SARA WATERS: Thank
you, everybody, for being here tonight with us. We're going to spend the extra
hour talking about the impacts of childhood trauma. And I'm going to
start also really briefly with a little
introduction of myself. As Kaitlin said, I'm
an assistant professor in human development at
the WSU Vancouver campus. And there, I am the director
of the Healthy Emotional Development Lab. So we study some of
the things that we're going to talk about
tonight as well as healthy emotional
development in early life, prenatal development, how the
relationship between the parent and the child, even
before they're born and across the first
few years of life really shape how children fare
both mentally and physically as they grow up. So I'll take this moment
to-- a little tiny plug that, if you are
somebody you know is in the Vancouver area,
the Clark County area and would like to know more
about the work that we do or to get involved
in research any way, please do send me email. Get in touch. We are always
interested in spreading the word about the
research that we're doing and also getting
students and community members involved in the
work that we have going on. So the very last slide of
my presentation tonight will have my email
address on it. So do jot that down
if you're interested. OK. So briefly, what are we
going to talk about tonight? We're going to start
by really just defining what childhood trauma is
and what it looks like. And then we're going to talk a
lot about how childhood trauma is linked to health outcomes. What do we know? What are the main
studies in this area? What does that mean for us? And then of course,
talking about how do we prevent childhood trauma
in the first place, and how do we help
trauma-exposed children or those who have trauma in
their own history, meaning, they're adults now that they
have trauma in their history? So what I'd like to
do, though, is really start with a note of warning. So obviously these are
not topics and issues that are easy to think about,
hear about, talk about. And many of us who
are drawn to this work and who might be attending
this webinar tonight have a real connection to the
topic of childhood trauma, either personally and/or
professionally, right? So either we or someone we know
has trauma in their history or are experiencing trauma
and/or we work with families or we are planning to work with
families who are experiencing or have experienced trauma. So particularly when we have
our own scars around this topic, coming from our own
past, it can really be challenging to engage with
this material, with this issue. And yet, at the
same time it's really powerful and important
in healing to learn, to educate, to think about what
we can do to overcome and to heal these wounds. So I just want to put it out
there and call it out and ask you guys to really take
care of yourselves tonight, and tomorrow, and every
day around these issues and do what you need
to do, especially if you have your own scars and
trauma and your own history. Really do whatever
it is that you need to do to feel safe
and take care of yourself around the stuff we're
going to talk about tonight. We're going to start with a sort
of straightforward definition of what childhood trauma is. And this comes from
the National Institute of Mental Health, NIMH. And they describe
childhood trauma as an experience
of an emotionally painful or
distressing event that results in lasting mental
and physical effects. So somewhat of a
useful definition, but I think it hints that what's
really important, that this is a difficult event that
happens in childhood, and it has an impact on
the child's development, so it has lasting effects
on both mental and physical health. And we're going to unpack,
tonight, a little bit of why does that happen? Why is it that trauma has
these long-lasting effects on our health? And to do that, we have to
really start thinking about how the parent/child
relationship has evolved, and humans in general have
evolved, in this way such that, especially in the first
few years of life, the primary caregiver, whether
that's mom, dad, grandparent, adoptive parent, foster
family, whoever that is, the person or
people who are providing the primary care
for the child really is acting as sort of the
child's regulatory system or their set of coping
strategies and coping skills, kind of an external
coping mechanism. The way that the
caregiver responds to the child, who restructures
the child's world, and responds to the child
when they're distressed, and helps the child
cope with and recover from small and large upsets
or distressing events is really the way that
we evolved as a species and is really critical
to the child being able to have that healthy
developmental process. So when the caregiver/child
relationship is not secure, is not a safe place for
the child to go to be held, to be comforted, to feel
safe, to feel secure, to have those
difficult situations processed and soothed
and made OK again, the child really
doesn't have, especially early in life, the
ability to cope with those kinds of
difficult really extremely emotionally and painful or
distressing events on her own. And I mean this in
a behavioral sense, and that, if we think of
a baby or young child, they don't have a lot of
coping strategies, especially in the first year of life. They can't escape negative
situations very well. They don't have language yet,
so they can't articulate what's going on with them very well. They really need caregivers
who are very tuned in, very present, and very
there to make sure that the child is
safe and secure. So I mean they
behaviorally, but I also mean that young children don't
have the neural development, they don't have the brain
development, or the brain architecture in place yet. And the brain, of course, talks
to the whole rest of the body, right? So when I say the
brain development, I'm talking about systems
throughout the body in terms of stress response
systems, hormones like cortisol that you've
probably heard of that gets released when we're
experiencing stress, the activation of things like
the immune system that can get triggered when we are sick, but
also when we are experiencing other kinds of trauma. And so this whole-- the brain and the way
that the brain organizes the entire body, the
physiology or the biology of children's reactions to
stress and traumatic events, is not online so to speak. It's not sophisticated
enough to be able to cope with
really difficult things. And so traumatic events
overwhelm the child's ability to cope. It overwhelms the biology
of the child's ability to cope with these situations. And I want to pause
because I don't remember if Kaitlin said this or not. But if there are
questions that arise that are basic
clarification questions, if I use a term that's not
clear or something like that, then I am happy to stop
and clarify as we go along, and then my plan is to
leave plenty of time at the end to answer
your questions or have more of a whatever
different direction we might want to go in question
and answer there at the end. But it there is
a term that I use that people are not familiar
with, please do use your chat function. And hopefully Kaitlin can
jump in and bring my attention to any kinds of clarifying
questions that I can answer. OK. So we're starting
to get a handle on why it is that really
difficult, emotionally evocative, scary things that
happen in early childhood have such a big impact. It's because the
child doesn't have all of the brain architecture
and physiological skills as well as the cognitive
skills to really be able to cope and make
sense of these things. And even as adults, traumatic
events are traumatic. They have long-lasting
effects, right? We can develop a diagnosis of
post-traumatic stress disorder as an adult. But as
a child, we really are not armed with
the biology as well as the cognition and the emotion
to cope with these things. And the thing that makes it
so potent in early childhood is, as we're going to talk about
again in just a minute, when we experience
trauma, when we have our coping mechanisms
overwhelmed and completely flooded and overpowered by
negative things that happen, it affects the way that those
processes, brain architecture and the rest of the biology
of stress and coping, it changes the way that those
things actually develop. So that's how we
start to understand these long-term or lasting
effects is that we actually change how the developmental
process is happening early in life. And that, of course,
is going to have all of these downstream
effects as well. So I want to talk a
little bit about what the trauma-exposed
child really looks like, like a child who has
experienced trauma. How does that manifest in
terms of behavior and things like that? So common symptoms of a child
who has been exposed to trauma include things like sudden,
extreme emotional responses or that inability to calm
down or to control emotions. So this makes
perfect sense given what I was just saying that
that young child depends on the caregiver to help
them cope with trauma and to help them cope
with any kind of difficult or upsetting things
from the crying and fussing that I'm hungry
or I need my diaper changed, all the way to something
much more extreme. The young child is really
reliant on the caregiver to know what those needs
are and to meet those needs, to soothe the
child, to help them. That's how they learn how
to control or regulate their emotions is
by the experience of the caregiver regulating
their emotions for them. So the child who has
experienced trauma who has had overwhelmingly
distressing events and did not have the caregiver
to help them cope with that and learn how to manage it,
somewhat understandably, ends up in a place where
they have extremely emotional responses, and they don't
know how to calm down, they don't know how
to control them, they're not developing
those abilities to regulate themselves
that kids, typically, are doing across this age span. There may be aggressive or
violent behavior, lashing out, and, again, an inability
to control behavior, a lack of impulse
control or an inability to think about consequences. And children who have
been exposed to trauma often are described as
acting spacey or zoning out, an inability to focus
their attention. Especially in the classroom
where the teachers are expecting them to sit and
focus and complete a task, the teachers often
will describe children as zoning out, spacing out,
meaning, these are sometimes the kinds of behaviors that we
might associate with raising a red flag for something like
Attention Deficit Hyperactivity Disorder, ADHD, or ADD,
Attention Deficit Disorder. So lack of ability to
control their impulses, they're spacing out, they're
not paying attention. And that is consistent
with a child who has ADD, it's also consistent
with a child who has been exposed to trauma. And the think about
children's behavior, the thing about development is
that a child's behavior always makes sense, always is adaptive. It has a logical function
if you understand where the child is coming from. So for a child who
is living in a home, say, where there's violence-- and maybe the
violence is occurring between the adults in the home. Maybe it is actually
perpetrated on the child. Regardless, the child is
a growing up in a home where there is regular violence. And so the aggressive
or violent lashing out makes a lot of sense for
a child who is constantly on edge, constantly
hypervigilant, constantly having to feel like they have
to monitor their environment all the time for safety, right? Because bad things
are happening. They don't know when
they're going to happen. They can't control how
they're going to happen, they can't keep
themselves safe, they can't get out of the situation. And oftentimes, in these sorts
of families, the caregivers, the people who are supposed
to be that safe haven or that safety zone of keeping
the child safe and secure, are either not available to
keep the child safe and secure because they are themselves
experiencing violence perpetrated against
them, or maybe most tragically, they are the
causes of the violence. They are the causes
of the trauma, of the really, really
overwhelmingly scary stuff that's happening is actually
coming from the caregiver. So the child not only
doesn't have that safe haven, but that safe haven
is actually the source of the fear and the trauma. So when you think
about that, and we think about what I
was just describing in terms of the overwhelming
emotional stress of these traumatic events
overwhelming and changing the brain architecture and the
way that biology is developing, the biological, physiological
systems within the child, then things like a
lack of impulse control or the inability to think
about consequences is really a direct result of the child
needing to act in the moment and to potentially to
keep themselves safe or to get their needs met. And these changes in brain
architecture that we see, these changes in, specifically,
the prefrontal cortex, the place where we do a lot
of the executive functions, as we call them, things
like acting or zoning out can often be a sign of
what we call dissociation. So when a traumatic
event has occurred, one of the ways that
adults and children alike make cope with
that is to distance themselves psychologically
from that event. People describe it as
being outside of their body and just watching a bad
thing happening to them. And it's because it's so
awful to be in your body and to be experiencing that. There's so little control,
it's so terrifying, that it's actually a very
adaptive useful strategy for children to create
that separation, to dissociate, and to be
outside of the experience, watching it rather than living
in that terror in that moment. Each of these things, so
each of these behaviors, when we see it from
that perspective, we can see how it has a very
important, useful function for helping children
survive, as best they can, traumatic events. Now of course, when the child
is in the school setting, or the child is with
peers, or something like that outside of
that same violent home, that's when these
behaviors that made a lot of sense and
actually, probably were really useful for the
child in that home environment, now get them into
trouble, right? Now that strategy that the use
of spacing out or checking out or zoning out that
prevented them from feeling the overwhelming
terror when they were in this violent
situation at home now gets me into
trouble at school. And they're accused of not
paying attention, of not working hard, these
kinds of things. So I think it's really
important to recognize A, what these behaviors can look
like because we don't always think about children's
difficulties at school from through a trauma
lens from the perspective of gee, could these be the
result of traumatic experiences in the home? And I think we can have a lot
more understanding about what it is that the child is trying
to do and what's going on, when we recognize that these
are not just negative behaviors that have to be overcome. That's true to some extent. You can't be
violent, you can't be having these extreme reactions
that you can't calm down, like, you're not able to
be successful in school and moving forward if
you have those things. But they served a really
important purpose, or they very logically from
what the child was experiencing in, say, that home or in
that traumatic situation in the first place. KAITLIN HENNESSY:
Excuse me, Dr. Waters, there is a
clarification question. What age group
are you describing that display of these
trauma-exposed behaviors? SARA WATERS: Well, so I've
been talking with the example of going into school, right? Now the things like
emotional responses that can't be
calmed down, things like lack of impulse
control, and even being spacey or sort
of being checked out, these are things that we
can see even in infancy. So the behaviors are-- but of course, there's
a certain amount of extreme emotional
responses or not being able to control themselves
in infancy, that are just normal developmental
where you are, right, like in your normal
developmental trajectory. And so the way to
think about this is that it's a lack
of impulse control, or if it's a lack of being
able to regulate emotions that kids typically should be
able to do at that age, right? And so the emotional
regulation of a two-year-old is obviously always going to
be much less sophisticated than the emotional regulation
of a seven-year-old. And at the same
time, there's going to be evidence of a
lack of the regulation that a two-year-old should
be at in a two-year-old that has been exposed to
trauma and, similarly, a lack of the emotion regulation
that a seven-year-old should be at in a seven-year-old who
has been exposed to trauma. So I hope gets at the question. So there's really
a, to some extent, these behaviors
really become obvious when kids get to school, right? So by five, six,
seven, when they enter school, that's
when it really becomes an issue because that's
when you hear teachers saying, hey, the kid can't
sit still, hey the kid doesn't pay
attention, hey, to the kid is getting into fights
with other kids, right? But the effects of the trauma
on the developing child are happening before that. And so there's a
developmentally-shifted version of those behaviors that are
emerging even in infants, toddlers, preschoolers before
they get to school as well. OK. So the next thing
I wanted to do was check in and see how many of
you are familiar with this term ACEs or have some exposure
or experience already with this idea of ACEs. OK. So a bunch of you
guys are right again, and it really is pretty split. One of you said, oh, I
have, or I've written a research paper on it already. And the next person
says never heard of it or totally unfamiliar. OK. So what we're going to talk
about next is a review for some of you guys, but it
also sounds like it will be new for
many of you as well or sort of a refresher
on, maybe, something they you've introduce
to, and so you have some familiarity with it. So ACEs stands for Adverse
Childhood Experiences. And the idea of ACEs is that
it captures 10 events that may or may not have happened
to you during childhood that are representative of the
kinds of traumatic events that we see predicting
long-term negative mental and physical health outcomes. So this abbreviation
aces really stands for adverse childhood
experiences, and here are the 10. Now this is not to say
that these 10 things are the only things that can be
traumatic events in childhood. That's certainly not the case. And these are things
that are experienced in normative populations. So obviously something
like living through a war, or being a refugee, or
something like that, losing your caregivers, having
your caregivers die, are definitely traumatic
events that could happen, or adverse childhood experiences
that are not on this list. This is really meant
to capture the more-- I don't want to call them common
or regular kinds of adversities or traumas, but in
a certain way they are, as we'll see the
statistics in just a minute. So all kinds of
child maltreatment fall into adverse
child experiences, whether that's physical abuse,
emotional abuse, or sexual abuse, as well as neglect. And they break that out
into emotional neglect-- so feeling unloved
and unsupported during your childhood. As well as physical neglect--
so not having enough food, clothing, shelter,
or things like that. And then there are things
like caregiver divorce. And so I say caregiver
here, meaning not limiting to just parents, right? So a divorce between
your primary caregivers, of violence against
caregivers, specifically violence against your female
caregiver, whether that's your mom or your
step mom or whoever that is, caregiver
substance abuse, caregiver mental illness. And I really mean pretty severe
mental illness-- schizophrenia, bipolar disorder, and
unregulated, unmedicated, untreated mental illness, and
then caregiver incarceration. And so if you look at
this list of events, these 10 experiences
that can happen-- and I should say that the way
that we think about adverse childhood experiences, the
way that we measure them-- and I'm going to talk about some
research that measures adverse childhood experiences
right now-- the way that we
measure them is that we ask adults to think
back on their childhood and answer a series
of yes/no questions around whether each of these
things happened to them. And so it'll involve
a description of, during my childhood, I felt
unloved or uncared for. I didn't matter
to my mom or dad, to the people who
took care of me, the adults who took care of me. And if you answered
yes, then that would flag that you had
experienced emotional neglect. And so it's really
your recollection of these things happening
during your childhood. And we can talk
more about what that means as a way of measuring
child trauma or child adversity as well. So what you'll see
here on this list of 10 is really violations of
or ruptures to or threats to that caregiver/child
relationship. So this idea of
child trauma happens when something really
hard, difficult, upsetting happens to the child, and they
don't have their caregiver to really help them manage that. So if the caregiver is
perpetrating abuse or neglect, and clearly the caregiver
is not a safe haven is not a safe place for the
child to go to be soothed and comforted and helped
manage those experiences-- and then, on the other side,
other things that can really make the caregiver unavailable
to the child, whether that's divorce, whether that's
addiction, whether that's mental illness, whether
they're completely not present, they're in prison, or
they're so terrified by their own
experiences when there's violence against the
caregiver that they're not able to be present for
the child because they're traumatized themselves. And so they can't be a safe
haven for somebody else when they're completely
overwhelmed by their own traumatic experiences. So these are the adverse
childhood experiences. And it's really, we just go
down the list, and people-- how many of these
you've experienced. So it could be
anywhere from 0 to 10. And if we look at the
original ACE survey, which was of 17,000 Californians in
San Diego, California I think, the breakdown is
something like this. So roughly 38% of the
people who participated in this original study reported
that they had not experienced any of those 10 adversities. 21% of people reported that they
had experienced one of those. You can imagine that often
that is caregiver divorce. 14% reported they had
experience two, 10% three, and then another 17% had
experienced four or more ACEs. And we've lumped
together four plus, four of more for a
couple of reasons. One, so we think of this
as risk begets risk. When you have experienced one
or two of these, especially at least two or three, it
really increases the likelihood that you will expect experience
more of them as well. And four really seems to be kind
of the tipping point for it, so that when you have
experienced four or more, you're much more likely to have
experienced a lot more, closer to 10, right? So we go back, and
we look at that list, you can imagine that physical
abuse and emotional abuse, for instance, often
co-occur, right? You can imagine that caregiver
mental illness and caregiver substance abuse often co-occur. And it's for a
variety of reasons. You can imagine that violence
against the caregiver and caregiver
incarceration can co-occur, that a caregiver
who is suffering from untreated mental illness
or substance abuse addiction is much more likely to be
at risk for neglect as well. So this is what I mean
by risk begets risk. So as we start to
add up the ACEs, we get much more likely
to have experienced even more of those ACEs. The other reason that
we say four plus is because, when we look at the
relationship between ACEs and health outcomes, there's
sort of a tipping point where four or more ACEs is worse than
three cases, and three ACEs is worse than two, and
two is worse than one, and one case is worse than zero. But once you get
to four or more, we don't see
significant differences in terms of your risk for
negative health outcomes associated with each of
those additional ACEs. There's kind of a
threshold effect almost. OK. So here are just the prevalence
rates from that first study from 1998. And you might think, OK,
that was 20 years ago. Have things gotten better? Have things gotten worse? What might this look like? Here are the prevalence
rates from a survey of 7,500 Washingtonians
that was done in 2009. So not completely current,
but about whatever that puts us, 10 years ago
or so, nine years ago. And what we see is strikingly
similar percentages of individuals reporting zero,
one, two, three, or four, right? Those look like they could
be from the same population, even though they're from
totally different places, different people, and
a decade or more apart. And I could show you
these kinds of pie charts from other surveys and
other parts of the country, and you'd see fairly
similar breakdown. So the tragedy of this
is just how many people have experienced
childhood trauma. If you look at the orange,
yellow, green and blue, almost 2/3 of people who are
reporting in these studies have experienced at least one,
if not multiple, childhood traumas, and that's
pretty sobering. The other side of that
story is that, if we are people who fall into
those orange, yellow, green, or blue slices of the pie,
we are far from alone. One of the things that
I think is really easy to feel when you
have experienced trauma is a great
sense of self-blame, a great sense of shame, a great
sense of what is wrong with me that I have such a
hard time dealing with, fill in the blank. Whatever aspect of adult life
that I'm struggling with, why is it so hard for me? Why do I struggle with
depression or anxiety? Why do I have this
issue and that issue? What did I do wrong? What is wrong with me? And that's very isolating to
think that there is something wrong with you, that you caused
this, that you're somehow to blame, that your
traumatic past, the things that
happened in your family are somehow uniquely awful. And the truth is there are a lot
of people who have experienced childhood trauma. There are a lot of people
who have experienced ACEs. There are a lot of us
all in the same boat around trying to
figure out how to heal and how to have the
best lives that we can given our traumatic history. And so I think, in some ways,
there's some hope in that. When we look at
figures like this, and we look at how
2/3 of these samples-- and like I said,
I could show you a pie chart of national surveys
that very similarly fall in that 2/3 of people are
reporting at least ACE if not more. We are far from alone. This is, in fact, arguably,
an epidemic, right? There's this more
common than not to be, as adults, figuring out
how to cope with these things from our childhood. Now, if we dig into
this study from 1998, the first author on this
research paper is Felitti. So Felitti et al., Felitti
and lots of other people worked on this paper. 17,000 adults, they
reported on their ACEs like I had described. They were asked to think
back on your childhood. Did this kind of thing
happen to you-- yes or no. Did that kind of thing
happen to you-- yes or no. And then the people
in this study gave the researchers access
to their medical records. And so the researchers
were able to look at the relationship
between people who had reported ACEs, how
many ACEs they had reported, and a whole host of mental
and physical health outcomes that had been diagnosed
by a medical professional. So we weren't just asking people
do you feel depressed, or do you have depression. We're actually looking
at their medical records, and they did that too. They asked people to
report on their own health. But they were also able
to look at medical records for physical health diagnoses. So you see here, in this
figure, that I have a bunch-- across the bottom,
we have a bunch of negative health outcomes. Having a BMI over 35, which
is considered morbidly obese, having a diagnosis of diabetes,
of cancer, heart disease, of stroke, of
chronic lung disease. So these are all
physical health outcomes. And then, as well, some
things that we would more consider mental health
outcomes-- things like depression, alcoholism,
or having a suicide attempt in your history. And what I'm going to
show you is the odds of having any of these things
in your medical records, if you have four or
more ACEs compared to if you have zero ACEs. So again, I was describing
how those are the two-- so zero ACEs, those
who have no trauma or adversity versus
that group of four, five, six, seven, eight, nine,
ten-- people who fall anywhere in that four or more. And so we see that, if you
do have four or more ACEs, your odds of having
morbid obesity is almost two times higher
than if you have zero. Similar rate for diabetes, a
little bit more for cancer, little bit higher for heart
disease, similar for stroke, your odds are almost four times
as great for lung disease. And this figure was really
incredible for those of us who study trauma because
it really drove home the fact that the
effects of trauma are not just mental, they're
not just psychological, they're physical. There are things
happening in the body as a result of early exposure
to adversity, early trauma that changed people's trajectories
and elevate their risk for-- what you see here are a lot
of the main killers in this country and, certainly, of the
long-term chronic disease-- cardiovascular disease,
cancer, diabetes, and COPD, or chronic lung disease, are
long-term chronic illnesses that cause a lot of
suffering, right? And then, if we turn to the
mental health diagnosis side, we see similar rates
for depression, even greater for alcoholism. And the odds of having a
suicide attempt in your history, if you have four or more ACEs,
is almost 12 times greater than if you have no
ACEs in your history. So it was this study, 20 years
ago now that it was published, that really got people thinking,
OK, there's something to this. There really is something about
adverse childhood experiences or early trauma
that is influencing health and well-being,
physical and mental health, across the lifespan. Because these people
when they participated in this study were
middle-aged or older. So this was decades of time
between the adversities that they were reporting
they had experienced and when they received
these health diagnoses. This pyramid sketch right
here is what we often use to describe how
we are conceptualizing how this is happening. What is going on? And so at the bottom
of the triangle, you see adverse
childhood experiences-- so having adversities
and multiple adversities or multiple traumas
in your childhood. Because you can see that
arrow starts at conception-- so right from the beginning,
having trauma exposure. You could do another whole talk
on the prenatal environment and how what goes on in
the prenatal environment shapes that child
after they're born. But if adverse
childhood experiences change neurodevelopment and
disrupt neurodevelopment, that those optimal
pathways for development are less likely to happen as
you have experienced more trauma and adversity-- so this
is that brain architecture and the physiology and the
biology associated with that that I was talking about. So when we have changes
in the brain architecture and the physiology
associated with that, those lead to changes in
our social, emotional, and cognitive functioning. So this idea that, as we
have experienced trauma that we're unable to cope
with and regulate well, our stress response system
in our bodies become changed, become tuned
to these experiences of overwhelming distress. And that has effects on
our neuroendocrine system-- so our hormones,
things like cortisol. That has effects on
our immune system. So we're more likely to
experience greater inflammation and inflammatory diseases
because of changes in the way that the immune system develops. It changes the development
of the prefrontal cortex where things like executive
function are really-- the prefrontal cortex is
key for the development of executive function. So when we impair or disrupt
the development there, we're going to see effects on
planning and impulse control and delayed gratification and
decision making and things like that. So when we have these changes-- and from there we see a
greater likelihood of behaviors that are risky, whether
that is drugs, alcohol, unprotected sex, just risky
behaviors in terms of driving unsafely, and things like
that, getting into fights, things like that, that
certainly increase this disease, disability,
and social problems. And those are the things
that feed into early death. So the research of understanding
how it is that trauma changes development and how that is,
then, linked to behavior, this is where the cutting edge
science and research really is. So things that I mentioned like
cortisol or the immune system-- those studies are emerging. We have good evidence
from animal models of what it is that's going on. It's much easier to test these
kinds of things in animals where we can do things like
remove an infant monkey from its caregiver and
look at what that does to the physiology, the biology,
and the brain architecture of the monkey over time. The ethics of that is a
whole other conversation, but currently that
is part of what we can do ethically,
scientifically to understand these things. And then, certainly, like
in rats or mice or something like that, we are able to do
a lot of trying to isolate what it is that's going on. Because of course,
the end goal is, if we can understand these
things, can we change them? Can we reverse them? Can we can we figure
out how to stop people from moving up this
triangle once they've had those experiences? And what I want to
shift to though, of course, is that,
ideally, we would not have childhood
trauma, we would not have adverse childhood
experiences at the rate that we do in the
first place, right? And so childhood
trauma is really the result of ruptures
in multiple systems. I am a firm believer that
virtually, without exception, parents love their children
and want to provide for them and to do their best for them. And when abuse and
neglect, when maltreatment happens, when there's violence
in the home, when there is substance abuse
in the home, it is the result of many,
many failures or problems with the supports that
the family receives, the access to health
care, on, and on, and on that allow these
cracks or these ruptures and these traumatic
events to happen. And so to prevent
childhood trauma, we really have to take action
across these multiple systems. This is, yes, of course it is
about helping parents develop better coping skills,
educating parents about resources and
about healthy parenting and the risk for
physical abuse that comes with harsh physical punishment. But it also has to come
from the health care system, from [INAUDIBLE], from schools. These are what I mean by
multiple levels of the system. So I want to say
that we're really fortunate that, in
Washington state, we have an example of this
multiple systems being tackled at once to prevent childhood
trauma in this Essentials for Childhood Initiative. And it involves educating
people about brain science and ACEs and resilience, not
unlike this webinar tonight. It involves transforming
systems and services to mitigate the
impact of trauma-- so having a trauma-informed care
in early childhood, in schools, in pediatrician's
offices, and all the touch points for families
in the community. It's about helping build
community ownership and impact. Because one of the big
ruptures in the system that allows for childhood
maltreatment to occur is the lack of social support
and the social isolation that is so common, that people
have nowhere to go, and they're overwhelmed,
and chronically stressed, and at their breaking point. And there's nobody there to give
them a little bit of relief, right? And to bring together
family-centered services around-- so that they're connected, so
that they're communicating, and so that they really
understand trauma. When you think about
that description of the trauma-exposed
child and how useful that could be for more
teachers to understand those kinds of things when
they see them in the child. Not that that necessarily
means childhood trauma exposure if they're acting
spacey, but it certainly could be something that
teachers could be thinking about and could know. And that's one of the things
that Washington state is really pushing. So prevention is obviously
key and the goal. We want this to not
happen to anybody. But for those of
us, or for children who have been exposed
to trauma, what are the keys to resilience,
the keys to healing? One of those is to
build the ability to cope with the
intense feelings. So this and building
a sense of safety are the things that have
been these two things that are so important for the
child/caregiver relationship to be able to do and that
have, more often than not, been deeply disturbed
or possibly destroyed in cases of childhood trauma-- so helping the child
develop the ability to cope with those
intense feelings and to rebuild a sense of
safety in the child's world. And hand-in-hand with
that is the ability to tell the trauma narrative. So far too often our
experiences of trauma fall into the
category of things we can't talk about, things that we
can't even think about, right? And in fact, that is
not the path to healing. So blocking it out
of your mind is not, or just not talking
about it and kind of brushing it under the rug,
is not the path toward healing. And it's not the path toward
healing for our children. So even very, very
young children-- two years old, three years
old, through drawing, through storytelling with
dolls, can tell their story of what just happened to them. Now. And that is very
powerful and important. And in some therapeutic
environments, that trauma narrative is co-told
by the caregiver and the child together so that
the caregiver can start to understand what the
child's experience of this is. Because particularly--
so, say, in a home where the primary caregiver is
experiencing intimate partner violence, say, there
is a desire to believe that the child doesn't
know what's going on or isn't affected if it's
not perpetrated against them. And that's not true. Similarly in homes
where the caregiver has difficulties with
addiction or mental illness. There is this desire to
believe that the caregivers are successfully keeping
the child unaware. And the research
shows overwhelmingly that that's not the case. And so empowering the child to
give voice to that which cannot be spoken is an important
part of the healing process. And that's true
for adults as well. Just, in childhood,
with limited language and with limited
cognitive understanding, we have to do even more to
create a safe space to allow the child to process and
speak those, or express without words, their
traumatic experiences. Some specific evidence-based
therapeutic practices for children and adults
who have experienced trauma include trauma-focused CBT. So CBT is Cognitive
Behavioral Therapy. And there is a trauma-focused
CBT that is most appropriate for slightly older
children, so say, seven or eight
through adolescence, because there's a lot
of language involved-- and so a lot of developing
skills, education for the parent, processing
strong emotions, healing those bonds, but through
dialogue and conversation. EMDR, or Eye Movement
Desensitization and Reprocessing treatment, can
be used in children or adults and sounds kind
of bizarre, maybe, but has really good evidence to
suggest that it enables people to decouple the traumatic
emotional reactions to the events that happened,
and in that way, begin to heal and move forward. And then, for families where the
child is under the age of five or six-- so really
quite young and doesn't have the linguistic and
cognitive sophistication for something like
trauma-focused CBT. There's a thing called
child/parent psychotherapy, which is where the parent
and the child, together, or the caregiver
and the child, meet with a therapist in
weekly sessions, sort of a traditional
psychotherapy model, but do process the trauma
and rebuild the safe bond and relationship, the secure
bonds between the caregiver and the child. And so when I say
these are some examples of evidence-based treatments
or therapeutic possibilities meaning that there have been
research studies testing the effects with a control group
and finding that these really do decrease the symptoms and
the negative outcomes, at least in the short term, for people
who have experienced trauma. All right. With that, I will say thank you. There's my email
address at the bottom. So do jot that down if
you're interested in talking more or learning more, and I
will open it up to questions. KAITLIN HENNESSY: We have a few
questions concerning the ACEs statistics and pie charts. Can you speak to the
age group of people polled if they were
from random surveys and if socioeconomic
status makes a difference? SARA WATERS: For instance, in
the survey from Washington, like I have on the slide,
it's a representative sample. So it's not a random sample. It was meant to capture the full
range of socioeconomic status, different family compositions,
different parts of the state, all of those kinds of things. So it was deliberately
aimed to poll families to make sure that all
parts of the state in all different
family compositions, socioeconomic status,
ethnicity, et cetera were represented
in those numbers. Both the original
ACEs study and others that have come out afterwards,
those effects of ACEs on physical and mental health,
those odds that you saw in that figure are
controlling for education, socioeconomic status,
use of smoking, and exercise, and other
kinds of health behaviors. So those effects are above
and beyond a lot of the things that we know can
explain differences in health outcomes-- access to health care. So all of those kinds of things
are already taken into account when we look at the differences
between those people who reported zero and those people
who reported four or more. KAITLIN HENNESSY:
This question is regarding why negative
health outcomes happen to people with ACEs. It says, are the
negative health outcomes symptomatic of the
ways that people cope, like smoking to relax
in the face of trauma leads to lung cancer or eating to
satisfy emotional discomfort? SARA WATERS: Yeah. So there's definitely a
component of that, right? So there's definitely
part of what this association between ACEs
and physical health outcomes is partly things
like just described, things like self-medicating
with alcohol or cigarettes or
drugs that, then, have their own negative
consequences down the line, or food for that matter. But that's not all
the relationship. There is a huge part of
this association that is not explained by behavior
that is explained by biological processes,
physiological processes that are changed as a
function of trauma. And that's when I
was starting to say. The research is still
emerging in this. So we're going to
continue to know more and more over the coming years. But the information that
we do have out there shows that the people
who've experienced early adversity, or
ACEs, on average-- this is, of course, no
individual person. But when we look at averages
of a group of people who have experienced multiple
ACEs versus those who have not experienced ACEs,
we see differences in brain activation. So there's neural differences. We see differences
in the functioning of the immune system. We see differences
in the functioning of neuroendocrine system,
the stress response system. So yes, part of it is behavior. And it can be kind of like
a feedback you know spiral. But part of it is that these
experiences in early life change biological systems
that, then, develop along a different trajectory,
a trajectory that puts you at greater risk for
disease and disability. KAITLIN HENNESSY: I'm
curious about ACEs from a generational standpoint. Do 20-year-old adults have
different ACEs reported than 50-year-old adults? SARA WATERS: That
is a good question. And I don't know
that I have a good-- so I have a study that I can
immediately bring to mind-- answers that. So the first real time that
this was studied in a real scientific way was
in the mid-90's. So that's the
generation-- that was 40, 50, 60, 70 at that time. There are studies
that have been done. The one I reported
was from 2009, but I can think of another
one that's coming out in 2012. And so, in that case, the
people who are 40s, 50s, 60s is in midlife and reporting
on their childhood trauma and their health are of
a different generation. And so, so far,
the pattern seems to suggest that, on average,
across the population or across a representative
sample from a state, we're not seeing dramatic
differences in the rates of traumas from people
who were middle-aged in the '90s versus people
who are middle-aged today. KAITLIN HENNESSY: In
regards to the behavior of a trauma-exposed child, will
behaviors persist if untreated, and will they remain into
adolescence and adulthood? SARA WATERS: If we don't
receive support and care, if we don't receive
help for other ways to manage the trauma
that we are experiencing, then we will continue to use
the best strategies that we have available to us, which
are, oftentimes, not the most adaptive or are going to
have a lot of other problems across different settings. So there are lots of
instances of resilience. There are lots of
people who have-- this is always averages. There are lots of people who
have had traumatic experiences and have had
post-traumatic growth, who are very resilient in the face
of these traumatic experiences. But recognizing
that, we still want to make our mission to provide
services and care for children and adults who have
experienced trauma. So we want to really recognize
that we use the tools that we have to get by, right? And if we have
experienced early trauma, and we don't have
the best tools, those are still the
best tools that we have. So until we have new
tools, more adaptive tools, tools that will
help us cope better across different situations
and really thrive, we're going to do the best
we can with what we have. And so, as a community, our job
is to get people better tools, right? It's to help them heal and
develop better ways of managing just for their own
sake and also to stop the intergenerational
transmission of maltreatment, right? So if you have experienced early
trauma or adverse childhood experiences
yourself, you're more likely to raise a
child who is also going to experience
adversity-- and so to stop that cycle
of maltreatment, that cycle of mental
illness, that cycle of abuse that can happen if there
isn't intervention. KAITLIN HENNESSY: Does the
trauma need to be ongoing, or are isolated events
also able to change social, emotional, cognitive,
or physical behaviors? SARA WATERS: So ongoing
trauma is certainly more disruptive than
single incidents, right? And particularly when
we look at that list of 10 adverse
childhood experiences, if you experience
some of those things at one point in
your childhood, it's fairly likely that
those were things that you experienced
over some period of time. There is usually
not a single episode of violence between caregivers
just once and then never again. It tends to be repetitive. At the same time,
a traumatic event like, says, the
loss of a caregiver, the loss of a parent-- so traumatic grief at
the loss of a caregiver can have really powerful
effects and certainly deserves the same kind of
intervention and support that any other kind of traumatic
event in childhood deserves. They're slightly different. So there is a specific
traumatic grief version of trauma-focused
CBT, for instance. So I think the answer is yes. A single traumatic event
can have negative impact, and certainly it
deserves intervention. It often doesn't have the same
level of impact as something that is chronic, something
that is ongoing, right? Because it is that
experience of not being able to find a safe
place, not having anywhere to go to escape the trauma,
day after day, that really overwhelms the child's
developing brain. KAITLIN HENNESSY: Besides
stopping the ongoing trauma and chronic stress,
what therapies are most supportive
of resilience? SARA WATERS: So trauma-focused
CBT and EMDR or regular CBT are both interventions that
can be used by individuals who are no longer
experiencing trauma, like it's in their childhood,
it's in their past, but who are still feeling
the effects of it. So if we've experienced
childhood trauma, say, and one of our coping mechanisms
was this dissociation, was this zoning out and
just leaving our bodies and getting away
from the situation where something awful was
happening to us, that becomes one of our coping mechanisms. And that means that,
into adulthood, when something really
stressful happens, your mind and your body goes
to that as a good strategy to use to get through
this stressful event. And so we can have episodes
of dissociation in adulthood. Or we can have flashbacks,
like a post-traumatic stress kind of a flashback around
certain people, certain smells, certain environments,
certain things that remind us of these things from our past. So the same kinds
of trauma therapies that can be used in
childhood or with families can also be used by
people who are carrying the legacy of those earlier
traumatic experiences, even if they're not
living through something like that right now. KAITLIN HENNESSY: If a child is
speaking about things that they are being conditioned
to not talk about, could that potentially
put them in danger? I'm confused on
how you would make a child feel safe without
removing them from their home. Can you please explain this? SARA WATERS: So this is a
really difficult question of when you have a child who
is experiencing maltreatment in the home, the question
of whether you remove them from the home or not. And certainly-- and
I think it really is a case-by-case
situation, in part, because the disruption
of the attachment bond between the caregiver
and the child, even though the
caregiver is maltreating is a huge rupture for the child. It's a huge loss. And so that needs
to be thought about. So in the examples that I
was giving of intervention and letting children giving
voice to these things that can't be spoken was really-- I was describing
examples of where the caregiver and the child
have come together into therapy, into a clinical intervention. And so there is some buy-in
from the maltreating caregiver to change the situation. Now sometimes this is-- so I've worked with
populations where this is a mother, a
female caregiver, who's in and intimately
violent relationship. And they may not be ready to
leave their violent partner, but they can be motivated
to go to therapy with their young child
to keep their child safe and to start to
understand what the impact of their romantic choices
are having on their child. But child/parent
psychotherapy has been used with caregivers
of very young children, like under age of three, who
are actively maltreating. And the process of going through
that and helping the parent come to understand the impact
of their actions on the child-- and what we think part of
what is really happening is, we're building a sense
of empathy for the child. And the parent can have-- so in randomized
controlled trials, that therapeutic intervention,
letting even a very young child express their trauma,
and the therapist helping the parents see
what the child is expressing and understand what the
child is expressing, can improve the quality,
like the security of the caregiver/child
relationship, changes the cortisol
response or the stress response of the child, even
up to a year or more later. So the child has less of
the really overwhelming biological stress response
and decreases maltreatment. So that's, I think, some
of the most hopeful kind of things that can happen
is to actually heal that relationship. Of course, that's not
always possible, right? So I think our goal is always
get families into treatment together and to heal
those bonds and to change that traumatic environment. But that's not always possible. So sometimes what
has to happen is for the child to be removed
from that environment. And like I said, that's
a case-by-case decision that has to get made. But when a child is in a
safe space, whether that is the therapeutic room
setting with parents, or whether that is
in a foster situation because they have been
removed from the home, the child need to be
able to tell their story. The child needs to be
able to feel safe enough to tell their story and to
feel like there are adults, caregivers around them,
who are strong enough to hear their story,
and to hold their pain, and to allow the
child to process what they've been through. So yeah, that's
probably not going to happen in a home
with active maltreatment where the parent is
not invested in getting any kind of intervention. But oftentimes, the
reunification process can be a change
point for families. So after a child
has been removed, but then in the
process of reunifying, and the bio parents getting
custody of their child back can be a point at
which they're really motivated to engage in
some kind of intervention and really change things
and enable them to keep their child in the home. KAITLIN HENNESSY:
Thank you, Dr. Waters. Our next question asks,
if childhood trauma is a catalyst for
behavior or dissociative disorder, what aspect should
be addressed or treated first? SARA WATERS:
Interesting question. So yeah-- so dissociative
identity disorder, which is what used to be called
multiple personality disorder, but is now called dissociative
identity disorder, is understood currently,
the current psychiatric conceptualization
of this diagnosis is, that it very often comes
out of early childhood trauma and is a product of the
fragmenting of the child's psyche as a way to survive
extreme trauma, extreme abuse. So raising awareness of this
is, I think, really important. Because there are
lots of therapies that we can get out
there when we're struggling with something. And if you know that you
have childhood trauma, and that perhaps things that
might be dissociative identity disorder or something
along those lines, things that might be borderline
personality disorder, or something along those
lines, as well as depression and anxiety may have its
roots in childhood trauma, then we want to be sure that
you find a therapist who is trained in trauma and who
has a trauma-focused approach to their therapy. Because retelling the stories
of your traumatic childhood without the proper
therapeutic process can, itself, be
retraumatizing, can be a way that triggers
post-traumatic flashbacks and can be its own
way of bringing you back into those experiences
biologically, physiologically in your body. And so that's part of what we
really want to be able to do is raise awareness
of how many things can be impacted by
childhood trauma so that we can get therapeutic
support from people who have that trauma training
and who are trauma informed. Because it's really
important to build, just like we do with
children, but it's just as important in adulthood,
is to build a safe space and to build the
abilities to cope with these overwhelming
emotional experiences before we unpack and tell
the trauma narrative. And so the therapist's
job is to really is-- and a trauma-informed therapist
will know how to do this well-- is to build that safe space and
help the person build skills to manage their overwhelming
feelings before they really start going through that
Pandora's box of experience. So ultimately, the trauma
needs to be shared, it needs to be
processed, it needs to be neutralized by being
brought out into the open. But doing that
too soon, or doing that where you don't have
those supports around you can, itself, be a
traumatic experience. KAITLIN HENNESSY: What
types of resources do you recommend for a caregiver
who has anger and/or temper issues which are negatively
impacting a young child? And does arguing and/or
yelling equate to an ACE? SARA WATERS: Arguing between
caregivers, yelling at a child, I think any parent is probably
guilty of that at some point. I don't think that we can
say, across the board, that that qualifies as a
trauma or an adversity. What makes it a traumatic
event is when it is ongoing. So like in the case of
arguing or fighting or yelling at your child,
when it is ongoing, and when it really undermines
the child's sense of safety-- so everybody fights, and
everybody yells at their child sometimes. But the difference
between what undermines a child's sense
of safety is when there's no real
reparation, there's no real coming back together and
re-establishing that bond, and knowing that
you love each other, and that, yeah, you
fought, yeah, you yelled, yeah, it was ugly, and we're OK. We can yell and still
love each other. And that has to be a really
authentic experience. Children are really
good at picking up things like stonewalling,
the cold shoulder, or the ugly non-speaking
tension that can happen between parents or caregivers. Like, you know, we don't want
to fight in front of the kids, so we're just low-level
hostile ignoring each other kind of thing. Kids pick up on that. Because kids are very
sensitive to that kind of emotional
climate in the home. And so it's not
coming back together in a way that is
authentic, in a way that is like truly held, and
connected, and shows-- that's actually what kids
need more than anything. Rather than never
being yelled at or never witnessing
fighting, because that's just not the reality of
life, is actually the seeing the full arc, that we can
get really mad at each other, and things can get really
nasty for a minute. And then it can come back
and be really loving again. And experiencing that full
cycle of a relationship, that's what's going to
enable kids to be successful in their
own relationships is the coming back together. So yelling or fighting
in itself is not what's going to be traumatic. It's when there is no
coming back together, when it is relentless,
when there's no time at which the child
really feels safe again, and is soothed. And it's just the fear and
the upset of the fight, and then there's-- things toned down, but
they're not really OK, or you're not really
sure if they're OK. And then it turns into
another big fight. And that escalation where
they never really get to come back to a place of
safety, that's when things become really problematic. And that's where getting
support, mental health services for the caregiver,
getting support, mental health services for the child-- and when a child is young,
like certainly under five, but maybe even older, mental
health services for the child means mental health services
for the relationship. It means the parent and
the child going to services together, as well as potentially
the couple of the parent getting their own support. So they can process
what is it that is so kicked up inside of
them that they're angry, that they're lashing
out, that they're not able to manage their emotions. They may have their
own traumatic history. They may have some
really, real, really, raw stuff going on inside
their own psyche that is stopping them from being able
to be more gentle and empathic and understanding
with their child. And they deserve to have that
held and soothed and healed as well.
