Adverse Childhood Experiences 12: welcome to the dark

Welcome to the dark, everyone.

When you think about it, all the children in the world are adding at least one Adverse Childhood Experience score and possibly more, because of Covid-19. Some will add more than one: domestic violence is up with stress, addiction is up, behavioral health problems are up, some parents get sick and die, and then some children are starving.

From the CDC Ace website:

“Overview:Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood. ACEs can include violence, abuse, and growing
up in a family with mental health or substance use problems. Toxic stress from ACEs can change brain development and affect how the body responds to
stress. ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood. However, ACEs can be prevented.”

Well, can they be prevented? Could Covid-19 be prevented? I question that one.

I have a slightly different viewpoint. I have an ACE Score of 5 and am not dead and don’t have heart disease. I spent quite a bit of time thinking about ACE scores and that it’s framed as kids’ brains are damaged.

I would argue that this is survival wiring. When I have a patient where I suspect a high ACE score, I bring it up, show them the CDC web site and say that I think of it as “crisis wiring” not “damaged”. I say, “You survived your childhood. Good job! The low ACE score people do not understand us and I may be able to help you let go of some of the automatic survival reactions and fit in with the people who had a nice childhood more easily.”

It doesn’t seem useful to me to say “We have to prevent ACE scores.” Um. Tsunamis, hurricanes, Covid-19, wars… it seems to me that the ACE score wiring is adaptive. If your country is at war and you are a kid and your family sets out to sea to escape, well, you need to survive. If that means you are guarded, untrusting, suspicious and wary of everyone, yeah, ok. You need to survive. One of my high ACE Score veterans said that the military loved him because he could go from zero to 60 in one minute. Yeah, me too. I’ve worked on my temper since I was a child. Now it appears that my initial ACE insult was my mother having tuberculosis, so in the womb. Attacked by antibodies, while the tuberculosis bacillus cannot cross the placenta, luckily for me. And luckily for me she coughed blood at 8 months pregnant and then thought she had lung cancer and was going to die at age 22. Hmmm, think of what those hormones did to my wiring.

So if we can’t prevent all ACE Scores, what do we do? We change the focus. We need to understand crisis wiring, support it and help people to let go of the hair trigger that got them through whatever horrid things they grew up with. 16% of Americans have a score of 4 or more BEFORE Covid-19. We now have a 20 or 25 year cohort that will have higher scores. Let’s not label them doomed or damaged. Let’s talk about it and help people to understand.

I read a definition of misery memoirs today. I don’t scorn them. I don’t like the fake ones. I don’t read them, though I did read Angela’s Ashes. What I thought was amazing about Angela’s Ashes is that for me he captures the child attitude of accepting what is happening: when his sibling is dying and they see a dog get killed and he associates the two. And when he writes about moving and how their father would not carry anything, because it was shameful for a man to do that. He takes it all for granted when he is little because that is what he knows. One book that I know of that makes a really difficult childhood quite amazing is Precious Bane, by Mary Webb. Here is a visible disability that marks her negatively and yet she thrives.

A friend met at a conference is working with traumatic brain injury folks. They were starting a study to measure ACE scores and watch them heal, because they were noticing the high ACE score people seem to recover faster. I can see that: I would just say, another miserable thing and how am I going to work through it. Meanwhile a friend tells me on the phone that it’s “not fair” that her son’s senior year of college is spoiled by Covid-19. I think to myself, uh, yes but he’s not in a war zone nor starving nor hit by a tsunami and everyone is affected by this and he’s been vaccinated. I think he is very lucky. What percentage of the world has gotten vaccinated? He isn’t on a ventilator. Right now, that falls under doing well and also lucky in my book. And maybe that is what the high ACE score people have to teach the low ACE score people: really, things could be a lot worse. No, I don’t trust easily and I am no longer feeling sorry about it. I have had a successful career in spite of my ACE score, I ran a clinic in the way that felt ethical to me, I have friends who stick with me even through PANDAS and my children are doing well. And I am not addicted to anything except I’d get a caffeine headache for a day if I had none.

For the people with the good childhood, the traumatic brain injury could be their first terrible experience. They go through the stages of grief. The high ACE score people do too, but we’ve done it before, we are familiar with it, it’s old territory, yeah ok jungle again, get the machete out and move on. As the world gets through Covid-19, with me still thinking that this winter looks pretty dark, maybe we can all learn about ACE scores and support each other and try to be kind, even to the scary looking veteran.

Take care.

Aces again

I am singing: “You are coming up ACES!”

Ok, but, hopefully not. Because I am talking about ACE scores, Adverse Childhood Experiences. See the CDC website, this is all based on a ginormous Kaiser study in the 1990s.

Here: About the CDC-Kaiser ACE Study |Violence Prevention|Injury Center|CDC

Yep. A very very interesting topic for a rural family practice physician.

For the Ragtag Daily Prompt: ACE.

Who is driving the car?

I am at my parent’s house.

My mother and I and the baby, a toddler, go out to the car which is a huge newish SUV. I open the back door and see a drawing lying on the seat, beside the car seat. It is a drawing of my son, from a photograph. My mother has written on it, her ideas about how she wants to do the painting. I took the photograph and know it: my son has an exuberant joyous toddler expression. I climb in to the SUV. My mother gets in the front and turns the car on. She pulls forward and I start screaming, “STOP! STOP DON’T DRIVE! THE BABY IS NOT IN THE CAR!” My mother is pulling forward and backing, in confusion. She stops.

I leap out and search. Under the car by the back wheel, but not under it, is a kitten. A black kitten, lying on its side. I reach and very gently pick it up, supporting its spine. I am crying. The kitten cries as I pick it up, with pain. I say, “She’s hurt! I am going to die!”

I wake up.

I think about the dream. Even though there is a picture of my son in the car, I am a teen in the dream. The toddler is not my son. The toddler is not my daughter. The toddler is my sister. My parents had old cars, never a new SUV. The house in the dream was my parent’s house in Alexandria, Virginia. We moved there when I started ninth grade and my sister started sixth. My parents sold the house and moved in 1996.

Who is driving the SUV? Is there a responsible adult? Are they taking care of the children? Or are they driving recklessly and leaving the children to try to care for each other? Some adults are not responsible and should not be driving.

 

My son took the photograph of my daughter in 2011 for a school project, recreating a movie poster: True Grit.

The future of medicine

we recognize the true embodied mind
we stop the stigma of the many beaten down
the damage done in childhood caught in time
hearts open and lift the broken off the ground

we learn that diagnoses are a crutch
drugs plaster over deep and seeping wounds
mental labels hurt the patients oh so much
we learn to listen: broken hearts sing grieving tunes

cruel medicines and thoughts are shelved for good
gentle boundaries surround hearts to keep them safe
we rise as friends and families and doctors really should
the angry monster revealed as longing waif

damage done in childhood to the brain
lays survival pathways that we no longer call insane

The photo is me and my sister Chris. I do not know who took it, but I think it was at my maternal grandparents. They are deceased, my parents are deceased, my sister is deceased. I don’t know who to credit.

Adverse Childhood Experiences 2: Out on a Limb

We are approaching a seismic shift in psychiatry. I am now going out of a limb to predict the direction we will go in.

The allopathic medical community will resist, including many psychiatrists. But it is the neurobiologists and brain imaging and psychiatrists who will prevail. If the creek don’t rise and we aren’t hit by a giant asteroid, nuclear winter, devolve into fighting over the remaining arable land as the world heats up….

I have been thinking about this all through my career, but especially since the lecture on adverse childhood experiences, which I heard in Washington, DC about ten years ago. I wrote about that lecture on January 6, 2015. The lecturer was a woman. She said that it appeared that the brain formed differently in response to childhood adverse experiences. She said that we don’t yet know what to do with this information.

Staggering understatement. I went from that lecture to one about ADHD. The lecturer was male. He said, “Children diagnosed with ADHD have brains that are different from normal children on PET scans and functional MRIs. We don’t understand this.” He sounded puzzled. I thought, he didn’t go to the previous lecture….

Childhood adverse experiences are scored zero to seven. I score a five. I am at high risk for addiction. I assumed this when I realized at age 19 that my father was an alcoholic and my mother was enabling. I was very very careful about alcohol. I tried pot twice and didn’t like it. I refused to try anything else, and refused benzodiazepines when I was depressed: they are addictive. With an ACE score of five, I am also at higher risk than a person with a score of zero for ALL mental health diagnosis: ADHD, depression, bipolar disorder, obsessive compulsive disorder, etc. People with a score of five had a 60% chance of being diagnosed with depression compared with a 10% chance in people with a score of zero over the life of the study. In the last fourteen years I’ve only been diagnosed with a “grief reaction” which is a temporary reaction to grief. It is also called an adjustment disorder. High adverse childhood experience scores are also at higher risk for morbidity and mortality from heart disease, emphysema, arthritis, basically everything and tend to die younger.

What this means, I think, is that our brains are plastic in utero and in childhood: the wiring is put down in response to the environment. This is adaptation. I have crisis wiring: my mother had tuberculosis when I was conceived and born. Really, from an evolutionary standpoint I AM weird: babies whose mothers had tuberculosis died. Quickly. I was saved because my mother coughed blood one month before I was due. A lot of blood. She thought she had lung cancer and would die. The fetus is bathed in those stress hormones, grief, fear….

I was removed from my mother at birth to save my life. I then was removed from people at 4 months and at 9 months. I grew up trying to be independent and highly suspicious of adults.

I predict that we are going to revamp all of our ideas about mental health. The brain wiring is set up depending on the environment, physical and emotional, that the child grows up in. My friend Johanna was outraged in college when we learned that the fetus and placenta basically take over the hormones of the woman for 9 months. “I’m not letting some baby grow in me and do that!” Johanna said. “I am going to figure out how to implant the pregnancy in a cow. You take good care of the cow and you can drink beer through the whole pregnancy! The cow won’t even notice when the baby falls out!” She has three children, an MD and a PhD in genetics. She did not use a cow.

The brain wiring is an adaptation to the environment. If there is war or domestic violence or addiction or mental health problems, the child’s brain kicks in emergency wiring. This is to help the child survive this childhood. As an adult they are then more at risk for mental health disorders, addiction and physical health disorders.

In the end, the sins of the parents, or the terrible circumstances of the parents, are visited upon the children. We have to take care of the children from the start in order to be healthy.

And people who have low adverse childhood experience scores don’t understand. They grew up with nice people and in a nice environment. They wonder why people can’t just be nice. The fear and grief and suspicion and emotional responses that appear maladaptive in adults, that is what helped people survive their childhoods. That is what I remember each time I see an addict in clinic, or someone who is on multiple psychiatric medicines, or someone who is acting out.

Don’t be perfect, ok?

This reminds me of a kid’s book I had, or possibly have. I may still have it. I don’t exactly know where it is. I’m not perfect. Anyhow, the book is about Peter Perfect, who did everything right. The drawings of the other kids being “bad” were fabulous. At the end the secret is revealed: Peter Perfect is a robot, with a large wind up key in the middle of his back.

I got this link from Big Red Carpet Nursing’s blog, about perfectionism being a big risk for suicide. Many thanks!

http://psychcentral.com/news/2014/09/26/perfectionism-linked-to-suicide/75399.html