In a plain brick building on a tree-lined street in Albany, NY, a 67-year-old man brought to his knees from a lifetime struggle with alcohol addiction fills out a survey. Across town, on the bucolic campus of a residential treatment center for troubled teenage boys, a counselor asks a 13-year-old the same questions.
- Did a parent often swear at you, insult you, put you down or humiliate you?
- Did you see your mother being hit, pushed, slapped or kicked?
- Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
What’s the point of dredging up bad memories with these and seven other questions? Believe it or not, there’s a long-term payoff for the man, the boy and the city and county of Albany.
Strangely enough, it has to do with the short-term, beneficial effects of the drugs they’re using. Nicotine reduces anger, increases focus and relieves depression. Alcohol relieves stress.
The 67-year-old learns that, all things considered, using alcohol was a reasonable coping strategy for
toxic stress caused by the abuse he suffered as a child. His counselors help him understand that his choices when he was a boy were appropriately self-protective. He wasn’t a bad kid. He was just a kid doing the best he could. And he now has the wherewithal to make different choices. This will go a long way to helping him deal with the abuse and end his reliance on the drug.
The teen is already smoking and drinking alcohol to cope with his childhood trauma, is skipping school, and is starting to steal. With counselors supporting the boy to help him learn how to avoid abuse and neglect, as well as build skills to incorporate some much-needed resilience into his life, he might not need to keep using biochemical coping strategies to get through a day. With assistance from people who care about him, he might not have to use the services of the place across town when he’s 67.
Note that counselors in both places didn’t see the man or the boy’s behavior as a character defect; no counselors looked at them as if they were “problems” and needed controls or punishment to stop their “bad” behavior.
And how is this approach good for Albany? The city and county can spend much less — hundreds of millions of dollars less — on health care, emergency services, police, courts, special ed, social services, and rehab required by the long-term consequences of ever more people using tobacco, alcohol and other drugs, food, sex, high-risk sports and/or overwork to cope. Who wouldn’t rather put more money toward parks, schools, libraries and swimming pools?
It’s no secret that our health care system, which is burdened with most of the consequences, is a voracious budget-eating Jabberwock. It will continue to devour ever larger and bloodier hunks of our financial resources unless we’re able to reduce costs.
In an attempt to reverse the trend, several communities across the U.S. are taking the unusual approach of starving the beast.
This is a different kind of beast-starving. These cities don’t want to starve the beast by hacking away at budgets to deprive people of the help they need. They want to reduce and eliminate that need. To do so, they say: Create healthier individuals, families and communities.
It’s not rocket science, they say. There are three simple rules:
- Make sure that children don’t experience toxic stress.
- Don’t further traumatize already traumatized children or adults.
- Prevent trauma by building resilience skills in individuals, families and communities.
No doubt, it’s a long-haul endeavor. But the payoff? Gargantuan.
Case in point: Let’s look at only the children who were abused in the U.S. in 2008. Add up the total lifetime economic burden resulting from their maltreatment. It’s a whopping $124 billion. Include all the people who were abused each year even for just the last 10 years, and begin including every year from 2012, and the number rolls into the trillions.
The CDC’s National Center for Injury Prevention and Control, which did those calculations, broke down that unfathomably large number into this:
The lifetime cost for one child who was a victim of maltreatment is $210,012 in 2010 dollars. This includes:
- $32,648 in childhood health care costs;
- $10,530 in adult medical costs;
- $144,360 in productivity losses;
- $7,728 in child welfare costs;
- $6,747 in criminal justice costs;
- $7,999 in special education costs.
In Albany, 1,218 children came under the purview of Child Protective Services in 2010. Just that group from that one year will cost the community $256 million over the kids’ lifetimes, never mind how those economic costs reflect a load of hurt for those children.
Each year, like clockwork, another group of more than one thousand children in Albany who are suffering horrendous experiences will come to the attention of CPS. And a system that’s currently designed to clean up only after the damage is done will start spending money on these children as they grow older and become adults.
But Albany wants to reverse that, to build in prevention and intervention in every agency, organization and business in the community.
Other cities are taking similar approaches, and all have different starting points:
- The City of Tarpon Springs, FL, declared itself to be “trauma-informed”.
- The Port Townsend, WA, public health department began screening pregnant women for childhood trauma.
- In Walla Walla, WA, the Children’s Resilience Initiative trained staff at a local school to change its school discipline system, and suspensions dropped 85% drop in one year.
- ACE task forces are being organized in Philadelphia, Chicago and San Francisco. Philadelphia was just awarded a $156,120 grant from the Robert Wood Johnson Foundation to “investigate the extent of adverse childhood experiences in the city, and to plan for a sustainable ACE-informed care infrastructure,” according to a press release from the Institute of Safe Families.
In Albany, NY, the impetus came from Dr. Heather Larkin, an assistant professor in the School of Social Welfare at the State University of New York – Albany. In 2008, she organized a community think tank to talk about implications and applications of the CDC’s Adverse Childhood Experiences (ACE) Study, which found a strong link between childhood trauma and adult onset of chronic disease, social and emotional problems. Her focus was to integrate ACE concepts into services for the community’s disadvantaged, including those who are homeless, mentally ill and the elderly poor.
Many social service organizations began integrating trauma-informed approaches in 2005, when the National Center for Trauma-Informed Care was established to support and assist integration of trauma-informed care in mental health, social services, criminal justice, and education. In a nutshell, being trauma-informed means instituting Rule No. 2, above — Don’t further traumatize already traumatized children or adults.
The CDC’s Adverse Childhood Experiences Study published its first research results in 1998, followed by 57 other publications through 2011. It showed that:
- childhood trauma was very common, even in employed white middle-class, college-educated people with great health insurance;
- there was a direct link between childhood trauma and adult onset of chronic disease, as well as depression, suicide, being violent and a victim of violence;
- more types of trauma increased the risk of health, social and emotional problems.
- people usually experience more than one type of trauma – rarely is it only sex abuse or only verbal abuse.
What’s childhood trauma? There are many types, but the ACE Study measured 10 – physical, verbal and sexual abuse; physical and emotional neglect; and five family dysfunctions. Those include a family member who is incarcerated, diagnosed mentally ill or addicted to alcohol or other drugs; witnessing a mother being abused; and loss of a parent through abandonment or divorce.
Parallel research on kids’ brains found that toxic stress physically damages a child’s developing brain. This was determined by a group of neuroscientists and pediatricians, including neuroscientist Martin Teicher and pediatrician Jack Shonkoff, both at Harvard University, neuroscientist Bruce McEwen at Rockefeller University, and pediatrician Bruce Perry at the Child Trauma Academy.
When children are overloaded with stress hormones, they’re in flight, fright or freeze mode. They can’t learn in school. They often have difficulty trusting adults or developing healthy relationships with peers (i.e., they become loners). To relieve their anxiety, depression, guilt, shame, and/or inability to focus, they turn to easily available biochemical solutions — nicotine, alcohol, marijuana, methamphetamine — or activities in which they can escape their problems — high-risk sports, proliferation of sex partners, and work/over-achievement.
Fortunately, the brain is plastic. The appropriate integration of resilience factors born out of ACE concepts — such as asking for help, developing trusting relationships, forming a positive attitude, listening to feelings — “mobilizes resilience and recovery,” says Larkin. “There’s an expectation that people can improve their lives.”
Out of Albany’s think tank meetings in 2008 came the HEARTS Initiative: Healthy Environments And Relationships That Support….youth, homeless, elderly, victims of domestic violence….whomever the 15 participating agencies are assisting. The Charles R. Wood Foundation gave $75,000 to the initiative last October.
“The main goal of HEARTS,” says Larkin, “is to reduce costly consequences of adverse childhood experiences later in life.”
The first agencies to integrate ACE concepts into their work are Senior Hope and the LaSalle School. Like many agencies that start using ACEs, they’re doing so slowly and methodically.
Think that alcohol and other drug addictions are the scourge of only the young? If so, check this out: The number of older adults with substance abuse problems is likely to double from 2.5 million in 1999 to 5 million in 2020. And with that comes five million more health problems, divorces, abused and estranged adult children and grandchildren, and/or homelessness. It’s never the case that an old alcoholic sits in a room and affects no one else’s life but his or her own.
At any one time at Senior Hope Inc., 50 to 75 people aged 50 and older are using its outpatient services. They find Senior Hope through the courts, physicians, family, and friends.
These people are in tough shape. A New York State Office of Alcoholism and Substance Abuse Services (OASAS) report of Senior Hope’s clients from 2008 to 2011 found that 73% are dependent on or are abusing alcohol, and 52% have been diagnosed mentally ill at some point in their lives, says Senior Hope’s executive director Nicole MacFarland.
Over the last 10 years, several hundred people have taken advantage of Senior Hope’s services, says MacFarland, and a good percentage of those have found some peace. Of those who completed the program in 2010, she says, citing another OASAS report, 68% were no longer using alcohol or drugs.
Integrating ACE concepts are helping Senior Hope’s staff tailor the care for its clients.
“We introduced the ACE questionnaire to the staff last year,” says MacFarland. “We went over the questionnaire together to talk about what we’d be asking the patients, and felt the questionnaire responses would help with the development of initial treatment plans.”
Since last November, 36 clients have filled out the 10-question ACE survey. A preliminary look at their scores shows they are high, says MacFarland.
“We’re just in the beginning stages of looking at how all of this is going to help our programming,” says MacFarland.
But she and the clinic’s counselors knew that they were on the right track when “we began to see people who were for first time in their lives talking about how these traumatic events in their childhood have influenced their lives, their addictions, their mental wellness, and their physical well being. It’s a turning point for them.”
In March, the clinic launched a trauma survivors group to provide people with a safe environment in which to explore childhood issues. “We’re very pleased,” says MacFarland. “We have five people in the group. We’re planning to open it to more people.”
Founded in 1854 by the De La Salle Christian Brothers to serve abandoned and orphaned boys, La Salle School’s 200 staff work with 230 boys and young men between 12 and 21 and their families. Some boys live at the school. Others live at home and attend school at LaSalle. Others participate in after-school programs or participate in counseling with their families.
LaSalle became trauma-informed several years ago, says Dave Wallace, director of clinical services. “When we’re working with juvenile justice, a child comes to our attention because of truancy or delinquency,” he explains. “Generally the behavior’s not the issue. What precipitated it was the trauma. The root cause is exposure to neglectful, abusive parents. We help the child build appropriate skills to limit or stop exposure to that.”
How does trauma-informed care relate to the ACE Study at LaSalle? “The CDC’s Adverse Childhood Experience Study put dollar figures on what NOT doing this work costs a community,” says Anne Moscinski, associate director for program services. “That in itself is advocacy for what our work is.”
LaSalle began collecting ACEs scores on all residential clients in February 2011. This month, they began asking people in their outpatient chemical dependency clinic and other community-based programming the 10 questions from the shortened version of the ACE survey.
“It helps guide our thinking and discussion with the child,” says Wallace. “If he’s experienced the loss of a family member, for example, we have the opportunity to address that.”
The ACE scores of the kids range from 3 to 10, says Wallace. “Some youth have 10 out of 10.”
Child welfare systems, through no fault of their own, fall short in two major ways.
The first: They operate in a culture that views what happens in a family is a private matter, so there’s no intervention until children have suffered months, even years of intense abuse or neglect. Being understaffed, underfunded and overburdened doesn’t help.
“When we meet some of our youngsters, we’re already wishing we’d met them a couple of years ago,” says Moscinski. “There are a lot of horrible things happening to children just an hour from our front door. We certainly would like to be preventing that. We’re just seeing the tip of the iceberg of what’s truly happening.”
The second failure is that the system addresses only half the problem. The ACE Study and the brain research shows that parents, especially parents who never received help addressing their own childhood trauma, need just as much help. The cold hard fact is that, if they don’t receive some type of help, they will just pass on what happened to them.
Instead, the system waits until families have descended into serious systemic abuse, charge in to rescue the children, cart the parents off to jail, and thus add to the trauma of everyone involved – including those who do the rescuing.
“The community outlook has not changed,” says Wallace. When people think of the family dynamics that result in an abused child, they think of second-rate parents who intentionally mistreat their kids. “But when you start looking at parents and their behavior, you see generation after generation” of substance abuse, mental illness, suicide, violence, being victims of violence.
The parents were victims of childhood trauma as well, says Moscinski. When they were children, their needs were never met, and they struggle as adults with issues rooted in their own ACEs. “They are usually doing the best they can,” she explains. “Without supportive, ACE-aware services, their own toxic experiences impact the health and well being of their children.”
Child welfare services and juvenile justice services seem to be only now beginning to grasp the powerful role that tending to the parents’ issues can and will have on the outcomes for their children, notes Moscinski. “Likewise, NOT tending to the parent’s issues compromises the impact of child-centered interventions. Funding has to allow for intensive services for the whole family. It does not now.”
The LaSalle staff say that one of the major hopes they have for people learning about the ACE Study is that improved awareness of the links between childhood trauma and the emotional and economic costs to the community might inspire more agencies to work together.
“The stars are aligning that might allow us to get better coordinated,” says Moscinski. “I was working this morning with a couple of other agencies. There was discussion about how to make something different happen at the point of arrest, to identify the services needed for that kid and his family immediately. I saw something on the news that the district attorney is aware of trauma. The seeds are bursting just under the ground. How well fertilized the ground is and how nurtured the seeds are, we don’t know yet.”