As I discussed in my previous blog post about human trafficking prevention, we must move very upstream in order to be most effective in stopping human trafficking. In this post I continue with the topic of prevention and discuss the linkages between adverse childhood experiences (ACEs) and the subsequent impacts on child development. The corresponding YouTube video can be viewed her.  These consequences can lead to greater risk of victimization as well as perpetration. One of the ways I see myself in this work is to be a bridge between the lay person and practitioner and the researcher or medical clinician.

Human trafficking prevention is very difficult because the contributing factors tend to be complex and do not neatly fit into a defined set of interventions. “Research regarding pre-trafficking vulnerabilities remains very limited. Simplified push and pull factor models of understanding why certain children are trafficked may mask complex and fluid interactions of cultural, societal, familial, economic and intrinsic vulnerabilities.” (1) However, we do know some of the general vulnerabilities to being exploited are and it is possible to work backward from there. As we move from the general to the specific, we can see that a lot of the issues can be traced to ACEs. Not always, but from a public health point of view, the pathways are compelling.

Addressing ACEs is perhaps the strongest prevention strategy against human trafficking. So much happens – positively as well as negatively – in our early lives that have lifelong implications. Here I will discuss some of the neuro-bio-psychological impacts that early trauma can have on an individual, leading to problems in adulthood. It seems obvious even for us who are not sociologists or psychologists to see that that ACEs have negative consequences for children in their near, not-so-near futures.

First, what are adverse childhood experiences (ACEs)? ACEs comes from the CDC-Kaiser Adverse Childhood Experiences Study, a groundbreaking public health study by Felitti and Anda (2) that discovered that childhood trauma leads to the adult onset of chronic diseases, depression and other mental illness, violence and being a victim of violence, as well as financial and social problems. The ACE Study has since published more than 70 research papers, and hundreds of other papers based on the ACE Study have also been published.

The ACE questionnaire (3) is 10 questions long and cover the following incidences before age 18:
— Physical, sexual and verbal abuse.
— Physical and emotional neglect.
— A family member who is: depressed or diagnosed with other mental illness; addicted to alcohol or another substance; in prison.
— Witnessing a mother being abused.
— Losing a parent to separation, divorce or other reason.

You can find the full 10-question survey here. Other ACE surveys have expanded the types of ACEs to include other forms of violence. The higher the ACE score, the more likely the person is to have more, and more severe health consequences.

What neuroscience is teaching us is that many of the negative effects of ACEs relate to epigenetic changes.
Uh. OK. Epi-what?
You have heard of our genome – that is our DNA – those acid-base pairs we see in the double helix. In Greek, “epi-” means “above”. The epigenome consists of the structures and chemical compounds that have been attached to the DNA (genome) and can regulate the activity or expression of the genes within, such as turning a gene on or off. Epigenetic modifications do not change the DNA sequence but can affect gene activity. These modifications can remain as cells divide and, in some cases, can be inherited through the generations. For example, telomeres are a part of the epigenome that protects genes from damage and ageing. When telomeres are short, the gene is more at risk for damage. Children who suffer abuse and neglect have shortened telomeres, which makes them more susceptible to problems like cancer and degenerative diseases. Environmental influences, such as a person’s diet and exposure to pollutants, and traumatic experiences can also affect the epigenome.

It is a very fascinating time in the science of neuro-bio-psychology because we can measure changes on a cellular level and then describe the behavioral outcomes of these changes. It is important to study this so that we can know how to prevent it but also, we can use the information to reassure and validate survivors that they are not “crazy” – there are actual physical changes in their brains that need recovery. It’s just not all about their will power.

Before we tackle some neuroanatomy, let’s review the four domains of child development. Cognitive involves problem solving, communication, concentration, memory, etc. Physical relates to your musculoskeletal system as well as fine and gross motor skills. Emotional development entails self-regulation, handling fear, recognizing and dealing with moods and other emotions. Social includes being able to develop safe relationships with adequate trust, social engagement and interaction. (Side note: Although pediatricians have a standard timeline for developmental milestones, these four domains can have independent maturation timelines.) Maturation of these domains is affected by the functionality of our brain structures and connections, which are in turn influenced by epigenetic modifications which are caused, for example, by traumatic experiences.

There is growing evidence in the field of developmental neurobiology of several interesting factors that negatively influence children that you may not have considered. The first is that trauma can have generational consequences. The children of parents who have higher ACE scores can also suffer. These are not necessarily direct biological effects, but indirect effect through epigenetic and behavioral changes. A study (4) states that “mothers who experienced more [ACEs] experienced more health risks in pregnancy and, in turn, had infants who were born with more infant health risks, which were associated with poorer developmental outcomes at 12 months.” Another study showed that children of parents (both moms and dads were surveyed) who had early life adversity have developmental challenges at age 2 years. (5) The lack of a father (death, imprisonment, abandoned, etc.) in the home has a negative impact particularly on the telomere of boys. By the age of 9 boys who had absent fathers had significantly shorter telomeres than boys who had fathers present. (6)

The second factor is that there are differences in the way that males and females are affected by traumatic experiences. We know that the influences of stress hormones in pre- and peri-natal periods are experienced differently by girls and boys. It is important to note that boys are MORE at risk, not less. They are less resilient, not more. They need more input and help from their caretakers (especially mom) than girls. “Boys are more vulnerable to maternal stress and depression in the womb, birth trauma (e.g., separation from mother), and unresponsive caregiving (caregiving that leaves them in distress).” (7) Schore’s work also suggests “that differences between the sexes in brain wiring patterns that account for gender differences in social and emotional functions are established at the very beginning of life; that the developmental programming of these differences is more than genetically coded, but epigenetically shaped by the early social and physical environment; and that the adult male and female brains represent an adaptive complementarity for optimal human function.” (7)

A review paper by McEwen (8) et al points out other difference between the sexes:

  • McEwen makes a note that many studies in his review used only male rodents. But the authors note that other studies indicate that “females and males also differ in the cognitive consequences of repeated stress, with males showing impairment of hippocampal dependent memory, whereas females do not” (8) I’m glad that he at least makes this point and that a lot of research studies do not delineate whether their animal studies are of one gender or the other.
  • “Taken together with the fact that estrogen, as well as androgen, effects are widespread in the central nervous system, these findings indicate that there are likely to be many more examples of sex on stress interactions related to many brain regions and multiple functions, as well as developmentally programmed sex differences that affect how the brain responds to stress”. (8)
  • “In men and women, neural activation patterns to the same tasks are quite different between the sexes even when performance is similar. This leads to the concept that men and women often use different strategies to approach and deal with issues in their daily lives, in part because of the subtle differences in brain architecture.” (8)

There also seems to be a relationship between the type of trauma and sex. For example, neglect has been shown to have a strong association with smaller corpus callosum size in boys, while sexual abuse was strongly linked to decreased corpus callosum size in girls. (9)

It is important to note that “maltreated males may be more likely to be arrested for violent offenses as adults, thus becoming prisoners and less likely to be involved in retrospective research studies. This fact can lead to a selection bias in retrospective studies, and a possibly mistaken idea that females are more vulnerable to early trauma. Early trauma experiences may lead to [greater changes in stress responses] in males compared to females, findings that are commonly seen in individuals with antisocial behaviors” (9)

Brain structures and networks can also be negatively affected. Here are few examples.

  • Physical brain development, such as myelination, connections, size, and structure of brain regions (e.g. hippocampus, amygdala, corpus callosum, frontal lobe areas, etc.) is disrupted or developed to deal with fear.
  • Likewise, the sympathetic nervous system, which is our stress response system is primed to be on high alert, even when there is no danger, inhibiting other functions such as concentration and learning.
  • Oxytocin release, which facilitates deepening interpersonal relationships, empathy, attachment, etc. can be hindered. However, it is positively influenced in the presence of supportive relationships.
  • Serotonin, which helps regulate our moods, behaviors and other physiological functions, etc.)
  • Immune system (susceptibility to infections, auto-immune diseases, inflammatory conditions)
  • Cognitive development is delayed or disrupted which can lead to a lower IQ, language deficiencies, concentration, memory problems, and other learning difficulties.
  • Executive function development, responsible for decision-making and sense of self, is disrupted when brain systems are preoccupied with safety and managing anxiety. This can lead to poor or no decision making as well as dissociative problems.

Other factors include timing. The earlier the trauma the more severe the psychological outcomes. Also, some neuro-chemical/biological changes in children are irreversible (such as some hormone receptors), and some are inheritable. (9)

On a positive note, support from caregivers, teachers, other adults has a protective effect, such as the release of Oxytocin. The gene-plus-environment interaction is important for the expression of both negative and positive outcomes following childhood trauma. It is not a foregone conclusion that a child with adversity will automatically be severely messed up. We can all name people who have survived horrific childhoods to grow up thriving and excelling. These systems are complex, but this also gives us hope. I’ll be discussing positive plasticity and resilience in the next webinar and blog post.

I want to summarize with a few take-home messages. Trauma and adversity in childhood causes changes in brains and bodies and these changes cause ripple effects in a child’s health and development that make them more vulnerable to health problems, mal-adaptive behaviors, and continued adversity, which then create vulnerabilities to being victims and/or perpetrators of exploitation and trafficking. It is important to recognize that there are various and profound differences in the way that males and females respond to stress on a neurobiological level, which as implications for psychological and behavioral differences. Therefore, we need to be more aware of these differences when considering interventions.
Childhood adversity IS PREVENTABLE. Prevention can be done through implementing widespread public health measures such as prenatal visits, screening for maternal/paternal mood disorders and other psych problems. We need to strengthen families and provide them with more support through public health, religious communities, etc. Ensuring a strong start for children includes education, nutrition, safety, mentoring, and opportunities for PLAY. TEACHERS and CAREGIVERS are key to making this happen, so we need to support them too. Making better decisions as young adults/adults is not simply a matter of behavior or choosing to do the right thing, and certainly not “just saying NO!”. Furthermore, this information is useful for psychoeducation of survivors so that they can understand that they are fighting physiology in their recovery – it’s not just a matter of will.

“Healthcare professionals are also encouraged to have influence, where possible, beyond the care of individual patients. Research, health insights, advocacy and promotion of a survivor input enhances the collaborative development of evidence-based approaches to prevention, intervention and aftercare of affected children and families.” (1) This statement applies not only to healthcare professionals but naturally to everyone.

“A society that places its focus on an infrastructure of primary prevention would be choosing the less costly option for victims and for itself.” (9)

References:
1. Wood LCN. Child modern slavery, trafficking and health: a practical review of factors contributing to children’s vulnerability and the potential impacts of severe exploitation on health. BMJ Paediatrics Open 2020;4:e000327. doi:10.1136/ bmjpo-2018-000327.
2. Felitti VJ. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: Adverse Childhood Experiences (ACE) Study. Am J Preventive Medicine Volume 14, Issue 4, pp 245-258, May 1998. http://www.acestudy.org
3. Aces Too High https://acestoohigh.com/got-your-ace-score/ 
4. Racine N, Plamondon A, Madigan S, et al. Maternal Adverse Childhood Experiences and Infant Development. Pediatrics. 2018;141(2):e20172495
5. Folger AT, Eismann EA, Stephenson NB, et al. Parental Adverse Childhood Experiences and Offspring Development at 2 Years of Age. Pediatrics. 2018;141(4):e20172826.
6. Mitchell C, McLanahan S, Schneper L, et al. Father Loss and Child Telomere Length. Pediatrics. 2017;140(2):e20163245
7. Schore A. All Our Sons: The developmental Neurobiology and neuroendocrinology of boys at risk. Infant Mental Health Journal. Vol. 38(1), 15–52 (2017) DOI: 10.1002/imhj.21616
8. McEwen BS, Gray JD, Nasca C. Recognizing resilience: Learning from the effects of stress on the brain. Neurobiology of Stress. 1 (2015) 1e11. http://dx.doi.org/10.1016/j.ynstr.2014.09.001.
9. De Bellis MD, Zisk AB. The Biological Effects of Childhood Trauma Child. Adolesc Psychiatr Clin N Am. 2014 April; 23(2):185–222. doi:10.1016/j.chc.2014.01.002.

Helpful Resources:
• Be Worried About Boys: https://acestoohigh.com/2017/02/14/be-worried-about-boys-especially-baby-boys/#more-6534
• Harris, N.B. The Deepest Well: Healing the Long-term Effects of Childhood Adversity. New York: Houghton Mifflin Harcourt, 2018.
• Levine, P. Trauma through a Child’s Eyes. New York: North Atlantic Books, 2010.