Asking a key question to understand puzzling behaviors

‘Trauma-informed care’ encourages mental health providers to look at behaviors as clues – as connecting dots to a bigger story.

A beautifully rehabbed row home on a crumbling Camden block defines a paradox.

Father Jeff Putthoff unlocks the door, and steps into a living room with comfy couches and walls covered in art work. Despite the cozy atmosphere, the people this was created for often feel very ill at ease in the space. 

“They will oftentimes say, ‘this place is overwhelming me, I gotta get out of here'” explains Putthoff.

The row house on State Street in Camden is part of Putthoff’s youth program “Hopeworks” and it’s a great place to examine a big movement that could revolutionize public health, and how social services are delivered. 

Asking a different question: What happened to you? 

For more than ten years, Hopeworks has been teaching struggling youth computer and life skills.

Some of the kids in the program move into the house on State Street to get away from toxic family situations – and Putthoff thought providing them this great, safe space would immediately make them feel better.

It didn’t, really. Residents reported being ‘freaked out’ after they moved in. And the computer training – those results were mixed, too. Putthoff and his staff would work hard to train a young person, and to set them up with a job. “And then they oftentimes blow it up, they underperform, they get angry, they don’t show up, they are unable to manage a schedule,” said Putthoff.

Putthoff’s staff was getting frustrated – and started to crack down.

“Youth might show up late, and people here would say ‘if you are three times late, you can’t come back for a month.'” But, this tough love wasn’t working at all, kids would just stop showing up, and that’s when Puthoff discovered a whole world of research on something called “trauma-informed care”. Simply put, it poses a different question: “We’re learning not to say to a youth ‘why did you do that?’ We’re trying to think about what happened to the youth. 

Knowledge base is spreading 

Putthoff is not the only one asking that different question. It seems to echo in the offices of social service providers everywhere, who are trying to really understand behaviors, rather than just jumping in to fix them.

And the word that keeps coming up is trauma. This is not PTSD, post traumatic stress disorder, we’re talking about here. PTSD is typically seen as a response to a specific traumatic event in a person’s life. Trauma, in this context, is chronic stress and adversity that starts in childhood, and changes people over time.

A lot of this thinking can be traced back to the so-called “ACE study.” It’s a massive, ongoing research project that started in the late 90s, and ties adverse childhood experiences to serious physical and mental health problems later in life. 

A game-changing study

“The power of the ACE study is that it’s simple,” says Robert Anda, one of the principle investigators for the study, which is a collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente’s Health Appraisal Clinic in San Diego.

For the initial study, Anda and others asked 17,000 middle class people 10 questions about their childhoods; had there been physical or sexual abuse, did they feel neglect, were their parents divorced, was there drug use in their home and so on. Each time a person answered ‘yes’ to a question, they got a point, the total is their “ACE score.” (You can take the ACE survey here)

“The voices of the 17.00 people in this study spoke, and it jumped right out at you. You don’t have to be a genius to interpret this data and see what it shows,” said Anda at the first national summit on adverse childhood experiences in Philadelphia last year. 

The lifelong impact of having a high ACE score, meaning, having experienced four or more different adversities, is devastating. The study found increased rates of cancer, heart disease, diabetes, obesity. High ACE scores are also connected to serious mental health and social problems.

“About 60 to 75 percent of substance dependence is directly correlated with early childhood adversity and stress,” said psychiatrist Steven Berkowitz, who heads the Penn Center for Youth and Family Trauma Response and Recovery in Philly. He says in Philadelphia, high rates of poverty typically mean high ACE scores. Berkowitz explains that over time, people adapt to ongoing adversity – for example to a lack of safety.

“When you feel chronically endangered, one of the best ways to take care of that is to become the aggressor rather than the victim, and we see that in the city all of the time.” 

Knowing the background, changing the approach: Trauma-informed care

“Trauma-informed care” takes the effects of childhood adversity into account, in essence, it means don’t jump in to fix a behavior. Look at the behavior as a clue – as something that tells a bigger story.

At Hopeworks in Camden, Latifah Kersey seems tense, and very much on edge, ready to jump up and go. The young mom has lived in some of the city’s most violent neighborhoods – and has adapted accordingly when she walks around.

“If I have my son, my boyfriend has to stay behind me and watch, cause I’m watching in front, I can’t see what’s in back of me,” she told me. I asked her if she ever relaxes, and she said ‘no, never.’

Think back to the house we visited at the beginning of the story – bright, newly renovated – and yet new residents typically can’t stand it. Father Jeff Putthoff says when viewed through this lens of life experience, the ‘get-me-out-of-here’ response suddenly makes sense. “They are very much ready to be attacked, so their bodies always have high levels of cortisol and adrenaline,” he said. “Our youth, when they move into a new situation they actually have a physiological response to moving into a safer space that’s uncomfortable.”

His staff now reviews these feelings with young people moving into the house, and offers them coping strategies, such as listening to music, or exercising.

Across the river in Philadelphia – understanding this context of traumatic experience is also becoming a guiding principle in delivering services.

“Just being aware that people come to us with those histories, and that opens up a different set of questions that we want to ask people,” said Dr. Arthur Evans, who heads the city’s department of behavioral health services. The department has changed its approach to becoming trauma-informed. “So that we’re not just looking at people’s symptoms, but we’re really trying to look at the underlying issues that led to those symptoms,” he said.

Evans says it’s an ongoing process – one he likens to turning an ocean liner around. It means a lot of staff training, making sure the latest treatments are used in the field. The department has made policy changes – such as avoiding out-of-state foster placement for children because that’s a traumatic experience and sending teams into neighborhoods after violent incidents. 

Who needs to know? 

The gospel of trauma informed care is also resonating with pediatricians who are increasingly dealing with behavior and developmental issues in children. Pediatrician Andy Garner of Case Western Reserve University is traveling all over the country, urging his colleagues that a kid’s relationship with their caretakers is as important a vital sign as their heart rate. “As a pediatrician when you see a family, a mother or a father, and it’s clear the relationship doesn’t seem quite right that they are stressed, they are not in tune with each other and the attachment is not going very well that’s a huge risk factor and a red flag that we want to address,” said Garner.

The American Academy of Pediatrics which represents 60,000 physicians, released a position paper on the impact of adverse childhood experiences and toxic stress in 2012. 

Momentum in Philadelphia

In Philadelphia, pediatricians, mental health providers and policy makers have formed an ACE task force that has been meeting regularly for two years. Pediatrician Joel Fein of the Children’s Hospital of Philadelphia is one of the chairs of Philadelphia’s Ace task force, and says that the city has become more “ACEs aware.””All of the systems that we have interacted with from police to behavioral health and elsewhere have really started to carry the flag for this knowledge base, and the activities that go along with it.”

Fein says so far, the task force has mostly been doing ground work, reaching out, connecting people from different disciplines, mapping out the problems. The next step is to figure out what exactly can be done about the issues. 

Not moving fast enough

The fact that the ACE study and trauma informed care has come to the attention of more people has U Penn psychiatrist Steven Berkowitz both hopeful and frustrated – he feels like there’s a lot of buzz, but not enough action. “There’s words and there are people doing some good work, but there is no policy, and this is the kind of huge issue that requires real policy change in order to make an impact.”

He says not enough is done to prevent adverse childhood experiences from happening in the first place, he would like to see political action – support for struggling families, parenting classes, education and on and on. He says prevention has been key in making a dent in other major public health problems.

“The first thing that had an impact on mortality rates on cancer was smoking prevention and I feel like that absolutely mimics what I’m talking about in terms of adverse childhood experiences.”

But, he knows it’s not going to happen any time soon. “That’s a lifetime’s work, that’s not going to happen in a couple of years or even a decade, it’s going to take much longer.”

While big changes may take years to happen – Berkowitz says there is one thing to keep in mind. There’s one factor that seems to protect children from the life-long impact of childhood adversity. “There has been an adult in your life that has paid attention and cared for you – that seems to be the most resilient-promoting factor.”

And that adult could be anybody – a teacher, a friend, a neighbor. Or you.