PT 2:
Before they added the new trauma-oriented questions, Anda spent a year pouring through the research literature to learn about childhood trauma, and focused on the eight major types that patients had mentioned so often in Felitti’s original study and whose individual consequences had been studied by other researchers. These eight included three types of abuse — sexual, verbal and physical. And five types of family dysfunction — a parent who’s mentally ill or alcoholic, a mother who’s a domestic violence victim, a family member who’s been incarcerated, a loss of a parent through divorce or abandonment. He later added emotional and physical neglect, for a total of 10 types of adverse childhood experiences, or ACEs.
The initial surveys began in 1995 and continued through 1997, with the participants followed subsequently for more than fifteen years. “Everything we’ve published comes from that baseline survey of 17,421 people,” says Anda, as well as what was learned by following those people for so long.
When the first results of the survey were due to come in, Anda was at home in Atlanta. Late in the evening, he logged into his computer to look at the findings. He was stunned. “I wept,” he says. “I saw how much people had suffered and I wept.”
This was the first time that researchers had looked at the effects of several types of trauma, rather than the consequences of just one. What the data revealed was mind-boggling.
The first shocker: There was a direct link between childhood trauma and adult onset of chronic disease, as well as mental illness, doing time in prison, and work issues, such as absenteeism.
The second shocker: About two-thirds of the adults in the study had experienced one or more types of adverse childhood experiences. Of those, 87 percent had experienced 2 or more types. This showed that people who had an alcoholic father, for example, were likely to have also experienced physical abuse or verbal abuse. In other words, ACEs usually didn’t happen in isolation.
The third shocker: More adverse childhood experiences resulted in a higher risk of medical, mental and social problems as an adult.
To explain this, Anda and Felitti developed a scoring system for ACEs. Each type of adverse childhood experience counted as one point. If a person had none of the events in her or his background, the ACE score was zero. If someone was verbally abused thousands of times during his or her childhood, but no other types of childhood trauma occurred, this counted as one point in the ACE score. If a person experienced verbal abuse, lived with a mentally ill mother and an alcoholic father, his ACE score was three.
Things start getting serious around an ACE score of 4. Compared with people with zero ACEs, those with four categories of ACEs had a 240 percent greater risk of hepatitis, were 390 percent more likely to have chronic obstructive pulmonary disease (emphysema or chronic bronchitis), and a 240 percent higher risk of a sexually-transmitted disease.
They were twice as likely to be smokers, 12 times more likely to have attempted suicide, seven times more likely to be alcoholic, and 10 times more likely to have injected street drugs.
People with high ACE scores are more likely to be violent, to have more marriages, more broken bones, more drug prescriptions, more depression, more auto-immune diseases, and more work absences.
“Some of the increases are enormous and are of a size that you rarely ever see in health studies or epidemiological studies. It changed my thinking dramatically,” says Anda.
Two in nine people had an ACE score of 3 or more, and one in eight had an ACE score of 4 or more. This means that every physician probably sees several high ACE score patients every day, notes Felitti. “Typically, they are the most difficult, though the underpinnings will rarely be recognized.”
The kicker was this: The ACE Study participants were average Americans. Seventy-five percent were white, 11 percent Latino, 7.5 percent Asian and Pacific Islander, and 5 percent were black. They were middle-class, middle-aged, 36 percent had attended college and 40 percent had college degrees or higher. Since they were members of Kaiser Permanente, they all had jobs and great health care. Their average age was 57.
As Anda has said: “It’s not just ‘them’. It’s us.”
Changing the landscape of understanding human development
In the last 14 years, Anda, Felitti and other CDC researchers have published more than 60 papers in prestigious peer-reviewed journals, including the Journal of the American Medical Association and the American Journal of Preventive Medicine. Other researchers have referenced their work more than 1,500 times. Anda and Felitti have flown around the U.S., Canada and Europe to give hundreds of speeches.
Their inquiry “changed the landscape,” says Dr. Frank Putnam, director of the Mayerson Center for Safe and Healthy Children at Cincinnati Children’s Hospital Medical Center and professor at the University of Cincinnati Department of Pediatrics. “It changed the landscape because of the pervasiveness of ACEs in the huge number of public health problems, expensive public health problems — depression, substance abuse, STDs, cancer, heart disease, chronic lung disease, diabetes.”
The ACE Study became even more significant with the publication of parallel research that provided the link between why something that happened to you when you were a kid could land you in the hospital at age 50. The stress of severe and chronic childhood trauma – such as being regularly hit, constantly belittled and berated, watching your father often hit your mother – releases hormones that physically damage a child’s developing brain.
Flight, fight or freeze hormones work really well to help us accelerate when we’re being chased by a vicious dog with big teeth, fight when we’re cornered, or turn to stone and stop breathing to escape detection by a predator. But they become toxic when they’re turned on for too long.
This was determined by a group of neuroscientists and pediatricians, including neuroscientist Martin Teicher and pediatrician Jack Shonkoff, both at Harvard University, neuroscientist Bruce McEwen at Rockefeller University, and pediatrician Bruce Perry at the Child Trauma Academy.
As San Francisco pediatrician Nadine Burke Harris recently explained to host Ira Glass on the radio program, “This American Life”, if you’re in a forest and see a bear, a very efficient fight or flight system instantly floods your body with adrenaline and cortisol and shuts off the thinking portion of your brain that would stop to consider other options. This is very helpful if you’re in a forest and you need to run from a bear. “The problem is when that bear comes home from the bar every night,” she said.
Dr. Nadine Burke Harris and faux patient (for the photo) If a bear threatens a child every single day, his emergency response system is activated over and over and over again. He’s always ready to fight or flee from the bear, but the part of his brain – the prefrontal cortex – that’s called upon to diagram a sentence or do math becomes stunted, because, in our brains, emergencies – such as fleeing bears – take precedence over doing math.
For Harris’ patients who had four or more categories of adverse childhood experiences “their odds of having learning or behavior problems in school were 32 times as high as kids who had no adverse childhood experiences,” she told Glass.
Together, the two discoveries – the ACE epidemiology and the brain research — reveal a story too compelling to ignore:
Children with toxic stress live much of their lives in fight, flight or fright (freeze) mode. They respond to the world as a place of constant danger. With their brains overloaded with stress hormones and unable to function appropriately, they can’t focus on learning. They fall behind in school or fail to develop healthy relationships with peers or create problems with teachers and principals because they are unable to trust adults. Some kids do all three. With despair, guilt and frustration pecking away at their psyches, they often find solace in food, alcohol, tobacco, methamphetamines, inappropriate sex, high-risk sports, and/or work and over-achievement. They don’t regard these coping methods as problems. Consciously or unconsciously, they use them as solutions to escape from depression, anxiety, anger, fear and shame.
What all this means, says Anda is that we need to prevent adverse childhood experiences and, at the same time, change our systems – educational, criminal justice, healthcare, mental health, public health, workplace – so that we don’t further traumatize someone who’s already traumatized. You can’t do one or the other and hope to make any progress.