Old Before Their Time: The Impact of Childhood Trauma

Teresa Huizar: Hi, I’m Teresa Huizar, your host of One in Ten. Now, it’s not often one has the opportunity to interview a research legend, but in today’s episode, Old Before Their Time: The Impact of Childhood Trauma, I speak with Dr. Frank Putnam, Professor of Psychiatry at UNC School of Medicine. Now, in my own 30-year career, I’ve read countless articles Frank has authored or co-authored, and especially on the Female Growth and Development Study.

This seminal 35-year longitudinal study has tracked a cohort of girls ages 6 to 15 who were child sexual abuse victims as they grew up, became mothers, and in some cases, grandmothers. Findings from the Female Growth and Development Study help answer key questions in our field. How does risk for child maltreatment travel across generations? Why are sexual abuse victims more likely to experience further abuse across their lifespan?

And what might we do to interrupt those cycles? But no aspect of his research is more compelling than answering the question: why do sexual abuse survivors grow old before their time? Since the Adverse Childhood Experiences study, we’ve known that survivors have increased risk of morbidity and mortality. But until now, we didn’t understand the biology behind that sad reality.

As you will hear, Dr. Putnam and his colleagues set out to answer that vital question in hopes that by doing so, we may learn how to prevent and interrupt it. I know you’ll find this conversation as thought-provoking as I did. Please take a listen.

Frank, welcome to One in Ten.

Frank Putnam: Well, thank you very much, I’m pleased to be here.

TH: I was so interested in the sort of book chapters that got sent over to me and reading about how you came into the work of child abuse because I think this is a story some folks may not know, and I found it fascinating. And so, could you talk a little bit about what brought you first to this work?

FP: Okay, so I was interested in essentially rapid shifts in mental state. So people who had panic attacks, where they went from feeling normal to suddenly having a terrifying panic attack. People who had switches between depression and mania or mania and depression, which can be very, very rapid. Flashbacks sort of thing, catatonic states.

There are number of examples in psychiatry where somebody goes from essentially a normal state, a euthymic state, to a very distressed state very rapidly, often within seconds, if you think about a panic attack. And so in terms of looking at that, I encountered a number of individuals who had what’s now called dissociative identity disorder, multiple personality disorder.

And these were adults. So they came in under other diagnoses to the National Institute of Mental Health where I was doing a fellowship at that time. And what witnessed these transitions between various altered personality states or dissociative identity states and thought this was pretty amazing and that somebody ought to be studying this because there didn’t seem to be really much about this in the research literature.

So I began working with adults and I had a large number of adults come in and complete a number of studies that involved both brain imaging and sort of psychophysiology and also a lot of cognitive kinds of studies and those sorts of things. And I talked to them sort of while we were waiting to start studies or finish studies and they all told me they had been this way since they were children.

And I thought, if that’s really true, I ought to be able to find child cases of this. And so with the help of these individuals, we created a profile of what a child with a dissociative disorder might look like. And I began circulating that profile to foster parents, to adoptive parents, to child therapists, to child protective services, anybody who would be seeing children that might be fairly behaviorally disturbed or seem to have significant psychiatric problems. And I asked to see them in consultation and together with an adult who would act as the essentially legal guardian. And as I began working with these children and observing these children, I just saw so much more going on.

So much more in terms of what I felt was changes in their biology, as well as real significant problems in their behavior and socialization. And I felt like, yes, some of these children probably had a dissociative disorder, but there was so much else going on. And the only way to understand this, I felt, was to follow it forward in time. That trying to reverse engineer this from an adult perspective and like what was the childhood like or what was happening developmentally.

It was just probably not going to be very effective. So I began seeing these children and in that context, I felt that we needed a longitudinal prospect of study to follow children into adulthood at least and understand how these experiences impacted their behavior and their biological development. I was very fortunate to connect with Penelope Trickett, Dr. Penny Trickett.

Unfortunately, Penny is deceased now, but we back about 1987 began a study which we called the Female Growth and Development Study. And that study enrolled girls who were 6 to 15 who were, had been sexually abused in the context of a family environment. So they were not traffic victims, they were abused in the context of their families. They were all child protective service substantiated cases and we began to follow them forward in time and this is called a cross-sequential design; we have a cross-section ages 6 to 15 and we’re following that forward in time. We have been following them for over 35 years at this point in time. We’ve seen them eight separate times. We’ve been following biological trajectories. We’ve been following psychological trajectories and following their physical development, their psychological development. And then we also, because they brought in an adult guardian, mostly their mothers, not abusing mothers, we had retrospective data on their mothers plus prospective data as we followed their mothers forward in time. And then at time six, we saw them eight separate times, we had them bring in their children. At that point, the mean age was, I think it was 18.

Many of them had children, or actually the mean age was older than that, but many of them had children. We saw 90 % of the children born to our children. And in addition to this abuse group, we had a comparison group that was matched on age, race, socioeconomic status, and whether they were in one or two parent-family homes at that time. And so we followed all of them forward in time and we still see them.

We’re still publishing research on this. We had a paper come out this week, as a matter of fact, on PTSD trajectories. And we saw certain things that predict who’s going to say have high levels of PTSD and who’s not, that were biological, essentially. So we remained quite involved with this sample.

TH: It’s been a remarkable study. And I’m curious about, and I want to dive more into it in a moment because it is as remarkable as it is, but are you aware of any other longitudinal study involving child sexual abuse that has gone on as long as yours? I mean, it’s really quite remarkable that you’re talking about now essentially across three generations.

FP: Yes, there is no study that’s exactly comparable. There are a few longitudinal studies in which child abuse is one of the things they look at, and particularly a study called the Dunedin study, where they looked at all the children born in Dunedin at a particular period of time, and they followed them into adulthood. And there they have their child protective services have records on it, so they know who was maltreated and who wasn’t, at least who showed up in the system. But other than that study, really no. There’s no other study that really has repeated evaluations of maltreated children over certainly a long period of time, I mean, 35, 40 years.

TH: When you think about the many papers that have been published from the study over 35 years, what do you yourself think of as seminal findings from the study? The things that you feel like this is where the science really changed based on the findings of you and your colleagues.

FP: So I think that really for me the insight from all this is it came fairly late. We were quite interested from the very beginning in did child sexual abuse accelerate puberty. And so much of the study was designed around looking at that particular trajectory. But as we began going through the study, we had other sort of developmental trajectories. For example, acquisition of verbal IQ.

Your verbal IQ increases to a certain point, and then it starts to tail off and then go down. And so we had another trajectory that we could follow. We looked at immune competence. We looked at the stress hormone access, actually, and that turned out to be extremely important. The cortisol studies that we did over time, which showed us that particularly our abused girls started with much higher levels of cortisol, significantly higher.

And by around age 18 or so, they were having significantly lower levels of cortisol. And that transition turns out to be very important in some of the other biological findings that we have. But bottom line was probably more than a year or two ago as I’m working on this book and working on the study, thinking about it, I really realized that the common feature here was accelerated biological aging.

And that many of the effects that we were seeing could be explained by accelerated biological aging. And we then got particularly sort of the study that really kind of nailed that was looking at the epigenetic changes in them. And we’re able to look at the genome and the epigenome and actually see how much biologically older they are than their birth age, for example. And that seems to be a big predictor of sort of negative outcomes.

TH: And I want to dive into that for a minute because I think a lot of listeners are probably familiar with literature around ACEs and child sexual abuse, for example, the sort of, you know, increased morbidity and mortality of those who’ve had that as one of their childhood adverse experiences. So I think one of the things, though, that people find confusing is that while they believe that, you know, they believe the data around, yes, your lifespan could be shorter and you could have more propensity for certain cancers or heart disease or other kinds of things. I think to your point, people weren’t quite sure like how though. And it seems to me that your study started answering those questions about what is the actual mechanism by which that’s happening. So for people who may not fully understand how those two things tie together, can you talk a little bit about that for folks who are not necessarily scientists but are child abuse professionals?

FP: Well, I think that’s exactly right. I mean, if you look at the original ACE study, which came out in 1998, one of the things they said is the relationship of these experiences to leading causes of death and chronic illness. And so they had identified there was a relationship between these experiences and these outcomes. And then subsequently, they published a very important paper. The lead author was Brown. And it was pointed out that if you had six or more of the classic ACE experiences, that your lifespan was about 20 years shorter and that you were about two and a half times more likely to die before age 66, I think it was. So we had this sense that these experiences were literally life-shortening, but we didn’t really know how. Well, aging is, of course, the biggest risk factor for all of these diseases that we’re talking about.

Second thing that we found in addition to aging is that there’s an increase in obesity, that as these experiences drive significant increases in obesity. And of course, obesity is its own huge risk factor for a lot of negative outcomes and chronic illnesses. Last I checked, there’s about 200 disorders that listed obesity as a significant risk factor.

So I think what we’re seeing is that this accelerated aging, including the fact that it seems to be driving this accelerated obesity, as well as change what I call cognitive stunting, that is it’s reducing the IQ as it goes over time and there’s a quicker shift over to the decline in the IQ curve, which we all experience as we get older.

These are the things that seem to be driving the outcomes that we have associated with classic ACEs.

TH: When we’re talking about these, in some cases we’re talking about what happens when you’re an adult and people’s eventual end. But I’m wondering too, what does it mean for children at a practical level that they may be aging faster than their peers, that they’re essentially getting old before their time? How does that kind of show up in what may be their behavior, their actions, their health, or other ways?

FP: Exactly. Well, we certainly see that impact, particularly in girls. And of course, our study only looked at girls. We were never able to get funding to study males, even though we tried multiple times to write grants both to the government and to private foundations. What we know from a lot of developmental psychology research is that early maturation is not generally a healthy thing for girls in our society.

It’s been long associated with earlier pregnancy, particularly earlier teenage pregnancy, but also earlier tobacco, alcohol, and drug use, more problems, behavioral problems, those sorts of things. It’s not so clear that that’s true for males. Typically males, if they’re bigger and stronger than their peers, they’re looked up to as leaders and that sort of thing. But girls are often really become targets, particularly for predatory males.

And a lot of what we also see was this very high rate of revictimization in our abused girls, just significantly higher. And particularly by strange males, the sort of date rape, peer rape was about equal. It was higher in abused girls, but it was not statistically so. But when you looked at unfamiliar or strange males, it was dramatically higher in the abuse group like that.

They’re cumulative traumatic experiences as a result of that. They’re having trouble. They’re also getting into trouble in a sense because they’re associated with these males, often three, four years older. So you’re thinking 14-year-old girls and 17 and 18-year-old guys. Terrible situation basically.

That’s going to cause all sorts of problems. So they’re having more trouble, they’re dropping out of school. A lot of times we’re looking at people, girls dropping out around 11th grade and pregnant. And so this just sets them off on a very difficult life trajectory. So it has a lot of these sort of negative effects on their development and really puts them in difficult situations.

TH: And really on a sort of life path that is going to be very challenging into the future too. I’m wondering, you know, because this has now gone on so long that it is also intergenerational in terms of the nature of the study, what have you really found about the transmission of risk over this period of time, over the 35 years when you’re looking at the initial children who were sexually abused now as mothers of their own children and in some cases grandmothers?

FP: Yes, yes. Well, I think for me, this is one of the big take-home lessons that the real focus of prevention should be on this transgenerational transmission of risk and that we should be working with multi-generational in prevention programs. We should be helping the mothers who are often have very high rates of maltreatment in our abused mothers. There’s a figure in there that shows you the difference between our comparison mothers and our mothers of our abused girls and then our abused girls they had much higher rates of children in child protective services than then. So we saw this across three generations basically the grandmothers, the original children and then the offspring of our children all of them had much higher rates. But there quite a few things that seem to be associated with transmission of risk and you have to think it’s not just simply being a victim of abuse, but also the depression that goes along with it, and often the substance abuse and the fact that they’re often unstable relationships. And put the children, offspring of our original children in, and in risk. So you see the stepfather or 11 boyfriends are often the maltreaters. So it’s not so much necessarily that the mothers of our children were abusive, it’s that they paired with partners who were the abusers. But there was, in their case, a lack of vigilance on their part. And this is where we saw the dissociation come into play. That seemed to be a really important factor in terms of problems with parenting was that they’re having dissociation. They’re not seen, they’re not vigilant, they’re not in a position to protect their children or to sort of see what’s going on. I think it’s often triggered by events in the home that are reminiscent of things that they experienced as children.

TH: It’s so interesting that you say that because I can definitely think of cases and I’m sure that you heard this as someone who headed a Children’s Advocacy Center yourself as well that you would get a question from a multidisciplinary team member about how did the mom not know, right? Especially if they were a survivor themselves, how did they not know this was happening? And you’re saying that in some cases this may be because seeing some more things triggered a dissociative state.

FP: Yes, yes, that’s what we’re saying is that least that statistically that higher level of dissociation seemed to be associated with lower vigilance and protective ability to protect their own offspring and sort of a blindness to what was going on in their own households. And I think that is important in the transition of risk across generations, that their mothers were also abusive. One of the things we saw, we did not treat these girls, but we got them into treatment. Most of them didn’t stay in treatment very long. One of the things that we noticed when we surveyed the therapists every quarter was how angry they were at their mothers and not the abusers so much. Very quickly, the therapies moved off of the abuse and on to difficulties with their mothers primarily. Now, this was back in 1987, 1988, 1989. So the treatment of abuse victims, child abuse victims, not, there wasn’t anything in terms of tested or evidence-based treatments at that time. So they got a lot of different things. If we just looked at numbers of sessions as a dose, we really didn’t see much effect from the treatment except one thing, which is those who had treatment felt that they had more options in life.

So that does seem to be associated with some resilience, but it didn’t really make a difference in most of the outcomes we looked at.

TH: That was kind of leading to my next question because I’m curious now that you have seen both the controlled route and these, the original cohort of abuse victims for as long as you have, what has buffered against the effects of this risk? In other words, what did you also discover that might be helpful for folks to better understand, to put into place, whether it’s programs or supports for caregivers or other kinds of things that can buffer against some of the effects that you’ve been finding.

FP: Well, one of the things we found that was very important was having an older role model woman in their lives. This was a particularly important factor and really makes a difference, I think. So those girls who were lucky enough to have a big sister or an aunt or a grandmother or somebody else in their life, a coach, a teacher, these were frequently associated with better outcomes than if they didn’t really have anybody in the sense that they could confide to. We looked at their social networks at repeated times. One of the things was that we turned up as being our study. When I say we, I’m referring to our study, turned up as being a really important social support for them. But the ones who really had what I call an older female role model was really a very important thing, so relationships are very important.

You know, healthy relationships, particularly with another woman.

TH: You know, it’s very interesting because over the years of my own career, I would read different studies that you were publishing based on this particular cohort. And one of the things I didn’t know until I read your book was about all the adversity you and your colleagues faced just in trying to pursue this study. And, you know, it’s interesting because I’d like to believe all the sort of backlash and avoidance of the topic of child maltreatment was over, but I think we know it’s not. But I’m curious about what you think really led to just the enormous numbers of hurdles that you all faced as you were, you know, persisting in the study.

FP: It was pretty interesting that continually we were coming up against roadblocks, impediments, that sort of thing. Some of them seemed just to be bureaucracy in a sense that this was a topic that made people uncomfortable, and they were not sure how we would handle it or that sort of thing. And so they preferred we didn’t do something like this. But there were other times when it seemed quite malignant and they did not want these studies to continue. I had a lot of trouble. When we were doing a study at the NIMH, for example, we weren’t allowed to do it on the campus. They said, yeah, you can do the study, but we won’t pay for it, and you can’t do it on the NIH campus. So we were able to get money from the WT Grant Foundation, and we rented office space in Wheaton, Maryland, and conducted the study there for about eight years. But the study had a lot of difficulty both at the NIH and then subsequently. But the other interesting thing was that we ultimately were always able to get funded. And there was always somebody there who said this was important and somehow we got money. There was one time where we submitted a grant and we got two perfect scores and one of the worst scores you could possibly get. We resubmitted the grant trying to address that person who gave us the worst score of that reviewer. We got two perfect scores, literally perfect scores, which is very rare and the worst score you could possibly get. So that would have been the end generally. You’re allowed two submissions and then you’re out. But because of that discrepancy, we were able to ask for a third situation and they put in another reviewer and we got three perfect scores.

So there was always, the study spoke for itself in a sense, and ultimately we tried hard enough, we were able come up with some funding for it. But yeah, we felt like we got ambushed a few times by, for whatever reason.

TH: I mean, grit and persistence is what paid off more than anything. I think that you all just kept at it. I mean, you believed in the value of the study. And I think it’s impressive that you’ve been able to carry it on all these many years. You know, one of the other things in your book that you talk about is you’ve had a long view of the child protective system overall in the US. You know, you’ve been able to see how it’s functioned and how elements of it function. I appreciated the way in which you pointed out that CPS workers just have such an incredibly challenging job made harder in many ways by the fact that the system itself is very fragmented. I’m curious, especially when you think about these girls and what might have helped them, how do you think about if you could design a child protection system that was trauma-informed and evidence-driven and all of those things from scratch, what could be done differently than we’re doing now to make a better system for kids for the future.

FP: Well, that’s a great question. I feel like as director of a CAC, one that was fairly large and was involved in actually three states. So we were in Ohio, in Cincinnati, we saw cases referred from about 20 counties in Cincinnati, but also cases from Indiana and cases from Kentucky, Northern Kentucky.

I felt like these systems, there wasn’t enough standardization and there was not enough standard protocols in these. And so that there seemed to be large discrepancies between how these studies, these different systems handled cases that were nominally the sort of same thing. So there were cases that I thought this would be taken to court and other cases where they simply dismissed it and yet if anything was maybe worse situation than that. So I feel like we need to do some more standardization, but it’s a tricky deal because this is under the control of the states, but really it’s expressed at the level of the county. So how we need to have some kind of national standardization that’s incentivized by funding and by regulation that says you need to do the following sorts of things to get the money. And then that needs to come down to the state level and there needs to be a more standardization at the state. And part of what I think needs to happen is we need to have a much better system for collecting data on this. And that can also be used to standardize reporting and to standardize interventions. So I think one of the very first things I would say is we really need to stop having 3,300 different systems out there, which is sort of the number of counties in the US, and have much more integrated kinds of systems that are following the same sets of rules. Plus, I think training is extremely important in these systems and that the differences across systems are often as a result of very different training that is the workers have experienced.

TH: One of the things that I did not know before reading the book was that you were there at the inception of NCTSN and the National Child Traumatic Stress Network. You were part of the group that helped come up with this idea and form it. And so I’ve just been a huge fan of NCTSN for years. I think they do amazing work. But I’m curious about; you’ve seen that evolve over time. And I’m curious about, has it become what you imagined it would be as a network?

How do you feel it has lived out what all of you who were involved in the founding had hoped for it?

FP: Well, in some ways, I think it’s exceeded what we thought might happen. And it’s become a reservoir of expertise in not just child abuse trauma, but other kinds of trauma, natural disasters, medical traumas, sort of the immigration traumas that we’re seeing now for the kids.

So it’s been a very important system. It’s also been very important to basically validating the kinds of interventions that are out there. There are a lot of, as you probably know, there are a lot of different models out there in terms of treatment, but the NCTSN has worked very hard to look at the science behind them and essentially both adopt the best ones, but also learn how to train those. I mean, it’s been very good at building capacity and training lots of therapists in evidence-based child treatment. I think part of the problem I see right now is that there’s an unequal funding in terms of that we need more funds at the national level. So to do better coordination across the system. I mean, when it started out, there was a pretty tight connection between the three levels, which are the sort of community levels, which are basically three systems and then level two is the university systems and then level one is the National Center which is located at both Duke and UCLA. And what’s happened is that it’s grown very large at the level three systems at the community systems there are I think about 150 funded systems, funded sites and maybe another 150 or so affiliated sites and I think we don’t have enough integration among those at this point in time. As a model that could be scaled up, I think it’s a great model because it really takes advantage of expertise at the local community level. It takes advantage of what the universities can bring to this in terms of training, in terms of developing systems, in terms of doing research and the national centers which can do the coordination as well as interact with organizations like NCA or the American Academy of Pediatrics or the American Academy of Child and Adolescent Psychiatry. So there’s opportunities at all three levels. I think it’s a remarkable system. Yeah, I was there. It was quite a set of meetings. But out of it came some really good stuff. And we have a lot of people to thank for that.

TH: 25 years of really remarkable growth and development and so many large systems that use materials developed through NCTSN. I think CACs frequently use their materials because we pass them on all the time because they’re just so well done. Just grateful for the fact that it exists for sure and we echo your belief that they can use more funding to do even more work than they’re doing now.

I wonder when you think over the course of your career and also the work that you’ve done on the Female Growth and Development study, if you can boil down a set of recommendations for policymakers to say, this is what we’ve learned, that if you acted on it, it would make the most significant difference for kids, what would it be?

FP: Well, first of all, I think that I make the argument a lot that this is a single best place to put prevention funds that in terms of thinking of all the things that we do prevention wise, whether it’s cigarette smoking or vaping or domestic violence or all the different kinds of prevention programs at the heart of them, really prevention of child abuse is a thing that’s probably going to have the biggest impact across all of these other things, whether they’re social or mental health or medical health. And certainly this is what we’re seeing with the medical health. If you want to prevent heart disease or cancer or premature mortality, it looks like the place to go is to prevent child abuse. Part of what I’m trying to convince people is that this is where we should be putting our resources and our funding. Now, what would we do with it? Well, I think we need more research, this study and I think other studies, and we’re not the only one as I look around who are beginning to discover that the impact of trauma is to cause accelerated aging. I’ve found at least 15 or other papers in the literature that have hints of this, they’re retrospective adult studies, but nonetheless, they’re supportive of our findings.

This gives us an opportunity to really have a much more mechanistic way of understanding of how these experiences hurt individuals. So the problem has been, as you said earlier, I mean, we knew these sorts of things were associated, but we didn’t know how. Now we’re beginning to know how. And there’s a lot of research on aging that we can tap into. And these epigenetic markers that we’re using to sort of show that we have accelerated biological aging also can be used to look at both the levels of trauma, but also some of them are reversible. So we may be able to use them as markers of therapeutic efficacy. So I think these are some of the ways that we will begin to be able to incorporate these findings. I think the other thing that has always been important in these studies is that they’re validated.

That a lot of victims, survivors, they want to be validated. This was very important that this really harmed me. This really affected me. It has changed my life. And this is one of the things that I experienced very early on when I would present some of the biological results. I would have people, survivors come up to me and basically say, you know, thank you. You know, I always knew this affected me, but you’re the first person who actually proves that.

So it was very important that this was validated. I think we need to be doing that on a much larger scale in this country. I mean, it’s such a harsh thing. And you see this right now with all the going on with the Epstein survivors, how they would like to be validated. And somehow that’s being withheld over and over and over again for reasons that are a little hard to fathom.

TH: You know, it’s an interesting thing that you point out because one of the things in our outcome measurement survey, we have a youth survey that we give to kids who go through CACs. And it’s so interesting how often they write in that the thing that helped them most or that they wanted to comment on is that someone believed them. It’s back to that validating thing. It’s just a powerful thing when you feel that you’re not being gaslit about what’s happened to you, it’s seriousness. You feel like somebody’s listened to you, they believed your story. Whether you’re an adult or a child, I just think that’s just critically important as you’re saying.

FP: Yeah, I absolutely agree with it. I mean, I think that’s the first thing we can all do is to believe the victim and to validate that this is a life-changing experience for many, many people. And then we need to take that seriously and move on from that to do what’s appropriate. It’s so hard.

TH: Yes. Well, I could talk to you for hours about the many things from your study and all the very fascinating work you’ve done, but I know that you have things to get off to as well. But I want to close by asking you, is there anything else that I should have asked you and didn’t, or anything else that you wanted to make sure that we talked about today?

FP: I think we did a pretty good job. The time just flew by. I felt like maybe we’re halfway through and you say, well, we’re closing down.

TH: Well, hang around, I’ll ask you more questions.

FP: Well, I think one of the things is that we’ve got to bring this to a more, to a topic of conversation that we can have in general, because that’s part of undoing it. We looked at abuse in the context of the family. And it was always this terrible secret, and nobody could talk about it, and that stops the validation.

I mean, I think one of the advantages that the Epstein victims have is that they have each other, that they can cross validate that they experience these things. Whereas if you’re abused in your family, it’s a big secret, even though other people in the family may know, and in fact may have happened to them also, but you can’t talk about it. There’s nobody you can go to that supports and validates you. And so I think one of the important things to do is to start talking about this in a very open way in our society. And I think that will both be validating, but it’s also going to suppress people who are doing this in their families. If they know that this is something that is now no longer can be kept a secret. And I think that may be one of the things that individuals can do to help stop this process and prevent further sexual abuse. I hope that we can understand better about the intergenerational transmission and risk factors and that we can make design interventions to work at the multi-generational level that will protect the children from this happening in the future and help the mothers who are often victims themselves essentially be able to be better mothers and deal with the fact that they’ve not only been traumatized but they may have depression or other sequelae from this. And so that’s what I hope we can start moving towards.

TH: You and your colleagues, by virtue of the study itself and the many papers published from it, have not just contributed to the literature, but you’ve contributed to the knowledge that all of us who work in the field have been able to exercise in our professional lives and professional judgments over these many years. So I just want to extend my personal thanks to you as someone who has read many of those papers many times. I’m just grateful. I’m truly grateful for the work that you’ve done and Jenny and Dr. Penny, sadly not with us, but still just a huge contributor to the knowledge that we all share today. So thank you so much.

FP: Well, I accept that on behalf of everybody who’s worked on this study. And that includes Penny and Jenny, but also many graduate students and post-docs and others. I don’t really remember how many, but I would guess at least 50 people have worked on various parts of the study over these years. Thank you.

TH: Thanks listening to One in Ten. If you liked this episode, please share it with a friend or colleague. And for more information about this episode or any of our other ones, please visit our podcast website at oneintenpodcast.org.