“I remembered thinking, ‘This is only the second incest case I’ve had in 23 years of practice’,” Felitti recalls. “I didn’t know what to do with the information. About 10 days later, I ran into the same thing. It was very disturbing. Every other person was providing information about childhood sexual abuse. I thought, ‘This can’t be true. People would know if that were true. Someone would have told me in medical school.’ ”
-Dr. Vincent Felitti, Co-Principal Investigator, the ACE Study
One of the most important research projects ever conducted occurred a mere 20 years ago, from 1995-1997. It involved 17,337 participants and has since generated over 70 scientific articles and over 100 workshop and conference presentations. Its implications are staggering.
Dr. Felitti had been curious about the high dropout rate (50%) among participants in Kaiser’s Obesity Clinic. Had they not been losing weight, there would have been little mystery, but those dropping out had all been successfully losing weight. Dr. Felitti began to suspect, based on interviews, that the weight gain had been a coping mechanism for fear, depression and anxiety. But where did the fear, depression and anxiety come from?
The study was the perfect storm of opportunity. Kaiser Permanente was the oldest HMO in the US, dating back to 1945. They had a huge base of long term members for whom they had comprehensive health histories. With what they had discovered in interviews, Dr. Vincent Felitti of Kaiser Permanente and Dr. Robert Anda of the Centers for Disease Control and Prevention, developed a questionnaire very specifically identifying 10 adverse childhood experiences.
The methodology was quite simple. It involved 10 specific questions to identify these 10 types of adversity encountered before the age of 18. No measure was taken of how often they occurred, how many times or how long these events continued, just if they had occurred for that individual at all. The ACE score was the number of “yes” responses on the questionnaire, from 0 to 10 for each participant. These were the questions as presented to participants:
Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Was a biological parent ever lost to you through divorce, abandonment, or other reason ?
Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
Was a household member depressed or mentally ill, or did a household member attempt suicide?
Did a household member go to prison?
The 17,337 volunteers were drawn from over 26,000 consecutive Kaiser Permanente members. Half were female, half male. Average age was 57. Nearly seventy five percent were white. Just over seventy five percent had attended college. All had jobs and health insurance with Kaiser. This was a relatively privileged sample. Yet the prevalence of childhood adversity among these middle and upper middle class participants was disturbingly high.
Recurrent physical abuse 28%
An alcohol and/or drug abuser in the household 27%
One or no parents 23%
Contact sexual abuse 21%
Someone in the household who is chronically depressed, mentally ill, institutionalized, or suicidal 17%
Emotional Neglect 15%
Mother is treated violently 13%
Recurrent emotional abuse 11%
Physical Neglect 10%
An incarcerated household member 6%
With the extensive heath histories, and with additional information about their lives, employment, finances, habits, and other personal data, it became possible to correlate ACE scores with outcomes throughout the participant’s lives. The likelihood of nearly every kind of undesirable outcome in adult life displayed a strong correlation with higher ACE scores. Many were proportionately more likely as the ACE scores rose. Some rose abruptly for ACE scores above 6. Here is a partial list of the many life difficulties that correlate with higher ACE scores:
The underlying mechanisms for why childhood trauma can have these lifelong effects are becoming better understood as research has become focused in how trauma impacts the individual. It’s been found that Childhood Adversity (trauma) can damage the developing brain, and unresolved trauma, at any age, can repeatedly trigger unnecessary and inappropriate sympathetic nervous system activation. This continually and repeatedly releases powerful hormones and neurotransmitters, keeping the wrong half of our endocrine system active, and over time progressively damages our nervous, endocrine and immune systems in particular and virtually every organ in our body by extension.
These effects cause more damage the longer they continue. For example, while not related to childhood trauma, statistics collected on veteran suicides indicated an alarmingly high number, 22 suicides a day, which was probably undercounted. The assumption by many was that veterans of recent wars in Iraq and Afghanistan were responsible for those high numbers. What was more disturbing was that the average age of those reported suicides was 59. These were predominantly Vietnam War vets; killing themselves over 40 years after the last shots were fired. Unresolved Trauma does more damage the longer it remains unresolved.
It’s really hard to quantify the problem. Not because we don’t have the statistics, or can’t do the math, it’s just that the numbers boggle the mind. In 2008, over three quarters of a million, 776,000, children were classified by Child Protective Services Agencies in the United States as being maltreated. Those would be just those reported and ultimately determined to have been maltreated. A number of the adverse childhood experiences measured in the study would not even count as “maltreatment,” or be reportable, or actionable. So this would be the tip of the iceberg. There is nothing remarkable about 2008 in that regard. It’s a pretty typical year.
As to the impact, it is estimated that new cases each year result in additional costs of $124 billion over the lifetimes of those individuals. Imagine if each New Years Day, instead of watching the ball drop in Times Square, the nation tuned in to watch a giant bonfire consume another $124 billion dollars. Make no mistake, that would be spectacular television. In $1 bills, the stack would be 8,500 miles high. That’s 35 times the altitude of the International Space Station. If spread on the ground instead it would cover over 500 square miles. So imagine several city blocks made out of money stacked five stories high. Burning. But that’s just the money. Money isn’t real. Human suffering is real.
Directly, and indirectly, childhood trauma is the source of most, perhaps almost all, human suffering. Imagine all the terrible things that happen to people: war, starvation, murder, assault, rape, genocide, robbery, unemployment, poverty, heart attack, stroke, liver disease, cancer, dementia, depression, anxiety, PTSD, mental disorders of all sorts, alcoholism, drug abuse, suicide.
Now imagine if we could make the vast majority of all that suffering vanish.
In 2004, with the inescapable conclusions of the ACE study, The substance Abuse and Mental Health Services Administration(SAMHSA) began an initiative to shift the nation’s health care delivery systems to become Trauma Informed. A trauma informed system recognizes the likelihood of trauma, the impact of trauma, the needs of traumatized individuals and that whatever the presenting diagnosis, it may simply be a symptom of unresolved trauma. Treating that symptom, without addressing the underlying trauma, will simply result in other symptoms. Trauma Informed Care screens for trauma, regardless of what the patient is complaining of, in order to address a source that will keep manifesting until it’s resolved.
The next step, which has been evolving from long before the ACE study, is the advent of Trauma Specific Care. Trauma Specific treatments actually resolve the traumatic memory and stop the manifestation of symptoms, the exponential flow of health, social, financial, mental, criminal and substance abuse outcomes from the unresolved memory.
Unfortunately, the adoption of effective Trauma Specific Treatments has been hampered by a number of factors. Some are as straightforward as a systemic preference for drug treatments, or payment systems geared toward treatments we now know to be ineffective for resolving trauma, or a vested belief that trauma can’t be resolved and thus a reliance on coping and managing strategies. These we can simply chalk up to inertia. With enough persistent effort, this inertia will yield and change will occur.
There is a much more pernicious problem with delivering trauma specific treatment. The quotation from Dr. Felitti that opened this article describes it. Denial. We don’t want to know. Knowing is itself traumatic. It’s horrifying to know that a family member is repeatedly raping the 5 year old your child plays with every day. It’s staggering to try to comprehend the enormity of suffering behind closed doors all over this country and around the world. If a Predator Drone fires a missile into a village full of families and no reporter files a story, did anyone scream?
"It is not clear that intelligence has any long-term survival value."
- Stephen Hawking
When we look, really look, at the suffering meted out by one human on another, when we realize that this flow of pain and suffering is predestined to accelerate, amplify and repeat until a determined effort interrupts it, we begin to wonder not if human beings will survive, but should they? It is as dispiriting and demoralizing a realization as one can experience. Little wonder we turn away.
It is not the first time that we, as a species, have buried our heads over the issues of trauma, and more specifically, childhood trauma. Early in his career, Freud undertook an extensive study of ‘hysteria’ in adult women. Neurosis, as he would later call it. His conclusions were very poorly received.
"I therefore put forward the thesis that at the bottom of every case of hysteria there are one or more occurrences of premature sexual experience...(incest)”
–Freud, The Aetiology of Hysteria, 1896
The medical community was aghast. The idea that fathers, and not a few, were molesting their own daughters was just preposterous. Unthinkable. Unimaginable. Unconfrontable. Many later believed that the blowback so early in his career was what caused him to recant these findings and ultimately produce the “Oedipus” complex, which can be seen as a victim blaming/shaming approach to marginalizing the memories of sexual abuse by parents. Yet, it is possible that his repudiation and denial of the widespread incest he had uncovered had a reason far closer to home for him. A letter to a friend during the period in question hints at the dilemma he faced.
“In all cases the father, not excluding my own, had to be accused of being perverse.”
-Freud excerpt from letter to a friend. –Child Sexual Abuse: It’s scope and our failure, Rebecca M Bolen, P.14-15
We can’t be certain that his fascination with cocaine was a welcomed distraction from what may have been a deeply personal conundrum, but it would make perfect sense. So 100 years before the ACE study, the “Father of Modern Psychiatry” stared the devil squarely in the face and hid under the bed. Punxsutawney Phil, the groundhog, under similar circumstances, only brings six more weeks of winter. When Freud failed to see his shadow, we got 100 more years of winter. Denial. Even the brave dare not look.
Yet, perhaps for the first time in the history of what we call ‘civilization’ we are looking. Many, many of us are looking. Committed leaders are taking steps. People are receiving effective treatments and individuals are learning how to deliver those treatments to others. I am citing below, some short videos outlining the significance of the ACE study. I urge you to take a closer look.
The courage to look, to be present for another, to hold space for another’s suffering, to enable them to make sense of it, that is the stuff of healing.
5 Minute Primer on ACES – Quick information on the ACE Study
8 Minute Overview on the ACE Study with co-principal investigators, on the significance of the study
16 Minute Ted Talk on the ACE Study
This is one of the topics we explore in the Intimacy, Connection Healing Series, a workshop for all those in the healing professions. Massage Therapists, Acupuncturists, Yogis, Counselors, Social Workers, Nurses, Breath workers, Energy workers and anyone with an interest in connecting more powerfully to heal.
We explore the powerful connection that sources healing and arises naturally in all healing work. Florida CEs for LTMs, LCSW, LMFT, & LMHC. New York CEs for LMTs.
Join me for my first workshop in Costa Rica, at Living Forest Retreat Center November 11-17
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