This article was originally published in The Notebook. In August 2020, The Notebook became Chalkbeat Philadelphia.
Since the spring of 2013, Roy Wade has seen the impact of trauma on urban youth and adults in low-income neighborhoods from three vantage points.
One is from his Children’s Hospital of Philadelphia research office 13 floors above Market Street.
A second is from his pediatrics office in the Cobbs Creek section of West Philadelphia.
And the third is from his travels in the neighborhoods to such places as boys’ and girls’ clubs, YMCAs, community health centers, homeless shelters, primary care sites and behavioral health organizations.
The goal of Wade and other CHOP researchers has been to take the original Adverse Childhood Experiences (ACE) study, a landmark 1998 examination of the effects of childhood trauma, and incorporate the voices of urban youth in ways that haven’t been heard before. This emphasis on listening to youth, researchers hope, will lead to better targeting of behavioral interventions.
“I wanted to understand what ACEs meant to them,” Wade said. “I wanted to speak their language of trauma.”
What he found was that the language that youths used to describe their experiences with trauma was hard-hitting, emotional, and sometimes graphic. One youth said in a Pediatrics journal article published by Wade and fellow researchers that “I seen my cousins getting raped by my uncles because they were addicted to drugs. … Literally if you woke up in the middle of the night, you would be scared to walk down the steps because your uncles were doing whatever to your cousins.”
Another said that “there were shootings every night, so much so that the kids couldn’t play outside. You wake up in the morning and find that someone in your friend’s family passed away.”
What are ACEs?
The ACE study was launched far away from Philadelphia – in an obesity clinic in San Diego, California.
There, physician Vincent Felitti wanted to find out why many women dropped out of weight loss programs. In many cases, he found, it was because they were still dealing with childhood trauma, often in the form of sexual molestation.
He and another researcher, Robert Anda, became fascinated about the frequency of trauma and designed a questionnaire asking respondents whether as children they had experienced adverse childhood experiences, including physical, sexual, or emotional abuse; physical or emotional neglect; witnessing domestic violence in the home; or living with someone who was a substance abuser, was mentally ill, or was imprisoned. These became the indicators of the original ACE study.
This first, 1998 ACE study was a joint effort by Kaiser Permanente Health Systems and the Centers for Disease Control and Prevention (CDC).
Researchers surveyed more than 17,000 participants in Kaiser Permanente HMOs in Southern California. The results shocked the public health community, at least in part because the subjects were largely middle-class Whites.
About two-thirds of the adults in the study had experienced one or more of the ACE indicators. Eighty-seven percent of that group had experienced two or more ACEs and were also more likely to show medical, mental, or social problems as adults.
The results also shocked educators and researchers, who contended that if this was true of the Kaiser subjects, it would have to be even more frequent in lower-income urban populations.
Sandra Bloom, a professor of public health at Drexel University and a nationally recognized expert on childhood trauma, says the 1998 study was the key to the development of trauma-informed education, in which the approach to troubled students changes from “What’s wrong with you?” to “What happened to you?” and “How can we help?”
The study, Bloom said, “drew the real focus on childhood and what’s happening to kids.”
Over the next decade and beyond, the 1998 study was replicated in other areas including Philadelphia, where the Institute for Safe Families contracted with the Public Health Management Corporation to survey city adults about their childhood experiences.
That study, conducted in late 2012 and early 2013, added five new urban ACE indicators: experiencing racism; witnessing violence; living in an unsafe neighborhood; living in foster care; and experiencing bullying.
It showed that 68 percent of the adults had experienced at least one of the original indicators. When the five urban indicators were added, the figure rose to 81 percent.
About one-third had experienced physical or emotional abuse, and more than 40 percent had witnessed violence. One in four had a household member with mental illness.
For some working in the Philadelphia School District, the findings have not been surprising. Attending a class in trauma-informed methods, Marie Acevedo, a bilingual counselor at Lincoln High School, looked up from a list of traumatic events in her workbook and said, half-jokingly, “Everyone in my life meets one of these conditions.”
Daun Kauffman, a 2nd-grade teacher who has worked in Hunting Park schools and blogs on urban education, recalled a former student who had experienced at least five major traumas by the age of 8, including abandonment by his mother as a baby, placement in foster care and seeing his father sent to prison and then die after his release. Kauffman told the story on ACEs Too High, a website dedicated to research on adverse childhood experiences.
Next steps
With the release of the Philadelphia ACE study, the Institute for Safe Families called for additional studies to “understand the impact of urban ACEs.” This is where Wade and his fellow researchers got to work.
Wade said that often a parent will bring a child to his office and say something along the lines of “The teacher says John has ADHD, and I can’t bring him back until he’s on meds.”
After a few probing questions Wade determines that the child doesn’t have attention deficit hyperactivity disorder, but rather is suffering from trauma.
“I can put the kid on Ritalin all I want to,” said Wade in an interview, “but unless I deal with the antecedents of his behavior, the outcomes aren’t going to change.”
The CDC has been incorporating questions about trauma into national surveys since 2009. But Wade has been searching for ways to sharpen the questions and make them more relevant to urban youth experiences. He would like to see them so widely accepted that they are incorporated into the standard practice of pediatricians and behavioral health providers.
“Our goal is to create a measure of life adversity experience that corresponds with the experiences that kids have,” said Wade, who grew up in Atlanta and remembers accompanying his Baptist minister father in visits to the sick.
It was there, he said, that he first became aware of the stresses of poverty and its effect on health outcomes.
In his 2013 study in Philadelphia, researchers partnered with social service organizations and held focus groups in which they surveyed 119 people from ages 18 to 26 who grew up in neighborhoods with at least 20 percent of the residents living at or below the federal poverty level.
The most commonly cited stressors they found included neighborhood crime and violence, child abuse, economic hardship, and lack of love and support in the family.
Not surprisingly, financial stressors were emphasized far more than in the original ACE study sample. One youth said that “the hardest thing was watching my mom struggle” to pay food and utility bills.
Wade’s current project, which is supported by the Stoneleigh Foundation, includes interviewing health care and social service organizations and children as young as 8 to further refine the questionnaire, making it more useful to pediatricians and other professionals who work with children.
He also hopes to do more work exploring the relationship between ACEs and socioeconomic status and treating ACEs as a family problem, encouraging parents to get help when they need it.
“What we know is that ACEs propagate themselves,” he said. On the other hand, he said, “Parents may improve their lifestyles because it’s helpful to the kids.”
And the results he is seeking go beyond research data and into what it could end up meaning to urban youths.
“I want to see them rise above their experiences, and achieve their true potential.”
The ACE indicators
Original indicators
Experiencing physical abuse
Experiencing sexual abuse
Experiencing emotional abuse
Experiencing physical neglect
Experiencing emotional neglect
Witnessing domestic violence in the home
Living with someone who abused substances
Living with someone who was
mentally ill
Living with someone who was imprisoned or sentenced to serve time
Additional Philadelphia Urban ACE indicators
Experiencing racism
Witnessing violence
Living in an unsafe neighborhood
Living in foster care
Experiencing bullying