Patients would carry soda into Dr. Gerard Clancy’s office, with cigarettes tucked away for after therapy.
Often victims of abuse or violent crime, they would seek soothing but risky behaviors to cope.
Overweight. Chronic pain. Chronic obstructive pulmonary disease. Type II diabetes. His former patients will die younger than they should, he said.
Clancy conducted therapy sessions until he became president of the University of Tulsa in 2016. At his psychiatry clinic, he saw firsthand how a lifetime of unhealthy habits wear on a person suffering post-traumatic stress disorder after a serious threat to his or her well-being.
“It dates back as much as anything to their behaviors and how they live their lives daily,” said Clancy, who remains a prominent leader in Tulsa’s mental-health network. “They walk in with the biggest QuikTrip thing of sugary Coca-Cola as possible. And as soon as they’re done seeing me, they go outside and smoke.
“Part of that is how their brain has been wired.”
Tulsa is at the forefront of revolutionary research to unlock a deeper knowledge of how social, behavioral, physical and environmental factors may affect brain development and health. Oklahoma is No. 1 in the nation in youths up to age 17 who have experienced two or more Adverse Childhood Experiences, according to the 2017 National Survey of Children’s Health conducted by the U.S. Census Bureau.
Trauma at a young age can negatively alter or stunt cognitive development, creating undesirable genetic changes that may even be passed onto future generations, some studies show.
Referred to as Adverse Childhood Experiences, ACEs include household dysfunction, neglect, abuse, poverty, crime, substance abuse and mental illness. Research is showing ACEs to be strong predictors of cognitive, behavioral and physical health, and mental wellness problems.
The initial question no longer is a superficial and judgmental, “What’s wrong with this kid?” Trauma-informed experts are nuanced, mining for answers by posing the more enlightening query, “What’s happened to him or her?”
ACEs are the common thread underlying behaviors that, from a logical standpoint, don’t make sense because they are knowingly harmful to the person, said Jennifer Hays-Grudo, director for the Center for Integrative Research on Childhood Adversity in Tulsa.
Things like smoking. Drinking to excess. Drugs.
“At the time, these behaviors were solutions to a larger problem,” Hays-Grudo said. “The larger problem is the fact that either you are a child being abused or neglected and feeling hopeless, or you’re an adult who didn’t develop the ability to soothe and regulate your emotions when you’re stressed.
“And in fact, your body didn’t develop the ability to help you do that. You might want to do that, but your body is programmed to get upset and stay upset because life is dangerous. That’s what your body learned as a child.”
Examples of long-term ramifications include premature death in adults, according to a study published in 2009 in the American Journal of Preventative Medicine.
Participants were questioned in 1996 and 1997 about potential ACEs under eight categories. People with an ACE score of 6 or higher were found to have died nearly 20 years earlier on average than those with no ACEs.
As transformative as germ theory was more than a century ago, ACEs appear poised to have a global effect.
Hays-Grudo noted how germ theory prompted wholesale changes in hospital policies and procedures to block the transmission of germs. Doctors no longer simply used the same instruments from patient to patient like during the Civil War.
The ongoing paradigm shift in how trauma affects developing brains has reverberated through scientific circles for two decades and now is beginning to filter more into public consciousness and practice.
Hence the more nuanced and illuminating question, “What’s happened to him or her?”
Suffering adolescents pursue risky but soothing behaviors
Children raised in traumatic environments grow up chasing instant and soothing behaviors. Think smoking or drinking or sex.
Depicted in an eight-stack pyramid, the unproven but promising theory describes how Adverse Childhood Experiences influence a person’s functioning and well-being from conception to death.
The pyramid’s base is generational embodiment or historical trauma, followed by social conditions and local context. ACEs disrupt neurodevelopment, which then leads to social, emotional and cognitive impairment. In turn, health-risk behaviors are adopted and cultivate disease, disability and social problems. Early death tops the pyramid.
Clancy, who also serves on the Laureate Institute for Brain Research advisory board, said the best interruption points to stop harmful programming of the brain are at home. But often those environments are chaotic.
So the next best option is schools, which must be a neighborhood’s anchor and safe place, Clancy said.
Kristin Atchley, former executive director of counseling at the Oklahoma Department of Education, said educators often have viewed in-school suspension and other punishment as appropriate ways to correct “bad” or “difficult” kids.
Actually, the “problem” students need wraparound services to help them cope and heal — not overly punitive measures, she said.
For example, Atchley said educators must be mindful of a kindergartner who is caught stealing from another student. Schools can’t punish young children who learn to steal as a survival mechanism, she said.
And that mindset must extend to other adverse behaviors that arise from ACEs to truly help struggling children.
“If our policies and procedures are saying the day a kid comes to school high they are out, we are not being restorative,” Atchley said. “And we are not getting that kid the actual services they need.”
Carrying a high ACE score doesn’t mean that a dire trajectory is set in stone.
Scientists already know how to counteract harm imparted by ACEs, which is especially critical early on because rewiring the brain becomes increasingly difficult as time passes.
PACEs — protective and compensatory experiences — are known to act as buffers or insulators against trauma, as well as promote healing. Most prominent is the unconditional love of a parent or mentor.
Other mitigating factors for trauma are strong friendships, mindfulness, exercise or physical activity, and hobbies or clubs. Think sports, band, 4-H, scouts, church, a coach or teacher.
PACEs provide opportunities to build the brain architecture that allows a person’s body to calm physiologically and learn positive habits and behaviors in the present and carry them into the future, said Hays-Grudo, of Tulsa’s Center for Integrative Research on Childhood Adversity.
“Children with high ACEs and no PACEs have a very difficult time in life because they don’t have the opportunity to develop the skills and the competencies — the psychological skills, the social skills and even the cognitive learning skills — to compensate for the abuse and neglect that has compromised how their brains develop,” she said. “ACEs are not a death sentence. I know many people with high levels of ACEs who live very happy and productive and good lives.
“And that’s generally because they also had many other good things going on in their lives.”
Strong predictors of behavioral, health problems
Strengthening the science supporting the ACE pyramid is paramount for researchers. And Tulsa is an important outpost in this endeavor, garnering national recognition.
Amanda Morris, a regents professor of human development at OSU-Tulsa, said the ACE test is a better predictor of health and behavioral outcomes than almost any other method. The power is derived from looking at myriad early stressors encompassed by household dysfunction and maltreatment.
“Those 10 items predict not only health but mental health outcomes,” Morris said. “And the rates at which they are predicting are better than many other simple measures and methods looking at one factor.”
Morris also is a researcher involved in the landmark Adolescent Brain Cognitive Development study. The Laureate Institute for Brain Research in Tulsa is one of 21 sites across the United States charting social, behavioral, physical and environmental factors that may affect brain development and health.
Nearly 12,000 subjects ages 9 or 10 were enrolled in the ABCD study, with 742 in Tulsa. Entry closed in October, with researchers set to track the participants for 10 years.
“So many studies are just one time point,” Morris said. “Sort of the chicken and the egg: what’s causing what? This allows us to look at cause and effect and change over time.”
Researchers regularly conduct intensive surveys, neurocognitive assessments and brain imaging to try to answer questions about influences in a more robust manner, she said.
The study doesn’t directly collect ACEs. But it does seek insights into stressors that would be categorized as ACEs.
What’s happening within brain
Consider the legs of a child who suffered from polio.
Even when cured of the crippling disease, the developmental opportunity or period for those muscles was lost, Hays-Grudo said. So polio survivors had to use leg braces for the rest of their lives, despite the absence of the disease.
“We see some of the same effects in the brain,” Hays-Grudo said. “There are sensitive periods where if the brain does not get the kind of stimulation it’s expecting as a human being — as a species, we expect certain things to happen in development — if it doesn’t happen, it’s much more difficult later on.
“It can happen. The brain can make up for it later, but there’s a lot of difficulty.”
Therein lies the importance of early childhood development.
Stress is a natural response to help keep a person alive in an emergency. The body pumps out cortisol and adrenaline, placing a person in a heightened state to achieve feats not usually within his or her ability.
But Hays-Grudo said the chemicals over a long time become corrosive. The chemicals are meant as a short-term response to protect the body or help it cope.
The levels are supposed to decrease and normalize once the threat subsides. But if the stressors are consistent, a person may stay in a hyper-vigilant state.
Wear and tear develops on the body and can result in auto-immune or heart diseases, as well as cancer, Hays-Grudo said.
“If this is happening in developing systems, it has a much worse effect and more enduring effect than if it happens to adults,” Hays-Grudo said. “Because now the brain is expecting this, and the brain is not getting exposed to other experiences that would allow other parts of the brain to develop.”
Scientists are learning how deep these alterations can go through “inherited epigenetics.”
Hays-Grudo described epigenetics as the chemicals that sit on top of our DNA and attach to its strands.
Epigenetics essentially act as on-off or dimmer switches that make it more or less likely for DNA to be replicated to create cells, Hays-Grudo said.
“When you turn off that process, you turn off some of the production of chemicals needed, for example, for brain cell regeneration — new neurons,” Hays-Grudo said. “It also may turn off receptors for all of the cortisol that you’re pumping out when you’re stressed, and then the cortisol doesn’t leave the body. You just stay stressed.
“So these epigenetic changes to certain DNA structures have given us a clue why some of these experiences last all the time. Why they literally change the body’s DNA blueprint for how to react to stress, and these changes can be passed across generations.”
Generational costs of trauma
Researchers repeatedly subjected adult male mice to mild foot shocks after introduction of an odor — fear conditioning. The conditioned males were mated with unconditioned females.
The Emory University scientists were examining offspring inheritance of a parent’s exposure to trauma. Or, simply put, trauma that transverses generations.
They found that two successive generations (children and grandchildren) exhibited behavioral sensitivity to the odor, with an enhanced representation of the odorant receptor’s pathway.
The offspring weren’t conditioned to fear the odor, nor did they learn the behavior from the conditioned male parent because they were separated. Evidence indicated the odor fear was passed biologically, with epigenetic marks that might be the basis for the inheritance.
The study was published in 2013 in Nature America.
Similar links are beginning to be established in humans.
A team of researchers studied 32 Holocaust survivors — interned in a concentration camp, witnessed or experienced torture, or had to flee or hide during World War II — and their adult children for biological effects of stress.
The scientists compared them against demographically similar control subjects who lived outside of Europe during the war, meaning they weren’t exposed to trauma from the Holocaust.
They found genetic alterations associated with Holocaust trauma present in both parents and their children that couldn’t be attributed to the offspring’s own traumatic experiences or psychopathology.
Morris, the OSU-Tulsa regents professor involved with the ABCD study, described ACEs as more of a social problem. A person can’t “catch them” like a sickness by talking about them, she said.
Openly dealing with ACEs rather than repressing trauma is a means to heal and recover. A public health and prevention approach, along with policy changes, are keys to halt the spread of ACEs, she said.
“So the science is really an important part of the story here. Why? Because it predicts these health and behavioral outcomes better than almost any other measure we have,” Morris said. “And the root of it is family dysfunction and things that we know — it’s difficult — but we know how to target and help families. Through resources. Through building good parenting skills and relationships.
“It’s not like a communicable disease. It’s a thing we can fix.”