting needs met through violence and power, or taught to act in certain ways. Summarized more simply, "Kids growing up in chronically adverse conditions who then later in life sexual offend are somehow using sex and sexual assault as the vehicle to meet psychological, emotional, and social needs." The point, again, is to understand why this behavior happens. She proposes that children raised in chronically traumatic conditions (ACE's) evolve: Just as mankind evolved, children from traumatic vs. healthy environments develop maladaptive vs. healthy behaviors.

She acknowledges that we know that there are children who do not grow up to abuse others despite horrific trauma, but that we need to shift our paradigm in our communities in how we look at policies so that those with trauma in their backgrounds can get the help and interventions they need.

How Do We Treat Trauma, And How Must Policy Change?

In wrapping up her speech, she looks at the trauma-informed approach from SAMHSA: Realizing the prevalence and impact of trauma, recognizing the symptoms of trauma, responding by including knowledge around trauma into policy, procedure, and practice, and avoiding re-traumatization. 

They discuss trauma-informed care and how to treat people in light of prior trauma as a way to solve a wide variety of problems besides just sexual violence. She also suggests a top-down, bottom-up approach by policymakers and other leaders. She talks about the need for role-models and supportive people who believe in those with trauma in their backgrounds, and how immensely helpful it is to have supports for those with ACE's and the earlier the better, but also for adults. Make sure that those with trauma have access to role models, mentoring, and are exposed to adults and peers who believe in them.

She suggests that people need to feel a certain accepted, valued, connected, and empowered, and without that, they resort to crime, gangs, teen pregnancy, and self-medication. In order to counter that, we must make opportunities for attachments, meaningful pursuits, self-efficacy, and self-sufficiency. 

She reinforces that while not every abused child becomes an abuser, those with ACE's are more likely to grow up to abuse others.

She goes back to the prevention pyramid from the first few slides and flipping the pyramid to focus on primary prevention, the need to teach respect, consent, and issues in creating solid gender roles, as well as focusing on secondary prevention for at-risk populations of trauma-informed care in helping those with ACE's. She also touches on tertiary prevention, which should be the smallest area of focus: Think about treatment, support, and accountability so that they can successfully lead a law-abiding life and be responsible citizens.

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