THE FIRST TIME THAT principal Jim Sporleder tried the New Approach to Student Discipline at Lincoln High School in Walla Walla, WA, he was blown away. Because it worked. In fact, it worked so well that he never went back to the Old Approach to Student Discipline. This is how it went down:
A student blows up at a teacher, drops the F-bomb. The usual approach at Lincoln – and, safe to say, at most high schools in this country – is automatic suspension. Instead, Sporleder sits the kid down and says quietly:
“Wow. Are you OK? This doesn’t sound like you. What’s going on?” He gets even more specific: “You really looked stressed. On a scale of 1-10, where are you with your anger?”
The kid was ready. Ready, man! For an anger blast to his face….”How could you do that?” “What’s wrong with you?”…and for the big boot out of school. But he was NOT ready for kindness. The armor-plated defenses melt like ice under a blowtorch and the words pour out: “My dad’s an alcoholic. He’s promised me things my whole life and never keeps those promises.” The waterfall of words that go deep into his home life, which is no piece of breeze, end with this sentence: “I shouldn’t have blown up at the teacher.”
And then he goes back to the teacher and apologizes. Without prompting from Sporleder.
“The kid still got a consequence,” explains Sporleder – but he wasn’t sent home, a place where there wasn’t anyone who cares much about what he does or doesn’t do. He went to ISS -- in-school suspension, a quiet, comforting room where he can talk about anything with the attending teacher, catch up on his homework, or just sit and think about how maybe he could do things differently next time.
Before the words “namby-pamby”, “weenie”, or “not the way they did things in my day” start flowing across your lips, take a look at these numbers:
2009-2010 (Before new approach)
798 suspensions (days students were out of school) 50 expulsions 600 written referrals 2010-2011 (After new approach)
135 suspensions (days students were out of school) 30 expulsions 320 written referrals “It sounds simple,” says Sporleder about the new approach. “Just by asking kids what’s going on with them, they just started talking. It made a believer out of me right away.”
The dark underbelly of school discipline
Take a short walk on the dark side of our public education system, and you learn some disturbing lessons about school punishment.
First. U.S. schools suspend millions of kids -- 3,328,750, to be exact. Since the 1970s, says a National Education Policy Center report published in October 2011, the suspension rate’s nearly doubled for white kids, to 6%. It’s more than doubled for Hispanics to 7%, and to a stunning 15% for blacks. For Native Americans, it’s almost tripled, from 3% to 8%.
Second. If you think all these suspensions are for weapons and drugs, recalibrate. There’s been a kind of “zero-tolerance creep” since schools adopted “zero-tolerance” policies. Only 5% of all out-of-school suspensions were for weapons or drugs, said the NEPC report, citing a 2006 study. The other 95% were categorized as “disruptive behavior” and “other”, which includes cell phone use, violation of dress code, being “defiant”, display of affection, and, in at least one case, farting.
Third. These suspensions don’t work for schools. Get rid of the “bad” students, and the “good” students can learn, get high scores, live good lives. That’s the myth. The reality? It’s just the opposite. Says the NEPC report: “…research on the frequent use of school suspension has indicated that, after race and poverty are controlled for, higher rates of out-of-school suspension correlate with lower achievement scores.”
Fourth. They don’t work for the kids who get kicked out. In fact, these “throw-away” kids get shunted off a possible track to college and onto the dead-end spur of juvenile hall and prison.
“Studies show that one suspension triples the likelihood of a juvenile justice contact within that year,” California Chief Justice Tani Cantil-Sakauye told the California Legislature last month. “And that one suspension doubles the likelihood of repeating the grade.”
Fifth. All these suspensions have led many communities to create “alternative” schools, where they dump the “bad” kids who can’t make it in regular public school. Lincoln High School was set up as one of those alternative schools.
How Mr. Sporleder stumbled across an epiphany in Spokane
It’s the Spring of 2010, and Jim Sporleder’s mind more or less silently exploded.
This is the guy with 25 years experience as a principal. In Walla Walla, he’s got a rep for really connecting with kids. He preaches “discipline with dignity”.
John Medina – a developmental molecular biologist who’s an improbable cross between an old-time rip-snortin’ preacher and Jon Stewart – just drilled a hole in Sporleder’s brain and dropped this in:
Severe and chronic trauma (such as living with an alcoholic parent, or watching in terror as your mom gets beat up) causes toxic stress in kids. Toxic stress damages kid’s brains. When trauma launches kids into flight, fight or fright mode, they cannot learn. It is physiologically impossible.
Sporleder was three years into an exhausting stint as principal of the Lincoln Alternative School. He’d asked for the position after reading a report about the troubled school. The report quoted a couple of Lincoln High’s kids: “We're the dumping ground,” one said. “Who cares about us,” another said. It wasn’t a question.
“That report riveted me,” says Sporleder. “I’m a person of faith. I felt called to come over here.”
Gangs controlled the school. It had only 50 students, but they were the toughest in the school system – the kids who’d been kicked out of other schools. Lincoln was their last chance.
“I didn't know if I was going to make it,” recalls Sporleder. “We had some pretty rough kids. It took me quite a while to get on top of that.”
And then, at the behest of Teri Barila, co-founder of the Children’s Resilience Initiative in Walla Walla, he goes to this meeting where this guy who’s part comedian, part evangelist, part scientist (and best-selling author of Brain Rules) more or less tells him that this “discipline with dignity” stuff is, well, useless. Punishing misbehavior just doesn’t work. You’re simply adding trauma to an already traumatized kid.
“He explained it in lay terms,” says Sporleder. “I got it.”
Now, some people who are well into their careers can’t handle a paradigm shift. It’s overwhelming. That’s mostly because it’s just too much trouble to change the way you do…everything.
Spoiler alert: Sporleder isn’t one of those people.
He returned from Spokane to light a fire under his teachers. He felt compelled to figure out a way to do something different to reach his kids, but wasn’t sure exactly how. Teri Barila was in a perfect position to assist.
This is your (damaged) brain on ACEs
Really good ideas that help people solve problems often take such a long time to move from research to implementation that it can cost a community millions of dollars. Twenty years ago, Washington State created a state network -- the Family Policy Council and 42 community public health and safety networks -- to share good information FAST to tackle a big, expensive problem: the high rates of child abuse and youth drug and alcohol abuse in the state. Teri Barila, a former fish biologist, leads the network in Walla Walla, a city of about 30,000 people in southeastern Washington.
About 10 years ago, the council caught wind of two major game-changing discoveries. One was the CDC’s Adverse Childhood Experiences Study (ACE Study). It showed a stunning link between childhood toxic stress and the chronic diseases people developed as adults. This includes heart disease, lung cancer, diabetes, some breast cancer, and many autoimmune diseases, as well as depression, violence, being a victim of violence, and suicide.
(To read the rest of the story, go to Lincoln High School in Walla Walla, WA, tries new approach to school discipline.) This story is cross-posted from ACEsTooHigh.com.
When a pregnant woman visits the Jefferson County Public Health clinic in Port Townsend, WA, a town of about 9,000 people on the northeast tip of the Olympic Peninsula, she’s asked the typical questions about tobacco, alcohol and other drug use. She’s also screened for something that most public heath departments, ob-gyns or primary care providers don’t even consider asking: her childhood trauma.
That’s because the public health nurses at Family Health Services know that a childhood full of toxic stress causes a lifetime of health problems, and, if not addressed, is usually passed on from parent to child.
But setting up a system to screen for child trauma, which seems so logical in hindsight, wasn’t an easy thing to do, says Quen Zorrah, a public health nurse who led the effort. Even after years of talking, reading research and preparation, the staff was still reluctant. But in the end, she and her co-workers concluded: If we can teach a client to put on a condom, we can ask a client about ACEs.
ACES are adverse childhood experiences, or child trauma. When 10 types of child trauma were measured in a CDC study of 17,000 people in San Diego, researchers were stunned to discover that not only it was very common, but it raised the risk of adult onset of chronic disease to unimagined levels. Even more startling was that these 17,000 people were middle-class, college-educated, mostly white people. And they all had jobs and good health care, because they were all members of Kaiser Permanente, the health maintenance organization where the study took place.
The CDC’s ACE Study measured physical, emotional and sexual abuse; emotional and physical neglect; living with a parent who’s an alcoholic or addicted to other drugs; witnessing the abuse of a mother; a family member in prison or diagnosed with mental illness; and a loss of a parent through divorce or abandonment. (Of course, there are other possible traumatic events a child can experience – such as severe illness, homelessness or surviving a catastrophic tornado or flood – but those were not measured.)
From this list, researchers determined each person’s ACE Score. Each type of trauma counts as one. Nearly 70 percent of the participants had an ACE Score of at least 1. And the odds were very high that if someone had one trauma, there were others. In other words, if your dad was an alcoholic, it’s likely that there was also emotional abuse in your background.
The study showed that the higher the ACE score, the higher the risk of disease, suicide, violent behavior, or being a victim of violence. People with an ACE score of 4 or more had starkly higher rates of heart disease and diabetes than those with ACE scores of zero. The likelihood of chronic pulmonary lung disease increased 390 percent; hepatitis, 240 percent; depression 460 percent; suicide, 1,220 percent. The percentages climbed to grim and astounding levels as the ACE score increased – people with an ACE score of 6, for example, had a 4,600 percent increase in the likelihood of becoming an IV drug user. And people with high ACE scores die, on average, 20 years earlier than those with low ACE scores.
ACE Study co-founder Dr. Vincent Felitti says that ACEs are the “most important determinant of the health and well-being of our nation.” Dr. Robert Anda, the other co-founder, calls ACEs a “chronic public health disaster.”
The reason that childhood trauma causes adult onset of chronic disease was determined by a group of researchers, including neurobiologist Martin Teicher and pediatrician Jack Shonkoff, both at Harvard University, and neuroscientist Bruce McEwen at Rockefeller University. They figured out that the toxic stress of chronic and severe trauma damages a child’s developing brain. It essentially stunts the growth of some parts of the brain, and fries the circuits with overdoses of stress hormones in others.
Children with toxic stress live their lives in fight, flight or fright (freeze) mode. Unable to concentrate, their brains are incapable of learning and they fall behind in school. They respond to the world as a place of constant danger, not trusting adults and unable to develop healthy relationships with peers. Failure, despair, shame and frustration follow.
As they transition into adulthood, they find comfort by overindulging in food, alcohol, tobacco (nicotine is an anti-depressant), drugs (methamphetamines are anti-depressants), work, high-risk sports, violence, a plethora of sexual partners….anything that pumps up feel-good moments so that they can escape – even briefly – the sharp, tenacious claws of agonizing memories and despair.
Several staff members in Family Health Services learned about ACE concepts in 2003, when Washington State’s [Family Policy Council]], which partners with 52 community public health and safety networks across the state, invited Dr. Felitti to speak at one of their meetings.
The Family Health Services staff came away determined that it was their responsibility to share the information with their clients.
“It’s similar to understanding the risk of tobacco use or alcohol use in pregnancy,” recalls Zorrah. “But nobody was using it. We couldn’t find anyone who said: ‘Here’s what you should do.’
After a small community grant became available, the staff of the Family Health Services applied to set up a system for ACEs screening. “We determined that we just had to figure it out on our own,” says Zorrah.
The biggest obstacle was fear. They thought that if they asked people questions – such as, “Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? Or attempt to actually have oral, anal, or vaginal intercourse with you?” -- they’d go into crisis. They also worried that clients would feel despair, shame or doomed when they learned their score.
Ironically, this fear of asking questions also occurred during the CDC’s ACE Study. The study’s advisory group was so worried about a patient having a psychological crisis that Dr. Felitti was required to wear a pager 24 hours a day, 7 days a week.
Even though they knew that none of the 17,000 people in the CDC’s ACE Study in San Diego ever had a problem after answering the study questions, the Family Health Service staff still prepared for a crisis before they began screening for ACEs in 2009. Spoiler alert: Not one ever occurred.
The nurses discovered what Drs. Felitti and Anda had learned: “People are already thinking about their childhood abuse,” says Zorrah. And the people who don’t want to think about it simply say they don’t have any problems.
An important part of the preparation was for all eight staff members to complete their own ACE survey so they’d know what the client might be feeling. “We did so privately,” says Zorrah. “For some of us, it was really hard to answer the questions.”
Since 2009, between 200 and 300 people have been screened for ACEs. It’s part of the routine intake assessment for pregnant women and their spouses or significant others, for parents involved with Child Protective Services, or for parents with children who have special health care needs.
The screening isn’t mandatory, says Zorrah. But most people want to complete the questionnaire as part of their health history. The assessment includes a two-page questionnaire, plus a short form of the ACE questionnaire.
Clients fill out the paper forms first, then meet with a nurse for an hour. Before telling them their score, the nurse provides them with appropriate health information – such as the health risks of tobacco, domestic violence, ACEs, of not getting adequate nutrition. They include the ACE information as part of routine health education and screening. “Once people have the test results, they don't listen the same way,” says Zorrah.
So far, most of their clients have ACE scores that are higher than the state average. That’s not surprising, notes Zorrah, because Family Health Services targets a high-risk population, people in Jefferson County who have had the most difficult lives, the people with the most health problems, including obesity, heart disease, diabetes, depression and higher rates of being victims of violence.
So, starting a conversation about a person’s score requires sensitivity:
- "Becoming pregnant often brings up thoughts of one's own childhood, thoughts of wanting to make life better for your child, making healthy changes.”
- “These questions help us understand your health risk.”
- "Science has proven what we all knew -- the bad things that happen to kids causes problems for their whole life."
- “People who have childhood trauma often have more health problems.”
The staff strives to make sure clients understand that the science is new because “we don't want them to feel guilt or shame about what their parents did or what they did as parents,” explains Zorrah.
They tell them that most people have a score of 1 or 2, and that responses to higher ACE scores – such as alcoholism, drug addiction, obesity, depression -- are normal. “For somebody who is an ACE survivor, a sense of shame is going to be one of their fundamental feelings,” Zorrah says. “When we normalize it, explain it as a science-based thing, it helps them reframe to move away from shame.”
The client responses?
“Well, duh!” was typical.
So was: “No wonder I'm so messed up.” “No wonder I’m sick all the time.” “No wonder I can't quit using…..drugs, alcohol, cigarettes.”
When one woman in her 60s who was parenting her grandchild was told that her ACE score was an 8, she said: “These are very, very good questions. Nobody has asked me about this before.” Understanding her own past motivated her to agree to mental health services for her grandchild.
“It's really quite an amazing experience to sit with somebody,” says Zorrah, “discuss the research, give them their score, and then have them say: ‘Now my life makes sense.’”
The nurses make sure to acknowledge how difficult life is with a high ACE score. They say: “How have you managed to get through your life with such an ACE score.?” or “People with a high ACE score like yours usually have to work harder at just about everything.”
The ultimate goal is to help people find their own motivation to change by giving them an understanding of their own life story and health risks, and then encourage them to make things different for their children.
“We see ACEs screening as a two-generation intervention,” Zorrah emphasizes. “It's an educational opportunity, and they get a score and a whole process to promote positive health behavioral changes affecting them and their child.”
It took the staff of Family Health Services a year to become comfortable with and confident about the process. “It was important for us for us to realize that it is not our job to fix their life or tear down their defenses, but to respect wherever it is they're starting from,” says Zorrah. “In fact, it may be unique opportunity for this client to sit with somebody who can really listen.”
But not everyone’s ready to talk about their childhood trauma. Zorrah recalls one man who was ordered by Child Protective Services to talk with her. He was livid that his children were in foster care, she says. He denied every question on the assessment and said his ACE score was zero. “I talked to him about brain development and trauma,” says Zorrah. “In the discussion, he disclosed that he had lived in over 30 foster homes. I asked him: “How did this affect you?’ ‘Fine. I've had a perfect life.’ I took this as a cue that he was not ready to discuss his own experiences. So we discussed the research. We talked about brain development. At end of visit, he thanked me for that visit. His defenses went down.”
Although Zorrah never saw him again, she feels that he took away some valuable information about himself and his children.
Zorrah’s looking forward to the time when asking about childhood trauma will be a normal part of any healthcare visit, so that everyone understands that a difficult childhood can contribute to a lifetime of health problems.
The changes that Family Health Services has made has inspired the community’s “Our Kids: Our Business” campaign, which kicks off next month. The campaign comprises a series of workshops and conferences for community members and health care professionals so that they can start the process to figure out how to integrate ACE concepts into their own practices.
Today, the staff of Family Health Services assumes that all of their clients are ACE survivors. The score is powerful,” notes Zorrah, “but the most important thing that we're doing is offering them this information that is sensitive and respectful and that helps them start to think about protecting their children from having a similar ACE score and, of course, moving forward with other positive changes in their life.”
This story is cross-posted from the ACEsTooHigh.com news site. You can find and download the Family Services Clinic parent health history questionnaire and the prenatal health history questionnaire at the end of the story on that site.
Secrets erupt on page after page from people who are pictured on Project Unbreakable, long-held secrets in the words on the posters they're holding. Words that fathers and step-fathers and grandfathers and mothers and brothers and boyfriends and dates and acquaintances said while abusing or raping them. "Now...Tell me you love me," says one poster. "It is not going to hurt if you just relax," says another.
The words make the unthinkable chillingly real: "Can I write you a check to keep you quiet?" "No one is going to believe you anyways." "Does that feel good?" "Stop struggling. You're only hurting yourself." "No puedes decir a nadie - es nuestro secreto." ("You can't tell anyone. It's our secret.") "This is a test. If you tell Mom, we'll both know you can't be trusted." "I wish you were a girl."
Project Unbreakable is art and art therapy, says Grace Brown, 19, a freshman at the School of Visual Arts in New York City. She launched the site in October 2011. "It just blows my mind that I’m able to do this," she says. "I’m able to use my art and the thing I love the most to help people begin to heal or continue their healing or complete their healing."
This is how Project Unbreakable works: People write words they remember their abuser saying on a poster, and Brown photographs them holding the poster. Each chooses to reveal none, some or all of her or his face. Some add information about the abuse on the site. Others say the words are enough. Some know the exact words they want to write, do so quickly and are finished. Others struggle, cry and want to talk.
Brown's mentor, Yvonne Moss -- an incest survivor, advocate and Brown's "New Jersey mom" -- says the project is a way for people to take back the power of the "words that were once used against them." So far, Brown has photographed 25 people herself. About 100 people have submitted their own photos. Dozens of submissions are waiting in a queue to be posted.
The project was born last Fall. Brown had been working on a photo project called 50 Extraordinary Women when a friend revealed her story of sexual abuse. The next morning, a Sunday, Brown woke up with the idea for Project Unbreakable. She began planning the site that day, started doing photographs that week, and launched the site a week later. In November, it gained momentum when two feminist sites mentioned it and Yvonne Moss posted about it on her blog.
In the last few days, The Guardian published a short post, Brown did an interview via Skype with a TV reporter in the Netherlands, another interview via email with a Washington Post reporter, and a phone interview with a blogger in Britain. Ten to 20 submissions from around the world pour into her inbox every day.
"I had no idea this would happen," she says. "Because it’s such a controversial thing, I was really scared. I was worried that people would think it was a negative thing. I'm completely shocked and amazed at what it’s gotten to."
It's not surprising. The National Center for Victims of Crime says that one out of four women and one out of six men experience sexual abuse before they are 18 years old. The U.S. Centers for Disease Control and Prevention's ACE Study (adverse childhood experiences) found similar results. That works out to about 45 million adults in the United States alone. And tens of millions more worldwide. It's safe to say that most of those people don't talk about the abuse for years, if ever, and even when they do, they're ashamed, as if they were to blame, and not their abusers. The traumatic experiences leave many living with post-traumatic stress disorder; many attempt to escape the memories by turning to alcohol, food, sex, smoking, risky activities or work for relief.
"I knew it would strike a chord," said Moss, 57, who was the first to be photographed showing her face. When she was five, her stepfather began molesting her every night for five years. When she was 10, he began raping her. "I didn’t realize the extent of where the project was going to go until the day that my picture launched. When she posted my picture, I blogged about it. Within 24 hours I had 800 hits on that post. If my blog was getting that much, hers had to be getting more."
Seeing Moss show her face inspired others to show theirs, including Brown, who relates her experience with her grandfather. "I've been surprised at how many young women show their faces," Moss says. "I wouldn't have done that at their age."
Of the women and men who are willing to show their faces, it's their expressions that stop you cold -- rage and grief wrapped in defiance. Some add their own words to echo their expressions:
Rape and abuse is vile and isn’t confined to women victims. I think every single poster abuser quote held up by the brave participants has been said to me after getting ass raped or having to perform oral sex on my Father from the age of six until I left home as a teenager. I never did tell and he never did slit my throat or kill himself. At certain times I wished he had. Not now. Thank you.
I refuse to hide anymore. If anything is owed, coming out of hiding is what I owe myself. I’m not afraid.
For others, it's a chance to ask questions:
The reason i feel ashamed and doubtful that it's a true attack is because the boy was a couple months younger than me. Although he had watched porn and knew what sex was, i didn't. It happened when i was really young. We both were. I just don't know. It's always bugged me.
I was brought to tears going through this blog, it breaks my heart. These people are so strong. I have a question though, is it rape if only fingers are used? And if I didn't explicitly say "no"?
I don't know what happened to me. I'm not even sure something did happen to me. I keep thinking I'm exaggerating, but my instincts tell me something's off. I think something happened, I'm not sure when, I'm not sure how. I realized that when an older man told me I was beautiful and he was fascinated with me (I was eighteen years old, he was forty) and I suddenly burst into tears. That had never happened to me. I felt something was off, I felt scared that something would happen again - but what?
With her years of wisdom and perspective, Moss has recently taken on the role of tackling these questions. She mostly assures them that they're not crazy; that their feelings and experiences are real; that if they did not consent, the experience was abuse or assault; and that it's a good idea to see a counselor.
She thinks Brown has hit a nerve because something like this would not have the same power if it was done in a therapist's office. "Because her project is strictly an artistic format," says Moss, "that's what’s been so empowering. It’s not a 'I’m sick and I need help' format. It’s a completely artistic project and it gives people the freedom to have their voice be heard."
"I’m not out to fix anyone," says Brown. She sees value in talk therapy, but regards this kind of art therapy as having the potential to reach and create a community of people who no longer feel alone and isolated. "The combination of the two can be powerful."
Brown is planning photo sessions in other cities. One is scheduled for March 3 in Washington, D.C. She's had invitations from people in other countries, and soon will be doing fundraising on IndieGoGo so that she can take her project to all the places in the world from which she's received invitations.
[This was cross-posted from ACEsTooHigh.com.]
[This is cross-posted from ACESTooHigh.com]
A few days before former Penn State assistant coach Jerry Sandusky was arrested on child sex abuse charges, and before Graham Spanier, president of Penn State, and long-time Penn State coach Joe Paterno were fired, NBA great Jerry West gave a very poignant interview on NPR about his new book: “West By West: My Charmed, Tormented Life.”
When West was a boy, his father beat him and his siblings. “You know, I know what corporal punishment is,” West told NPR host Scott Simon. “This was a lot more than that. And I think that I got to the point in my life where I’d had enough. And I told him one day after an incident with my sister where he had hit her and I just – I said to him, I said if you ever do that again, I am going to kill you. And I slept with a loaded shotgun under my bed.”
Despite Jerry West’s very difficult childhood, he became a success by anyone’s standards. However, as he says, “I can’t forget the things that I saw in my life. I will never forget those days.” He lives with depression. He says he doesn’t know what love is and, remarkably, has little self-esteem. Some people might say that Jerry West had some inner resilience that got him through those bad times. But that inner resilience was nurtured through playing basketball, where he had people who encouraged and mentored him.
So, let’s think about little Jerry West, the 10-year-old, for a moment. Or kids like him — kids who were targets for Sandusky’s charity, The Second Mlle. Those kids were called “disadvantaged”. That’s a euphemism — our society’s code for kids who are living with or have experienced trauma. That trauma can include a parent who has abandoned them, or a parent is an alcoholic or addicted to other drugs, a parent who beats them, verbally abuses them, or neglects them. Or a family member in jail or diagnosed with a mental illness. Or the kids have seen their mom beaten up. And yes, they might even be experiencing sexual abuse at home – that’s much more common than being sexually abused by a coach or a priest. And let’s say that these kids look up to a coach and dream of being a successful athlete, or of just relying on the organization and its adults to obtain some relief from what’s happening at home.
Let’s say that instead of having a supportive coach, West had a coach who sodomized him in the school’s shower room. Would little Jerry West have become an NBA star, or would that have been one trauma too many? Would his career have ended early because he drank himself into a stupor to stop the nightmares? Or would he have been unable to control his anger, beat up people at the slightest provocation and ended up a career criminal?
Contrary to popular belief, resilience is not innate. If you stress a child long enough and don’t provide any nurturing to recover from the stress, research shows that the effects are damaging and long-term. Just last month, Dr. Robert Block, president of the American Academy of Pediatrics, in an address at the organization’s annual meeting said:
“…toxic stress has now been shown to be a cause of behaviors like alcoholism and drug abuse, and a cause of significant diseases, from obesity to metabolic syndromes and diabetes, to cardiovascular and pulmonary disease and even some forms of cancer.”
Block cited the CDC’s Adverse Childhood Experience (ACE) Study, which began following 17,000 members of Kaiser Permanente in San Diego in the mid-1990s. Kaiser Permanente is a health maintenance organization with hospitals and clinics in several states around the country. The ACE Study exposed what CDC physician and epidemiologist Dr. Robert Anda calls a “chronic public health disaster”. Anda is one of the co-founders of the ACE Study, with Kaiser physician Dr. Vincent Felitti.
In a nutshell, the study measured 10 childhood traumas – physical, emotional and sexual abuse; emotional and physical neglect; a parent who’s an alcoholic or addicted to other drugs; a mother who’s been battered; a family member in prison or diagnosed with mental illness; and a loss of a parent through divorce, abandonment or death. (Of course, there are other possible traumatic events a child can experience – such as severe illness or catastrophic accident – but those were not measured.)
The findings stunned the researchers, and go a long way to explaining what happened at Penn State:
There’s a direct link between childhood trauma and adult onset of chronic disease, such as diabetes, heart disease, emphysema, and some types of cancer.
People who had three or four types of trauma during their childhood (experiencing physical abuse, an alcoholic parent, and witnessing a mother who’s a victim of domestic violence, for example, counts as an ACE score of 3) saw their risk of chronic disease jump 300 to 400 percent. Higher ACE scores resulted in risk levels increasing 800 to 1200 percent.
If a person experienced one type of trauma, there was a 90-plus percent chance that there would be more. In other words, trauma such as child sex abuse rarely occurs alone – substance abuse, mental illness or one of the other traumas also exists.
Only 30 percent of people in the study had zero ACEs.
Here’s the final stunner – the 17,000 people who participated in the study were 75 percent white, middle to upper-middle class, 76 percent had attended or graduated from college, and, since they were members of Kaiser through their employers, they had jobs and great health care.
Fourteen states have done their own ACE surveys and are finding similar results. Thanks to the ACE Study, people who thought that child trauma occurs mostly in inner cities in communities of color are beginning to understand that child trauma is common and occurs in all segments of society.
While the ACE Study was being done, brain researchers were providing the physiological explanation of how child trauma leads to adult onset of chronic diseases. When children endure continuous trauma, the hormones that provide the fight-flight-freeze response don’t turn off. The hormones become toxic – they actually damage a child’s brain. You can see the destruction on brain scans. Dr. Jack Shonkoff at the Harvard University’s Center on the Developing Child put together a great video that explains this.
The result: Kids can’t learn, they have difficulty making friends and they won’t trust adults. They can’t keep up in school, they get in fights or withdraw, and they’re suspended from school. They cope with their trauma by turning to alcohol and other drugs, they smoke, they become daredevils, they eat too much, they engage in inappropriate sexual behavior, and/or become overachievers, i.e., workaholics. All this helps numb the psychological pain of years of being beaten or enduring an uncle forcing sex on them whenever he visited or being awakened at 2 a.m. by a drunk parent to be yelled at for hours. Their “drug of choice” – smoking, drinking, food, work – helps them escape from the misery of feeling like failures or that, somehow, they were responsible for the trauma they experienced. Above all, their drug of choice tempers their feelings of isolation and abandonment because our institutions have done nothing to help them. (Note to those who think that education is the answer to convincing people that smoking, drinking or overeating is bad for them: Please consider this – why would we ever expect someone to give up overeating, drinking too much or smoking if that person regards those behaviors as solutions, not problems?)
Carried on for decades, the double whammy of the physiological effects of stress and coping behaviors will result in those chronic diseases that are costing our country the most emotionally and economically, says Dr. Vincent Felitti. Stress affects autoimmune functioning and releases inflammatory substances. Smoking, obesity, workaholism, alcoholism, drug abuse, etc. result in lung cancer, heart disease, diabetes, emphysema, depression, suicide, HIV-AIDS, and sexually transmitted diseases. People who have child trauma are also more likely to become perpetrators or victims of domestic violence and child abuse.
See the connection? Sandusky isn’t an evil man. He wasn’t born a pedophile. Pedophiles are made, not born. They’re shaped by the trauma that was done to them, and if they aren’t stopped and helped, they pass it on. And if he did the abuse that Pennsylvania’s Thirty-Third Statewide Grand Jury report accuses him of doing, then in all likelihood he has also passed on his sickness to another. It’s that simple.
And it’s that complex, because we’re all complicit in enabling child trauma, individually and institutionally (including my profession, the news media). Until it becomes visible on the body of a child – bruises, broken bones, starvation, etc. – our institutions don’t interfere in families where trauma occurs. In other words, our culture allows children to be beaten, raped, yelled at, ignored and/or starved. Our institutions further traumatize kids who act out their trauma by behaving badly in school by suspending them or ignoring those with obvious symptoms, or locking kids up. And when we can no longer ignore heinous abuse, our solutions are to shame and blame.
No wonder most child trauma remains hidden. That’s why the ACE Study found that 70 percent of people in those white middle-class families experienced at least one type of serious child trauma (other ACE studies are seeing the same results).
It’s easier for us to focus our fears on strangers instead of fathers, uncles, grandfathers, coaches, priests, mothers, aunts, etc. Or not to talk about it at all, as happened at Penn State. As Cherie Porter, my friend and a woman who’s fostered many abused and neglected babies, said, we just don’t have the language to talk about this. We wait until a situation escalates, in the Penn State case, allegedly to sodomy. And then we run screaming from the room, metaphorically speaking, and revert to the word, “evil”, which doesn’t help us solve anything.
There is hope, however. Small groups of people around the country are trying to figure out how to talk about this. They’re learning how to integrate the research about child trauma prevention into our society at every level, and how to make sure all of our institutions do not further traumatize children who are experiencing trauma.
As I’m writing this, there’s a meeting occurring in Minnesota, which is one of a small group of states – including Iowa, Nebraska, Illinois, Maine and Florida– whose goal is to become ACE-informed. Washington State is the leader in this effort, and has created a state-wide network called the Family Policy Council that partners with 42 community public health and safety networks not only to prevent child trauma but to create trauma-sensitive institutions – schools, juvenile justice systems, medical clinics — so that kids who are having hard time aren’t further traumatized, and to build resilience in them through nurturing and support.
Although the ACE Study shows a direct link between child trauma and adult onset of chronic disease, it’s not just health that’s affected by child trauma, says Dr. Rob Anda in this presentation he did in May at a meeting of the Alberta Family Wellness Initiative in Canada. “I see this as a developmental process that affects all of society,” he says.
We clearly saw that play out last week, when the consequences of child trauma brought down a university president and a football legend.
To be specific:
• 106 people indicated they'd lived with an alcoholic, problem drinker or someone addicted to street drugs.
• 194 people acknowledged they'd been emotionally abused.
• 161 noted they'd been physically abused.
• 155 indicated they'd been sexually abused.
For those of you who have no idea what I'm talking about, a recap: During two weeks -- from July 18 to July 29 -- we posted the simplified version of the ACE Study (the CDC's Adverse Childhood Experiences Study) questionnaire one question at a time in a daily poll. The 10 polls are aggregated here (you'll have to scroll down to find them). Each daily poll is accompanied by information about child trauma. You can find those on the ACEs group] page.
The CDC's ACE Study has been following 17,000 members of Kaiser Permanente, a health maintenance organization, in San Diego since the 1990s. Among this middle-class, overwhelmingly white, college-educated, employed population with great health insurance (Kaiser), the study found a link between childhood trauma, which was surprisingly common, and the adult onset of chronic disease. The ACE Study has been repeated in five states, the U.S. military has used it, as has the World Health Organization.
In the last post that accompanied the last poll on Friday, July 29, I promised to do an overview of all the polls by the following Monday. But I was so humbled that so many people were willing to revisit a difficult past by participating, however briefly, to vote in an anonymous poll, that I had to think about it for a while.
First....let's look at the results.
The screen grabs of all the posts are below. A reminder: These polls are completely unscientific. We published them just as a way to start the conversation.
Second....Just for conversation's sake, here are the ACE Study results for San Diego.
The weight of responses in our polls matches the top five in the ACE Study -- emotional, physical and sexual abuse; living with someone who's a problem drinker, alcoholic or addicted to street drugs; and losing a parent to divorce, abandonment or death.
Another remarkable finding of the ACE Study is that if a person had one adverse childhood experience, he or she was likely to have experienced others. In other words, family dysfunction usually isn't limited to just one thing. If a parent is an alcoholic, there's emotional or physical abuse or domestic violence that's likely to accompany it.
And the other eye-opener was that the more ACEs a person has, the more likely that disease will appear later in life. A person with an ACE score of four almost doubles her or his risk for obesity, heart attack and stroke; it almost quadruples the risk of emphysema.
Having childhood trauma doesn't mean that it will damage you for life. If there's an adult that steps in immediately to provide nurturing, then a child is likely to recover. However, if the trauma goes on for weeks, months or years, and there's nobody for the child to turn to, then stress hormones affect brain development, and a child has difficulty learning and interacting socially.
Third....What now? What are we going to do with this information?
I don't know. I think it's a question that our community has to answer, because my sense is that the people who participated in the poll are just the tip of the iceberg. Perhaps seeing the range of what's happening in other communities across the U.S. might provide some ideas:
- Washington State has taken the biggest steps. They recently passed a law authorizing public-private partnerships to incorporate the ACE Study into local community public health and safety networks to prevent childhood trauma. Ruth Kagi, who sponsored the bill, posted this oped about it in the Seattle Times.
- A pediatrician in San Francisco changed her practice to incorporate the ACE Study.
- Trauma-sensitive classrooms are springing up in Massachusetts and Washington State.
- A man in Merced, CA, has set up a local nonprofit called ACE Overcomers to help teens and adults overcome their experiences with child trauma.
- An Arizona consortium has partnered with the local PBS station to raise awareness of ACE.
We've taken an important first step -- us hosting a poll, you participating.
What do you want to do next?
For the last two weeks we've posted the simplified version of the ACE Study (the CDC's Adverse Childhood Experiences Study) questionnaire one question at a time in a daily poll. They're aggregated here. Each daily poll is accompanied by information about child trauma. Those are aggregated here, on the ACEs group page. This is the last in this series, and accompanies this last poll.
Thank you to everyone who participated and shared these difficult parts of your lives. We'll leave the polls open for a while longer. A follow-up post about all the polls will appear on Monday.
One of the ways to reduce the long-term effects of childhood trauma is to intervene immediately after a traumatic event occurs, otherwise post-traumatic stress disorder can develop and the physiology of a growing brain can be altered. A promising intervention called the Child and Family Traumatic Stress Intervention was tested on half of 106 children between the ages of 7 and 17 who had experienced a traumatic event. The other half had traditional support counseling. The children and their caregivers were recruited through emergency rooms, police, and child welfare and social services departments.
Most children experience at least one traumatic event while they're growing up, including abuse, witnessing violence, experiencing a serious illness or accident; one in five end up with post-traumatic stress disorder, according to this review of the project on ScienceDaily.com.
"This is the first preventative intervention to improve outcomes in children who have experienced a potentially traumatic event, and the first to reduce the onset of PTSD in kids," said lead study author Steven Berkowitz, MD, associate professor of Clinical Psychiatry at the University of Pennsylvania School of Medicine and director of the Penn Center for Youth and Family Trauma Response and Recovery. "If this study is replicated and validated in future studies, this intervention could be used nationally to help children successfully recover from a traumatic event without progressing to PTSD."
The four-part intervention occurs within 30 days of the traumatic event. In the first 90-minute session, the caregiver works with a counselor to fill out a long questionnaire about the trauma. In the second session, the child works with the counselor to do the same, according to this review of the project on PreventionAction.org. The counselor then helps the caregiver choose a strategy to improve communication between the child and caregiver, and the third and fourth sessions review progress and tweak the strategy. The strategies include recognizing and managing trauma symptoms and teaching coping skills.
After three months, the intervention was able to prevent chronic PTSD in 73 percent of the children. That's remarkable. But there's a catch, noted the researchers.
However, while CFTSI [the intervention] proved effective at treating those who received the intervention, the greatest challenge was getting needy families through the clinician’s door in the first place. Less than one in four of eligible and needy families actually agreed to participate and stay the course. According to Berkowitz and colleagues, this is because “caregivers are notoriously poor at recognizing acute post-traumatic stress symptoms in their children”. They argue that “it is incumbent upon child-serving systems such as pediatric emergency departments and child welfare agencies to facilitate the identification of exposed children in need of early intervention.”
It's not just needy families that can't or don't want to recognize traumatic symptoms in their children. As the ACE Study shows, it's also middle-class and upper-middle class families.
Editor's note: This is No. 9 out of 10 in a series of posts that accompany questions from the simple version of the ACE Study questionnaire developed by the Centers for Disease Control and Prevention. There are 10 questions on the simple ACE Study questionnaire; we posted the first five in polls last week and we're posting the rest this week. Today is the ninth question. Last week focused on the chronic diseases that show up in the lives of adults who experienced childhood trauma. This week focuses on how physicians, individuals, schools, and others are using the knowledge to heal or prevent child trauma.
Susan Cole is senior project director of the Trauma and Learning Policy Initiative at Massachusetts Advocates for Children and on the faculty of Harvard Law School. But before all this, she was a special education teacher. And she became concerned when she saw kids assigned to her classroom who she thought didn't belong. On some days they could learn without a problem, and the next day not be able to focus at all.
It turns out that in the 1990s, Boston schools were shunting thousands of kids into special education classes by classifying them as mentally retarded or just expelling them from school, when they were actually suffering from trauma. Unable to concentrate or participate appropriately, and under such severe stress that they walked through life with hair-trigger emotions, they often got into trouble. A task force was put together to investigate the impact of domestic violence on education, family law and other matters, and this led to creating the Trauma and Learning Policy Initiative at Massachusetts Advocates for Children.
Long-story-short, Cole went to law school because she felt she could have more impact on improving children's lives. She directs Harvard's Education Law Clinic, which is part of the Trauma and Learning Policy Initiative.
The goal of the Education Law Clinic is to help "children impacted by family violence and other adverse childhood experiences succeed in school", according to its website. Law students work with individual families and on policy issues. But Cole and others she worked with realized that trauma prevention needed to be incorporated into schools, starting at the first grade.
With five others, Cole wrote "Helping Traumatized Children Learn," also known as "The Purple Book", which has been downloaded tens of thousands of times. "We translated the ACE Study and neurobiological research into language that educators can understand," she said. "It helps people be kinder to kids who may be difficult." It also helps teachers, principals and other school staff develop a language that they can share to describe the low-achieving, non-disabled children.
"If one in four kids is sexually abused, we’re saying that we have to accept that any classroom is chock full of these kids," she says. Rather than turn a blind eye to children who are experiencing all types of trauma and acting out because of it, Cole wanted to help schools create an environment that helps children, and is comfortable enough for kids to talk about their problems if they want to.
"Kids spend most of their time at school," she said. "Where else can they have their underlying needs addressed, not feeling stigmatized by their ACEs, go on to achieve, become citizens and not feel marginalized? We think that place is school. You can’t fix a kid in a little room. They want to feel normalized in a group. They need validation and support."
Cole isn't interested in giving kids ACE scores. "We don't want to define kids by ACEs," she said. If children who are experiencing trauma and the neurobiological, psychological and social challenges associated with trauma, focusing on three things will help them be successful, said Cole:
- A strong relationship with a parent, or surrogate care-giver, who can be a teacher.
- Good cognitive skills
- An ability to self-regulate attention, emotions and behaviors.
The best way to do that is to create a classroom that teaches children about emotions and how to control them, she said. This creates an environment that is more conducive to learning so that kids can develop No. 2 on the list -- good cognitive skills. East Street Elementary in Ludlow, a town of 20,000 in Western Massachusetts, was one of the first schools to set up a pilot trauma-sensitive classroom....with a bunch of first-graders. I talked with Cole in 2008, toward the end of the first year it was put in place.
There's an incredible amount of work that goes into creating a trauma-sensitive classroom, and if you'd like more details, check out the keynote address for a 2009 trauma sensitive schools state conference that the East Street Elementary principal, Brett Bishop, presented.
Bishop chose the best, most-motivated first grade teacher and paired her up with a consultant to set up the trauma-sensitive classroom. It's a calm place, said Cole. The colors are calm. They created a special place lined with pillows for kids to go if they felt bad or needed to vent. During transitions, the kids listened to classical music. They brought in an intern from a mental health center to teach self-calming techniques, including breathing and exercise. In other words, the six- and seven-year-olds were taught to understand their own emotions as well as their classmates' emotions. And they were taught to regulate them, and help each other. "So rather than hitting somebody on the head, they knew to go in and hit pillows instead," said Cole.
Even with all this, a child would occasionally be so stressed out that he or she couldn't stay in the classroom. In that case, the child was sent to meet with Bishop. Instead of expelling or taking a punitive approach, he listened to the child express as best as possible, his or her frustrations, anger and sadness. And then he'd say, "You know, I've had days just like that. Let's go out and get an ice cream," said Cole.
"Our public policy revolves around taking kids out of school," she said -- which further traumatizes them. (To this point, a survey of several hundred juvenile probationers in Spokane, WA, found that the average age of their first expulsion from school was seven to eight years old.)
Although not without its hiccups, the pilot program was so successful that the goal was to make every classroom at East Street School a trauma-sensitive classroom.
Editor's note: This is No. 8 out of 10 in a series of posts that accompany questions from the simple version of the ACE Study questionnaire developed by the Centers for Disease Control and Prevention. There are 10 questions on the simple ACE Study questionnaire; we posted the first five in polls last week and we're posting the rest this week. Today is the eighth question. Last week focused on the chronic diseases that show up in the lives of adults who experienced childhood trauma. This week focuses on how physicians, individuals, schools, and others are using the knowledge to heal or prevent child trauma.
A few schools around the U.S. have begun incorporating lessons learned from the CDC's Adverse Childhood Experiences Study into classrooms. Called trauma-sensitive schooling, trauma-sensitive classrooms, or compassionate classrooms, they aim to try a different approach to helping stressed kids, who are usually labeled "disruptive" in traditional classrooms.
For 20 years, CBE Alternative High School in Spokane, WA, had already taken a different approach -- more individualized instruction and mentoring -- to educate its 400 students, all "high-risk" teens from several school districts. In 2006, recognizing that being a high-risk teen meant grappling with severe stress, the school overhauled its "processes and expectations" to accommodate the growing understanding that their students' past or ongoing trauma interfered with their brain development and their ability to concentrate, to control their emotions and to behave appropriately in class or in interactions with their peers.
When students are accepted into the school, each is interviewed. According to this case study by social worker Carrie Lipe and assistant principal Brian Dunlap, which appears in the publication The Heart of Learning and Teaching:
Students talk about being suspended or expelled for non-attendance, fighting or drug use, escaping school conflict and bullying, or about not getting along with school staff. Some mention the need for a more flexible schedule in order to hold down a job, take care of a sick or addicted parent, younger siblings, or their own young child. Some talk about struggling with an addiction themselves, or a mental illness or medical condition that has stood in the way of consistent school attendance. Some reveal disrupted relationships, multiple moves, family conflict or placement in foster care due to abuse or neglect in their family of origin. Some speak about running away, dropping out, couch surfing or living on the streets. Each student’s story differs in detail, but a common thread running many of our student’s experiences is ongoing STRESS.
Some of the changes the school has made include:
- Assigning each student a "go-to" adult, an adviser who meets briefly with the student every day.
- Identifying and supporting students most at-risk for dropping out.
- Adding Psych 101, a required discussion-based class that "straddles the line between group therapy and academics"; it offers "social/emotional skill building and topics relevant to coping with the consequences of interpersonal stress, including recognizing emotional triggers, regulating emotions, managing stress and increasing the capacity for self reflection."
- Adding classes requested by students, including Bio-Psychology (the biology of attachment, addiction, anxiety, anger, etc.) and Advanced Emotion Regulation.
- Starting a biofeedback program.
- Instituting training to help teachers and staff with their own triggers when they deal with students who operate in a more or less continual high stressed-out state.
The results have been stunning. The case study noted that, in the first three years, the the number of students staying enrolled through the end of the year more than tripled. And the number of students earning a year’s worth of credit (regardless how long they were enrolled) increased by a factor of ten compared to the previous year.
Editor's note: This is the seventh in a series of posts that accompany questions from the simple version of the ACE Study questionnaire developed by the Centers for Disease Control and Prevention. There are 10 questions on the simple ACE Study questionnaire; we posted the first five in polls last week and we're posting the rest this week. Today is the seventh question. Each day I'll take a look at some of the research — ACE, brain development, and epigenetics (the study of how experiences turn genes on and off) — to provide more information and context, as well as efforts to use the information to reduce and prevent child trauma. I encourage you to take the simple ACE test for yourself. There's also a link to the full 200-question survey.
Connie Valentine founded the Incest Survivor's Speakers Bureau (ISSB) in Northern California in the 1990s. When we met in 2004, I asked if the organization actually received many speaking requests. "Not so much," she laughed.
Connie is one of the most intrepid women I know. She set up the ISSB, and then started annual meetings to focus on child trauma, particularly child sex abuse. Some years, only a handful of people showed up. She was serene. It doesn't matter, she said. We'll hold it, and whoever shows up, that's who needs to be there. At the last meeting in April -- No. 17 -- 165 people attended. That's not bad for a gathering about an issue that most people would prefer that didn't exist in our world, and yet that has touched one out of four women and one out of six men.
In 2002, she wrote an open letter called "Dear Doctor", which was published by The Permanente Journal. Connie wanted the journal to use her real name, but the editorial board, after great debate, decided not to, to preserve the "anonymity of any involved persons", even though Connie did not name anyone in her essay, and her abuser is dead.
By the time I met Connie, she was well on the way to a healthy life. I wouldn't call her robust, but for all she's experienced, as she says, it's amazing that she's alive. In April, I asked if she was okay with her essay appearing on WellCommons. She agreed, and, again, wanted her real name used, for the same reason she gave The Permanente Journal: "I no longer feel shame about the events of my life. The shame belongs to the perpetrators. Rather, I feel sorrow. They are people who need forgiveness, and I forgive them."
Her essay is the story of many people who suffered child trauma, of our health care system, and of the power of healing. It is painful to read, and, in one paragraph, graphic.
SO DO NOT CONTINUE IF READING ABOUT CHILD SEX ABUSE WILL CAUSE YOU ANGUISH. Usually, we journalists put a barrier of our own descriptions of a situation between the people who experience it and our community. But this is a first-person account. No barriers.
I am your patient. We have known one another for a long time, and I want to thank you for healing me so many times.
At present, you know me only from annual checkups as a healthy 58-year-old, divorced, Caucasian female; 120 lbs, 5'6"; two adult children; parents and all four siblings living; family history of diabetes, epilepsy, alcoholism, bowel cancer, and heart disease; no medications.
You met me first in 1943 in Pennsylvania. I was a normal 5 lb 6 oz infant, born under general anesthesia. My mother nursed me for eight months, and I grew normally. You were surprised and concerned when I returned in six weeks for a well-baby check and immunizations. I had developed an extremely loud heart murmur, but you assured my worried mother no surgery was needed.
After I turned three, you saw me often in New Jersey, Virginia, Alabama, and Massachusetts. I had frequent, severe ENT problems, ear infections, strep throat, double pneumonia, scarlet fever, mumps, measles, chicken pox, "grippe" viruses, and a host of other pediatric problems. It is fair to say that sulfa and penicillin saved my life.
You may have noted in your chart that I was thin, compliant, and quite withdrawn. When I turned seven, you bandaged a deep cut on my thigh.
You surgically removed my tonsils and adenoids.
Later that year, you irradiated a regrowth of my adenoids. You also irradiated my enlarged thymus in a hopeful, experimental procedure. The hypothesis was that removal of the thymus gland would increase my immune system. Unfortunately, it had the reverse effect.
You probably made a note that I missed many months of school each year due to illness and that my lips and fingernails frequently turned blue. You x-rayed my teeth frequently and filled my numerous caries every year for decades.
You met me at a medical convention when I was a shy, embarrassed 12-year-old. As a group, you examined my heart, amazed at the murmur which could be heard without a stethoscope. You noted my thinness and suggested an enriched diet. You extracted four teeth for my braces.
When I was a pretty, studious, 14-year-old in Louisiana, you bound my fractured left arm to my body for six weeks after I was thrown from a horse. Later that year, you carefully put 167 stitches in my face after I was thrown face first through the passenger side of a non-safety-plate windshield during an automobile collision. Safety belts had not yet been developed. You told me it was a miracle my eyes were not damaged, because the glass cut through both eyelids. The following year in Texas, you removed the keloid scars, but I was no longer pretty. In fact, a priest who came to visit me in the hospital fainted when he saw me.
You treated me for acne.
You catheterized my heart before I went to college and found a persistent superior right vena cava, extra brachial arteries, and a valve defect. You told me not to climb mountains or go deep-sea diving.
You extracted my wisdom teeth.
You put me in a steam tent for a week in my Ivy League college infirmary for treatment of bronchitis. You treated me for severe dysentery (shigella) when I returned from my junior year in Europe. I had diarrhea all my life, so I did not call you until I was very ill. You told me how fortunate I was to be alive.
I was prevented from joining the Peace Corps due to the heart murmur.
Instead, I went to work in Central America after college graduation. While there, after I made a conscious decision to have my first love affair, you hospitalized me for a month. You explained I had a 50-50 chance of living and surgically lanced a severe pelvic inflammatory infection. Both fallopian tubes were closed due to scarring. You explained gently that I probably could not have children but that I was fortunate to be alive.
In my later 20s, in California, you treated me for a fractured bone in my foot, yeast infections, and more dental caries. After I biked up a mountain and had heart pains that radiated down my left arm, you reiterated the restriction not to climb mountains.
You listened to me for a year as I wept for my younger sisters (I took the 14-year-old for an abortion and brought the 15-year-old to live with me due to severe anorexia). I am grateful you never prescribed medication for my grief. Through my employment, you taught me about biofeedback, which served to reduce my anxiety.
When I finally got the courage to fall in love again, you prescribed birth control pills, in case we were wrong about the infertility. You gave me a hysterosalpingogram that showed a tiny opening in one fallopian tube.
You gave me immunizations before I went to live overseas, then treated me for head wounds in Thailand when I was beaten up by a stranger. After I went deep-sea diving and had heart pains that radiated down my left arm at 50 feet below the surface, you reiterated the restriction that I avoid deep-sea diving. You told me I was fortunate to be alive.
When I was 27, I received a letter from you about the radiation treatment 20 years before. You said I was at high risk for thyroid cancer due to the heavy dose to my throat area. You gave me a procedure that showed no cancer. It also showed I had only half a thyroid. I felt fortunate to be alive.
After I graduated from a master's program, you gave me a Wasserman test before my marriage at age 33. To our mutual surprise, you determined I was pregnant at age 37 and said I was probably carrying twins.
I stopped drinking alcohol the day you told me I was pregnant.
I didn't tell you I drank too much and had blackouts. I didn't tell you every relative I had was probably alcoholic. I didn't tell you my husband drank every night and used nonprescription drugs with increasing frequency. I didn't tell you about his scathing comments and humiliating treatment of me, and how I couldn't seem to leave him. I didn't tell you I had joined Al-Anon, a support group for spouses, families, and friends of alcoholics. I didn't tell you I had smoked a pack of cigarettes per day for ten years until I was 36 years old. I didn't tell you about the daily headaches that stopped, along with the cravings for cigarettes, after ten biofeedback sessions. I didn't tell you that I worked part-time for many years because of fatigue, distress, and inability to concentrate. I didn't tell you I had left my faith practice for over two decades and felt lost and alone. I didn't tell you that, as a child, I was moved to a new house every other year. I didn't tell you that, as an adult, I moved nearly every year in a vain effort to run away from my feelings. I didn't tell you about the fear, loss, and depression I felt, even when times were good. I didn't tell you about my suicidal ideation. I didn't tell you about my phobias of elevators, enclosures, injections, electricity, public speaking, and groups. I didn't tell you about the rage I felt when someone was maltreated. I didn't tell you that as a child I compulsively read everything I could find about the Holocaust. I didn't tell you how in adulthood, books on incest made me nauseous. I didn't tell you about the "covert" sex abuse by a family member who told me dirty jokes and gave me "funny" back rubs. I didn't tell you I had joined an incest survivors support group. I didn't tell you how spacey and jumpy I felt at times, especially when surprised. I didn't tell you about my frequent nosebleeds in childhood. I didn't tell you I kept a baseball bat by my bedroom door as a child. I didn't tell you about my terrible nightmares in childhood. I didn't tell you that I could not remember much of my childhood.
You didn't ask me, and I didn't think to tell you.
After several months, you determined through amniocentesis and fetal monitoring that there was only one healthy, male fetus. You kept careful track of my potential for diabetes and my loud heart murmur.
The pregnancy was unremarkable until seven months of gestation, when I developed high blood pressure and edema (which you diagnosed as preeclampsia), despite my good diet and high socioeconomic status. You put me on complete bed rest, but the water broke six weeks before my due date. After I labored for 12 hours, you did a Cesarean section with full anesthesia and delivered a healthy 2.2-kilo male child with an APGAR score of 9. I remained in the hospital for five days, although my son remained in an incubator for another five days. He had severe colic but was otherwise healthy. I nursed him for a year.
Twenty months later, again due to preeclampsia, you put me on complete bed rest at seven months, gestation during my second pregnancy. You scheduled me for a second Cesarean, and I delivered a healthy 6 LB, 7 oz, full-term female child.
We met frequently thereafter. My physical health deteriorated from stress as I turned 40 years old with a nursing infant and a toddler. You treated me for bronchitis, "flu" viruses, and a severe breast infection that brought an end to breast-feeding my one-year-old daughter.
I met you again because I could not swallow due to canker sores. You suggested prednisone, which I declined due to side effects. You biopsied tissue on my cervix, breast, ear, and back. You used the term "precancerous cells" but explained that surgery was not needed yet.
I met your colleague, a PhD nutritionist, through the phone book yellow pages and began an intensive vitamin regime that reversed all my symptoms after six months. I knew I was fortunate to be alive.
You immunized my children and treated them for frequent ear infections and sore throats. You treated my son at age four for a strange rectangular patch on his foot, which you diagnosed as cellulitis. You treated my daughter at age four for a kidney infection. After catheterizing her, you found a valve defect between her bladder and kidney.
You examined me when I had a ten-minute episode of intense pain in my vaginal area. You found nothing physically wrong.
You listened patiently as I wept about my failing marriage and alcoholic father and encouraged me to move on. After my divorce, you treated me for pneumonia.
You removed my uterus and ovaries after I bled for two years. You told me I had fibroid tumors. You gave me light general anesthesia for this surgery because I finally told you I was a recovering alcoholic and my body was very sensitive. You listened to my grief at the end of my miracle of childbearing. You prescribed estrogen and ten years later stopped the prescription because of the potential side effects.
You gave me annual general medical checkups, mammograms, colonoscopies, Pap smears, and blood tests. You continued to monitor my heart murmur with annual specialty examinations, electrocardiograms, and echocardiograms.
During my occasional bouts of angina, you would conduct a stress test but could find no reason for the pain. I was not able to buy life insurance because I was a high-risk patient. You were as mystified as I by the occasional sharp pains I felt in different parts of my body, and odd brief periods of malaise.
In 1988, after another automobile accident, you flushed my eyes to remove the glass that flew from an exploded mirror. A car had crossed the highway median and hit mine with such momentum that the other car flipped twice and landed upside-down. You patched my left eye and later found a corneal scar. You commented that I was fortunate to be alive and still sighted and prescribed glasses so I could see more clearly.
Then, in 1989, my life turned upside-down. My postdivorce life finally settled down, and my children began elementary school. I decided to look for the reason for the extensive childhood amnesia and why I felt so miserable despite my comfortable lifestyle. For the first time, I told you about the amnesia and asked you for hypnosis. I then began having frequent nightmares of dying animals and killing fields. Fortunately, you did not prescribe sleep medication.
For therapy, I found a nonphysician who specialized in treating sexually abused women. He did not believe in medicating emotional symptoms but rather, finding the source of the pain. This remarkable therapist, a former police investigator, understood that amnesia occurs for a very good reason. He spoke gently, compassionately, and simply. He had good boundaries, strong ethics, and a spiritual understanding. He knew that his clients may feel fragile but are actually very strong.
He had a program of simple education about amnesia, dissociation, and the chemical changes that take place in the body during trauma, coupled with worksheets for his clients to complete. He led a support group, which I did not take part in.
I told him about the experience I had at age seven, of being spanked with my pants pulled down. I explained I had talked about this event many times but never felt relief from the pain. I described a nightmare that plagued me, consisting of the sounds of the clink of a belt buckle and the zip of a zipper.
One pretty April morning in 1989, I went to the therapist's office. He led me through a relaxation exercise, instructing me to tense, then relax, each major muscle group. He then asked me to go to a well and find the child I used to be, nurture her, and ask her what happened. I did that and found myself as a distraught seven-year-old. I began talking about that day when I was spanked on my bare buttocks.
Suddenly, I began reliving the event. I refelt the sharp slaps. I saw the pants legs as my head hung down across the adult's knees. I refelt the humiliation and pain.
Then, just as suddenly, I stopped reliving the event. It felt as if I had pressed the "pause" button on an emotional and mental video of my life. I hung there, suspended in the midst of acute pain.
The therapist asked quietly, "Then what happened?" It felt as if I pushed the "play" button. I refelt being pulled up by my left arm, and heard the clink of a belt buckle and zip of a zipper. I refelt the terror as I was pushed to my knees, and the adult sat back down on the edge of the bed. I refelt his hand on the back of my head as he pushed his penis into my mouth and moved my head back and forth. I retasted the ejaculate. I refelt being pushed to the floor, and left, like a used condom, as he went out of the room.
I gagged and wept uncontrollably. And finally, I felt relief from that event. It has not troubled me since that day. A hidden psychological abscess had finally been lanced, and my mind quickly healed itself.
This began a five-year therapy period, during which I was able to fill in many of those blank places in my childhood. Each week I would remember just a little more, no more than I could bear. Some days, I could only relive a few minutes of the past. The pain at times felt unendurable, but the therapist assured me that I would feel better. I would scream with rage and fear on the drive home from his office. That's how I healed from each remembered betrayal.
What I remembered was about my grandfather, who was a physician. He went to war when I was an infant and returned in 1946, when I was three years old. He then began to harm me in every way imaginable. Some of you will not want to believe this. However, children exposed to this kind of abuse are someone's daughters and sons and they will someday be someone's spouse, parent, and patient. Will you recognize them in your practice, or will you look away?
My therapist once wondered aloud why I was not committed to the back ward of a state psychiatric hospital. I answered, "I dissociate well." He and I agreed I was fortunate to be alive.
I don't need to go into detail about the crimes and brutalities I endured. I'm sure you've seen patients who experienced similar events, although you may not have recognized them. My purpose is not to shock but to teach that children can display few psychological symptoms; that the body takes the brunt of the psychosomatic effects in those of us who dissociate well.
The purpose of my letter is to tell you what happened a year after I began trauma recovery. I went to see you for my annual cardiology examination. You listened to my heart, as you had for the past four and a half decades in different countries, different states, different hospitals, and different offices. You listened again, not looking at me. Then you did a quick electrocardiogram and glanced at my thick file. And listened again, with a puzzled look on your kind face.
Finally, you looked directly at me and said, "There is no more heart murmur. I can't explain why. But you no longer need to see me for annual examinations."
I applied for a life insurance policy the very next day, which I continue to have as a talisman of healing. My physical health has been excellent, despite other life stresses, ever since I began unearthing the buried events from my childhood that broke my heart. The angina and sharp pains resolved as soon as I remembered the origin of those pains. My emotional health and sense of well-being improves daily.
A physician colleague of yours in the Southern California Permanente Medical Group found that the long-term medical consequences of incest, rape, and molestation are
chronic depression morbid obesity marital instability high utilization of medical care gastrointestinal distress, and recurrent headaches.
He also found that the more adverse childhood experiences a person has endured, the higher the rate of
alcoholism drug abuse depression suicide attempts smoking poor health high number of sexual partners sexually transmitted disease ischemic heart disease cancer chronic lung disease skeletal fractures, and liver disease.
His research is extraordinarily validating to me, since I have a majority of the after-effects he describes. I believe that by storing the traumatic memories well out of consciousness, my immune system collapsed, resulting in illness and structural damage. The stress of repeated trauma may indeed have blown a hole in my heart valve. By remembering, talking about, and grieving these events, I found that the intense psychological pressure was relieved and my body simply healed itself. Nature prefers homeostasis. Even broken hearts can heal.
At a child abuse conference in Sacramento in the early 1990s, the psychologist, Dr John Briere, remarked that, if child abuse and neglect were to disappear today, the Diagnostic and Statistical Manual would shrink to the size of a pamphlet in two generations, and the prisons would empty. I agree. As physicians and particularly as pediatricians, you are in a position to help end this epidemic of child abuse. You must do so with great care, because perpetrators have gained inroads in the systems that are supposed to protect children. But you are in a unique position, and I encourage you to work together in this serious matter.
I am writing to thank the hundreds of you who treated me throughout my life, particularly when I was young. I am forever grateful for your concern for my health and well-being and for your gifts of antibiotics. I am even more grateful that you gave me biofeedback and relaxation as an adult rather than medication to blunt symptoms of my childhood trauma, so that the encapsulated, abscessed memories could surface and heal. I am, indeed, fortunate to be alive.
Editor's note: This is the sixth in a series of posts that accompany questions from the simple version of the ACE Study questionnaire developed by the Centers for Disease Control and Prevention. There are 10 questions on the simple ACE Study questionnaire; we posted the first five in polls last week and we're posting the rest this week. Today is the sixth question. Each day I'll take a look at some of the research — ACE, brain development, and epigenetics (the study of how experiences turn genes on and off) — to provide more information and context. I encourage you to take the simple ACE test for yourself. There's also a link to the full 200-question survey.
If the link between child trauma and the adult onset of chronic illness is so clear, why don't all physicians use it in their practice?
Some have, with an interesting result, said [Dr. Vincent Felitti, co-founder of the Centers for Disease Control and Prevention's ACE Study, last week in a webinar he did for SAMHSA -- the Substance Abuse and Mental Health Services Administration. SAMHSA is a federal agency whose goal is to reduce the impact of substance abuse and mental illness on America's communities.
When physicians at Kaiser Permanente, where the Adverse Childhood Experience Study took place, began asking patients about their childhood trauma (the biopsychosocial approach vs. a biomedical approach, below), an interesting phenomenon took place -- they made fewer visits to doctors.
In the Q-and-A following the webinar, Felitti answered these questions. The questions and answers are abbreviated and edited here. For the entire exchange, listen to the session.
Q. Does the decrease in doctor visits have to do with basic recognition of issues that underlie individual's behavior?
We have wrestled with that question for a long time. People have said to me, "You sent everyone for therapy, right?" No, rarely did we do that. What we did was to routinely ask about things kept secret, to enable people to speak openly about these topics, and we made it clear to them that they were acceptable to us as human beings. This all took place in a space of a few minutes. Does this mean that people are healthier? We don't know. They appear to be less troubled. By the way, doctor's office visits are not driven by disease, but by anxiety about disease.
Q. What would be a good lead-in question to get used to discuss these issues?
We have had enormous experience in using extensive paper-based questionnaires that were filled out by hand. Then we fed the questionnaire into a digital scanner, and it was reformatted into a formatted laser output. What we had in hand when we saw patients was really quite extraordinary. It made it possible for us to ask things like: I see on the questionnaire that you were the one who discovered your father's body when he hanged himself. Tell me how that's affect you later in your life. Or I see that you were molested when you were a kid. Tell me how that's affected you later in your life. Once it's out, then it's easier to bring it up. You know where you can go or don't need to go. The key question you want to pose is: Tell me how that's affected you later in your life. We have done this with enormous numbers of people -- over 440,000 people over 8 years -- very, very successfully.
Of course, not everybody was instantly comfortable doing this. But most of the staff became remarkably adept at doing this. The answers do not open a Pandora's Box. My colleagues initially said, I don't have an hour to listen. The answers tended to be one to one-and-a-half minutes long, often including information that enable a physician to figure out what he needed to do.
A. You said that using information clinically will be resisted? What is typical rationale, and what do you recommend that be overcome?
I think the true basis of resistance is that this approach awakens personal ghosts in us. Seemingly plausible explanations are that insurance doesn't cover it, I don't have time. All of those are partially real. Another reason that people correctly offer is that they've never been trained to do that kind of work. "If i'd been trained to be a shrink, then i would've been a shrink. I'm a pediatric endocrinologist," for example. But I think it's mostly that it awakens personal ghosts. This approach -- asking patients about their child trauma and how it affects their health -- represents a paradigm shift in primary care practices. This is not a minor shift.
Dr. Eric Blau, a Kaiser physician who worked with Felitti, provides some additional insight. “When the study was first being done,” says Blau, "I was shocked and didn’t believe it. It goes against everything we’re taught about why people get sick later in life. That’s related to genetics or things that happen to you as an adult.”
And though he now calls the study groundbreaking, Blau explains why the medical community just doesn’t know what to do with it.
“I can give you the cynic’s point of view. There’s no cure, so why are you bothering to ask patients about their childhoods? If they’re smoking because they were abused at age 5, what good is it to know? It’s better just to deal with cigarette addiction. And another view is that a lot of people just don’t have time in their offices to deal with this.”
Even though the ACE Study offers awareness, but no treatment, Blau still uses it in his practice.
“I ask them questions about their lives,” says Blau. “If they weigh 100 pounds more than they should, I don’t think it’s their genetics. I ask them when they got fat. People get fat because of things that happen to them as children. If you ask about this, then you can get to the root of the problem. We may not have a good therapy, but at least we can identify the problem. Sometimes it helps them, sometimes it doesn’t.”
The public health community, however, is beginning to embrace the study. Five states have included the ACE questionnaire in their Behavioral Risk Factor Surveillance System. Every state has one, and uses it to determine its population’s health so that it can put resources where they are needed to prevent illness, such as heart disease and lung cancer.
“For the first time, this will give us some population based data,” said Dr. David Brown, a CDC epidemiologist. “I fully expect data that comes out of states is going to support what we’ve seen in Kaiser data.”
He likens the slow acceptance of the ACE Study to another large public health issue — the dangers of high blood pressure. The first data about high blood cholesterol was gathered nationally in the late 1980s. Then pharmaceutical companies began doing clinical trials with cholesterol-reducing drugs. In the mid- to late-1990s, states began starting programs in heart disease and stroke. Between 2000 and 2005, all states offered programs. All of that came out of the Framingham Heart Study in Massachusetts, which began with a few thousand people in the 1950s. “That’s a long process,” says Brown. “That’s kind of where the ACE Study is at as well.”
What if depression wasn't a disease, but a normal response to trauma? That's one of the questions [Dr. Vincent Felitti, co-founder of the Centers for Disease Control and Prevention's ACE Study, posed this week in a webinar he did for SAMHSA -- the Substance Abuse and Mental Health Services Administration. SAMHSA is a federal agency whose goal is to reduce the impact of substance abuse and mental illness on America's communities.
He says our current approach to helping people get over addiction is all wrong. "You have to look at the benefits [of drugs, alcohol, food, etc.] rather than the risk," he said. People who are addicted to alcohol, cigarettes, drugs, food regard them as a solution, not a problem.
He showed several videos of his patients, including one who called the 200 extra pounds she carried "a protective barrier". When she was a child her grandfather sexually abused her. A man who had ended his addiction to alcohol and other drugs would not give up smoking. "It keeps a door closed to the past."
Why are addictions so difficult to treat? In this country, said Felitti, if someone has had a traumatic experience, perhaps decades ago, our attitude is "just get over it." But that's difficult, as he pointed out with this image of the brains of two children. The one on the left is a healthy 3-year-old American boy. The one on the right is a three-year-old Romanian boy who lived in one of the many Romanian orphanages that were known for severely neglecting children, thousands of whom were imprisoned in cribs and rarely given attention.
With no activity in a brain that is supposed to be making 700 new synapses a second, the experience of neglect, in this case, is sure to alter the brain architecture, said Felitti, which means its formation, and thus its function will be damaged. Traumatized children aren't able to concentrate in school. They have difficulty learning how to interact socially, because they're in flight, fight or freeze mode. They grow up using substances that offer relief from their situation, or to keep a door closed on the past, as Felitti's patient said. And the more types of trauma they experienced -- the higher their ACE score -- the more likely the addictive behavior.
Among the substances that help people cope with their traumas are alcohol.
The nicotine in cigarettes suppresses anger, is an anti-depressive, and helps with anxiety and hunger.
The consequences of child trauma also include addiction to anti-depressants. Felitti noted that methamphetamine was the first anti-depressant put on the market in the 1940s by Burroughs Wellcome Company under the brand name Methedrine. Noting the current rampant addiction to methamphetamines, Felitti said he doesn't think it's coincidental that so many people are addicted to an anti-depressant.
The behavioral outcomes of trauma and addiction include domestic violence. What's surprising in this graph is that the higher a woman's ACE score, the more likely that she will be a perpetrator, said Felitti. Women's victims are their children.
With trauma and addiction affecting people's work lives, poverty is an outcome of child trauma, said Felitti.
This is the fifth in a series of posts that accompany questions from the simple version of the ACE Study questionnaire developed by the Centers for Disease Control and Prevention. There are 10 questions on the simple ACE Study questionnaire; we've posted them in five polls this week and we'll post the rest next week. Today is the fifth question. Each day I'll take a look at some of the research — ACE, brain development, and epigenetic — to provide more information and context. I encourage you to take the simple ACE test for yourself. There's also a link to the full 200-question survey.
In yesterday's ACE poll -- a series of questions from the simple version of the Adverse Childhood Experience Study questionnaire developed by the Centers for Disease Control and Prevention -- 142 people (out of 369) said they'd been sexually abused before they were 18. As mentioned in previous posts, our polls are completely unscientific. And this series is really just to get the conversation started about the ACE Study and child trauma.
So, we can't say anything like "38 percent of our community was sexually abused as a child". We can only know that too many people are living with a memory of a horrible experience or experiences that has likely affected their lives in profound ways, including their health.
The ACE Study, which follows 17,000 people in San Diego who are members of the Kaiser Permanente health care maintenance organization, found that 20.7 percent -- one out of five people -- had been sexually abused before the age of 18; that rate was higher in women (25 percent, or one out of four), and lower in men (16 percent). Washington State, which did its own ACE survey in 2009, found that 12 percent of the population had been sexually abused -- 17.5 percent for women and 7 percent for men.
Most research shows that child sex abuse is higher than reported in Washington State. The researchers say the difference may be because the Washington survey was phone-based -- people answered these questions over the phone while talking to someone they didn't know. The ACE survey was a paper survey filled out by people in their homes, and they knew that it would be given to their doctors. There's a difference in degree of comfort there.
Okay. Enough with the numbers. They're appalling. And the lives altered....unspeakable. Literally. Of all the questions on the ACE Study, this is probably the one that addresses an issue that remains the least talked about, privately and publicly. What can you say about a grandfather who regularly rapes his six-year-old granddaughter? Or a military officer who brings his friends over to have sex with his daughter? Or a priest who fondles a choir boy? Or, as someone said in the comments on the poll yesterday, an optometrist who "took my hand and put it on his pants, over his penis. I was so young I didn't know what it was all about. Thank God he's dead now."
“It’s like you’re running all of your life,” said Ella Herman, 70, in an interview we did last year. Herman says she was sexually molested when she was a child, starting at age 4, by two uncles and a school bus driver. In her 20s, she weighed 115 pounds; she’s weighed as much as 300 pounds. She’s 5 feet 4 inches tall.
Herman was a member of Kaiser Permanente in San Diego. She owned and ran a successful day care center for 12 years before she had a heart attack at age 60. She joined a weight control clinic for the severely obese in the early 1990s, when Dr. Vincent Felitti, who ran the clinic, wanted to find out why people who were successfully losing weight were dropping out. One day he talked about the link he had found between child abuse and weight gain. That was a turning point for Herman.
“I remember him saying that he had read 25 charts,” recalled Herman, who is now retired and living in Mississippi. “And almost all of them had been sexually molested as kids, even the men. I started crying and another woman was crying and crying.”
Felitti went on to found the ACE Study with Dr. Robert Anda at the CDC. A big wake-up call for him was that many people in his weight clinic who were obese found that food was a solution, not a problem as he and the clinic had been addressing it. For many it was a barrier, a protection. One man told Felitti that, as a skinny, scrawny child, he was beat up nearly every day at school. When he gained a lot of weight, the kids stopped beating him up. Even as an adult, he was afraid to lose the weight. Another woman, who'd been raped at age 19, and had gained 100 pounds, said that being "overweight was being overlooked," and that's how she preferred it.
Other people who suffered child sex abuse or other trauma have chosen other solutions for their pain -- alcohol, prescription drugs, workaholism, risky sexual behavior, etc. It's not that people don't recognize that these solutions aren't bad for them. It's just that the pain of abandoning those protective solutions is greater than the pain of their consequences.
“Being obese really affects my body,” said Herman. “I have arthritis, lumbar spinal stenosis, got a heart stent. I take about 24 different kinds of meds a day. There’s just too much gone wrong.”
However, until she joined the Kaiser weight clinic, Herman had never connected her innate inability to lose weight with her fear of being sexually abused.
“I did not connect it at all,” she said. “I’ve lost 100 pounds about five or six times. Then the first time some man would say something to me about how I looked nice, I’d gain it back. Nobody talked about it before Dr. Felitti, and that’s the reason it had such a big impact on me. No one seemed to recognize this was going on. And then I found out it’s going on with a lot of people and I wasn’t the only one.”
Since she grasped the link between her extreme reluctance to lose weight with her childhood sex abuse, she’s made slow but steady progress to becoming a happier person, she said. And she told Felitti that she was willing to talk openly about this, because she wanted to do whatever she could to prevent the abuse she suffered in her life from happening to others.
We thank all of you who participated in yesterday's poll. For those of you who answered, "Yes", you no doubt recalled your experiences, and that isn't easy.
This is the fourth in a series of posts that accompany questions from the simple version of the ACE Study questionnaire developed by the Centers for Disease Control and Prevention. There are 10 questions on the simple ACE Study questionnaire, and for the rest of this week and next, we'll be putting one question out each day in a poll. Today is the fourth question. Each day I'll take a look at some of the research — ACE, brain development, and epigenetic — to provide more information and context. I encourage you to take the simple ACE test for yourself. There's also a link to the full 200-question survey.
So exactly how does trauma when you're a child cause you to have heart disease or diabetes when you're an adult?
It's a several step process, according to Dr. Jack Shonkoff, Center on the Developing Child at Harvard University. But it's pretty simple.
When you're born your brain isn't fully formed. Brains are built over time by growing nerve cells and making connections.
Baby's brains are forming connections between brain cells at a rate of 700 per second. For several years. Amazing.
The most-used connections become strongest. The least-used fade away. (Remember this when we get to types of stress.)
It's the interaction between the baby and her caregivers that shape those connections.
Healthy interactions promote healthy brain growth as well as healthy growth of our organ systems -- circulation, nervous, digestive, reproductive, etc.
Toxic interactions increase blood pressure, stress hormones, heart rate, blood sugar, inflammatory substances. These disrupt the growth of the brain and other organ systems.
Now....we need stress to grow. But it's gotta be good stress. There are three kinds of stress:
- Positive stress: For babies and toddlers, this is good stress that results in brief increases in heart rate and mild elevations in stress hormone levels. This stress occurs when kids learn to share toys, when they're told they can’t put 10 cookies in their mouth, explains Shonkoff. Children are learning how to adapt, live and cope. The stress that's happening at the biological level is mild, the child learns to deal with the stress with the help of an adult, and the system returns to normal.
- Tolerable stress: These are serious, but temporary stresses that are buffered by adults who help a child return to normal. Examples are a death in family, or living through a natural disaster. Shonkoff says that there's a question about which children will end up recovering from these situations, or who will be negatively affected with symptoms of PTSD, for example. "A plausible hypothesis is the extent to which children are helped to get through the stress by adults and how they're helped to adapt." At some point, the stress response system returns to baseline.
- Toxic stress: When a baby or a toddler or a young child experiences chronic neglect, regular exposure to violence, chronic abuse, and other trauma, their stress response is on all the time. If the adults in the child's life are unable to help him get through the stress to return to a normal level, or there is no adult to help a child return to normal, then the brain and body cannot turn off the stress response.
The stress response -- "flight, fright or freeze" -- is meant to deal with acute stress, Shonkoff points out, but it's not meant to be on all the time. If it is, it turns toxic, and physically disrupts the development of the brain and the organ systems. If children are in a constant state of trauma, they can't learn in school, and they can't learn how to interact socially, because they're basically too frightened of people. Unfortunately, we tend to call that "bad behavior" instead of seeing it for what it really is.
What is unknown is the point at which this damage is irreversible, and what causes that to vary from person to person. What is known is that there are many people who were not tossed a lifesaver before they crossed that line. We see those people every day -- among the homeless on the street, the severe alcoholics who miss work and lose themselves in alcohol-infused weekends, the severely depressed, the rage-aholics, the morbidly obese, the hoarders, etc.
A video of a presentation Shonkoff made at the Casey Family Programs Early Learning Symposium last November can be found here. If you want to learn more details about how disease prevention is an issue of early childhood, It's well worth watching.
This is the third in a series of posts that accompany questions from the simple version of the ACE Study questionnaire developed by the Centers for Disease Control and Prevention. There are 10 questions on the simple ACE Study questionnaire, and for the next two weeks, we'll be putting one question out each day in a poll. Today is the third question. Each day I'll take a look at some of the research — ACE, brain development, and epigenetic — to provide more information and context. I encourage you to take the simple ACE test for yourself. There's also a link to the full 200-question survey.
"We should know this about everybody we encounter in health and human services," said Dr. Robert Anda, a physician and research epidemiologist. He was giving a presentation at the Casey Family Programs Early Learning Symposium last November 4 in Seattle, WA.
He was referring to the child trauma histories of the 17,241 people who participated in the Centers for Disease Control and Prevention's ACE Study. Now, mind you, this group of people belong to the upper socioeconomic tier of this country (not the super-rich....they're in the socioeconomic stratosphere, but not without their ACE issues, as the news of celebrities' problems with alcohol or drug addiction shows). As Anda points out in his presentation (the video is here), they live in San Diego, not an inexpensive place to live. Only 6 percent have NOT graduated from high school. Most attended college. They all had good jobs, or were married to someone with a good job, and belonged to one of the best health-care organizations in the country. With their average age at 57, they had a prosperous life. But, take a look at this.
Nearly one out of three of these middle- and upper-middle class overwhelmingly white people grew up in a household where a parent was addicted...mostly to alcohol, but other drugs also. Nearly one out of three experienced physical abuse. Almost one out of four lost a parent to divorce or separation. One out of five were sexually abused. One out of six suffered emotional neglect and had a family member diagnosed with a mental illlness.
Prior to the ACE Study, we believed that these issues were found only in people who were poor and lived in the inner city, or were poor and lived in rural areas. As Anda has pointed out, "It's not just them; it's us, too." Which explains a lot, such as why our obesity, heart disease, and cancer rates are so high and climbing.
The kicker is that if a person has one adverse childhood experience, they're likely to have more. Only one out of three people had no childhood trauma. One our of four had an ACE score of one. Forty percent had at least two. One out of four had three or more, which is the level where significant links between ACE scores and adult onset of chronic illness begin to show up. One out of 10 had five or more, and these people are often those that physicians see the most, or who show up in emergency rooms the most often.
Anda told me that, when the ACE Study first started, he got up in the middle of the night to check the computer run for the first batch of questionnaires. As he looked at the results, he began crying. He couldn't believe what he was seeing. As he says in the video, "How come I didn't know this? Nobody taught me this!"
How do the CDC researchers who are involved in the ACE Study know it's for real? Well, it's a little difficult for 17,000 people to coordinate their responses; and if you keep seeing the same trends, it's unlikely that people are making this stuff up. And, the researchers been cross-checking with other studies -- most of which focus on just one of the experiences -- and those results are pretty much the same. And other states that are conducting their own ACE studies, are finding similar results. In his presentation, he compares Washington State's results with San Diego's.
So, why is this so important? When a child grows up in a toxic environment, one where there's a LOT of stress and danger, that child's brain is physically affected. More about that in tomorrow's post.
To cope, many kids start "escaping" into alcohol or other drugs, risky sexual behavior, risky financial behavior (shopaholicis), overeating, smoking, etc. Choose your poison. The poison that masks itself as a solution to give you a break from a misery that surrounds you as soon as you go home.
The kids that choose alcohol risk further damage to their brain development. Brains, those complex globs of jelly, don't mature until we're in our mid-20s. In this study reviewed by Karin Zeitvogel at Agence France Presse, Stanford University and University of California researchers found that binge-drinking can have a long-lasting effect on teens, especially on girls. Binge-drinking is at least five drinks for males and four for females. The brain scans of the research participants, none of whom had a drinking problem, showed less activity in several regions than teens who had not been drinking in the previous three months.
"These differences in brain activity were linked to worse performance on other measures of attention and working memory ability," Stanford University psychiatry professor Susan Tapert, a co-author of the study, said.
This is the second in a series of posts that accompany questions from the simple version of the ACE Study questionnaire. There are 10 questions on the general ACE Study questionnaire, and for the next two weeks, we'll be putting one question out each day in a poll. Today is the second question. Each day I'll take a look at some of the research — ACE, brain development, and epigenetic — to provide more information and context. I encourage you to take the simple ACE test for yourself. There's also a link to the full 200-question survey.
For the answer, you'll have to read to the end. And the story behind this link between cholesterol scores and ACE scores begins with, of all things, our polls.
Our WellCommons polls are entirely unscientific — you can't tell if they're accurate or not — but we think they're kind of interesting.
If our polls can be believed, however, most of us in Lawrence and Douglas County watch 1-4 hours of television every day. We're not worried enough about the risk of brain cancer to stop using our cell phones. We're about evenly divided between being morning people and not no way ever never. We're also evenly divided between ordering fries or salad as a side dish. Most of us have seen a dentist in the last six months. (Perhaps that means that most of the people who voted have dental insurance?) But quite a few haven't seen a dentist in 5 years.
If our polls come anywhere close to reflecting the Lawrence-Douglas County community, they say we're a healthy bunch — most of us can do between 10 and 70 pushups! (And more than I expected can do 100 — must be the influence of Red Dog Days.) And a surprising 41 percent of people voting in this poll ate four or more servings of vegetables each day. Wow. Somehow I don't think that 41 percent of the 110,000 people living in Douglas County eat that many vegetables every day. Maybe they're counting french fries. Maybe we need to have a poll to ask if people believe that poll.
By far the poll that attracted the most votes was this one:
There were some other interesting results, too. A LOT of people said they were bullied in elementary school. That poll accompanied a post about the bullying prevention program at Prairie Park Elementary.
And quite a few people -- mostly women, no doubt -- have been victims of domestic violence:
That last one got me to thinking that it would be very interesting to run a series of polls based on the ACE Study -- the Adverse Childhood Experience Study at the U.S. Centers for Disease Control and Prevention. So, that's what we're doing, this week and next.
What's so special about the ACE Study? It shows a direct link between child trauma and diabetes, heart disease, lung cancer, and a host of other chronic illnesses that people get when they're adults. The higher a person's ACE score, the higher risk of chronic disease when they're an adult.
There are 10 types of trauma measured in the ACE Study. Five are personal -- physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to the family: a parent who's an alcoholic, a mother who's a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment. Each type of trauma counts as one. So a person who's been physically abused, with one alcoholic parent, and a mother who was beaten up has an ACE score of three.
Of course, we know that there are other types of child trauma — a family member with a serious illness or major injury, death of a sibling, being bullied in school. Although the ACE Study didn't measure those, in the bigger picture, there's no doubt that they can have an effect on a child's long-term development. In other words, trauma is trauma, and it can damage the developing brain of a child.
The original ACE Study began in San Diego at Kaiser Permanente — a health maintenance organization with nearly 9 million members in the U.S. About 17,000 people participated. Researchers found that one out of four people had an ACE score of 3 or more; one out of six had an ACE score of 4 or more. With an ACE score of 4, smoking and lung disease are 390 percent more likely; sexually transmitted disease, 250 percent; depression, 460 percent; suicide, 1,220 percent more likely.
What was most surprising to me is that most of the 17,000 people who participated were overwhelmingly white, middle- and upper-middle class, college-educated, with jobs and great health insurance (they all belonged to Kaiser). Their average age was 57. If these people, with all of their support systems and resources, had such a difficult time, what about people who don't have resources?
The ACE Study is catching on — five states have done their own ACE Study. Washington State was the first, in 2009, and found similar results to the CDC research.
Last yeaer, Dr. Robert Anda, one of the co-founders of the ACE Study, and Dr. David Brown of the CDC did an analysis of Washington State's ACE survey: Adverse Childhood Experiences & Population Health in Washington: The Face of a Chronic Public Health Disaster. Here are a couple of paragraphs from his introduction:
Until very recently, this public health disaster has been hidden from view. Our society has treated the abuse, maltreatment, violence and chaotic experiences of our children as an oddity that is adequately dealt with by emergency response systems -- child protective services, criminal justice, foster care, and alternative schools -- to name a fiew. These services are needed and are worthy of support -- but they are a dressing on a greater wound.
Our society has bought into a set of misconceptions. Here are a few: ACEs are rare and they happen somewhere else. They are perpetrated by monsters. Some, or maybe most, children can escape unscathed, or if not, they can be rescued and healed by emergency response systems. Then these children vanish from view...and randomly reappear -- as if they are new entitities -- in all of your service systems later in childhood, adolescence, and adulthood as clients with behavioral, learning, social criminal, and chronic health problems.
The first step toward healing, says Anda, comes with understanding the problem. Calculations that he and Brown did in their analysis showed that if the causes of ACE were removed in Washington State, heart disease would decrease by 25 percent, cancer by 24 percent, asthma by 22 percent, smoking by 36 percent, HIV risk by 59 percent and divorce by 33 percent. That's a lot of emotional cost and economic cost that could be eliminated.
So, this is our first baby step — just to get the conversation rolling. There are 10 questions on the general ACE Study questionnaire, and for the next two weeks, we'll be putting one question out each day in a poll. We're publishing the first one today. Each day I'll take a look at some of the research — ACE, brain development, and epigenetic — to provide more information and context. I encourage you to take the simple ACE test for yourself. There's also a link to the full 200-question survey.
To end with the beginning: What do cholesterol scores and ACE scores have in common? A high cholesterol score is a simple way to understand that you've got a serious health issue that can lead to heart disease, and you need to exercise and eat less and better to lower the score. A high ACE score is a simple way to understand the link between your chronic illness and your childhood trauma. You can't undo the past to lower the score, but understanding it may put you on a better path to improving your health. And, just as important, by understanding the link between your own child trauma and chronic illness — or the link between a relative or friend's child trauma and chronic illness — you can be part of the solution to make sure your children, grandchildren and your community's children have low ACE scores.
“I can’t tell you how many parents who fill out our survey say, ‘I don’t like my kid’,” Jack Edgerton said. Edgerton is executive director of Parent Trust for Washington Children.
Now, that’s a sentence that convinces me that people can be divided into two camps: Those who cannot possibly imagine a parent saying such a thing. And those who are all too familiar with the sentiment -- either feeling it, or having experienced it with their own parents.
It’s akin to “Women are from Venus and Men are from Mars”, but worse: Parents who can’t imagine not liking their kid (except for the moment the 17-year-old wrecks the car) think there’s something seriously wrong with the parents who don’t like their kids.
Parents who don’t like their children are reluctant to say so -- they’re either afraid to admit it, or just put up with it, and live out their lives believing that what was good enough for them is good enough for their own children.
The solution is in understanding the roots and consequences of childhood trauma so that those who have little or no experience in giving or receiving trauma can empathize and help create solutions with those who have.
It’s not unusual for parents who say “I don’t like my kid,” to reveal that they didn’t like spending time with their own parents, says Edgerton. And why? Because their parents didn’t like spending time with them when they were children.
The consequences can be dire and long-lasting: neglect and/or abuse, which often accompanies other family trauma, such as a parent who’s depressed or has other mental illness, a parent who’s an alcoholic, a mother who’s a victim of domestic violence, a family member in prison, or a parent who disappears through divorce, abandonment and/or death. In other words, all the types of trauma that comprise the ACE score. (A high Adverse Childhood Experience score during childhood substantially increases the risk of chronic illness as an adult -- more on that later.)
And now these parents are replaying their past with their own children.
“We need to move them from that to ‘I enjoy being with my child’,” Edgerton says.
One way that Edgerton has seen parents do a complete 180-degree turn is through group discussion. This is a good time to explain what Parent Trust does. It’s been serving families in Washington State since 1978 by "teaching families skills to promote early learning, improve family bonding, develop new family and life management skills for both parents and children, and prevent child abuse and neglect", according to its website. The organization serves about 15,000 people a year, in several programs, including four for parents and caregivers.
“I remember one group that spent six or seven weeks in discussion with a father who was having a hard time going through a bedtime routine with his son. The kid was having tantrums. The group suggested that he create an environment in which the child could calm down. What we saw happening was that the dad was going through the motions, but he didn’t have his heart in it.
“As time went on, the father became more agitated about the kid and the situation. Finally another dad turned to him and said in exasperation: ‘You’re going to lose it with this kid. You’re going to do something you regret. That was my life. And you don’t want to experience my life.’
“The dad yelled back: ‘Nobody ever did this for me. Why should I do this for my kid?’
“There was complete silence in the group. That dad finally said, ‘I get it now’.”
It was an amazing moment, to see the light bulb go off over that father’s head, said Edgerton. That was the moment the dad realized that he was becoming the parent that he didn’t like.
After that, the group worked with the dad on developing positive experiences so his child could bond with his dad in a positive way, not a negative way.
“One of the things that we do is we teach parents how to play with their child,” says Edgerton. “We have to teach them because so many of them never played with their parents. This is a behavior they now have to learn. They become embarrassed, they think their kid’s going to think they’re dumb if they play Barbie with them. But the kid craves that.”
The Parent Trust staff teach the parents who participate in their programs about the ACE Study -- the CDC/Kaiser Adverse Childhood Experience Study. They have them calculate their own scores, and link their childhood trauma with the behavior that’s currently affecting their lives and the lives of their children.
Then they teach them positive or protective behaviors that break the cycle of passing on high ACE scores to their children. Many parents have said that learning about ACE provided great relief because it helps them understand their own behavior, and makes them more determined to raise children with a lower ACE score than their own.
One notable aspect of Parent Trust’s approach is that the staff doesn’t focus on trauma alone anymore. “We talk about ACEs rather than trauma experiences,” says Edgerton. “To our way of thinking, experiences with ACEs are the root of trauma. Let’s cut out the middleman.”
But what's an ACE score and why should anyone care? Well, your ACE score may explain the state of your health, and why you eat, smoke, work, drink, or do drugs too much or engage in risky behavior too often. It may explain why you weight 100 pounds more than is healthy for you, why you’re depressed or angry, and/or why smoking or drinking relieves your stress. The ACE Study (Adverse Childhood Experience) is an ongoing project of the Centers for Disease Control and Kaiser Permanente, in which researchers have followed the health of 17,000 people since the late 1990s. The study found a direct link between child trauma and the adult onset of chronic disease, including lung and heart disease, diabetes and depression.
People with an ACE score of 4 or higher -- measured by the different types of trauma, not incidents of trauma -- have a greater risk of these diseases. Examples: Morbid obesity in women has been linked to emotional abuse in their childhoods. An ACE score of 4 increases the likelihood of lung disease by 390 percent and depression by 490 percent.
You can do a rough calculation of your score by filling out this questionnaire. The startling findings have inspired many organizations, five states, the U.S. military and several countries to do their own ACE surveys.
One of the challenges in health and human services, says Edgerton, is that social service agencies have separated the nine ACEs and have tried to deal with each one individually. For example, separate organizations address alcohol abuse, child abuse, obesity and smoking.
“We rarely look it as a continuum of challenges that families face,” he says. Researchers have found that if there’s one ACE, such as child abuse, there are others, such as alcoholism and/or depression. “There’s cascading effect in parents who are passing on a cascade of ACEs to their children -- alcohol and drugs, incarcerated parents, neglectful behavior. They’re passing all of those ACEs onto their children. And then teaching their children how to replicate ACEs in their children.”
By breaking through the “ACE barrier”, Parent Trust staff helps parents reverse the pattern.
[This is one of a series of posts about how organizations in other communities across the U.S. are incorporating the findings of the ACE Study in social services, schools, juvenile justice, and public health.]
Arizona ACE consortium partners with PBS station to look at link between child trauma and adult chronic disease
Arizona has a statewide ACE consortium that's coordinated by Marcia Stanton, a social worker at the Injury Prevention Center at Phoenix Children's Hospital. In an email, she noted that the consortium is "working to enhance public awareness of the issue of childhood trauma and evidence-based prevention policies and programs."
The consortium has partnered with the local PBS station on programming that looks at the link between child trauma and adult chronic illness. On the station's Strong Kids site you'll find a couple of videos about the effects of child trauma. One is a 10-minute interview with Dr. Vincent Felitti, one of the co-founders of the CDC's Adverse Childhood Experiences Study. A second 25-minute video features interviews with local experts in Phoenix.
I'll be talking with Stanton soon to find out more information about the state consortium, and will report back here.
"Can a stressful childhood make you a sick adult?" In this fascinating article in the March 21 issue of The New Yorker, author Paul Tough addresses that question as he looks at how Dr. Nadine Burke, a pediatrician who founded the Bayview Child Health Center in San Francisco's Bayview-Hunters Point neighborhood "faced a crisis of confidence" in how she was treating her patients.
Tough starts out by telling the story of Monisha Sullivan, who's lived a lifetime of stress in her short 16 years in Bayview-Hunters Point, San Francisco's poorest neighborhood. Her parents were addicted to drugs. Shortly after her birth, her mother abandoned her in the hospital. She lived with her father until she was 10, when she and her brother were put in a foster care home, the first of 10 she's lived in. When she came to the clinic, she had asthma, scabies, strep throat and a weight problem. And she has a baby daughter.
Sullivan encountered Nadine Burke at a moment when Burke was just beginning to think deeply about the physical effects of anxiety. She was immersing herself in the rapidly evolving sciences of stress physiology and neuroendocrinology. What if Sullivan’s anxiety wasn’t merely an emotional side effect of her difficult life but the central issue affecting her health? According to research that Burke had been reading, the traumatic events that Sullivan experienced in childhood had likely caused significant and long-lasting chemical changes in both her brain and her body, and these changes could well be making her sick, and also increasing her chances of serious medical problems in adulthood. And Sullivan’s case wasn’t unusual. Two years after Sullivan’s first visit, Burke has transformed her practice. She believes that regarding childhood trauma as a medical issue helps her treat more effectively the symptoms of patients like Sullivan.
Burke has found that 67 percent of her patients have an ACE score of one or more, and 12 percent have a score of 4 or more, which the CDC's ACE Study found would greatly increase the risk of adult onset of chronic disease. The ACE Study itself, which focused on 17,000 middle- and upper middle-class, mostly white, employed San Diegans with good health coverage, found similar results: almost two-thirds reported at least one ACE, and 12.5 percent reported an ACE score of 4 or more.
To find out how Burke has changed her practice, you'll have to read the entire article. For that, you have to subscribe to the digital or print edition of The New Yorker. I'll lend my copy out for anyone who wants to stop by the News Center and pick it up (on Friday, April 8, or after).
Last month, a small group of people met to talk about trauma, specifically to discuss the ACE Study (the CDC's Adverse Childhood Experiences Study) and how to incorporate trauma prevention and trauma-sensitive care into Lawrence-Douglas County organizations, businesses and institutions.
The big question is: how can we start and continue a public conversation about something as difficult as trauma, especially child trauma?
In case you haven’t heard about the CDC's ACE Study, it’s a ground-breaking, mind-bending study that identified a direct link between childhood trauma and the adult onset of chronic disease, such as diabetes, heart disease, lung cancer and COPD, often referred to as emphysema.
ACE scores between four and 10 can identify those of us who are at risk for developing chronic diseases or explain why we have chronic disease. Knowing our ACE score can help us take steps to change or prevent the behavior that leads to those diseases in ourselves and in our children, and to start creating a community that talks easily and unashamedly about trauma and how to prevent it. (Here's a simplified version of the questionnaire.) Using ACE Study scores can help move the conversation about trauma from the cloistered office of a therapist or other health care provider into a public discussion. In other communities, ordinary people are "talking ACEs", and are also providing their own ideas about trauma prevention and care.
So, our small group met in the in the News Center basement conference room, a comfortable place for a discussion. We’d planned to meet for an hour. We ended up talking for two.
It was an extraordinary and exploratory conversation, and although we talked about many topics, the common thread was trauma, and how its sticky tendrils can snake their way into people’s lives and choke off happiness and good health.
Toni Detherage, community liaison and family resource advocate at Success by 6, talked about how she’s incorporated trauma-informed care into parenting classes. She’s helping parents move away from blaming and shaming, and giving them new skills to create a trauma-free environment for their children. She provided us the definitions of trauma, which can be found in our resources section. It’s important to note, she said, that severe trauma changes the way the brain works and develops, which is a critical aspect of understanding why child trauma can change a child’s life forever.
Jason Wescoe, chief operating officer for the Community Health Center of Southeast Kansas, in Pittsburg, runs a patient-owned and operated clinic that integrates dental, mental, and physical health. That clinic is busy -- it serves 20,000 people a year, regardless of their ability to pay. Trauma-informed care can give pediatricians another tool, he says, because a behavioral health specialist isn’t always available.
Lori Winfrey, an advanced registered nurse practitioner who is clinic manager of Health Care Access, often sees people who have chronic diseases that have emerged out of adverse childhood experiences. Some are able to make the connection between their disease and their trauma; others have not, she says.
Bob Trepinski, director of the Marian Clinic in Topeka, talked about the changes he’s seen in people who participate in weight programs at the clinic, which provides mental, dental and physical health services to uninsured, low-income individuals and families. It takes many agencies to work on a variety of themes to make a difference, he noted.
Lanell Finneran is a special education teacher in the secondary therapeutic classroom at Bert Nash Community Mental Health Center, where she teaches middle school and high school students and helps them learn how to manage their mental health issues. She also is a registered drama therapist and board certified trainer, and an adjunct professor of drama therapy at KSU.
Carolyn Chinn-Lewis, director of operations for the Kansas Children's Discovery Center in Topeka and president of the Downtown Lawrence Rotary Club is interested in working with other people in our community to build a safe, create and health environment for our children to develop and grow.
Dennis Anderson, managing editor of LJWorld.com and the Lawrence Journal-World, has been a Bigs in School (a Big Brothers Big Sisters program) in Lawrence for the last five years, a youth counselor for five years in Connecticut, and has also coached youth baseball teams for 12 years. "It's vital that our community understand how stress affects our children and we learn how to properly react. Not every issue or problem can be treated the same way,” he says.
Sometime during our discussion, we came to the conclusion that we’re on to something.
We want to start a conversation on WellCommons about trauma-informed care, trauma prevention and ACEs in the Lawrence/Douglas County community. We think everyone who provides health, education or social services to individuals or families would find the information useful. Physicians, teachers, police officers, parks and recreation staff, nurses, dentists, chiropractors -- anyone could benefit from knowing about and using ACEs.
For our first steps, we’ll be looking into what other states and communities have done. Toni mentioned that Florida is a trauma-informed state -- every publicly funded program has a trauma-prevention component. Maine has a network of houses for family foster care; they’ve found that approach works best at preventing child abuse. We also know of trauma-sensitive elementary school classrooms in Massachusetts, and probation departments in Washington state that incorporate ACEs and a trauma-sensitive approach to helping youth in the juvenile justice system.
We want to learn as much as possible about what’s happening in other communities, and then organize some workshops for our own to figure out how best to incorporate this information into our daily lives.
If you’re interested in this, or have ideas on how to proceed, please join our group so that we can start the discussion on WellCommons.
A study of 70,000 nurses found a link between abuse they experienced as children and teens, and type 2 diabetes they developed as adults. Patricia McAdams wrote up the study in Health Behavior News Service. It was published in the December 2010 issue of the American Journal of Preventive Medicine.
“Much, although not all, of this association is explained by the greater weight gain of girls with a history of abuse,” said lead study author Janet Rich-Edwards. “The weight gain seems to start in teenage years and continues into adulthood, increasing the risk of diabetes.”
The research project is one of many coming out of the Nurses Health Study II, which was started in 1989 with 67,853 registered nurses. It is an outgrowth of the first Nurses Health Study, which began in 1976.
What startled the researchers at Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital was how many nurses reported that they'd suffered physical and sexual abuse:
54 percent of nurses reported physical abuse and 34 percent reported sexual abuse before age 18. Moderate and severe physical and sexual abuse were associated with 26 percent to 69 percent higher risks of diabetes in maturity.
That's not surprising to ACE Study researchers, who, in 2002, published research that found a direct link between child trauma and obesity. They looked at physical, sexual and emotional abuse in 13,000 people who were members of the Kaiser Permanente Health Maintenance Organization in San Diego, CA. Most were white, had attended college, were employed and had health insurance (Kaiser).
The two types of trauma researchers found that were most associated with body weight and obesity were physical and emotional abuse.
In a weight clinic run by Kaiser Permanente, many people who were severely overweight and grappling with type 2 diabetes were able to lose enough weight and become healthy again so that they no longer needed medication. The weight clinic is unusual in that the starting point of discussion with participants is to recognize that being overweight isn't a problem; for many people who are obese, it's a solution.
One woman was reported to have told a physician why she'd gained 105 pounds in the year after she was raped at age 23. "Overweight is overlooked," she told the physician. "And that's the way I need to be."
More on this in a later post.