By JOY CHUBA, LCSW
The first time we meet with a healthcare provider, we’re likely to be asked a series of questions. What is your age, sex, height, weight, race, ethnicity? What illnesses are common in your family? How often do you exercise? Do you smoke?
One question that may not come up is “Were you abused as a child?”
It’s routine to screen for risk factors that can predispose a patient to serious illnesses. By conducting an initial interview with a patient to determine biological risk factors – age, sex, race, ethnicity, age, family history and so on – as well as lifestyle risk factors, like smoking or physical inactivity, doctors can more effectively tailor care to their patients.
But these screenings often overlook a critical risk factor for lifelong illness … and one that affects more than half of all adults in the United States: childhood trauma.
In the late 1990s, researchers from Kaiser and the CDC partnered to survey more than 17,000 adults about their exposure to childhood trauma. A traumatic event goes beyond academic stress or fears about fitting in. In this study, trauma was measured through 10 specific, serious adverse childhood experiences (referred to as ACEs).
These included emotional, physical, and sexual abuse; emotional and physical neglect; exposure to domestic violence; mental illness; parental separation; household substance abuse; or the incarceration of a family member. Someone who didn’t experience any of these would have an ACE score of zero; a person who experienced all of them would have an ACE score of 10.
What the study found was groundbreaking: The more adverse experiences a child has, the higher their risk of poor health outcomes later in life.
In the subsequent years of research, more than 40 health outcomes have been found to have a dose-response relationship with trauma. For each additional ACE a person has experienced, they are at a higher risk for heart disease, diabetes, stroke, broken bones, depression, COPD, obesity, depression, suicide, several types of STIs, cancers – and many, many more.
That’s a serious issue, not least because childhood trauma is far more common than you might expect: 67 percent of adults in the United States have experienced at least one ACE, and 12 percent – about one in every eight people – have an ACE score of 4 or more.
Despite how prevalent trauma is, the tendency to treat it as a social problem – rather than a physiological fact – is hard to shake. After all, if adults with high ACE scores are at a higher risk for behaviors like smoking and drug abuse, how do we know that those behaviors aren’t the true cause of illness? Isn’t this an issue of unhealthy coping mechanisms rather than physical health?
But the data doesn’t bear that out. Even when a patient exhibits zero behavioral risk factors, their childhood trauma may still have a direct and life-threatening impact on long-term health. To explain why, researchers have taken a closer look at the biological and chemical pathways behind trauma.
What research found
In highly stressful situations, the sympathetic nervous system kicks in to create a fight-or-flight response. This cascading series of split-second changes – muscle tension, racing heart, stress hormones, dilated pupils – works to keep the body awake, alert and energized until the danger has passed. However, when this stress response is repeatedly triggered, it becomes harder to relax and rest – even when the danger has passed. In essence, an individual can be in the physiological state of flight-or-fight constantly and is referred to as toxic stress.
Toxic stress during childhood can harm the developing body at its most basic levels. It measurably changes the nervous, endocrine, and immune systems, and even the physical structure of DNA. Over a lifetime, those changes make it harder to focus, solve problems, plan ahead, and balance risks and rewards.
Because of these neurological changes, survivors of adverse experiences often struggle in school, have a lower rate of graduation, and have lower lifelong earning potential. They may struggle to manage their emotions and relationships, respond more negatively to stress, and engage in higher-risk behaviors than those individuals who have an ACE score of zero.
For those who have already survived dangerous and stressful experiences, that may seem like a dishearteningly bleak prognosis. But there’s good news, too: Those outcomes aren’t predestined.
It’s true that trauma is a predictor of poor health, but it’s not a guarantee. Like any other condition, it can be effectively treated and also prevented … and the best way to do that is through specific, trauma-informed care.
Instead of starting the conversation with, “What’s wrong with you?” a practitioner trained in trauma-informed care asks: “What happened to you?” By recognizing that behaviors and symptoms may be caused by adverse experiences, we can treat them more effectively. An approach rooted in safety, trust and empowerment is essential.
Consider two patients served by the same healthcare provider
A woman with a close family member diagnosed with breast cancer is twice as likely to develop breast cancer as well. To provide effective care, a doctor should take note of that patient’s family history and recommend earlier or more frequent screenings.
Another woman has an ACE score of 4, meaning she has more than double the risk of developing chronic obstructive pulmonary disease (COPD). But unless her doctor is taking a trauma-informed approach, they may not identify that risk factor at all. In the worst-case scenario, dismissing or disregarding a patient’s experiences can also re-traumatize a patient and aggravate the problem.
Effective treatment starts with respect and compassion: recognizing a person’s experiences and helping them choose their path to recovery. This intentionally positive approach to overcoming past adversity is sometimes called the “PACEs” model, to symbolize a step-by-step path toward healing.
At the Children’s Advocacy Center Osceola, we provide one-on-one advocacy to underage victims of sexual abuse and their non-offending caregivers. Offering support to the whole family is critical. In cases of child sexual abuse, non-offending caregivers and relatives are often deeply shaken. They have their own crisis to recover from before they can effectively advocate for and support their child.
We serve hundreds of children and their families each year, usually referred to us through law enforcement or child protective services following the initiation of a formal investigation. Many of those cases are called in by community members including healthcare providers, physicians and nurses who notice the signs of neglect or hear a report of abuse from a child.
Not only is this required by law, but it’s also a critical safeguard for our community’s children. Accurate and timely reports can prevent abuse from continuing, empower the family to seek support and treatment, and minimize the long-term effects of trauma through prompt and informed care.
While the science behind childhood trauma and health outcomes has been well-documented since the initial 1997 ACEs study, the trauma-informed approach is often seen as a niche development in the field of mental health and recovery. What is commonplace in organizations that serve survivors of abuse and neglect is still not widely understood by many physicians and care providers.
But a single-pronged approach isn’t enough. As with any health issue, a long-term solution will require advances in both prevention and treatment across a multitude of disciplines. That starts with social and economic policies that build stronger families, academic programs for mentorship and counseling, routine screening for signs of abuse and neglect, and a trauma-informed approach to medical care.
As we gain a better understanding of the ways we can prevent, identify, and treat the impact of trauma, we can more effectively intervene to help patients of all ages find a path to safety and recovery.
Joy Chuba, LCSW, is executive director of the Children’s Advocacy Center (CAC) Osceola and a current officer of the local Child Abuse Prevention Task Force. CAC Osceola is a program of Embrace Families.