ACE Surveillance Study of Teachers and Administrators in Public and Private Schools in Southwest Nigeria, West Africa 

 
Note: These findings were presented at the Child Trauma Conference in Lagos on October 25-26, 2019. Paper Title


Rationale: 
Many children today live with layers of stress both subtle and overt which in this report are collectively referred to as Adverse Childhood Experiences (ACEs). Specifically, these ACEs are physical, emotional and sexual abuse; physical and emotional neglect; household dysfunction and domestic violence as well as community violence. The children have a life marked by chaos, unpredictability and excessively high expectations beyond the child’s capability. The National Survey of Children’s Health (NSCH, 2016) report stated that nearly 35 Million US Children experienced one or more types of childhood trauma. Other studies showed that many children have their needs belittled or dismissed, and many children’s needs are ignored and criticized. These children often have no adult to share their frightening and painful experiences with. These experiences are at times by the hands of their caregivers with no buffer to protect them. Some children endure multiple types of adversities of trauma early in childhood while some are living with developmental trauma. Examples of this are childhood experiences of no attachment relationship to any parent, unintentional neglect by working parents in congested urban areas that force parents to keep toddlers in overnight care centers; and attachment separation resulting from an impaired caregiver who is emotionally unavailable and/or contentious parental divorce. 

Other sources of toxic stress to children these days are psychological maltreatment by temperamental parents with the unresolved emotional trauma of their own. This at times is coupled with angry domestic helpers (maids, nannies, drivers, and houseboys) who are traumatized teenagers themselves. These multiple sources all add to the adversities this generation of children endures especially in affluent West African suburban communities. Few of the children also experience acute and non-interpersonal trauma from RTA or natural disasters with a feeling of helplessness. Many research studies depict qualitative distinctions in outcomes of traumas during adolescence but, regardless of the type or source of childhood traumas, each trauma has the potential to have a significant impact on each individual. 

The Center for Disease Control’s epidemiology study of 1700 adults (ACE Study, Anda et al 1999, 2006), established that exposure to adversity in childhood increases risks for multiple health issues in adulthood. Although only 5-13% of children exposed to childhood adversity have PTSD, 80% will have comorbid conditions (Solomon & Davidson 1997). 

The focus of this study is to determine the prevalence of ACEs in communities in Africa and to prevent childhood trauma through surveillance and education of adults in charge of the care of children in multiple settings. 

ACEs Definitions 

This data is a sum of all returned survey forms collected from participants (schoolteachers, caregivers, and school administrators) attending Trauma-Informed Education (TIE) Workshops in multiple sites in 3 Southwest states of Nigeria. The Adverse Childhood Experiences data are categorized into three groups of the original 10 question Survey: abuse, neglect, and household/environmental challenges. 

Each category is divided into multiple subcategories. All ACE questions refer to the respondent’s first 18 years of life. 

  • Abuse (1)
    • Emotional abuse: A parent or other adult in your home ever swore at you, insulted you, humiliated you, belittle your feelings or put you down.
    • Physical abuse: A parent or other adult in your home ever push, grab, slap, hit, beat, kicked or physically hurt you or leave marks.
    • Sexual abuse: An adult or person at least 5 years older ever touched you in a sexual way or tried to make you touch their body in a sexual way or attempted to have sex with you. 
  • Neglect 
    • Emotional Neglect: You feel no one in your family loved you or thought of you as important; family members didn’t look out for each other or support each other.
    • Physical Neglect: You often feel that you didn’t have enough food, wore dirty clothes and had no one to protect you. Parents too drunk or high to take care of you or go to the doctors.
  • Household/Environmental Challenges 
    • Intimate partner violence: (2) Parents or adults in home ever slapped, hit, kicked, punched or beat each other up.
    • Substance abuse in the household: A household member was a problem drinker or alcoholic or used street drugs or abused prescription medications. 
    • Mental illness in the household: A household member was depressed or mentally ill or a household member attempted suicide.
    • Parental separation or divorce: Parents were ever separated or divorced.
    • Incarcerated household member: A household member went to prison. 

1. Abuse Questions were modified from the original CDC-Kaiser ACE Study to make them more appropriate for a telephone survey. 

2. In the original CDC-Kaiser ACE Study, the question pertained only to the mother being treated violently. 

Executive Summary
From 2014 to 2016, individuals, dispersed in ten (10) institutions, participated in the ACE study. The form, self-administered, is comprised of ten (10) dichotomic questions {yes/no} associated with 10 ACE domains: 

First

Executive Summary From 2014 to 2016, multiple Trauma-Informed Education workshops were conducted in institutions (high schools and a church congregation) in multiple cities, in three states in Southwest Nigeria, namely; Lagos. Ibadan, Lekki, Epe, Shagamu in Nigeria. Over 2000+ teachers attended these trainings during this period. The original ACE study 10 question survey was offered to 981 individuals dispersed in ten (10) institutions. 826 individuals returned the ACE survey supplied by Suburban Healthcare Initiative, INC. The form, a self- administered anonymous survey, was comprised of ten (10) dichotomic questions {yes/no} associated with 10 ACE Domains: 

  1. Emotional Abuse
  2. Physical Abuse
  3. Sexual Abuse
  4. Emotional Neglect
  5. Physical Neglect
  6. Separation/Divorce
  7. Mother/Stepmother (Treated with Violence)
  8. Alcohol/ Drug Abuse
  9. Depressed Parent or Suicide
  10. Jailed/Imprisoned Family Member 

ACE Questions Summary The number of respondents is N= 826. ACEs during their first 18 years, 

  • Almost half (45.04%) of respondents experienced emotional abuse 
  • Two out of five (42.13%) encountered physical abuse 
  • One out four (25.06%) experienced sexual abuse 
  • One fourth (25.67%) encountered emotional neglect 
  • One-tenth (11.62%) experienced physical neglect 


ACEs SCORE Summary
The number of respondents is N=826 

  • 190 respondents (23%) have a total ACE score equal to zero while 
  • 636 respondents ( 77%) have a score higher or equal to 1. 
  • 168 respondents (20.34%) scored 4 or higher. 

Second

ThirdACEs Prevalence 
The prevalence estimates reported below are from attendees of the Trauma-Informed Education training in Lagos, Shagamu, Ibadan and Lekki Nigeria (n=826). 


Prevalence of ACEs by Category for Participants Completing the original CDC ACE survey 2014-2016. 

Figure 2- ACEs Question Overview (N=826) 

Fourth

FifthSixth
MAJOR FINDINGS 

  • The prevalence of ACEs from the Teachers attending the TIE training in southwest Nigeria is different from that of the original ACE Study. The data in Nigeria showed higher scores in all categories of abuse and neglect and lower scores in mental health and substance use sub-categories. 
  • This data showed less than a quarter of the responders reported zero ACE score (ACE 0=23%) compared to (ACE 0=36%) in the original ACE study and (ACE 0= 52%.) in the NSCH, 2016 ACE Study of 0-17year old, 
  • The original Ace study reported two-thirds (66.6%) of surveyed adults reported at least one ACE. This study reports ACE score of one (1) or higher was three-quarters of the responders (77%)’ 
  • The Original ACE Survey stated more than one in five (23%) reported three or more ACEs, this survey in Nigeria was (ACE 3+=36%) and ACE score higher or equal to 4 is (20.34%). 

CONCLUSION 
This is a small study that simply set out to determine the preliminary prevalence of ACEs in the attendees of the Trauma-Informed workshops for educators. 

The conclusion from the original ACE study of individuals with ACE score of 4 or higher is that these individuals are assumed traumatized. This prevalence data conducted in southwest Nigeria of individuals with ACE score of 4 and higher corresponds with 20% of those surveyed and therefore deemed traumatized or survivors of childhood trauma. The participants are teachers and administrators across 3 southwest states, but they are originally from different states of the country. Future studies will seek data from all adults with age, tribe and education data included. 

CDC-Kaiser ACE-Study findings report ACEs are common across all populations and that some populations are more vulnerable to experiencing adversity because of the social and economic conditions in which they live, learn, work and play. It is with this understanding that this surveillance study was conducted to gather preliminary ACEs prevalence data in Nigeria. This small sample is a preliminary study of how ACES is expressed in southwest Nigeria. 

Many ACE Study findings show a graded dose-response relationship between ACEs and negative health and well-being outcomes. In other words, as the number of ACEs increases so does the risk for negative health outcomes. Below is the CDC report on the lasting impacts of early adversity. 


Association between ACEs and Negative Outcomes 

Seventh

Content source: National Center for Injury Prevention and Control, Division of Violence Prevention 

Selected Journal Publications on ACEs and Negative Health Outcomes: 

Anda RF, Brown D Root causes and organic budgeting: fW.unding health from conception to the grave [122.06 KB, 3 Pages, Print Only] Ped Health. 2007;1(2):141–143. 

Anda RF, Butchart A, Felitti VJ, Brown DW. Building a framework for global surveillance of the public health implications of adverse childhood experiences. AM J Prev Med. 2010 Jul;39(1):93-8. 

Edwards, VJ, Dube SR, Felitti VJ, Anda RF. It’s OK to ask about past abuse. Am Psych. 2007;62(4):327–328. 

Edwards, VJ, Anda RF, Dube SR, Dong M, Chapman DF, Felitti VJ. The wide-ranging health consequences of adverse childhood experiences. In Kathleen Kendall-Tackett and Sarah Giacomoni (eds.) Victimization of Children and Youth: Patterns of Abuse, Response Strategies, Kingston, NJ: Civic Research Institute; 2005. 

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 1998;14:245–258. 

Felitti V. Adverse childhood experiences and adult health [145.14 KB, 3 Pages, Print Only. Acad Pediatr. 2009;9:131-132. 

Foege WH. Adverse childhood experiences: A public health perspective. Am J Prev Med. 1998;14:354–355. 

Gilbert LK, Breiding MJ, Merrick MT, Parks SE, Thompson WW, Dhingra SS, Ford DC. Childhood adversity and adult chronic disease: An update from ten states and the District of Columbia, 2010. Am J Prev Med. 2015;48(3):345-9. 

Merrick MT, Guinn AS. (2018). Child Abuse and Neglect: Breaking the intergenerational link. American Journal of Public Health, 108(9), pp.1117–1118. 

Ports KA, Merrick MT, Stone DM, Wilkins NJ, Reed J, Ebin J, & Ford DC. (2017). Adverse Childhood Experiences and Suicide Risk: Toward Comprehensive Prevention. American Journal of Preventive Medicine, 53(3), 400-403 

Weiss JS, Wagner SH. What explains the negative consequences of adverse childhood experiences on adult health? Insights from cognitive and neuroscience research. Am J Prev Med. 1998;14:356–360. 

Whitfield CL. Adverse childhood experiences and trauma. Am J Prev Med. 1998;14:361–363.

Note: We are heading to Lagos April 15-18, 2020, Nairobi Kenya in August 12-14, 2020 and Freetown, Sierra Leone  October 22-23, 2020 regarding ACES and mental health interventions for the African Child and families.

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