Several times a year, I am asked to speak about juvenile justice issues at classrooms full of graduate students studying public policy, or some similar subject. These days when I talk about criminal justice–juvenile or otherwise—I always bring up the issue of trauma.
I trot out the results of research showing that kids in the juvenile justice system are 8 times more likely to suffer from post traumatic stress disorder—PTSD—than non-incarcerated kids in the community.
I note that the prevalence of PTSD is higher among girls in the justice system (49%) than among boys in the system (32%).
I explain that for school age kids, PTSD can look a lot like attention-deficit disorder, with the accompanying lack of concentration, resulting poor grades, plus the kind of inability to sit still that often leads to school discipline.
Then I tell the students that there is a newer way to look at the kind of extreme stress and trauma that can cause PTSD in kids—along with related difficulties in school performance, behavior and so on.
It is called Adverse Childhood Experiences—OR ACEs.
THE ORIGINAL ACEs STUDY
In the late 1990s, Vincent Felitti, founder of the Department of Preventive Medicine for Kaiser Permanente in San Diego, and Robert Anda of the US Centers for Disease Control, conducted a landmark study that examined the effects of what they termed adverse childhood experiences–ACEs—things like abuse, neglect, domestic violence and other forms of family dysfunction and catastrophe.
Felitti and Anda studied around 17,000 people in all, the majority of whom were white, well-educated, and middle class or above. Each subject was asked to answer a series of questions about highly stressful events or conditions in their childhood, along with another basic set of questions about physical and emotional issues in their adulthood.
When the researchers analyzed the resulting data, they found find a powerful connection between the level of adversity faced and the incidence of many health and social problems. The two also discovered that ACEs were more common than they had expected. About 40 percent of Felitti and Anda’s respondents reported two or more ACEs, and 25 percent reported three or more.
Since then, similar studies and surveys have been conducted in several states, with findings that are either consistent, or more dramatic.
It is at around this point in my lecture that I ask the class members if they’d like to take an ACEs test themselves.
It isn’t the full test that Felitti and Anda gave, only a 10-question quiz, but it will still give them a good idea of what we’re talking about.
YOU TOO CAN TAKE THE ACES QUIZ
If you click the link below you can take it yourselves.
Of course there are other significant forms of childhood trauma that are not listed in the quiz: having a friend killed, repeated exposure to community violence, surviving and recovering from a severe accident, being the subject of severe bullying or violence by a friend or acquaintance….and so on.
Moreover, the test doesn’t measure traumatic events occurring in young adulthood, or adulthood, which can compound the effects of earlier trauma, or cause it’s own after effects.
Yet it’s a good place to start.
After everyone has finished and privately noted their personal scores, we talk further about how trauma is the unacknowledged elephant in the room when it comes to the subjects of school discipline, justice policy, prisoner reentry, etc., and also, as it turns out, when it comes to physical health.
I tell stories about the young men and women I got to know during my first few years of gang reporting in the early 1990’s, and how their ACEs scores were off the charts. And now, 20 years later, many of them are struggling with the physical and emotional issues that the first ACEs study described.
When we talk about criminal justice policy reform, juvenile justice reform, school discipline reform, prisoner reentry, we also have to have the conversation about trauma, I say.
When the class is over, there is inevitably a cluster of students who want to talk more. Once we’ve chatted a little, I ask those who have lingered behind if they’d be willing to reveal their own ACE scores; what they tell me no longer surprises: ….5….6…7….
And in the last class at which I lectured, one obviously bright woman took a breath and said… “10.”
(Her story is an interesting one and I hope to persuade her to write about it for WLA)
BRINGING ACES INTO THE LIGHT
I bring all this up because this week NPR’s Laura Starecheski produced an excellent three part series for All Things Considered about the world of ACEs, which will further explain why this topic is something we should all know more about.
Part 1 is titled Can Family Secrets Make You Sick and it talks about the Felitti/Anda study, and how it was received—when it first came out, and now.
Here a clip.
In the 1980s, Dr. Vincent Felitti, now director of the California Institute of Preventive Medicine in San Diego, discovered something potentially revolutionary about the ripple effects of child sexual abuse. He discovered it while trying to solve a very different health problem: helping severely obese people lose weight.
Felitti, a specialist in preventive medicine, was trying out a new liquid diet treatment among patients at a Kaiser Permanente clinic. And it worked really well. The severely obese patients who stuck to it lost as much as 300 pounds in a year.
“Oh yeah, this was really quite extraordinary,” recalls Felitti.
But then, some of the patients who’d lost the most weight quit the treatment and gained back all the weight — faster than they’d lost it. Felitti couldn’t figure out why. So he started asking questions.
First, one person told him she’d been sexually abused as a kid. Then another.
“You know, I remember thinking, ‘Well, my God, this is the second incest case I’ve seen in [then] 23 years of practice,’ ” Felitti says. “And so I started routinely inquiring about childhood sexual abuse, and I was really floored.”
More than half of the 300 or so patients said yes, they too had been abused.
Felitti wondered if he’d discovered one of the keys to some cases of obesity and all the health problems that go along with it.
THE FIFTEEN YEAR GAP
In Part 2, NPR and Starecheski offered their own interactive ACEs test and what the scores mean.
Part 3 is titled 10 Questions Some Doctors are Afraid to Ask
I met Felitti last fall and he said that when he and Anda first published their results in the late 1990s, they expected an overwhelming response from the medical community.
Instead for the next fifteen years they got….crickets.
Here’s what the CDC’s Anda told Starecheski:
“I thought that people would flock to this information,” Anda says, “and be knocking on our doors, saying, ‘Tell us more. We want to use it.’ And the initial reaction was really — silence.”
In fact, it took a long time to even get the study published. A number of top medical journals rejected the article, Anda says, “because there was intense skepticism.”
Here are some clips from the rest of the story:
For one thing, doctors aren’t taught about ACE scores in medical school. Some physicians wonder what the point would be, as the past can’t be undone. There also is no way to bill for the test, and no standard protocol for what a doctor should do with the results.
But Felitti thinks there’s an even bigger reason why the screening tool largely has been ignored by American medicine: “personal discomfort on the part of physicians.”
Some doctors think the ACE questions are too invasive, Felitti says. They worry that asking such questions will lead to tears and relived trauma … emotions and experiences that are hard to deal with in a typically time-crunched office visit.
According to Dr. Jeff Brenner, a family doctor and MacArthur Fellows award-winner in Camden, N.J., getting these rough measures of adversity from patients potentially could help the whole health care system understand patients better.
The ACE score, Brenner says, is “still really the best predictor we’ve found for health spending, health utilization; for smoking, alcoholism, substance abuse. It’s a pretty remarkable set of activities that health care talks about all the time.”
Brenner won his MacArthur fellowship in 2013 for his work on how to treat the most complicated, expensive patients in his city — people who often have high ACE scores, he found.
“I can’t imagine, 10, 15 years from now, a health care system that doesn’t routinely use the ACE scores,” he says. “I just can’t imagine that.”
Brenner only learned about ACE scores a few years ago, and says he regrets not integrating the tool into his practice sooner. But like most doctors, he says, he was taught in medical school to not “pull the lid off something you don’t have the training, time or ability to handle.”
In theory, Brenner says, talking to patients about adverse childhood experiences shouldn’t be any different than asking them about domestic violence or their drinking — awkward topics that doctors routinely broach now.
KANSAS CITY TRIES “TRAUMA INFORMED” CARE FOR KIDS
The good news is that there are some promising programs popping up all around the nation, including a number in California, which make use of what we know about the effects of childhood trauma.
For instance, we’ve talked several times about Dr. Nadine Burke Harris, and her remarkable pediatric practice in San Francisco. And there is this pediatric program in Kansas City, profiled by Eric Adler for the Kansas City Star. Here’s a clip:
Never mind the little girl’s name. What’s important is that she was about 10 years old and all the doctors she had seen month after month had failed to ease her pain.
The girl’s stomach wrenched. Her chest tightened. Her skull seared with lightning-bolt headaches.
Then at Children’s Mercy Hospital, pediatrician Lisa Spector decided to probe with a different set of questions. Instead of asking what was wrong physically, Spector asked the girl what had happened to her in her young life. Quickly, the crux of her pain became clear:
“It was impacting her physical and mental health,” Spector said.
At school, she was bullied. At home, she witnessed repeated domestic violence. She talked of her dad belittling and abusing her emotionally. She recently had been a victim of an attempted carjacking; the thief fled after seeing her in the back seat.
Day to day, she was living a tense and unsure existence that was translating itself into hobbling pain.
That the child’s troubles ultimately eased not with medication but with counseling can be credited to a serious effort by Children’s Mercy to focus on “trauma-informed” care.
For a growing number of children across the country, the approach has become the key to their emotional and mental health, “the most important thing we can do for people,” said Marsha Morgan, chief operating officer for behavioral health at Truman Medical Center.
Trauma-informed care focuses on the notion that a traumatic event in childhood, either experienced or witnessed, can alter the biology of the brain. A trauma-informed strategy works on multiple fronts — using counseling and changes to one’s personal interactions and environment — to lessen or bypass those negative associations while forming new and more positive associative pathways in the brain.
“I’ve worked in this field for over 42 years, and this is the most important thing I’ve ever done,” Dr. Morgan told Adler as they talked about the hospital’s trauma work.
We’ll be talking more about trauma, its effects,. and what can be done to prevent and address them, as we profile more of important programs over the coming weeks and months