Chronic adversities change the architecture of a child’s brain, altering the expression of genes that control stress hormone output, triggering an overactive inflammatory stress response for life, and predisposing the child to adult disease.
“I felt myself a stranger at life’s party.”
New findings in neuroscience, psychology, and medicine have recently unveiled the exact ways in which childhood adversity biologically alters us for life. The past can tick away inside us for decades like a silent time bomb, until it sets off a cellular message that lets us know the body does not forget the past. Something that happened to you when you were five or fifteen can land you in the hospital thirty years later, whether that something was headline news, or happened quietly, without anyone else knowing it, in the living room of your childhood home.
No matter how old you are, or how old your children may be, there are scientifically supported and relatively simple steps that you can take to reboot the brain, create new pathways that promote healing, and come back to who it is you were meant to be.
Our findings are disturbing to some because they imply that the basic causes of addiction lie within us and the way we treat each other, not in drug dealers or dangerous chemicals. They suggest that billions of dollars have been spent everywhere except where the answer is to be found. Our findings indicate that the major factor underlying addiction is adverse childhood experiences that have not healed with time and that are overwhelmingly concealed from awareness by shame, secrecy, and social taboo.
“I wept, I saw how much people had suffered and I wept.” Robert Anda
“Our findings exceeded anything we had conceived. The correlation between having a difficult childhood and facing illness as an adult offered a whole new lens through which we could view human health and disease. Here was the missing piece as to what was causing so much of our unspoken suffering as human beings. Time does not heal all wounds. One does not ‘just get over’ something, not even fifty years later. Instead time conceals. And human beings convert traumatic emotional experiences in childhood into organic disease later in life.” Vincent Felitti
Adverse childhood experiences are the main determinant of the health and social well being of a nation.
This book explores how the experiences of childhood shape us into the adults we become. Cutting-edge research tells us that what doesn’t kill you doesn’t necessarily make you stronger. Far more often, the opposite is true: the early chronic unpredictable stressors, losses, and adversities we face as children shape our biology in ways that predetermine our adult health. This early biological blueprint depicts our proclivity to develop life altering adult illnesses such as heart disease, cancer, autoimmune disease, fibromyalgia, and depression. It also lays the groundwork for how we relate to others, how successful our love relationships will be, and how well we will nurture and raise our own children.
My own investigation into the relationship between childhood adversity and adult physical health began after I’d spent more than a dozen years struggling to manage several life limiting autoimmune illnesses while raising young children and working as a journalist. In my forties, I was paralyzed twice with an autoimmune disease known as Guillain-Barré syndrome, similar to multiple sclerosis, but with a more sudden onset. I had muscle weakness; pervasive numbness; a pacemaker for vasovagal syncope, a fainting and seizing disorder; white and red blood cell counts so low my doctor suspected a problem was brewing in my bone marrow; and thyroid disease.
Still I knew: I was fortunate to be alive, and I was determined to live the fullest life possible. If the muscles in my hands didn’t cooperate, I clasped an oversized pencil in my fist to write. If I couldn’t get up the stairs because my legs resisted, I sat down halfway up and rested. I gutted through days battling flulike fatigue, pushing away fears about what might happen to my body next; faking it through work phone calls while lying prone on the floor; reserving what energy I had for moments with my children, husband, and family life; pretending that our “normal” was really okay by me. It had to be, there was no alternative in sight.
Increasingly, I devoted my skills as a science journalist to helping women with chronic illness, writing about the intersection between neuroscience, our immune systems, and the innermost workings of our human hearts. I investigated the many triggers of disease, reporting on chemicals in our environment and foods, genetics, and how inflammatory stress undermines our health. I reported on how going green, eating clean, and practices like mind-body meditation can help us to recuperate and recover. At health conferences I lectured to patients, doctors, and scientists. My mission became to do all I could to help readers who were caught in a chronic cycle of suffering, inflammation, or pain to live healthier, better lives.
In the midst of that quest, three years ago, in 2012, I came across a growing body of science based on a groundbreaking public health research study, the Adverse Childhood Experiences Study, or ACE Study. The ACE Study shows a clear scientific link between many types of childhood adversity and the adult onset of physical disease and mental health disorders. These traumas include being verbally put down and humiliated; being emotionally or physically neglected; being physically or sexually abused; living with a depressed parent, a parent with a mental illness, or a parent who is addicted to alcohol or other substances; witnessing one’s mother being abused; and losing a parent to separation or divorce. The ACE Study measured ten types of adversity, but new research tells us that other types of childhood trauma, such as losing a parent to death, witnessing a sibling being abused, violence in one’s community, growing up in poverty, witnessing a father being abused by a mother, being bullied by a classmate or teacher, also have a longterm impact.
These types of chronic adversities change the architecture of a child’s brain, altering the expression of genes that control stress hormone output, triggering an overactive inflammatory stress response for life, and predisposing the child to adult disease. ACE research shows that 64 percent of adults faced one ACE in their childhood, and 40 percent faced two or more.
My own doctor at Johns Hopkins medical institutions confessed to me that she suspected that, given the chronic stress I’d faced in my childhood, my body and brain had been marinating in toxic inflammatory chemicals my whole life, predisposing me to the diseases I now faced.
My own story was a simple one of loss. When I was a girl, my father died suddenly. My family struggled and became estranged from our previously tight knit, extended family. I had been exceptionally close to my father and I had looked to him for my sense of being safe, okay, and valued in the world. In every photo of our family, I’m smiling, clasped in his arms. When he died, childhood suddenly ended, overnight. If I am honest with myself, looking back, I cannot recall a single “happy memory” from there on out in my childhood. It was no one’s fault. It just was. And I didn’t dwell on any of that. In my mind, people who dwelled on their past, and especially on their childhood, were emotionally suspect.
I soldiered on. Life catapulted forward. I created a good life, worked hard as a science journalist to help meaningful causes, married a really good husband, and brought up children I adored, children I worked hard to stay alive for. But other than enjoying the lovely highlights of a hard won family life, or being with close friends, I was pushing away pain.
I felt myself a stranger at life’s party. My body never let me forget that inside, pretend as I might, I had been masking a great deal of loss for a very long time. I felt myself to be “not like other people.”
Seen through the lens of the new field of research into Adverse Childhood Experiences, it suddenly seemed almost predictable that, by the time I was in my early forties, my health would deteriorate and I would be brought, in my case, quite literally, to my knees.
Like many people, I was surprised, even dubious, when I first learned about ACEs and heard that so much of what we experience as adults is so inextricably linked to our childhood experiences. I did not consider myself to be someone who had had Adverse Childhood Experiences. But when I took the ACES questionnaire and discovered my own ACE Score, my story also began to make so much more sense to me. This science was entirely new, but it also supported old ideas that we have long known to be true: “the child is father of the man.” This research also told me that none of us is alone in our suffering.
One hundred thirty three million Americans suffer from chronic illness and 116 million suffer from chronic pain. This revelation of the link between childhood adversity and adult illness can inform all of our efforts to heal. With this knowledge, physicians, health practitioners, psychologists, and psychiatrists can better understand their patients and find new insights to help them. And this knowledge will help us ensure that the children in our lives, whether we are parents, mentors, teachers, or coaches, don’t suffer from the long term consequences of these sorts of adversity.
To learn everything I could, I spent two years interviewing the leading scientists who research and study the effects of Adverse Childhood Experiences and toxic childhood stress. I combed through seventy research papers that comprise the ACE Study and hundreds of other studies from our nation’s best research institutions that support and complement these findings. And I followed thirteen individuals who suffered early adversity and later faced adult health struggles, who were able to forge their own lifechanging paths to physical and emotional healing.
In these pages, I explore the damage that Adverse Childhood Experiences can do to the brain and body; how these invisible changes contribute to the development of disease including autoimmune diseases, long into adulthood; why some individuals are more likely to be affected by early adversity than others; why girls and women are more affected than men; and how early adversity affects our ability to love and parent.
Just as important, I explore how we can reverse the effects of early toxic stress on our biology, and come back to being who we really are. I hope to help readers to avoid spending so much of their lives locked in pain.
Some points to bear in mind as you read these pages:
– Adverse Childhood Experiences should not be confused with the inevitable small challenges of childhood that create resilience. There are many normal moments in a happy childhood, when things don’t go a child’s way, when parents lose it and apologize, when children fail and learn to try again. Adverse Childhood Experiences are very different sorts of experiences; they are scary, chronic, unpredictable stressors, and often a child does not have the adult support needed to help navigate safely through them.
– Adverse Childhood Experiences are linked to a far greater likelihood of illness in adulthood, but they are not the only factor. All disease is multifactorial. Genetics, exposures to toxins, and infection all play a role. But for those who have experienced ACEs and toxic stress, other disease promoting factors become more damaging.
To use a simple metaphor, imagine the immune system as being something like a barrel. If you encounter too many environmental toxins from chemicals, a poor processed food diet, viruses, infections, and chronic or acute stressors in adulthood, your barrel will slowly fill. At some point, there may be one certain exposure, that last drop that causes the barrel to spill over and disease to develop.
Having faced the chronic unpredictable stressors of Adverse Childhood Experiences is a lot like starting life with your barrel half full. ACEs are not the only factor in determining who will develop disease later in life. But they may make it more likely that one will.
– The research into Adverse Childhood Experiences has some factors in common with the research on post-traumatic stress disorder, or PTSD. But childhood adversity can lead to a far wider range of physical and emotional health consequences than the overt symptoms of posttraumatic stress. They are not the same.
– The Adverse Childhood Experiences of extreme poverty and neighborhood violence are not addressed specifically in the original research. Yet clearly, growing up in unsafe neighborhoods where there is poverty and gang violence or in a war-torn area anywhere around the world creates toxic childhood stress, and that relationship is now being more deeply studied. It is an important field of inquiry and one I do not attempt to address here; that is a different book, but one that is no less important.
– Adverse Childhood Experiences are not an excuse for egregious behavior. They should not be considered a “blame the childhood” moral pass. The research allows us to finally tackle real and lasting physical and emotional change from an entirely new vantage point, but it is not about making excuses.
This research is not an invitation to blame parents. Adverse Childhood Experiences are often an intergenerational legacy, and patterns of neglect, maltreatment, and adversity almost always originate many generations prior to one’s own.
The new science on Adverse Childhood Experiences and toxic stress has given us a new lens through which to understand the human story; why we suffer; how we parent, raise, and mentor our children; how we might better prevent, treat, and manage illness in our medical care system; and how we can recover and heal on a deeper level than we thought possible.
And that last bit is the best news of all. The brain, which is so changeable in childhood, remains malleable throughout life. Today researchers around the world have discovered a range of powerful ways to reverse the damage that Adverse Childhood Experiences do to both brain and body. No matter how old you are, or how old your children may be, there are scientifically supported and relatively simple steps that you can take to reboot the brain, create new pathways that promote healing, and come back to who it is you were meant to be.
To find out about how many categories of ACEs you might have faced when you were a child or teenager, and your own ACE Score, turn the page and take the Adverse Childhood Experiences Survey for yourself.
TAKE THE ADVERSE CHILDHOOD EXPERIENCES (ACE) SURVEY
You may have picked up this book because you had a painful or traumatic childhood. You may suspect that your past has something to do with your current health problems, your depression, or your anxiety. Or perhaps you are reading this book because you are worried about the health of a spouse, partner, friend, parent, or even your own child, who has survived a trauma or suffered adverse experiences. In order to assess the likelihood that an Adverse Childhood Experience is affecting your health or the health of your loved one, please take a moment to fill out the following survey before you read this book.
ADVERSE CHILDHOOD EXPERIENCES SURVEY
Prior to your eighteenth birthday:
1. Did a parent or another adult in the household
often or very often . . . swear at you, insult you, put you down, or humiliate you? Or act in a way that made you afraid that you might be physically hurt?
Yes No, If yes, enter 1
2. Did a parent or another adult in the household
often or very often . . . push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured?
Yes No, If yes, enter 1
3. Did an adult or person at least five years older than you
ever touch or fondle you or have you touch their body in a sexual way? Or attempt to touch you or touch you inappropriately or sexually abuse you?
Yes No, If yes, enter 1
4. Did you often or very often feel that
noone in your family loved you or thought you were important or special? Or feel that your family members didn’t look out for one another, feel close to one another, or support one another?
Yes No, If yes, enter 1
5. Did you often or very often
feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or that your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Yes No, If yes, enter 1
6. Was a biological parent ever lost to you
through divorce, abandonment, or another reason?
Yes No, If yes, enter 1
7. Was your mother or stepmother often or very often
pushed, grabbed, slapped, or have something thrown at her? Or was she sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over the course of at least a few minutes or threatened with a gun or knife?
Yes No, If yes, enter 1
8. Did you live with anyone who was
a problem drinker or alcoholic, or who used street drugs?
Yes No, If yes, enter 1
9. Was a household member
depressed or mentally ill, or did a household member attempt suicide?
Yes No, If yes, enter 1
10. Did a household member go to prison?
Yes No, If yes, enter 1
Add up your “Yes” answers: (this is your ACE Score)
Now take a moment and ask yourself how your experiences might be affecting your physical, emotional, and mental well-being. Is it possible that someone you love has been affected by Adverse Childhood Experiences they experienced? Are any children or young people you care for in adverse situations now?
Keep your Adverse Childhood Experiences Score in mind as you read the stories and science that follow, and keep your own experiences in mind, as well as those of the people you love. You may find this science to be the missing link in understanding why you or your loved one is having health problems. And this missing link will also lead to the information you will need in order to heal.
How It Is We Become Who We Are
Every Adult Was Once a Child
If you saw Laura walking down the New York City street where she lives today, you’d see a well dressed forty six year old woman with auburn hair and green eyes who exudes a sense of “I matter here.” She looks entirely in charge of her life, as long as you don’t see the small ghosts trailing after her.
When Laura was growing up, her mom was bipolar. Laura’s mom had her good moments: she helped Laura with school projects, braided her hair, and taught her the name of every bird at the bird feeder. But when Laura’s mom suffered from depressive bouts, she’d lock herself in her room for hours. At other times she was manic and hypercritical, which took its toll on everyone around her. Laura’s dad, a vascular surgeon, was kind to Laura, but rarely around. He was, she says, “home late, out the door early, and then just plain out the doom”
Laura recalls a family trip to the Grand Canyon when she was ten. In a photo taken that day, Laura and her parents sit on a bench, sporting tourist whites. The sky is blue and cloudless, and behind them the dark, ribboned shadows of the canyon stretch deep and wide. It is a perfect summer day.
“That afternoon my mom was teaching me to identify the ponderosa pines,” Laura recalls. “Anyone looking at us would have assumed we were a normal, loving family.” Then, something seemed to shift, as it sometimes would. Laura’s parents began arguing about where to set up the tripod for their family photo. By the time the three of them sat down, her parents weren’t speaking. As they put on fake smiles for the camera, Laura’s mom suddenly pinched her daughter’s midriff around the back rim of her shorts, and told her to stop “staring off into space.” Then, a second pinch: “no wonder you’re turning into a butterball, you ate so much cheesecake last night you’re hanging over your shorts!”
If you look hard at Laura’s face in the photograph, you can see that she’s not squinting at the Arizona sun, but holding back tears.
When Laura was fifteen, her dad moved three states away with a new wife to be. He sent cards and money, but called less and less often. Her mother’s untreated bipolar disorder worsened. Laura’s days were punctuated with put downs that caught her off guard as she walked across the living room. “My mom would spit out something like, ‘You look like a semiwide from behind. If you’re ever wondering why no boy asks you out, that’s why!”’ One of Laura’s mother’s recurring lines was, “You were such a pretty baby, I don’t know what happened.” Sometimes Laura recalls, “My mom would go on a vitriolic diatribe about my dad until spittle foamed on her chin. I’d stand there, trying not to hear her as she went on and on, my whole body shaking inside.”
Laura never invited friends over, for fear they’d find out her secret: her mom “wasn’t like other moms.”
Some thirty years later, Laura says, “In many ways, no matter where I go or what I do, I’m still in my mother’s house.” Today, “If a car swerves into my lane, a grocery store clerk is rude, my husband and I argue, or my boss calls me in to talk over a problem, I feel something flip over inside. It’s like there’s a match standing inside too near a flame, and with the smallest breeze, it ignites.” Something, she says, “just doesn’t feel right. Things feel bigger than they should be. Some days, I feel as if I’m living my life in an emotional boom box where the volume is turned up too high.”
To see Laura, you would never know that she is “always shaking a little, only invisibly, deep down in my cells.”
Laura’s sense that something is wrong inside is mirrored by her physical health. In her mid thirties, she began suffering from migraines that landed her in bed for days at a time. At forty, Laura developed an autoimmune thyroid disease. At forty four, during a routine exam, Laura’s doctor didn’t like the sound of her heart. An EKG revealed an arrhythmia. An echocardiogram showed that Laura had a condition known as dilated cardiomyopathy. The left ventricle of her heart was weak; the muscle had trouble pumping blood into her heart. Next thing Laura knew, she was a heart disease patient, undergoing surgery. Today, Laura has a cardioverter defibrillator implanted in the left side of her chest to prevent heart failure. The two-inch scar from the implant is deceivingly small.
John’s parents met in Asia when his father was deployed there as an army officer. After a whirlwind romance, his parents married and moved to the United States. For as long as John can remember, he says, “my parents’ marriage was deeply troubled, as was my relationship with my dad. I consider myself to have been raised by my mom and her mom. I longed to feel a deeper connection with my dad, but it just wasn’t there. He couldn’t extend himself in that way.”
John occasionally runs his hands through his short blond hair, as he carefully chooses his words. “My dad would get so worked up and pissed off about trivial things. He’d throw out opinions that we all knew were factually incorrect, and just keep arguing.” If John’s dad said the capital of New York was New York City, it didn’t matter if John showed him it was Albany. “He’d ask me to help in the garage and I’d be doing everything right, and then a half hour into it I’d put the screwdriver down in the wrong spot and he’d start yelling and not let up. There was never any praise. Even when he was the one who’d made a mistake, it somehow became my fault. He could not be wrong about anything.”
As John got older, it seemed wrong to him that “my dad was constantly pointing out all the mistakes that my brother and I made, without acknowledging any of his own.” His dad chronically criticized his mother, who was, John says, “kinder and more confident.”
When John was twelve, he interjected himself into the fights between his parents. One Christmas Eve, when he was fifteen, John awoke to the sound of “a scream and a commotion. I realized it was my mother screaming. I jumped out of bed and ran into my parents’ room, shouting, ‘What the hell is going on here?’ My mother sputtered, ‘He’s choking me!’ My father had his hands around my mother’s neck. I yelled at him: ‘You stay right here! Don’t you dare move! Mom is coming with me!’ I took my mother downstairs. She was sobbing. I was trying to understand what was happening, trying to be the adult between them.”
Later that Christmas morning, John’s father came down the steps to the living room where John and his mom were sleeping. “No one explained,” he says. “My little brother came downstairs and we had Christmas morning as if nothing had happened.”
Not long after, John’s grandmother, “who’d been an enormous source of love for my mom and me,” died suddenly. John says, “It was a terrible shock and loss for both of us. My father couldn’t support my mom or me in our grieving. He told my mom, ‘You just need to get over it!’ He was the quintessential narcissist. If it wasn’t about him, it wasn’t important, it wasn’t happening.”
Today, John is a boyish forty. He has warm hazel eyes and a wide, affable grin that would be hard not to warm up to. But beneath his easy, open demeanor, John struggles with an array of chronic illnesses.
By the time John was thirty three, his blood pressure was shockingly high for a young man. He began to experience bouts of stabbing stomach pain and diarrhea and often had blood in his stool. These episodes grew more frequent. He had a headache every day of his life. By thirty four, he’d developed chronic fatigue, and was so wiped out that sometimes he struggled to make it through an entire day at work.
For years, John had loved to go hiking to relieve stress, but by the time he was thirty five, he couldn’t muster the physical stamina. “One day it hit me, I’m still a young man and I’ll never go hiking again.’ ”
John’s relationships, like his physical body, were never quite healthy. John remembers falling deeply in love in his early thirties. After dating his girlfriend for a year, she invited him to meet her family. During his stay with them, John says, “I became acutely aware of how different I was from kids who grew up without the kind of shame and blame I endured.” One night, his girlfriend, her sisters, and their boyfriends all decided to go out dancing. “Everyone was sitting around the dinner table planning this great night out and I remember looking around at her family and the only thing going through my mind were these words: ‘I do not belong here.’ Everyone seemed so normal and happy. I was horrified suddenly at the idea of trying to play along and pretend that I knew how to be part of a happy family.”
So John faked “being really tired. My girlfriend was sweet and stayed with me and we didn’t go. She kept asking what was wrong and at some point I just started crying and I couldn’t stop. She wanted to help, but instead of telling her how insecure I was, or asking for her reassurance, I told her I was crying because I wasn’t in love with her.”
John’s girlfriend was, he says, “completely devastated.” She drove John to a hotel that night. “She and her family were shocked. No one could understand what had happened.” Even though John had been deeply in love, his fear won out. “I couldn’t let her find out how crippled I was by the shame and grief I carried inside.”
Bleeding from his inflamed intestines, exhausted by chronic fatigue, debilitated and distracted by pounding headaches, often struggling with work, and unable to feel comfortable in a relationship, John was stuck in a universe of pain and solitude, and he couldn’t get out.
Georgia’s childhood seems far better than the norm: she had two living parents who stayed married through thick and thin, and they lived in a stunning home with walls displaying Ivy League diplomas; Georgia’s father was a well-respected, Yale-educated investment banker. Her mom stayed at home with Georgia and two younger sisters. The five of them appear, in photos, to be the perfect family.
All seemed fine, growing up, practically perfect.
“But I felt, very early on, that something wasn’t quite right in our home, and that no one was talking about it,” Georgia says. “Our house was saturated by a kind of unease all the time. You could never put your finger on what it was, but it was there.”
Georgia’s mom was “emotionally distant and controlling,” Georgia recalls. “If you said or did something she didn’t like, she had a way of going stone cold right in front of you she’d become what I used to think of as a moving statue that looked like my mother, only she wouldn’t look at you or speak to you.” The hardest part was that Georgia never knew what she’d done wrong. “I just knew that l was shut out of her world until whenever she decided I was worth speaking to again.”
For instance, her mother would “give my sisters and me a tiny little tablespoon of ice cream and then say, ‘You three will just have to share that.’ We knew better than to complain. If we did, she’d tell us how ungrateful we were, and suddenly she wouldn’t speak to us.”
Georgia’s father was a borderline alcoholic and “would occasionally just blow up over nothing,” she says. “One time he was changing a light bulb and he just started cursing and screaming because it broke. He had these unpredictable eruptions of rage. They were rare but unforgettable.” Georgia was so frightened at times that “I’d run like a dog with my tail between my legs to hide until it was safe to come out again.”
Georgia was “so sensitive to the shifting vibe in our house that I could tell when my father was about to erupt before even he knew. The air would get so tight and I’d know, it’s going to happen again.” The worst part was that “We had to pretend my father’s outbursts weren’t happening. He’d scream about something minor, and then he’d go take a nap. Or you’d hear him strumming his guitar in his den.”
Between her mother’s silent treatments and her dad’s tirades, Georgia spent much of her childhood trying to anticipate and move out of the way of her parents’ anger. She had the sense, even when she was nine or ten, “that their anger was directed at each other. They didn’t fight, but there was a constant low hum of animosity between them. At times it seemed they vehemently hated each other.” Once, fearing that her inebriated father would crash his car after an argument with her mother, Georgia stole his car keys and refused to give them back.
Today, at age forty nine, Georgia is reflective about her childhood. “I internalized all the emotions that were storming around me in my house, and in some ways it’s as if I’ve carried all that external angst inside me all my life.” Over the decades, carrying that pain has exacted a high toll. At first, Georgia says, “My physical pain began as a low whisper in my body.” But by the time she entered Columbia graduate school to pursue a PhD in classics, “I’d started having severe back problems. I was in so much physical pain, I could not sit in a chair. I had to study lying down.” At twenty six, Georgia was diagnosed with degenerative disc disease. “My body just started screaming with its pain.”
Over the next few years, in addition to degenerative disc disease, Georgia was diagnosed with severe depression, adrenal fatigue, and finally, fibromyalgia. “I’ve spent my adult life in doctors’ clinics and trying various medications to relieve my pain,” she says. “But there is no relief in sight.”
Laura’s, John’s, and Georgia’s life stories illustrate the physical price we pay, as adults, for childhood adversity. New findings in neuroscience, psychology, and medicine have recently unveiled the exact ways in which childhood adversity biologically alters us for life.
This groundbreaking research tells us that the emotional trauma we face when we are young has farther reaching consequences than we might have imagined.
Adverse Childhood Experiences change the architecture of our brains and the health of our immune systems, they trigger and sustain inflammation in both body and brain, and they influence our overall physical health and longevity long into adulthood.
These physical changes, in turn, prewrite the story of how we will react to the world around us, and how well we will work, and parent, befriend, and love other people throughout the course of our adult lives.
This is true whether our childhood wounds are deeply traumatic, such as witnessing violence in our family, as John did; or more chronic living room variety humiliations, such as those Laura endured; or more private but pervasive familial dysfunctions, such as Georgia’s.
All of these Adverse Childhood Experiences can lead to deep biophysical changes in a child that profoundly alter the developing brain and immunology in ways that also change the health of the adult he or she will become.
Scientists have come to this startling understanding of the link between Adverse Childhood Experiences and later physical illness in adulthood thanks, in large part, to the work of two individuals: a dedicated physician in San Diego, and a determined medical epidemiologist from the Centers for Disease Control (CDC). Together, during the 1980s and 1990s, the same years when Laura, John, and Georgia were growing up, these two researchers slowly uncovered the stunning scientific link between Adverse Childhood Experiences and later physical and neurological inflammation and life changing adult health outcomes.
The Philosophical Physicians
In 1985 physician and researcher Vincent J. Felitti, MD, chief of a revolutionary preventive care initiative at the Kaiser Permanente Medical Program in San Diego, noticed a startling pattern: adult patients who were obese also alluded to traumatic incidents in their childhood. Felitti came to this realization almost by accident.
In the mid 1980s, a significant number of patients in Kaiser Permanente’s obesity program were, with the help and support of Felitti and his nurses, successfully losing hundreds of pounds a year nonsurgically, a remarkable feat. The program seemed a resounding success, up until a large number of patients who were losing substantial amounts of weight began to drop out.
The attrition rate didn’t make sense, and Felitti was determined to find out what was going on. He conducted face-to-face interviews with 286 patients. In the course of Felitti’s one-on-one conversations, a striking number of patients confided that they had faced trauma in their childhood; many had been sexually abused. To these patients, eating was a solution: it soothed the anxiety, fear, and depression that they had secreted away inside for decades. Their weight served, too, as a shield against unwanted physical attention, and they didn’t want to let it go.
Felitti’s conversations with this large group of patients allowed him to perceive a pattern, and a new way of looking at human health and well-being, that other physicians just were not seeing. It became clear to him that, for his patients, obesity, “though an obvious physical sign,” was not the core problem to be treated, “any more than smoke is the core problem to be treated in house fires.”
In 1990, Felitti presented his findings at a national obesity conference. He told the group of physicians gathered that he believed “certain of our intractable public health problems” had root causes hidden “by shame, by secrecy, and by social taboos against exploring certain areas of life experience.”….
Childhood Disrupted. How Your Biography Becomes Your Biology, and How You Can Heal
by Donna Jackson Nakazawa
get it at Amazon.com
The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study
Vincent J. Felitti, MD
Department of Preventive Medicine Kaiser Permanente Medical Care Program
”In my beginning is my end.” T.S. Elliot, “Four Quartets”
A population based analysis of over 17,000 middle class American adults undergoing comprehensive, biopsychosocial medical evaluation indicates that three common categories of addiction are strongly related in a proportionate manner to several specific categories of adverse experiences during childhood. This, coupled with related information. suggests that the basic cause of addiction is predominantly experience dependent during childhood and not substance dependent. This challenge to the usual concept of the cause of addictions has significant implications for medical practice and for treatment programs.
Purpose: My intent is to challenge the usual concept of addiction with new evidence from a population based clinical study of over 17,000 adult, middle class Americans.
The usual concept of addiction essentially states that the compulsive use of ‘addictive’ substances is in some way caused by properties intrinsic to their molecular structure’. This view confuses mechanism with cause. Because any accepted explanation of addiction has social. medical. therapeutic, and legal implications, the way one understands addiction is important. Confusing mechanism with basic cause quickly leads one down a path that is misleading. Here, new data is presented to stimulate rethinking the basis of addiction.
Background: The information I present comes from the Adverse Childhood Experiences (ACE) Study. The ACE Study deals with the basic causes underlying the 10 most common causes of death in America; addiction is only one of several outcomes studied.
In the mid 1980s, physicians in Kaiser Permanente’s Department of Preventive Medicine in San Diego discovered that patients successfully losing weight in the Weight Program were the most likely to drop out. This unexpected observation led to our discovery that overeating and obesity were often being used unconsciously as protective solutions to unrecognized problems dating back to childhood.” Counterintuitively, obesity provided hidden benefits: it often was sexually, physically, or emotionally protective.
Our discovery that public health problems like obesity could also be personal solutions, and our finding an unexpectedly high prevalence of adverse childhood experiences in our middle class adult population, led to collaboration with the Centers for Disease Control (CDC) to document their prevalence and to study the implications of these unexpected clinical observations. I am deeply indebted to my colleague, Robert F. Anda MD, who skillfully designed the Adverse Childhood Experiences (ACE) Study in an epidemiologically sound manner, and whose group at CDC analyzed several hundred thousand pages of patient data to produce the data we have published.
Many of our obese patients had previously been heavy drinkers, heavy smokers, or users of illicit drugs. Of what relevance are these observations; do they imply some unspecified innate tendency to addiction? Is addiction genetic, as some have proposed for alcoholism? Is addiction a biomedical disease. a personality disorder. or something different? Are diseases and personality disorders separable. or are they ultimately related? What does one make of the dramatic recent findings in neurobiology that seem to promise a neurochemical explanation for addiction? Why does only a small percent of persons exposed to addictive substances become compulsive users?
Although the problem of narcotic addiction has led to extensive legislative attempts at eradication, its prevalence has not abated over the past century. However. the distribution pattern of narcotic use within the population has radically changed. attracting significant political attention and governmental actions The inability to control addiction by these major, well intended governmental efforts has drawn thoughtful and challenging commentary from a number of different viewpoints.
In our detailed study of over 17.000 middle class American adults of diverse ethnicity, we found that the compulsive use of nicotine, alcohol, and injected street drugs increases proportionally in a strong, graded dose response manner that closely parallels the intensity of adverse life experiences during childhood. This of course supports old psychoanalytic views and is at odds with current concepts, including those of biological psychiatry, drug treatment programs, and drug eradication programs.
Our findings are disturbing to some because they imply that the basic causes of addiction lie within us and the way we treat each other, not in drug dealers or dangerous chemicals. They suggest that billions of dollars have been spent everywhere except where the answer is to be found.
Study design: Kaiser Permanente (KP) is the largest prepaid. non profit. healthcare delivery system in the United States; there are 500,000 KP members in San Diego, approximately 30% of the greater metropolitan population. We invited 26,000 consecutive adults voluntarily seeking comprehensive medical evaluation in the Department of Preventive Medicine to help us understand how events in childhood might later affect health status in adult life. Seventy percent agreed, understanding the information obtained was anonymous and would not become part of their medical records.
Our cohort population was 80% white including Hispanic, 10% black, and 10% Asian. Their average age was 57 years; 74% had been to college. 44% had graduated college; 49.5% were men.
In any four year period, 81% of all adult Kaiser Health Plan members seek such medical evaluation; there is no reason to believe that selection bias is a significant factor in the Study. The Study was carried out in two waves. to allow mid point correction if necessary. Further details of Study design are described in our initial publication.
The ACE Study compares adverse childhood experiences against adult health status, on average a half century later. The experiences studied were eight categories of adverse childhood experience commonly observed in the Weight Program. The prevalence of each category is stated in parentheses. The categories are:
1. recurrent and severe physical abuse (11%)
2. recurrent and severe emotional abuse (11%)
3. contact sexual abuse (22%)
growing up in a household with:
4. an alcoholic or drug user (25%)
5. a member being imprisoned (3%)
6. a mentally ill, chronically depressed, or institutionalized member (19%)
7. the mother being treated violently (12%)
8. both biological parents not being present (22%)
The scoring system is simple: exposure during childhood or adolescence to any category of ACE was scored as one point. Multiple exposures within a category were not scored: one alcoholic within a household counted the same as an alcoholic and a drug user; if anything, this tends to understate our findings. The ACE Score therefore can range from 0 to 8. Less than half of this middle class population had an ACE Score of 0; one in fourteen had an ACE Score of 4 or more.
In retrospect, an initial design flaw was not scoring subtle issues like low level neglect and lack of interest in a child who is otherwise the recipient of adequate physical care. This omission will not affect the interpretation of our First Wave findings, and may explain the presence of some unexpected outcomes in persons having ACE Score zero. Emotional neglect was studied in the Second Wave.
The ACE Study contains a prospective arm: the starting cohort is being followed forward in time to match adverse childhood experiences against current doctor office visits, emergency depanment visits, pharmacy costs, hospitalizations, and death. Publication of these analyses soon will begin.
Findings: Our overall findings. presented extensively in the American literature, demonstrate that:
– Adverse childhood experiences are surprisingly common. although typically concealed and unrecognized.
– ACEs still have a profound effect 50 years later, although now transformed from psychosocial experience into organic disease, social malfunction, and mental illness.
– Adverse childhood experiences are the main determinant of the health and social well being of the nation.
Our overall findings challenge conventional views, some of which are clearly defensive. They also provide opportunities for new approaches to some of our most difficult public health problems. Findings from the ACE Study provide insights into changes that are needed in pediatrics and adult medicine, which expectedly will have a significant impact on the cost and effectiveness of medical care.
Our intent here is to present our findings only as they relate to the problem of addiction, using nicotine, alcohol, and injected illicit drugs as examples of substances that are commonly viewed as ‘addicting‘. If we know why things happen and how, then we may have a new basis for prevention.
Smoking tobacco has come under heavy opposition in the United States, particularly in southern California where the ACE Study was carried out. Whereas at one time most men and many women smoked, only a minority does so now; it is illegal to smoke in office buildings, public transportation, restaurants, bars, and in most areas of hotels.
When we studied current smokers, we found that smoking had a strong, graded relationship to adverse childhood experiences Figure 1 illustrates this clearly. The p value for this and all other data displays is .001 or better.
This stepwise 250% increase in the likelihood of an ACE Score 6 child being a current smoker, compared to an ACE Score 0 child. is generally not known. This simple observation has profound implications that illustrate the psychoactive benefits of nicotine; this information has largely been lost in the public health onslaught against smoking but is important in understanding the intractable nature of smoking in many people.
When we match the prevalence of adult chronic bronchitis and emphysema against ACEs, we again see a strong dose response relationship. We thereby proceed from the relationship of adverse childhood experiences to a health risk behavior to their relationship with an organic disease. In other words, Figure 2 illustrates the conversion of emotional stressors into an organic disease, through the intermediary mechanism of an emotionally beneficial (although medically unsafe) behavior.
One’s own alcoholism is not easily or comfortably acknowledged; therefore. when we asked our Study cohort if they had ever considered themselves to be alcoholic, we felt that Yes answers probably understated the truth, making the effect even stronger than is shown. The relationship of self acknowledged alcoholism to adverse childhood experiences is depicted in Figure 3. Here we see that more than a 500% increase in adult alcoholism is related in a strong, graded manner to adverse childhood experiences.
Injection of illegal drugs
In the United States the most commonly injected street drugs are heroin and methamphetamine. Methamphetamine has the interesting property of being closely related to amphetamine, the first anti depressant introduced by Ciba Pharmaceuticals in 1932.
When we studied the relation of injecting illicit drugs to adverse childhood experiences, we again found a similar dose response pattern; the likelihood of injection of street drugs increases strongly and in a graded fashion as the ACE Score increases (Figure 4). At the extremes of ACE Score. the figures for injected drug use are even more powerful. For instance, a male child with an ACE Score of 6, when compared to a male child with an ACE Score of 0, has a 46 fold (4.600%) increase in the likelihood of becoming an injection drug user sometime later in life.
Although awareness of the hazards of smoking is now near universal. and has caused a significant reduction in smoking, in recent years the prevalence of smoking has remained largely unchanged. In fact. the association between ACE score and smoking is stronger in age cohorts born after the Surgeon General’s Report on Smoking.
Do current smokers now represent a core of individuals who have a more profound need for the psychoactive benefits of nicotine than those who have given up smoking? Our clinical experience and data from the ACE Study suggest this as a likely possibility. Certainly, there is good evidence of the psychoactive benefits of nicotine for moderating anger anxiety, and hunger.
Alcohol is well accepted as a psychoactive agent. This obvious explanation of alcoholism is now sometimes rejected in favor of a proposed genetic causality. Certainly, alcoholism may be familial, as is language spoken. Our findings support an experiential and psychodynamic explanation for alcoholism, although this may well be moderated by genetic and metabolic differences between races and individuals.
Analysis of our Study data for injected drug use shows a powerful relation to ACEs. Population Attributable Risk (PAR) analysis shows that 78% of drug injection by women can be attributed to adverse childhood experiences. For men and women combined, the PAR is 67%. Moreover, this PAR has been constant in four age cohorts whose birth dates span a century; this indicates that the relation of adverse childhood experiences to illicit drug use has been constant in spite of major changes in drug availability and in social customs, and in the introduction of drug eradication programs.
American soldiers in Vietnam provided an important although overlooked observation. Many enlisted men in Vietnam regularly used heroin. However, only 5% of those considered addicted were still using it 10 months after their return to the US.” Treatment did not account for this high recovery rate.
Why does not everyone become addicted when they repeatedly inject a substance reputedly as addicting as heroin? If a substance like heroin is not inherently addicting to everyone, but only to a small minority of human users, what determines this selectivity? Is it the substance that is intrinsically addicting, or do life experiences actually determine its compulsive use? Surely its chemical structure remains constant.
Our findings indicate that the major factor underlying addiction is adverse childhood experiences that have not healed with time and that are overwhelmingly concealed from awareness by shame, secrecy, and social taboo.
The compulsive user appears to be one who, not having other resolutions available, unconsciously seeks relief by using materials with known psychoactive benefit, accepting the known long term risk of injecting illicit, impure chemicals. The ACE Study provides population based clinical evidence that unrecognized adverse childhood experiences are a major, if not the major, determinant of who turns to psychoactive materials and becomes ‘addicted’.
Given that the conventional concept of addiction is seriously flawed, and that we have presented strong evidence for an alternative explanation, we propose giving up our old mechanistic explanation of addiction in favor of one that explains it in terms of its psychodynamics: unconscious although understandable decisions being made to seek chemical relief from the ongoing effects of old trauma, often at the cost of accepting future health risk.
Expressions like ‘self destructive behavior’ are misleading and should be dropped because, while describing the acceptance of long term risk, they overlook the importance of the obvious short term benefits that drive the use of these substances.
This revised concept of addiction suggests new approaches to primary prevention and treatment. The current public health approach of repeated cautionary warnings has demonstrated its limitations, perhaps because the cautions do not respect the individual when they exhort change without understanding.
Adverse childhood experiences are widespread and typically unrecognized. These experiences produce neurodevelopmental and emotional damage, and impair social and school performance. By adolescence, children have a sufficient skill and independence to seek relief through a small number of mechanisms, many of which have been in use since biblical times: drinking alcohol, sexual promiscuity, smoking tobacco, using psychoactive materials, and overeating. These coping devices are manifestly effective for their users, presumably through their ability to modulate the activity of various neurotransmitters. Nicotine, for instance. is a powerful substitute for the neurotransmitter acetylcholine. Not surprisingly, the level of some neurotransmitters varies genetically between individuals.
It is these coping devices, with their short term emotional benefits, that often pose long term risks leading to chronic disease; many lead to premature death. This sequence is depicted in the ACE Pyramid (Figure 5). The sequence is slow, often unstoppable, and is generally obscured by time, secrecy, and social taboo. Time does not heal in most of these instances. Because cause and effect usually lie within a family, it is understandably more comforting to demonize a chemical than to look within. We find that addiction overwhelmingly implies prior adverse life experiences.
The sequence in the ACE Pyramid supports psychoanalytic observations that addiction is primarily a consequence of adverse childhood experiences. Moreover, it does so by a population based study, thereby escaping the potential selection bias of individual case reports.
Addiction is not a brain disease, nor is it caused by chemical imbalance or genetics. Addiction is best viewed as an understandable, unconscious, compulsive use of psychoactive materials in response to abnormal prior life experiences, most of which are concealed by shame, secrecy, and social taboo.
Our findings show that childhood experiences profoundly and causally shape adult life‘ ‘Chemical imbalances’. whether genetically modulated or not, are the necessary intermediary mechanisms by which these causal life experiences are translated into manifest effect. It is important to distinguish between cause and mechanism. Uncertainty and confusion between the two will lead to needless polemics and misdirected efforts for preventing or treating addiction, whether on a social or an individual scale.
Our findings also make it clear that studying any one category of adverse experience, be it domestic violence. childhood sexual abuse, or other forms of family dysfunction is a conceptual error. None occur in vacuum; they are part of a complex systems failure: one does not grow up with an alcoholic where everything else in the household is fine.
If we are to improve the current unhappy situation, we must in medical settings routinely screen at the earliest possible point for adverse childhood experiences. It is feasible and acceptable to carry out mass screening for ACEs in the context of comprehensive medical evaluation. This identifies cases early and allows treatment of basic causes rather than vainly treating the symptom of the moment. We have screened over 450, 000 adult members of Kaiser Health Plan for these eight categories of adverse childhood experiences. Our initial screening is by an expanded Review of Systems questionnaire; patients certainly do not spontaneously volunteer this information. ‘Yes’ answers then are pursued with conventional history taking: “I see that you were molested as a child. Tell me how that has affected you later in your life.”
Such screening has demonstrable value. Before we screened for adverse childhood experiences, our standardized comprehensive medical evaluation led to a 12% reduction in medical visits during the subsequent year. Later, in a pilot study, an on site psychoanalyst conducted a one time interview of depressed patients; this produced a 50% reduction in the utilization of this subset during the subsequent year. However, the reduction occurred only in those depressed patients who were high utilizers of medical care because of somatization disorders.
Recently, we evaluated our current approach by a neural net analysis of the records of 135,000 patients who were screened for adverse childhood experiences as part of our redesigned comprehensive medical evaluation. This entire cohort showed an overall reduction of 35% in doctor office visits during the year subsequent to evaluation.
Our experience asking these questions indicates that the magnitude of the ACE problem is so great that primary prevention is ultimately the only realistic solution. Primary prevention requires the development of a beneficial and acceptable intrusion into the closed realm of personal and family experience. Techniques for accomplishing such change en masse are yet to be developed because each of us, fearing the new and unknown as a potential crisis in self esteem, often adjusts to the status quo. However, one possible approach to primary prevention lies in the mass media: the story lines of movies and television serials present a major therapeutic opportunity, unexploited thus far, for contrasting desirable and undesirable parenting skills in various life situations.
Because addiction is experience dependent and not substance dependent, and because compulsive use of only one substance is actually uncommon, one also might restructure treatment programs to deal with underlying causes rather than to focus on substance withdrawal. We have begun using this approach with benefit in our Obesity Program, and plan to do so with some of the more conventionally accepted addictions.
The current concept of addiction is ill founded. Our study of the relationship of adverse childhood experiences to adult health status in over 17,000 persons shows addiction to be a readily understandable, although largely unconscious, attempt to gain relief from well concealed prior life traumas by using psychoactive materials. Because it is difficult to get enough of something that doesn’t quite work, the attempt is ultimately unsuccessful, apart from its risks. What we have shown will not surprise most psychoanalysts, although the magnitude of our observations is new, and our conclusions are sometimes vigorously challenged by other disciplines.
The evidence supporting our conclusions about the basic cause of addiction is powerful and its implications are daunting. The prevalence of adverse childhood experiences and their long term effects are clearly a major determinant of the health and social well being of the nation. This is true whether looked at from the standpoint of social costs, the economics of health care, the quality of human existence, the focus of medical treatment, or the effects of public policy.
Adverse childhood experiences are difticult issues, made more so because they strike close to home for many of us. Taking them on will create an ordeal of change, but will also provide for many the opportunity to have a better life.
Adverse Childhood Experiences Study
The Adverse Childhood Experiences Study (ACE Study) is a research study conducted by the American health maintenance organization Kaiser Permanente and the Centers for Disease Control and Prevention. Participants were recruited to the study between 1995 and 1997 and have been in long-term follow up for health outcomes. The study has demonstrated an association of adverse childhood experiences (ACEs) (aka childhood trauma) with health and social problems across the lifespan. The study is frequently cited as a notable landmark in epidemiological research, and has produced many scientific articles and conference and workshop presentations that examine ACEs.
In the 1980s, the dropout rate of participants at Kaiser Permanente’s obesity clinic in San Diego, California, was about 50%; despite all of the dropouts successfully losing weight under the program. Vincent Felitti, head of Kaiser Permanente’s Department of Preventive Medicine in San Diego, conducted interviews with people who had left the program, and discovered that a majority of 286 people he interviewed had experienced childhood sexual abuse. The interview findings suggested to Felitti that weight gain might be a coping mechanism for depression, anxiety, and fear.
Felitti and Robert Anda from the Centers for Disease Control and Prevention (CDC) went on to survey childhood trauma experiences of over 17,000 Kaiser Permanente patient volunteers. The 17,337 participants were volunteers from approximately 26,000 consecutive Kaiser Permanente members. About half were female; 74.8% were white; the average age was 57; 75.2% had attended college; all had jobs and good health care, because they were members of the Kaiser health maintenance organization. Participants were asked about 10 types of childhood trauma that had been identified in earlier research literature:
– Physical abuse
– Sexual abuse
– Emotional abuse
– Physical or emotional neglect
– Exposure to domestic violence
– Household substance abuse
– Household mental illness
– Family member (attempted) suicide
– Parental separation or divorce
– Incarcerated household member
In one way or another, all ten questions speak to family dysfunction.
The ACE Pyramid represents the conceptual framework for the ACE Study, which has uncovered how adverse childhood experiences are strongly related to various risk factors for disease throughout the lifespan, according to the Centers for Disease Control and Prevention.
According to the United States’ Substance Abuse and Mental Health Services Administration, the ACE study found that:
Adverse childhood experiences are common. For example, 28% of study participants reported physical abuse and 21% reported sexual abuse. Many also reported experiencing a divorce or parental separation, or having a parent with a mental and/or substance use disorder.
Adverse childhood experiences often occur together. Almost 40% of the original sample reported two or more ACEs and 12.5% experienced four or more. Because ACEs occur in clusters, many subsequent studies have examined the cumulative effects of ACEs rather than the individual effects of each.
Adverse childhood experiences have a dose response relationship with many health problems. As researchers followed participants over time, they discovered that a person’s cumulative ACEs score has a strong, graded relationship to numerous health, social, and behavioral problems throughout their lifespan, including substance use disorders. Furthermore, many problems related to ACEs tend to be comorbid, or co-occurring.
About two-thirds of individuals reported at least one adverse childhood experience; 87% of individuals who reported one ACE reported at least one additional ACE. The number of ACEs was strongly associated with adulthood high-risk health behaviors such as smoking, alcohol and drug abuse, promiscuity, and severe obesity, and correlated with ill-health including depression, heart disease, cancer, chronic lung disease and shortened lifespan.
Compared to an ACE score of zero, having four adverse childhood experiences was associated with a seven fold (700%) increase in alcoholism, a doubling of risk of being diagnosed with cancer, and a four-fold increase in emphysema; an ACE score above six was associated with a 30-fold (3000%) increase in attempted suicides.
The ACE study’s results suggest that maltreatment and household dysfunction in childhood contribute to health problems decades later. These include chronic diseases, such as heart disease, cancer, stroke, and diabetes, that are the most common causes of death and disability in the United States. The study’s findings, while relating to a specific population within the United States, might reasonably be assumed to reflect similar trends in other parts of the world, according to the World Health Organization. The study was initially published in the American Journal of Preventive Medicine.
The ACE Study has produced more than 50 articles that look at the prevalence and consequences of ACEs. It has been influential in several areas. Subsequent studies have confirmed the high frequency of adverse childhood experiences, or found even higher incidences in urban or youth populations.
The original study questions have been used to develop a 10-item screening questionnaire. Numerous subsequent surveys have confirmed that adverse childhood experiences are frequent.
The CDC runs the Behavioral Risk Factor Surveillance System (BRFSS), an annual survey conducted by individual state health departments in all 50 states. An expanded survey instrument in several states found each state to be similar. Some states have collected additional local data. Adverse childhood experiences were even more frequent in studies in urban Philadelphia, and in a survey of young mothers (mostly younger than 19). Internationally, an Adverse Childhood Experiences International Questionnaire (ACE-IQ) is undergoing validation testing. Surveys of adverse childhood experiences have been conducted in Romania, the Czech Republic, the Republic of Macedonia, Norway, the Philippines, the United Kingdom, Canada, China and Jordan.
Child Trends used data from the 2011/12 National Survey of Children’s Health (NSCH) to analyze ACEs prevalence in children nationally, and by state. The NSCH’s list of “adverse family experiences” includes a measure of economic hardship and shows that this is the most common ACE reported nationally.
Neurobiology of Stress
Cognitive and neuroscience researchers have examined possible mechanisms that might explain the negative consequences of adverse childhood experiences on adult health. Adverse childhood experiences can alter the structural development of neural networks and the biochemistry of neuroendocrine System and may have long term effects on the body, including speeding up the processes of disease and aging and compromising immune systems.
Allostatic load refers to the adaptive processes that maintain homeostasis during times of toxic stress through the production of mediators such as adrenalin, cortisol and other chemical messengers. According to researcher Bruce S McEwen, who coined the term:
“These mediators of the stress response promote adaptation in the aftermath of acute stress, but they also contribute to allostatic overload, the wear and tear on the body and brain that result from being ‘stressed out.‘ This conceptual framework has created a need to know how to improve the efficiency of the adaptive response to stressors while minimizing overactivity of the same systems, since such overactivity results in many of the common diseases of modern life. This framework has also helped to demystify the biology of stress by emphasizing the protective as well as the damaging effects of the body’s attempts to cope with the challenges known as stressors.”
Additionally, epigenetic transmission may occur due to stress during pregnancy or during interactions between mother and newborns. Maternal stress, depression, and exposure to partner violence have all been shown to have epigenetic effects on infants.
As knowledge about the prevalence and consequences of adverse childhood experiences increases, trauma informed and resilience building practices based on the research is being implemented in communities, education, public health departments, social services, faith-based organizations and criminal justice. A few states are considering legislation.
As knowledge about the prevalence and consequences of ACEs increases, more communities seek to integrate trauma informed and resilience building practices into their agencies and systems. Tarpon Springs, Florida, became the first trauma informed community in 2011. Trauma informed initiatives in Tarpon Springs include trauma awareness training for the local housing authority, changes in programs for ex-offenders, and new approaches to educating students with learning difficulties.
Children who are exposed to adverse childhood experiences may become overloaded with stress hormones, leaving them in a constant state of arousal and alertness to environmental and relational threats. Therefore, they may have difficulty focusing on school work, and consolidating new memory, making it harder for them to learn at school.
Approximately one in three or four children have experienced significant ACEs. A study by the Area Health Education Center of Washington State University found that students with at least three ACEs are three times as likely to experience academic failure, six times as likely to have behavioral problems, and five times as likely to have attendance problems. These students may have trouble trusting teachers and other adults, and may have difficulty creating and maintaining relationships.
The trauma informed school movement aims to train teachers and staff to help children self-regulate, and to help families that are having problems that result in children’s normal response to trauma, rather than simply jumping to punishment. It also seeks to provide behavioral consequences that will not retraumatize a child. Punishment is often ineffective, and better results can often be achieved with positive reinforcement. Out of school suspensions can be particularly bad for students with difficult home lives; forcing students to remain at home may increase their distrust of adults.
Trauma sensitive, or compassionate, schooling has become increasingly popular in Washington, Massachusetts, and California. Lincoln High School in Walla Walla, Washington, adapted a trauma informed approach to discipline and reduced its suspensions by 85%. Rather than standard punishment, students are taught to recognize their reaction to stress and learn to control it.
Spokane, Washington, schools conducted a research study that demonstrated that academic risk was correlated with students’ experiences of traumatic events known to their teachers. The same school district has begun a study to test the impact of trauma informed intervention programs, in an attempt to reduce the impact of toxic stress.
In Brockton, Massachusetts, a community wide meeting led to a trauma informed approach being adopted by the Brockton School District. So far, all of the district’s elementary schools have implemented trauma informed improvement plans, and there are plans to do the same in the middle school and high school. About one-fifth of the district teachers have participated in a course on teaching traumatized students. Police alert schools when they have arrested someone or visited at a student’s address.
Massachusetts state legislation has sought to require all schools to develop plans to create “safe and supportive schools”.
At El Dorado, an elementary school in San Francisco, California, trauma-informed practices were associated with a suspension reduction of 89%.
Social service providers, including welfare systems, housing authorities, homeless shelters, and domestic violence centers are adopting trauma informed approaches that help to prevent ACEs or minimize their impact. Utilizing tools that screen for trauma can help a social service worker direct their clients to interventions that meet their specific needs. Trauma informed practices can also help social service providers look at how trauma impacts the whole family.
Trauma informed approaches can improve child welfare services by 1) openly discussing trauma and 2) addressing parental trauma.
The New Hampshire Division for Children Youth and Families (DCYF) is taking a trauma informed approach to their foster care services by educating staff about childhood trauma, screening children entering foster care for trauma, using trauma informed language to mitigate further traumatization, mentoring birth parents and involving them in collaborative parenting, and training foster parents to be trauma informed.
In Albany, New York the HEARTS Initiative has led to local organizations developing trauma informed practice. Senior Hope Inc, an organization serving adults over the age of 50, began implementing the 10 question ACE survey and talking with their clients about childhood trauma. The LaSalle School, which serves orphaned and abandoned boys, began looking at delinquent boys from a trauma informed perspective and began administering the ACE questionnaire to their clients.
Housing authorities are also becoming trauma informed. Supportive housing can sometimes recreate control and power dynamics associated with clients’ early trauma. This can be reduced through trauma informed practices, such as training staff to be respectful of clients’ space by scheduling appointments and not letting themselves into clients’ private spaces, and also understanding that an aggressive response may be trauma related coping strategies.
The housing authority in Tarpon Springs provided trauma awareness training to staff so they could better understand and react to their clients’ stress and anger resulting from poor employment, health, and housing.
A survey of 200 homeless individuals in California and New York demonstrated that more than 50% had experienced at least four ACEs. In Petaluma, California, the Committee on the Shelterless (COTS) uses a trauma informed approach called Restorative Integral Support (RIS) to reduce intergenerational homelessness. RIS increases awareness of and knowledge about ACEs, and calls on staff to be compassionate and focus on the whole person. COTS now consider themselves ACE informed and focus on resiliency and recovery.
Health care services
Screening for or talking about ACEs with parents and children can help to foster healthy physical and psychological development and can help doctors understand the circumstances that children and their parents are facing. By screening for ACEs in children, pediatric doctors and nurses can better understand behavioral problems.
Some doctors have questioned whether some behaviors resulting in attention deficit hyperactivity disorder (ADHD) diagnoses are in fact reactions to trauma. Children who have experienced four or more ACEs are three times as likely to take ADHD medication when compared with children with less than four ACEs.
Screening parents for their ACEs allows doctors to provide the appropriate support to parents who have experienced trauma, helping them to build resilience, foster attachment with their children, and prevent a family cycle of ACEs. Trauma informed pediatric care also allows doctors to develop a more trusting relationship with parents, opening the lines of communication.
At Monteflore Medical Center ACEs screenings will soon be implemented in 22 pediatric clinics. In a pilot program any child with one parent who has an ACE score of four or higher is offered enrollment and receive a variety of services. For families enrolled in the program parents report fewer ER visits and children have healthier emotional and social development, compared with those not enrolled.
Most American doctors as of 2015 do not use ACE surveys to assess patients. Objections to doing so include that there are no randomized controlled trials that show that such surveys can be used to actually improve health outcomes, there are no standard protocols for how to use the information gathered, and that revisiting negative childhood experiences could be emotionally traumatic. Other obstacles to adoption include that the technique is not taught in medical schools, is not billable, and the nature of the conversation makes some doctors personally uncomfortable.
Some public health centers see ACEs as an important way, especially for mothers and children, to target health interventions for individuals during sensitive periods of development early in their life, or even in utero.
For example, Jefferson Country Public Health clinic in Port Townsend, Washington, now screens pregnant women, their partners, parents of children with special needs, and parents involved with CPS for ACEs. With regard to patient counseling, the clinic treats ACEs like other health risks such as smoking or alcohol consumption.
Resilience is not a trait that people either have or do not have. It involves behaviors, thoughts and actions that can be learned and developed in anyone.
According to the American Psychological Association (2017) resilience is the ability to adapt in the face of adversity, tragedy, threats or significant stress such as family and relationship problems, serious health problems or workplace and financial stressors. Resilience refers to bouncing back from difficult experiences in life. There is nothing extraordinary about resilience. People often demonstrate resilience in times of adversity. However, being resilient does not mean that a person will not experience difficulty or distress as emotional pain is common for people when they suffer from a major adversity or trauma. In fact, the path to resilience often involves considerable emotional pain.
Resilience is labeled as a protective factor. Having resilience can benefit children who have been exposed to trauma and have a higher ACE score. Children who can learn to develop it, can use resilience to build themselves up after trauma. A child who has not developed resilience will have a harder time coping with the challenges that can come in adult life. People and children who are resilient, embrace the thinking that adverse experiences do not define who they are. They also can think about past events in their lives that were traumatic and, try to reframe them in a way that is constructive. They are able to find strength in their struggle and ultimately can overcome the challenges and adversity that was faced in childhood.
In childhood, resiliency can come from having a caring adult in a child’s life. Resiliency can also come from having meaningful moments such as an academic achievement or getting praise from teachers or mentors. In adulthood, resilience is the concept of self-care. If you are taking care of yourself and taking the necessary time to reflect and build on your experiences, then you will have a higher capacity for taking care of others.
Adults can also use this skill to counteract some of the trauma they have experienced. Self-care can mean a variety of things. One example of selfcare, is knowing when you are beginning to feel burned out and then taking a step back to rest and recuperate yourself. Another component of self-care is practicing mindfulness or engaging in some form of meditation. If you are able to take the time to reflect upon your experiences, then you will be able to build a greater level of resiliency moving forward.
All of these strategies put together can help to build resilience and counteract some of the childhood trauma that was experienced. With these strategies children can begin to heal after experiencing adverse childhood experiences. This aspect of resiliency is so important because it enables people to find hope in their traumatic past.
When first looking at the ACE study and the different correlations that come with having 4 or more traumas, it is easy to feel defeated. It is even possible for this information to encourage people to have unhealthy coping behaviors. Introducing resilience and the data that supports its positive outcome in regards to trauma, allows for a light at the end of a tunnel. It gives people the opportunity to be proactive instead of reactive when it comes to addressing the traumas in their past.
Since research suggests that incarcerated individuals are much more likely to have been exposed to violence and suffer from posttraumatic stress disorder (PTSD), a trauma informed approach may better help to address some of these criminogenic risk factors and can create a less traumatizing criminal justice experience. Programs, like Seeking Safety, are often used to help individuals in the criminal justice system learn how to better cope with trauma, PTSD, and substance abuse.
Juvenile courts better help deter children from crime and delinquency when they understand the trauma many of these children have experienced.
The criminal justice system itself can also retraumatize individuals. This can be prevented by creating safer facilities where correctional and police officers are properly trained to keep incidents from escalating. Partnerships between police and mental health providers can also reduce the possible traumatizing effects of police intervention and help provide families with the proper mental health and social services.
The Women’s Community Correctional Center of Hawaii began a Trauma Informed Care Initiative that aims to train all employees to be aware and sensitive to trauma, to screen all women in their facility for trauma, to assess those who have experienced trauma, and begin providing trauma informed mental health care to those women identified.
Faith based Organizations
Some faith based organizations offer spiritual services in response to traumas identified by ACE surveys. For example, the founder of ACE Overcomers combined the epidemiology of ACEs, the neurobiology of toxic stress and principles of the Christian Bible into a workbook and 12-week course used by clergy in several states.
Another example of this integration of faith based principles and ACEs science is the work of Intermountain Residential’s chaplain, who has created a curriculum called “Bruised Reeds and Smoldering Wicks” a six week study meant to introduce the science behind ACEs and early childhood trauma within the context of Christian theology and ministry practice. Published in 2017, it has been used by ministry professionals in 30 states, the District of Columbia, and two Canadian provinces.
Faith based organizations also participate in the online group ACES Connection Network.
The Faith and Health Connection Ministry also applies principles of Christian theology to address childhood traumas.
Vermont has passed a bill, Act 43(H.508), an act relating to building resilience for individuals experiencing adverse childhood experiences which acknowledges the life span effects of ACEs on health outcomes, seeks wide use of ACE screening by health providers and aims to educate medical and health school students about ACEs.
“Vermont first state to propose bill to screen for ACEs in health care”, ACEs Connection, 18 March 2014
Previously Washington State passed legislation to set up a public-private partnership to further community development of trauma informed and resilience building practices that had begun in that state; but it was not adequately funded.
On August 18, 2014, California lawmakers unanimously passed ACR No. 155, which encourages policies reducing children’s exposure to adverse experiences.
Recent Massachusetts legislation supports a trauma informed school movement as part of The Reduction of Gun Violence bill (No. 4376). This bill aims to create “safe and supportive schools” through services and initiatives focused on physical, social, and emotional safety.