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How an obesity clinic sparked one of the nation’s most revolutionary health surveys
In 1985, a 28-year-old woman walked into Vincent Felitti’s obesity clinic and asked for help. She weighed 408 pounds, and she wanted to get thin.
She’d come to the right place. Felitti, an internist, was founder and chief of the Department of Preventive Medicine at the managed-care giant Kaiser Permanente San Diego. As part of that work, he’d developed a program to help people safely shed 300 pounds or more.
In just a year, the woman lost 276 pounds and reached her goal weight: 132. But she didn’t stay there long.
Felitti, distressingly, was seeing the same problem with many patients. They lost hundreds of pounds, vastly improved their health, then quit the program and regained the weight in short order. “I thought, “What the hell is going on?” Felitti says.
Now this woman, too, was fleeing success. In a single three-week period, she gained nearly 40 pounds.
When he asked her what triggered it, she confided that a co-worker, a much older man, had sexually propositioned her. She’d been bingeing ever since. Mostly, she ate while sleepwalking.
“How long have you been doing that?” Felitti asked. At first, she said she had no idea. But as they kept talking she divulged her secret: Her grandfather sexually abused her for years, starting when she was 10. That’s when the sleep eating started.
That one patient, he says, is the person who sparked the ACE Study, one of the largest and most groundbreaking of its kind. The woman’s story of sexual abuse and rapid weight gain made Felitti wonder how many other patients had childhood traumas.
He started interviewing other patients in the weight program and asked colleagues to do the same. They found that, out of 286 people, 55 percent reported they’d been sexually abused as children. It was a rate more than double the estimated prevalence of childhood sexual abuse in the country.
When Felitti presented his findings to a conference of obesity specialists in 1990, he was greeted by snorts of disbelief. But researchers at the Centers for Disease Control were intrigued. How was early trauma connected to future health?
Felitti and CDC epidemiologist Robert Anda co-founded the ACE study to find out. The large-scale epidemiological survey tallied the incidence and lifetime impacts of an entire spectrum of what the physicians called “adverse childhood experiences.”
“Adverse childhood experiences are the main determinant of the health and social well-being of the nation." Vincent Felitti and Robert Anda, in the ACE study
Up to that point, childhood trauma research tended to examine a single issue and outcome — for example, child sexual abuse and adult depression. Anda and Felitti looked at multiple intersecting traumas that fed upon each other in families.
More than 17,000 Kaiser Permanente members in San Diego — most of them white, educated and middle-to-upper-class — answered the ACEs questionnaire.
The survey asked about adversities in 10 categories, including physical, sexual or psychological abuse; emotional or physical neglect; divorce; mental illness, substance abuse, domestic violence, criminality in the household; and parental absence. A “yes” answer counted as one point, with a maximum score of 10.
Participants’ ACE scores were compared to their medical records, among other analyses. The results, published in 1988, showed that ACEs were everywhere.
According to the survey:
- Nearly two-thirds of participants — 64 percent — reported at least one adverse childhood experience.
- More than 20 percent reported three or more; 12 percent had four or more.
- Women had higher rates of trauma, nearly across the board.
Adverse experiences put people at greater risk of cognitive, emotional or social impairments, mental illness and chronic disease.
As a person’s ACEs score increased, so did the odds of bad outcomes — a march-step known as a dose-response. With four or more ACEs, health risks rose significantly.
For people with four or more adversities, as compared to people with none, the risk of a suicide attempt increased 1,200 percent. The risk of alcoholism rose seven-fold; the odds of cigarette smoking jumped two-to-four-fold.
The lifelong high stress substantially increased the risk of heart, liver or lung disease; stroke; diabetes; hepatitis; autoimmune disorders and cancer. Having six or more ACEs could shorten a person’s life by 20 years.
Follow-up surveys established similar rates nationwide and around the world. In 2010 the World Health Organization reported the results of a survey spanning 52,000 adults in 21 nations: 62 percent had one ACE, almost exactly the rate in the 1998 study.
“Adverse childhood experiences are the main determinant of the health and social well-being of the nation,” Felitti and Anda concluded in a 2004 study, one of 86 they’ve now published.
Are ACEs still such a dire problem?
Felitti doesn’t hesitate. “Oh yes.”
How childhood events leave New Mexico’s kids at riskContinue reading
Reading about adverse childhood experiences and toxic stress can be, well, stressful. The problems they cause — brain impairments, mental illness and disease — are enough to make things sound hopeless.
“We’re not victims, and we’re not unchangeable,” said Christina Bethell, co-author of a 2017 report aptly called Balancing ACEs with HOPE (Health Outcomes for Positive Experience). Bethell, the director of the Child and Adolescent Health Measurement Initiative at Johns Hopkins University, works in what she calls “the science of thriving.”
Positive, loving experiences build brain health and resilience in children; they act as a buffer against the bad things. They also counterbalance the harm from toxic stress, her research shows.
A groundswell of other researchers, brain scientists and mental health professionals say damage from ACEs is reversible and people of all ages — particularly those age 0 to 3 — can recover.
“There’s no such thing as throwaway children,” says Deborah Harris, senior consultant for New Mexico’s Infant Mental Health Teams.
Childhood trauma is a serious matter. If you’ve experienced it, experts advise getting help from a trauma-informed specialist, someone experienced in helping people recover from toxic stress.
But everyone can begin the path to wellness.
Healing can start with simple steps like deep breathing. They’re as basic as cooing to your baby.
All manner of solutions and research in this realm — as well as simple tools for parents — are available at prominent institutes, such as the Center on the Developing Child at Harvard University.
Helping your baby
The mantra is “the earlier the better.” Here are ways to promote brain healing while creating a loving, nurturing relationship:
- Build positive experiences, whether it’s through a game of peekaboo or a reading of “Goodnight Moon.”
- Coo, babble, point, and make silly faces. Scientists call this “serve and return,” and it’s key to building brain health.
- Kiss, hold and talk to your baby. Repeat. Repetitive positive experiences build healthful new neural pathways that get stronger over time.
- Ban tobacco at home.
- Share a family meal at least four days a week.
- Limit children to two hours of screen time a day.
- Read to young kids daily. Insist that older children do their homework.
- Participate in your children’s activities.
- Don’t worry about being a perfect parent; be a “good enough” parent. What’s good enough? Bethell found that children who are most resilient are those who can say “My family stood by me in hard times; I had someone I could talk to about difficult things.”
Adults also need to reduce stress. Here’s what helps:
- Breathing: Yes, breathing. Inhale deeply. Exhale. Repeat.
- Meditation: One of the top recommended interventions, it’s restorative for the brain.
- Progressive muscle relaxation: An effective way to relieve tension and anxiety by simply clenching and releasing muscles.
- Exercise. Crunches and half-marathons are not required. The goal is to move and get outside: Research shows that simply touching a tree or hearing a bird sing reduces stress.
- Get enough sleep, eat nutritious food, listen to music and spend time with loving (non-stressful) friends and family.
- Hypnosis: Find a certified clinical hypnotherapist at the American Society of Clinical Hypnosis.
- EMDR: Eye Movement Desensitization and Reprocessing has been used for decades to help people heal from traumatic memories.
- Trauma-Sensitive Yoga: This form of yoga was developed by the Massachusetts-based Trauma Center at the Justice Resource Institute.
- Write the wrongs: Vincent Felitti, co-founder of the ACE study, recommends that patients write their autobiographies.
- Try neurofeedback or its cousin, biofeedback.
- Talk to a compassionate person; get treatment from someone trained in trauma care. Or walk into your doctor’s office with the ACE survey.
Science finds childhood trauma can alter brain development
Today, more than at any other time in history, science and medicine show the vast, interconnected dance between a baby’s outside world and the core of its being: its brain.
The most basic human connections are being understood through the lens of brain science, neuroscience, behavioral science and beyond, revealed in magnetic resonance imagining at institutes such as Harvard University’s Center on the Developing Child.
Today’s studies show the harm down to the dendrites and DNA.
Severe trauma, also known as adverse childhood experiences, can leave children in near-constant fear and anxiety, always on the verge of fight-flight-or freeze mode, research shows. The result can be a constant release of stress hormones in the body, harmful enough to alter architecture in the developing brain.
“The biological response to this toxic stress can be incredibly destructive and last a lifetime,” the American Academy of Pediatrics described the process in a 2014 policy paper.
Beatings that leave bruises, sexual or emotional abuse, domestic violence, a drug-addicted parent — those and other major childhood adversities can shrink key parts of the brain, MRI scans show.
“We’ve seen the impacts of adverse childhood experiences for years,” said Deborah Harris, senior consultant for New Mexico’s Infant Mental Health Teams. The program sees some of the state’s most vulnerable babies, removed from their homes by Child Protective Services for maltreatment. “Now we actually have the brain research to support the theory.”
Harris says the science shows how critical it is to give infants and children the services they need. They can’t be expected to get over the abuse on their own.
“It’s embedded in their brain and body,” Harris said.
The concept of adverse childhood experiences, or ACEs, was born in 1998 with a study of more than 17,000 Kaiser Permanente patients in San Diego.
It revealed that physical abuse, sexual abuse and other ACEs were far more common than previously understood. And as the study discovered, the more ACEs people experienced, the more likely they were to have bad outcomes, including drug abuse, alcoholism, mental illness, suicide, cancer and chronic, life-shortening diseases.
The ACE study offered the medical world a new way to understand human development. The brain science has taken it even further.
Brain scans show childhood trauma can cause shrinkage in the hippocampus, the area linked to memory storage and retrieval. The constant state of high-stress can alter the amygdala, the brain’s fear-processing center, and affect the neuro-endocrine and immune systems.
Harvard University’s Center on the Developing Child defines toxic stress as “excessive or prolonged activation of stress response systems in the body and brain.” That sort of activation can lead to dysfunction in the prefrontal cortex, the area of the brain linked to cognition and decision-making.
On one thing, all researchers agree: Trauma is particularly harmful from ages 0 to 3, when more than 1 million new neural connections in the brain are formed every second.
The stress from child maltreatment can hinder the formation of neural pathways, which let neuro-signals zoom across different parts of the brain to form critical connections, research shows.
A thriving neural network promotes health in the parts of the brain responsible for behavior, language, memory, motor skills, impulse control and executive functioning, according to the 1998 landmark study that launched the ACEs concept.
Chronic releases of stress hormones are also linked to changes in the way DNA is expressed. The study of epigenetics examines how stress can modify chemical “markers” on genes, switching them on or silencing them.
Scientists now theorize that toxic stress causes epigenetic changes that allow trauma to be transmitted over the generations. The mechanism offers an explanation for the historical trauma experienced by Native Americans, by children of Holocaust survivors, and others.
In response, the AAP has called for “a new basic science of pediatrics,” based on an “ecobiodevelopmental” model. It would take into account how children’s experiences — and traumas — can shape lives well into the future.