Trauma Informed

Consider the rate at which an infant learns to recognize loved ones, to explore the world, to communicate. Or the pace of a toddler pulling herself upright, declaring her preferences, forming attachments to siblings, caregivers, the family pet. Or a school child discovering the joy of reading, a love of dinosaurs, the ability to make music. The malleability of the human brain early in the lifespan makes it all possible. that same plasticity also makes us uniquely sensitive to insults in our formative years. 

For the past 15 years, perinatal epidemiologist Virginia Rauh, MSW, ScD, has investigated the effect of pesticides on prenatal and early childhood development, documenting how exposure to environmental contaminants increases the risk for low birth weight, asthma, and attention deficit hyperactivity disorder. Frequently, those same families participating in her studies of exposure to pollutants were contending with socio-economic insults, as well. “These things are not randomly distributed,” says the professor of Population and Family Health, who is also deputy director of the Columbia Center for Children’s Environmental Health. “People who can least afford to address problems of pollution and toxic exposures are most likely to be exposed.” 

As co-founder of CHILD, the Columbia Mailman School’s Child Health Initiative for Learning and Development, Rauh takes an expansive view of adversity. “I think of it as individual experiences that might happen within a family, stressors that have to do with substandard housing, instability, poverty, and a whole variety of things.” Like biochemical and physical insults, adverse childhood experiences—ACEs, in technical parlance—can have a synergistic effect. The higher a person’s ACE score—measured on a scale of one to ten, with points associated with experiences of physical and sexual abuse, as well as domestic violence, substance use by a parent, and parental incarceration—the greater one’s risk for everything from skeletal fractures to heart disease, from academic troubles to incarceration.

At its worst, such toxic stress alters hormone signaling, immune function, even the fidelity with which DNA is transcribed and translated to orchestrate the structure and function of a person’s brain and body—some of the same outcomes affected by environmental pollutants. “Whether you have an adverse effects exposure from a social condition or a chemical, it damages the brain,” says Rauh, who previously served as a social worker in a neonatal intensive care nursery, grappling with the combined effects of environmental and psychosocial stressors in new families. “We live in a complex, multi-level universe, and the conditions in a whole community can be just as important as the conditions in a person’s household.”

In January 2018, Rauh signed on as co-director of Trauma-Free NYC, which aims to increase public awareness of ACEs; serve as a resource for the creation of a cross-sector coalition; promote research and demonstration activities; and design educational, training, and service learning programs in trauma-informed practices throughout the New York metro region. “People are just beginning to understand how early adversity affects brain development,” says Rauh. “Toxic childhood exposures have persistent biological effects that can lead to long-term difficulties.”

As a physician whose practice includes young adults who were diagnosed with HIV during incarceration, Alwyn Cohall, MD, a professor of Sociomedical Sciences and of Population and Family Health, and director of the Harlem Health Promotion Center, sees the clinical aftermath of early developmental insults, which themselves frequently extend from America’s legacy of racism. “When you look at social determinants of health—poverty, inadequate housing, and lack of resources for schools—you see a tremendous concentration of all these factors intersecting on certain communities,” says Cohall. “These communities are oftentimes poor communities and often communities of color.”

Consider, for example, the story of a youth Cohall encountered as head of Project stay (Services to Assist Youth), a New York State Department of Health–funded program that provides confidential health services to young people affected by or infected with hiv/aids. One parent had battled addiction, the other had been incarcerated. As a result, the youngster had been in and out of foster care, and by the time he was 19, he’d been incarcerated himself. Soon after being released, he tested positive for gonorrhea and hiv/aids. “His ACE score was about a nine,” says Cohall, who also directs GetHealthyHarlem. “He was at the top of the list in terms of trauma, which influenced and fueled his risk-taking behaviors.”

 The stay team helped the young man receive medical care—it turned out that in addition to sexually transmitted infections, he had high blood pressure and prediabetes—as well as mental health and substance abuse services. “These interventions helped to stabilize him while he dealt with some of the baggage and trauma that he had experienced in his early life,” says the physician. Now in his mid-20s, that young man is back in school, has a job, has his blood pressure and weight and viral loads all under control. “In many ways,” says Cohall, “his life has been reassembled. But it took having an integrated team to do that, and it took getting HIV to have those services coordinated enough to provide that kind of care.”

Society owes people like Cohall’s patient even more than a personal team, says Rauh. Often, their own early childhood experiences extend a family and community legacy of trauma stretching through multiple generations. “There is historical, institutionalized trauma that shapes these outcomes for whole groups of people,” she says. “You’re not going to be very effective in addressing an individual problem unless you are aware that the person is embedded in an entire community that has been impacted across generations. No child will maintain positive effects in a community where the public schools may not be good, nutritional deficiencies are present, and there are larger toxic conditions.” 

In 2017, Manhattan District Attorney Cyrus Vance, Jr., awarded a four-year, $10.3 million grant to establish a Washington Heights Youth Opportunity Hub, part of a $58 million criminal justice investment initiative. Cohall, who co-directs the hub, sees the interdisciplinary effort—which includes faculty at NewYork-Presbyterian Hospital, the New York State Psychiatric Institute, and the Columbia Mailman School, along with collaborators from several community-based organizations—as an opportunity to develop the comprehensive services that could promote resilience and recovery among those hardest hit by intergenerational trauma. The first order of business will be responding to each participant’s unique constellation of cultural needs, medical and mental health challenges, and personal history with adverse experiences. And so, in addition to medical, psychological, and substance use treatment, the Washington Heights program will also feature academic support, recreational activities, vocational training, even programs for parents of teens. “Trauma may impact academic performance. Kids who perform poorly may become truant, may drop out of school, become susceptible to involvement in the ‘underground economy,’ and are at risk for getting swept up in the tsunami that is the ‘school-to-prison’ pipeline,” says Cohall. “We know they often don’t trust institutions—social, academic, health, government—and why should they? Often their experiences with such institutions have only re-traumatized them. We have a mountain to climb in order to reach out, rebuild trust, and repair generations of damage.”

Licensed counselor Jasmine Banks is a columnist for Parents magazine; her work has also appeared in The Fix and The Root.