Transcript The Story of A Child’s Path to Mental Illness and Suicide Presented by her mother Ann Jennings Ph.D. www.TheAnnaInstitute.Org.

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. Annan
This is me, Ann Jennings
This is my daughter Anna
She is the artist. She took her life at the age of 32.
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

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 Discussion
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
A Snapshot of Anna’s Life
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.org
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.org
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.org
The damaging consequences
of childhood trauma:
Research Findings
The Adverse Childhood
Experiences Study
(ACE)
Collaboration between Kaiser Permanente’s Department of
Preventive Medicine in San Diego and the Center for Disease
Control and Prevention (CDC)
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
Childhood experiences are powerful
determinants of who we become as adults

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.
Adverse Childhood Experiences*
Abuse of Child



Recurrent Severe Emotional abuse
Recurrent Physical abuse
Contact Sexual abuse
Impact of Trauma and Health
Risk Behaviors to Ease the Pain
Neurobiologic Effects of Trauma




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.







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 services

ACE study views health risk behaviors
as attempts to cope with impacts and
ease pain of prior trauma,

NOT as symptoms, bad habits, selfdestructive behavior, or public health
problems.
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
Of 17,000 HMO members:

72% had attended college

77% were white

62% were 50 or older
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
recognition
 acknowledgement
 action

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.
Adverse Childhood Experiences
and Current Smoking
20
18
16
14
12
%
10
8
6
4
2
0
0
1
2
3
ACE Score
4-5
6 or more
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) .
Childhood Experiences and
Adult Alcoholism
18
16
4+
% Alcoholic
14
12
3
10
2
8
6
1
4
2
0
0
ACE Score
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
ACE Score and Intravenous
Drug Use
% Have Injected Drugs
3.5
3
2.5
2
1.5
1
0.5
0
0
1
2
3
4 or more
ACE Score
N = 8,022
p<0.001
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
Childhood Experiences Underlie
Rape
35
4+
% Reporting Rape
30
25
20
3
2
15
10
5
1
0
0
ACE Score
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.
ACE Score and Hallucinations
Ever Hallucinated* (%)
12
10
Abused
Alcohol
or Drugs
8
No
Yes
6
4
2
0
0
1
2
3
4
5
6
ACE Score
*Adjusted for age, sex, race, and education.
>=7
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 2005

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
% With a Lifetime History of
Depression
Childhood Experiences
Underlie
Chronic Depression
80
70
60
50
40
30
20
Women
Men
10
0
0
1
2
ACE Score
3
>=4
Chronic Depression

Adults with an ACE score of 4 or
more were 460% more likely to be
suffering from depression .
Childhood Experiences
Underlie Suicide
25
4+
% Attempting Suicide
20
15
3
10
2
5
0
1
0
ACE Score
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.

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.
% with Job Problems
ACE Score and
Serious Job Problems
18
16
14
12
10
8
6
4
2
0
0
1
2
ACE Score
3
4 or more
Much of what causes time to
be lost from work is actually
predetermined decades earlier
by the adverse experiences
of childhood.
Adverse Childhood Experiences and
Likelihood of > 50 Sexual Partners
Adjusted Odds Ratio
4
3
2
1
0
0
1
2
ACE Score
3
4 or more
Adverse Childhood Experiences and
History of STD
Adjusted Odds Ratio
3
2.5
2
1.5
1
0.5
0
0
1
2
ACE Score
3
4 or more
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
35
30
25
Pink =self
Yellow =mother
20
15
10
5
0
Never
Once,
Twice
Sometimes
Often
Very
often
Sexual Abuse of Male Children and Their
Likelihood of Impregnating a Teenage Girl
35
1.8x
30
1.3x
25
20
1.4x
1.0 ref
15
10
5
0
Not
abused
16-18yrs
11-15 yrs
<=10 yrs
Age when first abused
% have Unintended PG, or AB
ACE Score and Unintended
Pregnancy or Elective Abortion
80
Unintended Pregnancy
70
Elective Abortion
60
50
40
30
20
10
0
0
1
2
ACE Score
3
4 or more
Effect of ACEs on Mortality
Age Group
Percent in Age Group
60
19-34
35-49
50-64
>=65
50
40
30
20
10
0
0
2
4
ACE Score
0 ACE 60% live to 65
4 ACE less than 3% live to 65
Many chronic diseases
in adults are determined
decades earlier, in childhood.
Other Studies on Childhood
Sexual and/or Physical
Abuse
Sarah
Joe,
Anna
John
Mary

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.

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.

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

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

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
Yet the Silence Continues
“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
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

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
Lasting Alterations in
Self Perception
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
Sense of helplessness, paralysis, captivity,
inadequacy, powerlessness, danger, fear
Continues over the lifespan
Sense of Shame, Guilt, Self-Blame, Being Bad
Continues over the lifespan
Sense of defilement, contamination, spoiled,
degraded, debased, despicable, evil
Continues over the lifespan
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
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





Isolation, Withdrawal
Disruption in Intimate Relationships
Repeated Search for Rescuer
Persistent Distrust
Repeated Failures of Self-Protection
So, what do our children ask of us?
That we:
 Pay attention
 Overcome our lack of
knowledge
 Ask “What Happened?”
 Overcome our fear
 Speak out and break the silence
The Story of Anna:
A Childs Path to Mental Illness
www.AnnaFoundation.org
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

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
The
1950s –
1960s

Ideal was the nuclear
family model vs village –
isolating.

Gender roles were
prescribed.

Racial/Class/
Income/other cultural
separation

Rise of consumer culture
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

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 19
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.
 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.
Intergenerational
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.
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
Cover for record produced by Catholic organization - of Anna’s
parents giving advice to other young married couples
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’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
A major city in the Midwest
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
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.”
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.”
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.”
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!”
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!”
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

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….
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.”
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
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
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.
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.”
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.”
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.”
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….”
Anna’s dad:

“I remember around three or four she became overreactive, 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
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 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.
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.”
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.”
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)



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
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.”
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

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…..”
“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
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”
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
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
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.”
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.”
“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
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’.
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…..”
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

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
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




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)
Wedge Shapes
Missing arms on all four figures – something overhead
figures, theme of need for protection – both pictures have
2nd figure less prominent – wedge shapes - rain









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
House colored in – wedge shapes – no windows
Body parts missing – wedge shapes
Red House – Windows filled in
No arms – Faces crossed out – Distortions – Figures in big
square except one to right - overdrawing abdominal parts
Body fragmentation – missing body parts – rain – wedge
shapes – splitting up torso
Geometric body shape; overdrawing
abdomen; body part distortions
Themes of Protection
Nursery School
Age 4 yrs 9 mo to 5 yrs 10 mo
Anna, far left in picture
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.”
Con’t
 “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.”

“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.”
Con’t

“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.”
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.
Anna recalls:
Anna, middle of front row

“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:
“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
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 Tree
Kindergarten:
Age 5 yrs 10 mo to 6 yrs 8 mo

Sometimes high achievement can
fool people into missing signs of
continuing abuse

Records show Anna scored in the 99th 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 99th percentile, that you can’t get
higher than that!”
Hope persisted –
along with love of family celebrations
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
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.”
Collage of yarn, paper cutouts, drawing
Collage flower of colored or painted paper cut outs and yarn
Cut out crayoned house
with no windows.
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’.”
Anna titled this
picture “A four
year old Chinese
girl next to a
bush of bell
flowers”.
November 1966
Christmas. Created by Anna at her Aunt Dorothy’s house. Age 5 ½- 6
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
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
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
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.


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.

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

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 adults
Anna breaks. Hides herself. Withdraws completely.
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.

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

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.org
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
Impact of Trauma and Health
Risk Behaviors to Ease the Pain
Long-Term Consequences to
Anna of Unaddressed Trauma
Neurobiologic Effects of Trauma
Disease and Disability











Expulsion from family
MH Treatment
Forced Medication
Seclusion and Restraint
Shock Treatment

Health Risk Behaviors




Smoking
Suicide attempts
Repetition of original trauma
Self Injury
Eating disorders
Poor self rated health
Social Problems








Other not in ACE Study:
Disrupted neuro-development
Difficulty controlling anger-rage
Hallucinations
Depression
Panic reactions
Anxiety
Sleep problems
Flashbacks
Dissociation
Homelessness
Prostitution
Delinquency
Inability to sustain employment
Re-victimization: rape, DV
compromised ability to parent
Long-term use of mental health
and social services
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 = $5,417,032
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

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

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 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 silence
Becoming Trauma-Informed
A Personal and
Professional Challenge
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 Books
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
Do Something!!
“If you think you’re too
small to make a difference,
try sleeping in a room with
a mosquito.”
African Proverb
 In
the context of your role, be
it personal or professional,
how might what you’ve seen
alter the way you do your
work?
Presentation created by
Ann Jennings Ph.D.
For further information contact:
[email protected]
www.TheAnnaInstitute.Org