One out of ten individuals responded yes to the question “Did a parent or other adult in the household often or very often swear at you, insult you, or put you down?”
More than a quarter responded yes to the questions “Did one of your parents often or very often push, grab, slap, or throw something at you?” and “Did one of your parents often or very often hit you so hard that you had marks or were injured?” In other words, more than a quarter of the U.S. population is likely to have been repeatedly physically abused as a child.
To the questions “Did an adult or person at least 5 years older ever have you touch their body in a sexual way?” and “Did an adult or person at least 5 years older ever attempt oral, anal, or vaginal intercourse with you?” 28 percent of women and 16 percent of men responded affirmatively.
One in eight people responded positively to the questions: “As a child, did you witness your mother sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her?” “As a child, did you witness your mother sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard?”15
Each yes answer was scored as one point, leading to a possible ACE score ranging from zero to ten. For example, a person who experienced frequent verbal abuse, who had an alcoholic mother, and whose parents divorced would have an ACE score of three. Of the two-thirds of respondents who reported an adverse experience, 87 percent scored two or more. One in six of all respondents had an ACE score of four or higher.
In short, Felitti and his team had found that adverse experiences are interrelated, even though they’re usually studied separately. People typically don’t grow up in a household where one brother is in prison but everything else is fine. They don’t live in families where their mother is regularly beaten but life is otherwise hunky-dory. Incidents of abuse are never stand-alone events. And for each additional adverse experience reported, the toll in later damage increases.
Felitti and his team found that the effects of childhood trauma first become evident in school. More than half of those with ACE scores of four or higher reported having learning or behavioral problems, compared with 3 percent of those with a score of zero. As the children matured, they didn’t “outgrow” the effects of their early experiences. As Felitti notes, “Traumatic experiences are often lost in time and concealed by shame, secrecy, and social taboo,” but the study revealed that the impact of trauma pervaded these patients’ adult lives. For example, high ACE scores turned out to correlate with higher workplace absenteeism, financial problems, and lower lifetime income.
When it came to personal suffering, the results were devastating. As the ACE score rises, chronic depression in adulthood also rises dramatically. For those with an ACE score of four or more, its prevalence is 66 percent in women and 35 percent in men, compared with an overall rate of 12 percent in those with an ACE score of zero. The likelihood of being on antidepressant medication or prescription painkillers also rose proportionally. As Felitti has pointed out, we may be treating today experiences that happened fifty years ago—at ever-increasing cost. Antidepressant drugs and painkillers constitute a significant portion of our rapidly rising national health-care expenditures.16 (Ironically, research has shown that depressed patients without prior histories of abuse or neglect tend to respond much better to antidepressants than patients with those backgrounds.17)
Self-acknowledged suicide attempts rise exponentially with ACE scores. From a score of zero to a score of six there is about a 5,000 percent increased likelihood of suicide attempts. The more isolated and unprotected a person feels, the more death will feel like the only escape. When the media report an environmental link to a 30 percent increase in the risk of some cancer, it is headline news, yet these far more dramatic figures are overlooked.
As part of their initial medical evaluation, study participants were asked, “Have you ever considered yourself to be an alcoholic?” People with an ACE score of four were seven times more likely to be alcoholic than adults with a score of zero. Injection drug use increased exponentially: For those with an ACE score of six or more, the likelihood of IV drug use was 4,600 percent greater than in those with a score of zero.
Women in the study were asked about rape during adulthood. At an ACE score of zero, the prevalence of rape was 5 percent; at a score of four or more it was 33 percent. Why are abused or neglected girls so much more likely to be raped later in life? The answers to this question have implications far beyond rape. For example, numerous studies have shown that girls who witness domestic violence while growing up are at much higher risk of ending up in violent relationships themselves, while for boys who witness domestic violence, the risk that they will abuse their own partners rises sevenfold.18 More than 12 percent of study participants had seen their mothers being battered.
The list of high-risk behaviors predicted by the ACE score included smoking, obesity, unintended pregnancies, multiple sexual partners, and sexually transmitted diseases. Finally, the toll of major health problems was striking: Those with an ACE score of six or above had a 15 percent or greater chance than those with an ACE score of zero of currently suffering from any of the ten leading causes of death in the United States, including chronic obstructive pulmonary disease (COPD), ischemic heart disease, and liver disease. They were twice as likely to suffer from cancer and four times as likely to have emphysema. The ongoing stress on the body keeps taking its toll.
WHEN PROBLEMS ARE REALLY SOLUTIONS
Twelve years after he originally treated her, Felitti again saw the woman whose dramatic weight loss and gain had started him on his quest. She told him that she’d subsequently had bariatric surgery but that after she’d lost ninety-six pounds she’d become suicidal. It had taken five psychiatric hospitalizations and three courses of electroshock to control her suicidality. Felitti points out that obesity, which is considered a major public health problem, may in fact be a personal solution for many. Consider the implications: If you mistake someone’s solution for a problem to be eliminated, not only are they likely to fail treatment, as often happens in addiction programs, but other problems may emerge.
One female rape victim told Felitti, “Overweight is overlooked, and that’s the way I need to be.”19 Weight can protect men, as well. Felitti recalls two guards at a state prison in his obesity program. They promptly regained the weight they had lost, because they felt a lot safer being the biggest guy on the cellblock. Another male patient became obese after his parents divorced and he moved in with his violent alcoholic grandfather. He explained: “It wasn’t that I ate because I was hungry and all of that. It was just a place for me to feel safe. All the way from kindergarten I used to get beat up all the time. When I got the weight on it didn’t happen anymore.”
The ACE study group concluded: “Although widely understood to be harmful to health, each adaptation [such as smoking, drinking, drugs, obesity] is notably difficult to give up. Little consideration is given to the possibility that many long-term health risks might also be personally beneficial in the short term. We repeatedly hear from patients of the benefits of these ‘health risks.’ The idea of the problem being a solution, while understandably disturbing to many, is certainly in keeping with the fact that opposing forces routinely coexist in biological systems. . . . What one sees, the presenting problem, is often only the marker for the real problem, which lies buried in time, concealed by patient shame, secrecy and sometimes amnesia—and frequently clinician discomfort.”
CHILD ABUSE: OUR NATION’S LARGEST PUBLIC HEALTH PROBLEM
The first time I heard Robert Anda present the results of the ACE study, he could not hold back his tears. In his career at the CDC he had previously worked in several major risk areas, including tobacco research and cardiovascular health. But when the ACE study data started to appear on his computer screen, he realized that they had stumbled upon the gravest and most costly public health issue in the United States:
child abuse. He had calculated that its overall costs exceeded those of cancer or heart disease and that eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters.20 It would also have a dramatic effect on workplace performance and vastly decrease the need for incarceration.
When the surgeon general’s report on smoking and health was published in 1964, it unleashed a decades-long legal and medical campaign that has changed daily life and long-term health prospects for millions. The number of American smokers fell from 42 percent of adults in 1965 to 19 percent in 2010, and it is estimated that nearly 800,000 deaths from lung cancer were prevented between 1975 and 2000.21
The ACE study, however, has had no such effect. Follow-up studies and papers are still appearing around the world, but the day-to-day reality of children like Marilyn and the children in outpatient clinics and residential treatment centers around the country remains virtually the same. Only now they receive high doses of psychotropic agents, which makes them more tractable but which also impairs their ability to feel pleasure and curiosity, to grow and develop emotionally and intellectually, and to become contributing members of society.
CHAPTER 10
DEVELOPMENTAL TRAUMA: THE HIDDEN EPIDEMIC
The notion that early childhood adverse experiences lead to substantial developmental disruptions is more clinical intuition than a research-based fact. There is no known evidence of developmental disruptions that were preceded in time in a causal fashion by any type of trauma syndrome.
—From the American Psychiatric Association’s rejection of a Developmental Trauma Disorder diagnosis, May 2011
Research on the effects of early maltreatment tells a different story: that early maltreatment has enduring negative effects on brain development. Our brains are sculpted by our early experiences. Maltreatment is a chisel that shapes a brain to contend with strife, but at the cost of deep, enduring wounds. Childhood abuse isn’t something you “get over.” It is an evil that we must acknowledge and confront if we aim to do anything about the unchecked cycle of violence in this country.
—Martin Teicher, MD, PhD, Scientific American
There are hundreds of thousands of children like the ones I am about to describe, and they absorb enormous resources, often without appreciable benefit. They end up filling our jails, our welfare rolls, and our medical clinics. Most of the public knows them only as statistics. Tens of thousands of schoolteachers, probation officers, welfare workers, judges, and mental health professionals spend their days trying to help them, and the taxpayer pays the bills.
Anthony was only two and a half when he was referred to our Trauma Center by a child-care center because its employees could not manage his constant biting and pushing, his refusal to take naps, and his intractable crying, head banging, and rocking. He did not feel safe with any staff member and fluctuated between despondent collapse and angry defiance.
When we met with him and his mother, he anxiously clung to her, hiding his face, while she kept saying, “Don’t be such a baby.” He startled when a door banged somewhere down the corridor and then burrowed deeper into his mom’s lap. When she pushed him away, he sat in a corner and started to bang his head. “He just does that to bug me,” his mother remarked. When we asked about her own background, she told us that she’d been abandoned by her parents and raised by a series of relatives who hit her, ignored her, and started to sexually abuse her at age thirteen. She’d become pregnant by a drunken boyfriend who left her when she told him she was carrying his child. Anthony was just like his father, she said—a good-for-nothing. She had had numerous violent rows with subsequent boyfriends, but she was sure that this had happened too late at night for Anthony to notice.
If Anthony were admitted to a hospital, he would likely be diagnosed with a host of different psychiatric disorders: depression, oppositional defiant disorder, anxiety, reactive attachment disorder, ADHD, and PTSD. None of these diagnoses, however, would clarify what was wrong with Anthony: that he was scared to death and fighting for his life, and he did not trust that his mother could help him.
Then there’s Maria, a fifteen-year-old Latina, one of the more than half a million kids in the United States who grow up in foster care and residential treatment programs. Maria is obese and aggressive. She has a history of sexual, physical, and emotional abuse and has lived in more than twenty out-of-home placements since age eight. The pile of medical charts that arrived with her described her as mute, vengeful, impulsive, reckless, and self-harming, with extreme mood swings and an explosive temper. She describes herself as “garbage, worthless, rejected.”
After multiple suicide attempts Maria was placed in one of our residential treatment centers. Initially she was mute and withdrawn and became violent when people got too close to her. After other approaches failed to work, she was placed in an equine therapy program where she groomed her horse daily and learned simple dressage. Two years later I spoke with Maria at her high school graduation. She had been accepted by a four-year college. When I asked her what had helped her most, she answered, “The horse I took care of.” She told me that she first started to feel safe with her horse; he was there every day, patiently waiting for her, seemingly glad upon her approach. She started to feel a visceral connection with another creature and began to talk to him like a friend. Gradually she started talking with the other kids in the program and, eventually, with her counselor.
Virginia is a thirteen-year-old adopted white girl. She was taken away from her biological mother because of the mother’s drug abuse; after her first adoptive mother fell ill and died, she moved from foster home to foster home before being adopted again. Virginia was seductive with any male who crossed her path, and she reported sexual and physical abuse by various babysitters and temporary caregivers. She came to our residential treatment program after thirteen crisis hospitalizations for suicide attempts. The staff described her as isolated, controlling, explosive, sexualized, intrusive, vindictive, and narcissistic. She described herself as disgusting and said she wished she were dead. The diagnoses in her chart were bipolar disorder, intermittent explosive disorder, reactive attachment disorder, attention deficit disorder (ADD) hyperactive subtype, oppositional defiant disorder (ODD), and substance use disorder. But who, really, is Virginia? How can we help her have a life?1
We can hope to solve the problems of these children only if we correctly define what is going on with them and do more than developing new drugs to control them or trying to find “the” gene that is responsible for their “disease.” The challenge is to find ways to help them lead productive lives and, in so doing, save hundreds of millions of dollars of taxpayers’ money. That process starts with facing the facts.
BAD GENES?
With such pervasive problems and such dysfunctional parents we would be tempted to ascribe their problems simply to bad genes. Technology always produces new directions for research, and when it became possible to do genetic testing, psychiatry became committed to finding the genetic causes of mental illness. Finding a genetic link seemed particularly relevant for schizophrenia, a fairly common (affecting about 1 percent of the population), severe, and perplexing form of mental illness and one that clearly runs in families. And yet after thirty years and millions upon millions of dollars’ worth of research, we have failed to find consistent genetic patterns for schizophrenia—or for any other psychiatric illness, for that matter.2 Some of my colleagues have also worked hard to discover genetic factors that predispose people to develop traumatic stress.3 That quest continues, but so far it has failed to yield any solid answers.4
Recent research has swept away the simple idea that “having” a particular gene produces a particular result. It turns out that many genes work together to influence a single outcome. Even more important, genes are not fixed; life events can trigger biochemical messages that turn them on or of
f by attaching methyl groups, a cluster of carbon and hydrogen atoms, to the outside of the gene (a process called methylation), making it more or less sensitive to messages from the body. While life events can change the behavior of the gene, they do not alter its fundamental structure. Methylation patterns, however, can be passed on to offspring—a phenomenon known as epigenetics. Once again, the body keeps the score, at the deepest levels of the organism.
One of the most cited experiments in epigenetics was conducted by McGill University researcher Michael Meaney, who studies newborn rat pups and their mothers.5 He discovered that how much a mother rat licks and grooms her pups during the first twelve hours after their birth permanently affects the brain chemicals that respond to stress—and modifies the configuration of over a thousand genes. The rat pups that are intensively licked by their mothers are braver and produce lower levels of stress hormones under stress than rats whose mothers are less attentive. They also recover more quickly—an equanimity that lasts throughout their lives. They develop thicker connections in the hippocampus, a key center for learning and memory, and they perform better in an important rodent skill—finding their way through mazes.
We are just beginning to learn that stressful experiences affect gene expression in humans, as well. Children whose pregnant mothers had been trapped in unheated houses in a prolonged ice storm in Quebec had major epigenetic changes compared with the children of mothers whose heat had been restored within a day.6 McGill researcher Moshe Szyf compared the epigenetic profiles of hundreds of children born into the extreme ends of social privilege in the United Kingdom and measured the effects of child abuse on both groups. Differences in social class were associated with distinctly different epigenetic profiles, but abused children in both groups had in common specific modifications in seventy-three genes. In Szyf’s words, “Major changes to our bodies can be made not just by chemicals and toxins, but also in the way the social world talks to the hard-wired world.”7,8
The Body Keeps the Score Page 19