If you saw Laura walking along the New York City street where she lives today, you would see a well-dressed 46-year-old woman with auburn hair and green eyes, someone who seems to carry with her an unmistakable sense of “I belong here.” She looks entirely in command of her life. Yet beneath Laura’s confident exterior lies a history of trauma: a mother with bipolar disorder who could move from braiding her daughter’s hair to attacking her with insults, and a father who moved out of state with his future wife when Laura was 15.
She remembers a family trip to the Grand Canyon when she was 10. In a photograph taken that day, Laura and her parents sit together on a bench, all dressed in tourist whites. “Anyone looking at us would have assumed we were a normal, loving family,” she says. But just as they forced smiles for the camera, Laura’s mother suddenly pinched her daughter’s waist and told her to stop “staring off into space.” Then came another pinch: “No wonder you’re turning into a little butterball. You ate so much cheesecake last night your stomach is hanging over your shorts!” If you look closely at Laura’s face in the photograph, you can see that she is not squinting against the Arizona sun. She is holding back tears.
After her father left, he still sent cards and money, but he called less and less. Meanwhile, her mother’s untreated bipolar disorder worsened. Sometimes, Laura says, “My mother would launch into a vicious tirade about my father until spit foamed at her chin. I would stand there trying not to hear her go on and on, while my whole body shook inside.” Laura never invited friends over. She was afraid they would discover her secret: her mother “was not like other mothers.”
Some 30 years later, Laura says, “In many ways, no matter where I go or what I do, I am still in my mother’s house.” Today, “If a car suddenly swerves into my lane, if a grocery-store clerk is rude, if my husband and I argue, or if my boss calls me in to talk through a problem, I feel something flip inside me. It is like there is a match standing too close to a flame inside my body, and with the slightest breeze, it catches fire.”
To look at Laura, you would never know that she is “always trembling a little, only invisibly, deep down in my cells.”
Her sense that something is wrong inside her is reflected in her physical health. During a routine examination, Laura’s doctor discovered that she had dilated cardiomyopathy and would need a cardioverter defibrillator to keep her heart pumping. The two-inch scar left by the surgery only hints at the far deeper scars she carries from childhood.
For as long as John can remember, he says, his parents’ marriage was deeply troubled, and so was his relationship with his father. “I consider myself to have been raised by my mother and grandmother,” he says. “I longed for a deeper connection with my father, but it just wasn’t there. He couldn’t reach out in that way.” John’s poor relationship with his father was due largely to his father’s reactivity and need for control. If John’s father said the capital of New York was New York City, there was simply no point in telling him it was Albany.
As John grew older, it seemed wrong to him that his father “was constantly pointing out every mistake my brother and I made, without ever acknowledging any of his own.” His father relentlessly criticised his mother, who was “kinder and more confident.” At 12, John began stepping into the fights between his parents. He remembers one Christmas Eve when he found his father with his hands around his mother’s neck and had to pull them apart. “I was always trying to be the adult between them,” John says.
John is now 40, with a boyish face, warm hazel eyes and a broad, affable grin. But beneath his easy, open manner, he struggles with a range of chronic illnesses. By the time he was 33, his blood pressure was alarmingly high. He began experiencing bouts of stabbing stomach pain and diarrhoea, and often found blood in his stool. He suffered from headaches almost every day. By 34, he had developed chronic fatigue so severe that he sometimes struggled to get through a full workday.
John’s relationships, like his body, were never fully healthy. He ended a year-long romance with a woman he deeply loved because he felt overwhelmed with anxiety around her normal, “happy family.” He simply did not know how to fit in. “She wanted to help,” he says, “but instead of telling her how insecure I felt around her, I told her I wasn’t in love with her.” Bleeding from inflamed intestines, exhausted by chronic fatigue, weakened and distracted by pounding headaches, often struggling at work, and unable to feel comfortable in intimacy, John was trapped in a universe of pain and solitude, and he could not find his way out.
Laura’s and John’s stories show the physical price we can pay in adulthood for trauma that occurred 10, 20, even 30 years earlier. New findings in neuroscience, psychology and immunology tell us that the adversity we face in childhood has consequences more far-reaching than we once imagined. Today, in laboratories across the country, neuroscientists are examining the once-inscrutable connection between brain and body, and breaking down at a biochemical level how the stress we experience in childhood and adolescence catches up with us in adulthood, altering our bodies, our cells and even our DNA.
Emotional stress in adult life affects us physically in measurable, life-altering ways. We know that when we are stressed, chemicals and hormones flood the body and raise inflammation levels. That is why stressful events in adulthood are linked to an increased likelihood of catching a cold or having a heart attack.
But when children or adolescents face adversity, especially unpredictable stressors, the scars are deeper and longer-lasting. When a young brain is thrust into stressful situations again and again without warning, and stress hormones are repeatedly ramped up, small chemical markers known as methyl groups attach themselves to specific genes that regulate the activity of stress-hormone receptors in the brain. These epigenetic changes impair the body’s ability to turn off the stress response. In ideal circumstances, a child learns how to respond to stress and recover from it, developing resilience. But children who experience chronic, unpredictable stress undergo biological changes that keep their inflammatory stress response switched on.
Joan Kaufman, director of the Child and Adolescent Research and Education programme at the Yale School of Medicine, recently analysed DNA from the saliva of happy, healthy children and from children who had been removed from abusive or neglectful parents. Children who had experienced chronic childhood stress showed epigenetic changes at nearly 3,000 sites on their DNA, across all 23 chromosomes, altering how appropriately they would be able to respond to and recover from future stressors.
Children who experience early adversity have a daily drip of fight-or-flight hormones running through them — as if there were no off switch
Similarly, Seth Pollak, professor of psychology and director of the Child Emotion Research Laboratory at the University of Wisconsin-Madison, found startling genetic changes in children with histories of adversity and trauma. Pollak identified damage to a gene responsible for calming the stress response. This particular gene was not working properly; the children’s bodies could not rein in their heightened stress reaction. “A crucial set of brakes are off,” Pollak says.
Imagine that your body receives its stress hormones and chemicals through an IV drip. When danger appears, the drip is turned up high; when the crisis passes, it is switched off. Children whose brains have undergone epigenetic changes because of early adversity can be imagined as having an inflammation-promoting drip of fight-or-flight hormones running every day — as if there were no off switch.
Experiencing stress in childhood changes a person’s baseline of wellbeing for decades to come. In people such as Laura and John, the endocrine and immune systems produce a damaging, inflammatory cocktail of stress neurochemicals in response to even small stressors: an unexpected bill, an argument with a spouse, a car cutting in front of them on the highway, a creak on the stairs. This can continue for the rest of their lives. They may overreact to life’s inevitable stressors and find it harder to recover from them. They are always responding. Meanwhile, without knowing it, they are marinating in inflammatory chemicals, setting the stage for full-scale disease later on: autoimmune disease, heart disease, cancer, fibromyalgia, chronic fatigue, fibroid tumours, irritable bowel syndrome, ulcers, migraines and asthma.
Scientists first came to understand the relationship between early chronic stress and later adult disease through the work of a dedicated physician in San Diego and a determined epidemiologist at the Centers for Disease Control and Prevention in Atlanta. Together, during the 1980s and 1990s — the years when Laura and John were growing up — these two researchers began a paradigm-shifting public-health investigation known as the Adverse Childhood Experiences Study, or ACE Study.
In 1985, Vincent J Felitti, chief of a revolutionary preventive-care initiative at Kaiser Permanente in San Diego, noticed a startling pattern among adult patients at an obesity clinic. A significant number of patients, with the support of Felitti and his nurses, were successfully losing hundreds of pounds a year — a remarkable achievement — only to withdraw from the programme despite their success. Determined to understand the attrition, Felitti conducted face-to-face interviews with 286 patients. A common denominator emerged. Many confided that they had suffered some form of trauma in childhood, often sexual abuse. For these patients, eating was a solution, not the problem. It soothed anxiety and depression they had carried for decades; their weight served as a shield against unwanted attention, and they did not want to let it go.
Felitti’s interviews gave him a new way of seeing human health and wellbeing, one that other physicians were not yet seeing. He presented his findings at a national obesity conference, arguing that “our intractable public health problems” had roots hidden “by shame, by secrecy, and by social taboos against exploring certain areas of life experience.” His peers quickly attacked him. One person even stood up in the audience and accused Felitti of offering “excuses” for patients’ “failed lives.” Felitti, however, was unmoved. He felt sure he had uncovered a piece of information of enormous importance to medicine.
After a colleague who attended the same conference suggested that he design a study involving thousands of patients with a wide range of diseases, not just obesity, Felitti joined forces with Robert Anda, a medical epidemiologist at the CDC who was then studying the relationship between coronary heart disease and depression. Felitti and Anda used Kaiser Permanente’s vast patient population to establish a national epidemiological laboratory. Of the 26,000 patients invited to take part in their study, more than 17,000 agreed.
Anda and Felitti surveyed these 17,000 individuals about roughly 10 types of adversity, or adverse childhood experiences, probing their childhood and adolescent histories. Questions included: “Were you ever separated from a biological parent through divorce, abandonment or another reason?” “Did a parent or other adult in the household often swear at you, insult you, put you down or humiliate you?” “Was a household member depressed or mentally ill?” Other questions addressed family dysfunction, including growing up with a parent who was alcoholic or addicted to other substances; being physically or emotionally neglected; being sexually or physically abused; witnessing domestic violence; having a family member sent to prison; feeling that no one provided protection; and feeling that one’s family did not look out for one another. For each category to which a patient answered yes, one point was added to that person’s ACE score. An ACE score of 2 meant that the person had experienced two categories of childhood adversity.
It is important to be clear: the patients Felitti and Anda surveyed were not troubled or disadvantaged in the usual sense. Their average age was 57, and three-quarters had attended college. These were “successful” men and women, mostly white, middle-class, with stable jobs and health benefits. Felitti and Anda expected the number of yes answers to be fairly low.
The correlation between a difficult childhood and adult illness gave us a new lens through which to understand human health and disease
When the results came in, Felitti and Anda were shocked. Sixty-four per cent of participants reported at least one category of early adversity. Of those, 87 per cent had experienced additional adverse childhood experiences. Forty per cent had suffered two or more ACEs. Twelve and a half per cent had an ACE score of 4 or higher.
Felitti and Anda wanted to know whether there was a correlation between the number of adverse childhood experiences a person had faced and the number and severity of illnesses and disorders that person developed in adulthood. The correlation proved so powerful that Anda was not only stunned, but deeply moved.
“I wept,” he says. “I saw how much people had suffered, and I wept.”
Felitti was deeply affected as well. “Our findings exceeded anything we had imagined. The correlation between a difficult childhood and adult illness gave us a whole new lens through which to view human health and disease.”
Here, Felitti says, “was the missing piece explaining so much of our unspoken suffering as human beings.”
The number of adverse childhood experiences a patient had suffered could largely predict the amount of medical care that person would need in adulthood. The higher the ACE score, the more doctor’s appointments the patient had had in the previous year, and the more unexplained physical symptoms they reported.
People with an ACE score of 4 were twice as likely to be diagnosed with cancer as people who had faced no childhood adversity. For every additional ACE point, the chance of being hospitalised with an autoimmune disease in adulthood rose by 20 per cent. Someone with an ACE score of 4 was 460 per cent more likely to experience depression than someone with a score of 0.
An ACE score of 6 or higher shortened a person’s lifespan by nearly 20 years.
Researchers wondered whether people who experienced childhood adversity were also more likely to smoke, drink or overeat as coping strategies. Sometimes they were. But unhealthy habits did not fully explain the correlation Felitti and Anda found between adverse childhood experiences and later illness. For example, people with ACE scores of 7 or higher who did not drink or smoke, were not overweight or diabetic, and did not have high cholesterol still had a 360 per cent higher risk of heart disease than people with ACE scores of 0.
“Time,” Felitti says, “does not heal all wounds. One does not simply ‘get over’ something — not even 50 years later.” Instead, he says, “Time conceals. And human beings convert traumatic emotional experiences in childhood into organic disease later in life.”
These illnesses are often chronic and lifelong. Autoimmune disease. Heart disease. Chronic bowel disorders. Migraines. Persistent depression. Even today, physicians puzzle over these conditions: why they are so common, why some patients are more vulnerable than others, and why they are so difficult to treat.
The more research is done, the more detailed the evidence becomes for the profound connection between adverse experiences and adult disease. Scientists at Duke University in North Carolina, the University of California, San Francisco, and Brown University in Rhode Island have shown that childhood adversity harms us at the cellular level, prematurely ageing our cells and affecting longevity. Adults who faced early-life stress show greater erosion of telomeres, the protective caps at the ends of DNA strands that keep DNA healthy and intact. As telomeres erode, we become more prone to disease and age faster. As our telomeres age and expire, our cells expire, and eventually, so do we.
Researchers have also found correlations between specific kinds of adverse childhood experiences and a range of diseases. Children who lose a parent, experience emotional or physical abuse, suffer childhood neglect, or witness conflict between their parents are more likely as adults to develop cardiovascular disease, lung disease, diabetes, headaches, multiple sclerosis and lupus. Difficult childhood circumstances increase the chances of developing myalgic encephalomyelitis, or chronic fatigue syndrome, six-fold in adulthood. Children who lose a parent have triple the lifetime risk of depression. Children whose parents divorce are twice as likely to suffer a stroke later in life.
Laura’s and John’s stories show that the past can tick inside us for decades like a silent time bomb, until it triggers a cellular message reminding us that the body does not forget its history.
Something that happened when you were five or 15 can land you in the hospital 30 years later
John’s ACE score would be 3: a parent often put him down; he witnessed his mother being harmed; and his father clearly suffered from an undiagnosed behavioural health disorder, perhaps narcissism or depression, or both.
Laura’s ACE score was 4.
Laura and John are hardly alone. Two-thirds of American adults quietly carry wounds from childhood into adulthood, with little or no awareness of how deeply those wounds affect their daily health and wellbeing. Something that happened when you were five or 15 can land you in the hospital 30 years later, whether it made headlines or occurred quietly, known to no one else, in the living room of your childhood home.
The adversity a child faces does not have to be severe abuse in order to create deep biophysical changes that later lead to chronic health problems in adulthood.
“Our findings showed that the 10 different types of adversity we examined were almost equal in the damage they caused,” Felitti says. He and Anda found that no single ACE significantly outweighed another. This remained true even though some types, such as sexual abuse, are regarded by society as especially shameful and therefore severe, while others, such as physical abuse, are more overtly violent.
This makes sense when you consider how the stress response is supposed to work at its best. You meet a bear in the woods, and your body floods with adrenaline and cortisol so that you can quickly decide whether to run away or stay and try to frighten the bear. Once the crisis is over, you recover, your stress hormones subside, and you go home with a dramatic story. But for Laura and John, the feeling that the bear is still out there somewhere, circling in the woods, stalking, and might attack again any day, at any moment, never goes away.
There are many bears out there. Chronic parental conflict; ongoing low-level humiliation, blame and shame; chronic teasing; the quiet divorce between two secretly seething parents; a parent’s premature departure from a child’s life; the emotional scars of growing up with a hypercritical, unstable, narcissistic, bipolar, alcoholic, addicted or depressed parent; physical or emotional abuse or neglect — these occur in far too many families. Although the details differ from home to home and neighbourhood to neighbourhood, they are all precursors to the same organic chemical changes deep in the grey matter of the developing brain.
Every few decades, a groundbreaking psychosocial “theory of everything” helps us develop a new understanding of why we are the way we are, and how we became that way. In the early 20th century, Sigmund Freud transformed psychology by arguing that the unconscious governs much of our waking life and dreams. Jungian theory taught, among other things, that people tend toward introversion or extroversion, helping lead Katharine Cook Briggs and her daughter Isabel Briggs Myers to develop a personality indicator. More recently, neuroscientists discovered that ages zero to three form a critical synaptic window for brain development, giving rise to Head Start and other preschool programmes. The correlation between childhood trauma, brain architecture and adult wellbeing is the newest, and perhaps most important, psychobiological theory of everything.
Today’s research on adverse childhood experiences is revolutionising how we see ourselves, how we understand why we became who we are, why we love as we do, how we can better nurture our children, and how we can work toward realising our own potential.
So far, more than 1,500 studies based on Felitti and Anda’s landmark ACE research show that physical and emotional suffering are rooted in the complex workings of the immune system, the body’s master operating centre. What happens to the brain in childhood sets the programming for how our immune systems will respond for the rest of our lives.
The unifying principle of this new theory of everything is this: your emotional biography becomes your physical biology, and together they write much of the script for how you will live. Put another way, your early stories write your biology, and your biology writes the way your life unfolds.
Unlike previous theories of everything, however, this one has been astonishingly slow to change medical practice, according to Felitti. “Very few internists or medical schools are interested in embracing the added responsibility that this understanding imposes on them.”
With ACE research now available, we might hope that physicians will begin to see patients as the holistic sum of their experiences and embrace the understanding that a stressor from long ago can be a health-risk time bomb that has already exploded. A medical paradigm that recognises adverse childhood experiences as one of many key factors that can play a role in disease could save many patients years in the healing process.
But seeing this connection takes time. It means asking patients to complete an ACE questionnaire and delving into their histories for insight into the sources of both physical and emotional pain. As healthcare budgets have grown tighter, doctors spend less time one-on-one with patients in the examination room. The average physician schedules patients back to back in 15-minute intervals.
Still, the cost of not intervening is far greater — not only in lost human health and wellbeing, but also in additional healthcare expenses. According to the CDC, the total lifetime cost of child maltreatment in the United States is $124 billion each year. The lifetime healthcare cost for each individual who experiences childhood maltreatment is estimated at $210,012, comparable to other costly health conditions such as stroke, whose lifetime estimated cost is $159,846 per person, or type 2 diabetes, estimated at between $181,000 and $253,000.
Further blocking change is the fact that adult physical medicine and psychological medicine remain in separate silos. Using ACE research requires breaking down long-standing divisions in healthcare between what is “physical” and what is “mental” or “emotional,” and that is difficult to achieve. Physicians have been trained to deal with what they can touch with their hands, see with their eyes, or observe through microscopes, scans and tests.
Just as physical wounds and bruises heal, just as we can regain muscle tone, we can recover function in underconnected areas of the brain
Now that we have scientific evidence that childhood experience can genetically modify the brain, we can no longer draw that line in the sand. Hundreds of studies show that childhood adversity harms mental and physical health, putting us at higher risk for learning disorders, cardiovascular disease, autoimmune disease, depression, obesity, suicide, substance abuse, failed relationships, violence, poor parenting and early death. In the face of that evidence, we can no longer afford to maintain such distinctions.
Science tells us that biology does not have to be destiny. ACEs can last a lifetime, but they do not have to. Just as physical wounds and bruises heal, just as we can regain muscle tone, we can recover function in underconnected areas of the brain. If ACE research has one crucial lesson, it is this: the brain and body are never static. They are always becoming, always changing.
Even if we have been set on high-reactive mode for decades, or for a lifetime, we can still dial it down. We can respond more appropriately to life’s inevitable stressors and move away from an overactive inflammatory response. We can become neurobiologically resilient. We can turn harmful epigenetics into healthier epigenetics and rescue ourselves. We carry within us the capacity to create better health. We might call this courageous undertaking the neurobiology of awakening.
Today, scientists recognise a range of promising approaches that can help create new neurons, a process known as neurogenesis; form new synaptic connections between those neurons, known as synaptogenesis; promote new patterns of thought and reaction; bring underconnected areas of the brain back online; and reset the stress response so that we reduce the inflammation that makes us ill.
You can begin where you are, no matter how deep your scars are or how long ago they occurred. Many mind-body therapies not only help calm your thoughts and improve emotional and physical wellbeing; research suggests that they also have the potential to reverse, at a biological level, the harmful impact of childhood adversity.
Recent studies indicate that people who practise mindfulness meditation and mindfulness-based stress reduction show increases in grey matter in parts of the brain associated with stress management, as well as changes in genes that regulate stress response and inflammatory hormone levels. Other research suggests that neurofeedback can help regrow brain connections lost to adverse childhood experiences.
Meditation, mindfulness, neurofeedback, cognitive therapy and EMDR, or eye movement desensitisation and reprocessing therapy, are promising new paths to healing. They can be part of any patient’s recovery plan, if healthcare practitioners begin treating the whole patient — past, present and future — without separating physical health from mental health, and if they encourage patients to explore all available treatment options. The more we learn about the toxic impact of early stress, the better equipped we become to counter its effects, and to uncover new strategies and modalities that can help us return to who we truly are, and to who we might have become had childhood adversity not intervened.
This article is adapted and reprinted from Childhood Disrupted: How Your Biography Becomes Your Biology, and How You Can Heal by Donna Jackson Nakazawa, published by Atria. Copyright © Donna Jackson Nakazawa, 2015.
