The hidden epidemic of early trauma and the prevention of pathology by Evan Dwan

It was many years ago that the villagers of Downstream recall spotting the first body in the river. Some old timers remember how spartan were the facilities and procedures for managing that sort of thing. Sometimes, they say, it would take hours to pull 10 people from the river, and even then, only a few would survive.

Though the number of victims in the river has increased greatly in recent years, the good folks of Downstream have responded admirably to the challenge. Their rescue system is clearly second to none: most people discovered in the swirling waters are reached within 20 minutes — many less than 10. Only a small number drown each day before help arrives — a big improvement from the way it used to be.

Talk to the people of Downstream and they’ll speak with pride about the new hospital by the edge of the water, the flotilla of rescue boats ready for service at a moment’s notice, the comprehensive health plans for coordinating all the manpower involved, and the large numbers of highly trained and dedicated swimmers always ready to risk their lives to save victims from the raging currents. Sure, it costs a lot but, say the Downstreamers, what else can decent people do except to provide whatever is necessary when human lives are at stake.

Oh, a few people in Downstream have raised the question now and again, but most folks show little interest in what’s happening Upstream. It seems there’s so much to do to help those in the river that nobody’s got time to check how all those bodies are getting there in the first place.

That’s the way things are, sometimes.

(Ardell, 1977: 179.)

In the mid 1980s, Dr Vincent Felitti was running an obesity clinic in San Diego. Felitti noticed a strange trend: the drop-out rate was highest amongst those who were most successfully losing weight. Just when they were close to reaching their goals, they would drop out permanently or return again in a few months. Felitti and his colleagues were bemused as to why this was happening.

He asked one of these successful patients what she thought might explain this behaviour. The patient reported that she had started putting the weight back on after an older man in work had started flirting with her. It emerged that this patient had a history of incest at the hands of her grandfather which began when she was 10, the same age at which she first began to put on weight. Felitti realised that the weight was an attempt to protect herself from the recurrence of this trauma. The weight gain was not the problem, but a solution to the problem of unwanted sexual attention. The same patterns showed up with 186 other patients: time and again, Felitti saw a link between obesity and sexual abuse. He got colleagues to screen their obese patients for abuse and they came back with the same results. This led to the landmark Adverse Childhood Experiences (ACE) study (Felitti et al., 1998).

The original ACE study was a collaboration between Kaiser Permanente Medical Centres and the

Centres for Disease Control and Prevention. The study was conducted with over 17,000 middle-class adults to explore the effects of childhood adversity on adult health. The study showed how ten categories of adverse experiences have negative consequences decades later on a large number of health risks, social problems and reduced life expectancy. The ACE categories include growing up in a family with different types of abuse, including incest, alcoholism, drug abuse, mental illness, criminal behaviour and domestic violence. The ‘ACE scores’ were calculated by adding the number of categories experienced rather than the number of events within one category. It was found that less than half of participants had an ACE score of zero. 67% of the population had experienced at least one category of ACE. 12.6% had four or more categories. Additionally, there was also a dose-response relationship between ACE’s and poor health outcomes. The higher your ACE score the greater the risk to your long-term health.

The study then matched the ACE score with health risks like heart disease, diabetes, obesity, depression and suicide. For each category the risk increased with an increase in the ACE score with no exceptions. The more ACE scores a person experienced, the greater the likelihood of health problems developing in adulthood. An increase in ACEs also leads to an increase of risk for engaging in destructive relationships, substance abuse, smoking, alcoholism and drug use. The Dunedin health and development study (Poulton et al., 2015) has also shown that people who experience childhood maltreatment were found to have elevated levels of inflammation twenty years later.

Childhood adversity gets under the skin, writes Nadine Burke-Harris, as our biography becomes our biology (Burke-Harris, 2018).

Early adversity alters a child’s developmental trajectory, triggering chronic inflammation and hormonal changes that can last a lifetime. Early adversity can alter how DNA is read and how cells replicate, creating a vulnerability to many different diseases, both physical and mental. Many people ‘overcome’ early adversity and create successful lives only to develop lung cancer, stroke, heart disease or depression with little understanding of where these diseases came from.

According to the neuropsychologist Allan Schore, the roots of psychopathology lie in early traumatic attachment experiences (Schore, 2012). The beginnings of living systems set the stage for every aspect of an organism’s functioning throughout the lifespan. A scientific consensus is emerging, writes Schore, that the origins of adult disease can be found in the developmental and biological disruptions in early childhood (Schore, 2012). Early relational trauma has been referred to as ‘The Hidden Epidemic’ (Lanius et al., 2010).

Emotional systems are shaped by early parenting and the wider culture and society, writes psychotherapist Sue Gerhardt (2014). When these influences are less that optimal it leads to social and emotional problems later in life. Conception through to the first two years is the most important period of development. The foetus is picking up signals about cultural conditions even while in the womb and figuring out: is this a loving and nourishing culture it is being born into? Or do they need to prepare for conditions of hardship and deprivation?

At the end of WW2, ‘The Dutch Hunger Winter’ occurred (Lumey et al., 2007). As the Nazi’s retreated they cut off all food supplies and for a season the Dutch starved. Foetuses during that time learned that food was scarce and their metabolism adapted leading to increased risk of metabolic syndrome and many other poor health outcomes. Robert Sapolsky (2004) notes that if lots of glucocorticoids (stress hormone) are passed through to the foetus it learns that it is a stressful world out there. The result is that they prepare for that by secreting lots of glucocorticoids. Rats who are stressed prenatally show elevated stress levels throughout their lifetime (Sapolsky, 2004).

Dr Michael Meaney and his colleagues at McGill University looked at two groups of rat mothers and rat pups (Meaney and Szyf, 2005). Researchers noted that the development of the pups’ response to stress was directly affected by whether the mother was a ‘high licker’ or a ‘low licker’. The pups of high licking mothers had lower levels of stress hormones. Pups of low licking mothers had higher spikes of corticosterone in response to a stressor and they had a harder time shutting off their stress response compared to the other pups. The licking and grooming that the pups received in the first ten days of life predicted changes to their stress response that lasted an entire lifetime. These changes continued into the next generation because female pups who had high-licking mothers became high lickers themselves.

The centre for the developing child at Harvard University argues that healthy development can be thrown off kilter by excessive or prolonged activation of the stress response. Toxic stress can have a negative impact on learning, behaviour and health throughout life. Our bodies are prepared to respond to threat or challenge by increasing heart rate, blood pressure and stress hormones. When a child experiences stress in an environment of supportive adults their stress response is quickly brought down again through the regulating presence of others. This leads to the development of a healthy stress response. However, if this support is not there and the stress is long-lasting it can have a damaging impact on the development of the stress response system and the brain leading to negative long-term health outcomes.

Positive stress is essential for learning and development and is linked to a slight increase in heart rate and mild elevation in hormone levels. If the stress is time-limited and the child is buffered by supportive, nurturing relationships, these factors prevent what otherwise might cause damage to the child’s biology. Toxic stress occurs when the stress is strong, frequent and prolonged. This occurs in situations of abuse and neglect, or when the child is in a chaotic or violent environment or has unresponsive caregivers. These conditions increase the risk for stress-related disease and cognitive impairment (Centre on the developing child, 2017).

Psychologist, Darcia Narvaez argues that when stress has gone on too long or when there is too much stress at a critical period, the system becomes sensitised to greater reactivity (Narvaez, 2014). When an infant is left to cry for a long period the brain becomes flooded with stress hormones that are toxic and kill neuronal connections. Opioids are diminished and pain circuits are activated. In the absence of responsive care, the child may learn to disconnect from their emotional experience. It may appear 42

as if the baby is fine but their system is being flooded by corrosive cortisol. Prolonged grief that may arise from feeling isolated can lead to future mood disorders. Distress that is not relieved in early life influences the genetic expression of the GABA neurotransmitter. This leads to anxiety and depression as well as a future tendency to use alcohol for the relief of stress (Narvaez, 2014).

Narvaez (2014) notes that where responsive care is absent the stress response system can become shaped towards oversensitivity leading to poor mental and physical health outcomes and accelerated aging and premature death. A dysregulated stress response lays the foundation for an increased risk of psychopathology, including tendencies towards violence. The ‘Unabomber’ Ted Kaczynski experienced severe trauma at nine months of age by being separated from his mother for several days during a hospital stay. His mother noted that this changed his personality (Narvaez, 2014).

James Prescott, a developmental psychologist, argues that for many years studies have documented how failure of maternal-infant bonding places nations at risk of depressive, drug-addictive and violent behaviours (Prescott, in Narvaez, 2012). Cross-cultural studies of tribal cultures have confirmed John Bowlby’s claim that maternal love in infancy and childhood is as important for mental health as vitamins are for physical health. Birth complications in combination with maternal rejection at age one predicts violent behaviour at age eighteen (Prescott, in Narvaez, 2012). Pain and pleasure in early life, writes Prescott, determines whether we follow a path of peace, harmony and happiness or alienation, violence and depression (Prescott, in Narvaez, 2012).

There is evidence of an increase in emotional disorders in childhood and adolescence, according to Allan Schore (2012). There is also compelling evidence that adverse biological and developmental disruptions are rapidly increasing. The declining mental health of children is having a marked effect on psychosomatic and psychosocial disorders which have deep impacts on society. The American Academy of Childhood and Adolescent Psychiatry in recent years has described a ‘crisis’ in children’s mental health where one in five has a diagnosable psychiatric disorder and one in ten has a mental illness that impairs everyday living (Schore, 2012). Why has there not been a massive response to this crisis? Schore (2012) suggests that defences against uncertainty and painful information (denial, repression, dissociation) operate not just individually, but collectively in a culture, to avoid facing the stressors that lie at its core.

Sue Gerhardt (2014) points to a 400% rise in depression in the United States since the late 1980s. Antisocial behaviour has also increased in this time. There may be many reasons for this including a more stressful and competitive way of life, less certain values, cynicism, and materialism. Women’s lives have also changed during this period in which they are participating more in the economy while their children are still very young. More babies are being cared for by strangers during the day and tired parents at night. Gerhardt argues that to counter this trend there is a greater need for flexibility in work practices, shared parenting and community facilities and support. If parents prefer to delegate child-rearing to others, then these professionals need to be better trained and given greater incentives to have greater commitment to their jobs. This all requires financial resources and investment.

The good news, according to Gerhardt, is that successful solutions exist. One approach is to provide more health visitors to homes to provide guidance and encouragement with parenting. Another is parenting programmes. These solutions are easy to establish and have been effective wherever they have been tried. There is evidence that these interventions lead to massive long-term savings in social costs as a result of crime, of putting children into care and of managing the consequences of poor emotional regulation.

The researcher David Olds (1988) has developed the nurse-family partnership programme in which nurses support vulnerable mothers to develop good relationships with their infants. ‘Watch, Wait and Wonder’, ‘Video Interaction Guidance’, and ‘Circle of Security’ are other programmes that have a similar aim (Gerhardt, 2014). What is most important is that the professional helper develop a positive, supportive relationship with the family and encourage caregivers to reflect on what the baby is feeling and how to support the baby’s development (Gerhardt, 2014).

Beginning in 1975 and continuing for almost thirty years, Alan Sroufe and his colleagues followed 180 children and their families in the Minnesota longitudinal study of risk and adaptation (Sroufe, 2009). The study set out to answer questions about the role of nature versus nurture and personality and the environment in development. They found that quality of care and biological factors were closely interwoven. The key issue and determinant of resilience and successful adaptation was found to be in the nature of the parent-child relationship – how parents felt about and interacted with their children. Sroufe’s study showed that ‘secure attachment’ is a significant protective factor against the development of disease. Dan Siegel (2012) defines secure attachment as the relationship a child has with a sensitive, attuned caregiver. Secure attachment reflects a positive enough environment that creates a sense of basic trust (Heller, 2019).

Interventions that enhance the mental health, executive functioning and regulation skills of vulnerable mothers which begin as early as pregnancy suggest promising ways to protect the developing brains of children, says Schore (2012). He concludes that there is a lot of evidence to show that we can maximise the short and long-term effects of interventions by concentrating on the period of the brain growth spurt (from the last trimester of pregnancy of through to the second year). The question is, are governments willing to fund this?

The earliest stages of life are critical because they contain within them our possible futures, writes Schore (2012). Where is the best place to invest our resources in order to optimise the well-being of human societies and future health? The measure of how much we value our early beginnings is measured in the money we put into social programmes that support young children and families. Early prevention programmes have an impact not just on infancy but on the health of the individual and community across the entire lifespan. These programmes are capable of not just altering the intergenerational transmission of psychopathology and physical disease but also optimising emotional security and hence health and well-being throughout the lifespan.

Evan Dwan has worked in the education field for over 15 years, with both children and adults. He currently works in adult and community education teaching a broad range of subjects including sociology, psychology, stress and resilience. He is in his final year of psychotherapy training.

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IAHIP 2021 - INSIDE OUT 95 - Autumn 2021