Until recently child abuse, neglect and maltreatment were commonly relegated to the fields of social issues, family issues and perhaps legal issues. But many pediatricians are beginning to see it more and more as a public health problem.
Let us begin our discussion of child abuse and maltreatment by picturing in our mind an old and grizzled street person who has spent his life begging for money and food, who is likely suffering from a substance abuse issue or two, shows obvious signs of significant mental illness and even the most cursory medical exam would reveal a number of serious physical ailments. Now consider for a moment the obvious fact that every older person was once a baby; our street beggar included. Despite his current appearance, he was once a beautiful child with a promising life ahead of him.
But somehow, this rosy cheeked baby became this wretched man. What happened? The information we are about to present will provide us with a powerful if shocking answer.
The Adverse Childhood Experience Study (ACES) was conducted by Kaiser Permanente and the Centers for Disease Control and Prevention in Atlanta. The study ran from 1995 through 1997 at Kaiser Permanente’s San Diego clinic where more than 45,000 standardized, well-care examinations were done annually. Over the course of the study, questionnaires were sent out and more than 17,000 patient volunteers responded. The average age of the respondents was between 50 and 60. 75% were white, 93% graduated high school and nearly 40% had college degrees. It should also be noted that the participants in the study all carried private health insurance, which means they were likely working at what we would call decent jobs.
The participants were asked detailed questions about their current and past health in addition to questions regarding specific aspects of their early social history. The events surveyed included physical abuse, verbal abuse, sexual abuse, domestic violence, family and household substance abuse, mental illness, family incarcerations and parental separation or divorce. A single point was assigned for exposure to any of these adverse childhood experiences. The fewer exposures one had to adverse childhood experiences the lower their score.
The resulting data revealed overwhelming evidence of the negative health, social, and economic impact that result from childhood trauma. The study showed that the higher ACES number an adult reported, the more likely they were to experience significant, physical health problems such as asthma, stroke, cardiovascular, kidney and Chronic Obstructive Pulmonary Disease. A strong correlation was also drawn between mental health challenges such as depression and unhealthy behaviors such as smoking, drinking and engaging in risky social behavior.
Close to two-thirds of the respondents had a score of 1 or higher, which meant they suffered at least one incident of child maltreatment. 25% had a score of 2 and approximately 6% had a score of 4. What is remarkable is that a respondent’s positive response in one category meant that there was an 80% likelihood of having a second adverse childhood experience, and a 70% chance of having a third. In addition to evaluating whether the respondent was exposed to the adverse experiences in childhood, the surveys also asked how often, severe and invasive the abuse was.
Taken in its entirety, the study reveals that abuse creates a domino-like effect of cascading health issues. Increased ACES scores correlated to increased rates of smoking in adulthood which in fact led to increased rates of lung cancer. Increases in rates of alcoholism lead to increases in all the alcohol related diseases, such as heart and liver disease. In addition, higher ACES scores were directly linked to chronic depression in both men and women along with a commensurate increase in the rates of attempted suicides. As the ACES scores increase even higher, heart disease, the leading cause of morbidity and mortality in adults in American society, increases as well. Adverse childhood experiences affect rates of cancer, liver disease, skeletal fractures, osteoporosis, teen pregnancies, socially transmitted infections and mental health.
Not unexpectedly, the only factor that did not increase along with higher ACES scores is longevity or life span. In fact, people with the lowest ACES scores had the longest life spans and those with scores of 4 or higher would no longer respond when they got to their 60s, 70s and 80s. We may logically assume that they did not respond because they were either deceased or severely incapacitated to the point where they could not respond.
It was originally postulated that adverse childhood experiences led to social, emotional and cognitive problems in childhood. This eroded the young victims’ sense of self-esteem and confidence and as a result led them to make poor life decisions, to socialize with the “wrong” people, to begin smoking, abusing recreational drugs and indulging in unsafe physical relationships. This would explain their lack of healthy life choices and the resultant onset of hypertension, heart and liver disease, cancers, immunological and inflammatory ailments, depression and heightened rates of suicide.
However, as time passed more thought was given to the question of how child abuse and maltreatment resulted in the manifestation of biological illness and early death and the answer that emerged was: stress.
Let us begin by explaining that stress is not always a bad thing. In fact, there is a whole lot of “good stress” in our lives and as a matter of fact mild to moderate stress in childhood is integral to heathy growth and development. Doctor visits, inoculations, tests, calls to the principal’s office, bratty siblings and managing difficult chores are all examples of everyday stressors that help us learn responsibility, push us to acquire new skills and capabilities, build character and resilience and expand our sense of the possible.
There next higher category is called tolerable stress, which can in fact cause some trauma in young children, but with the proper nurturing by loving and understanding adults the effects can be buffered and will essentially leave little or no lasting impact. These tolerable stressors include death in the family, divorce, war, serious illness and injury and natural disasters.
A third and dramatically more severe type of stress is referred to as toxic stress. Toxic stress is the frequent and continual stress on young children who lack adequate protection and support from adults. Unrelenting physical, emotional and sexual attacks, especially when perpetrated by the very people who are responsible for the child’s safety and well-being, result not only in extreme effects on the child’s emotional development, but also on the child’s biological development as well.
Just about everybody has experienced the ‘fight or flight” response that kicks in when we find ourselves in danger or under extreme duress. The body draws blood away from the organs that are seen as superfluous for the moment and hyper energizes the body parts that will help us either do battle or escape. The brain’s prefrontal cortex where much of our learning, impulse regulation and mental development take place ceases to be a priority during a fight or flight event. On the other hand, the parts of the brain that play a role in fighting and survival, such as the amygdala, become hyper stimulated and dominant.
When a child victim of unrelenting maltreatment knows that the next attack could come at any time and there is nothing he or she can do about it, the effect of the toxic stress causes the still developing brain to become hard-wired in ways that may render children unable to concentrate, learn, trust others, regulate their emotions, deal with transition and change and remain in a constant state of hypervigilance. In fact, scans show that abused children do not access major regions of the brain in school, only those parts associated with survival. As a result, when a child victim encounters even a mild stressor, such as a teacher casually asking about a missing homework assignment, their brains are hard wired to launch a full blown “fight of flight” response.
Emerging science further indicates that while the child’s DNA is not affected by their maltreatment, the way the body relates to and processes the DNA does change in these children. Due to this finding, epigeneticists are now saying that these conditions can be passed down from parent to child and thus can become generational.
Adversity can lead to toxic stress, which will negatively affect neurobiology and epigenetics. In addition, blood flow is removed from the digestive tract, which can contribute to food and digestive disorders. High levels of hormones, like cortisol, are chronically present in the body, which can lead to autoimmune diseases.
For these kids it’s an unending cycle. Hurt children will act differently in school, will be misunderstood, will get into trouble, will be hurt again and all this time the adults around them will not grasp why the children cannot control themselves and behave like others and more punitive measures are applied to render the children even less trusting and more hurt.
To summarize, child maltreatment is a leading cause of toxic stress which in turn leads to a tragically broad range of poor health outcomes. Therefore, child maltreatment is no longer just a mental health issue, a child welfare issue or a legal issue. It is in fact a public health issue. It turns innocent, hopeful, cherubic children into pitiful, grizzled adults who may not survive to middle age.
This article is based on address given by Dr. Cindy Christian at Project Innocent Heart’s Inaugural Event at the University of Pennsylvania. Click here to watch the a video of her presentation.