How does childhood trauma affect health and what can social workers do about it?
One evening in the summer of 2006, Seanna Crosbie, MSSW ’00, was sitting in her Austin living room, transfixed by a slideshow playing on her computer screen.
“I was so moved that I don’t think I slept for a couple of days. It was like a huge light bulb going off in my head,” Crosbie remembers.
At the time, Crosbie worked as a therapist for the Austin Child Guidance Center, a nonprofit that provides mental health services. She treated children and youth involved with the juvenile court system, some living in the community and some in secure facilities. Most of them came to her with thick case files and diagnoses of conduct and substance-use disorders. During therapy, as they opened up, many eventually shared significant experiences of trauma and abuse.
That evening, Crosbie was looking for answers to a question that had been nagging her for a while: What if the violence in the children’s homes and communities was really driving what had been diagnosed as conduct problems?
The ACE Study
The slideshow gave her a resounding yes, backed by a decade of evidence obtained through the Adverse Childhood Experience Study (ACE Study), one of the longest investigations conducted to understand associations between childhood trauma and health.
The ACE Study started in the 1990s under Dr. Vincent Felitti, a specialist in preventive medicine at a Kaiser Permanente clinic in California, and Dr. Rob Anda, an epidemiologist at the Centers for Disease Control and Prevention. More than 17,000 individuals who were completing a comprehensive physical examination at Kaiser Permanente clinics chose to participate in it. They provided detailed information about their childhood experiences of abuse, neglect, and family dysfunction through a screening tool, or a set of questions, that Felitti and Anda had put together. Most of the participants were white, middle-aged, and middle- to upper-class California residents.
The ACE study is tracking participants’ medical status still today. Over the course of two decades, research results have demonstrated a strong association between childhood traumatic experiences and poor physical, mental, and behavioral outcomes later in life.
“I remember that evening watching this video with Felitti and Anda explaining how trauma makes an impact on depression, psychosis, heart disease, cancer… I remember thinking that if we could screen kids for trauma at a younger age and help them, we could actually extend people’s lives,” Crosbie says.
In the last decade, offshoot studies have expanded ACE research into other populations. Scholars are also trying to understand exactly how trauma affects health, drawing from disciplines as varied as neurobiology, behavioral sciences, sociology, and medicine. They have found out, for example, that trauma activates a stress response where the body releases hormones that provide energy for “fight or flight.” When this activation is frequent or prolonged during childhood it can lead to what experts call “toxic stress,” which in turn can impair cognitive or executive functions — thought, judgement, self-control — well into adult years.
Adverse experiences and trauma do not dictate the future of a child, however, because they can be mitigated with other experiences that help build resilience. In the aftermath of the ACE Study, moreover, researchers have developed evidence-based clinical treatments to help children who have experienced trauma and adversity.
“We have to be careful about over-interpreting the ACE Score,” says Beth Gerlach, a researcher at the School of Social Work. “There is the ACE screening tool but there are also resilience screening tools. As practitioners, we can use both to tell our clients, okay, you had these experiences that might have these adverse effects, but look also at these other experiences and how they can help build your strength.”
“Experts on the topic of toxic stress suggest that we use the ACE screening as a beginning of a conversation about these experiences and how they may be affecting our clients as adults instead of focusing so much on the score they get. Ultimately, it’s about looking at the meaning our childhood experiences have for us as adults, in our health outcomes, our emotional outcomes, our ability to form relationships,” Gerlach adds.
In the aftermath of the ACE Study, moreover, researchers have developed evidence-based, effective clinical treatments to help children who have experienced trauma and adversity. Treatments such as Trauma-Focused Cognitive-Behavioral Therapy and Parent-Child Interactive Therapy include attention to parenting ability and work on establishing behaviors that promote resilience in the child and the parent.
“Once I felt that I had learned enough, I needed to move to a place of action,” Crosbie recalls. “So I told my boss that we not only needed to offer trainings about the ACE Study and evidence-based treatments to the community, but that we ourselves, as an agency, needed to become trauma-informed.”
By then, Crosbie had moved from therapist to director of program services at the Austin Child Guidance Center. In 2012, she led the center in a year-long process of reviewing their policies, and changing them according to the principles of trauma-informed care.
For instance, the center started to screen all clients for trauma, trained all clinicians in Trauma-Focused Cognitive-Behavioral Therapy, and included trauma-friendly indicators in the feedback they sought from clients. The center also sought to protect staff members against secondary trauma through balanced caseloads where no one has a full caseload of trauma survivors, a generous vacation package, internal clinical supervision, and yoga classes once a week.
“We have seen some amazing changes. Because we are able to identify trauma earlier and provide an evidence-based treatment, clients are getting better faster,” Crosbie says.
“Recently, a play therapist who has started to use Trauma-Focused Cognitive-Behavioral Therapy with clients who had been sexually abused, told me that her clients are getting better in fourteen weeks when it used to take six months!” she adds.
Central Texas initiatives
In 2013, Crosbie also spearheaded the Trauma-Informed Care Consortium of Central Texas or TICC, which she chairs. TICC serves as a clearinghouse about trauma-informed care, and maintains an updated online calendar of trainings in Central Texas and beyond.
“I realized that many agencies in Austin were doing trauma work but were not necessarily trauma informed. We were all calling each other and I thought that we needed a more formal process for sharing information. We started with the idea of having 15 agencies participating, and we have now grown to almost 70!” Crosbie says.
Gerlach, who represents the School of Social Work’s Child & Family Research Institute at TICC, says that it’s very exciting to see practitioners throughout the state gradually incorporating trauma-informed care in their work with children and families.
Gerlach and colleagues Tina Adkins and Monica Faulkner have been working to spread trauma-informed care practices into the foster care system, health care, and schools. Faulkner has also been working on a trauma-informed care curriculum for sex education.
“At a recent training, we provided strategies to social workers for supporting parents and caregivers who have experienced trauma. The goal is to address multigenerational healing,” Gerlach says.
“We already know that caregiver’s behavior is the most important factor to change a child’s experience around trauma. With these trainings we want to help practitioners open this conversation in a way that is time-limited, feasible, and can help remove some of the shame and stigma parents with traumatic childhoods may be experiencing as they themselves navigate parenting,” Gerlach continues.
TICC has also launched a cross-disciplinary trauma conference. The first one took place in 2015 and featured Dr. Vincent Felitti as the keynote speaker.
“It was so exciting to meet him in person!” says Crosbie. “I shared that I get impatient when I go around the state and see that many clinicians are still unaware of the ACE Study. And he said, ‘Seanna, it has taken 20 years for the word to get out in the medical community.’ His advice was to slow down and keep taking baby steps.”
When asked to summarize the significance of the ACE Study for her career, Crosbie doesn’t hesitate.
“It’s probably been one of the most meaningful pieces of knowledge that I have gained in my practice,” she says. “It’s driven all of the work that I have done since that summer evening when I found about it.”
By Andrea Campetella | Spring 2016