Treating Adverse Childhood Experiences in Rural America

Teresa Huizar (TH)

Hi, I’m Teresa Huizar, your host of One in Ten. In today’s episode, Treating Adverse Childhood Experiences in Rural America, I speak with Dr. Lindsay Druskin Grimes, Clinical and Research Postdoctoral Fellow at Kennedy Krieger Institute. Now, many of us are familiar with the original adverse childhood experiences, or ACEs, study. This was the first time that the effects of trauma on physical and mental health were documented in ways that affirmed what clinicians were seeing in their practice every single day.

In the 40 years since, many studies have followed that have examined some particular aspects of ACEs. Today, as you’ll hear, we examine the relationship between ACEs, the day-to-day functioning of kids, and treatment engagement in rural children’s advocacy centers. Are children with high ACEs scores more or less likely to engage in treatment? Are kids who are functioning well in their home or school more or less likely to attend treatment?

And, what do we know about the ways in which we can buffer against adverse childhood experiences? I know you’ll be as interested in this thought-provoking conversation as I was. Please take a listen.

 

Hi Lindsay, welcome to One in Ten.

 

Lindsay Druskin Grimes (LDG)

Thanks so much for having me. I’m really excited to be here to speak more about this work.

 

TH

How did you come to this work looking at the relationship between ACEs and treatment engagement?

 

LDG 
Yeah, I was really fortunate to start my graduate training at West Virginia University, being able to work in a state that has unfortunately been impacted pretty heavily by the opioid crisis and a lot of children being removed from their homes and going into child welfare. And so, my first year of my graduate training, I was able to take on a position at the local child advocacy center, the Monongalia County Child Advocacy Center, and just kind of fell in love with the work there. The people there are incredible.

They were supportive of all of my interest in doing research with that population and was able to also build up my skills clinically working with traumatized youth. I was just able to stay there over the course of my graduate training. I ended up sticking around there for all four years of my program and have kind of continued to collaborate with them ever since.

 

TH

What a great story. You know, we’re a little biased about CACs. We think they’re absolutely fantastic and glad that you found that too. So, because we do have a worldwide audience and not everybody is as familiar with the ACEs, or adverse childhood experiences study and literature as you are, could you just briefly talk about what it demonstrates and especially what we know about it as it relates to dose response? Because I think that that’s an important concept throughout your paper.

 

LDG

Yeah, absolutely. So, adverse childhood experiences or ACEs are these set of experiences that children can have that are potentially frightening or dangerous or violent and might lead to them developing post-traumatic stress or ultimately being diagnosed with PTSD or post-traumatic stress disorder. There’s been a lot of research on ACEs. Kind of the first most seminal study on ACEs done through the Kaiser Permanente organization by Dr. Felitti. There was an original study where he looked at kind of a subset of ACEs, abuse, like physical or sexual abuse, household dysfunction characteristics, like a parent being incarcerated or divorce or domestic violence in the home, and then also neglect, so emotional or physical neglect in which kids aren’t getting the basic needs met.

And, those specific experiences that children can really have a striking impact on mental and physical health across the lifespan. So, kids who have more ACEs are more likely to have poor physical health, greater health risk behaviors like substance use or alcohol use, and also significant mental health impacts as well. So greater risk for suicide attempts, depression, anxiety, really just the full spectrum of impact on health.

And, they also found that it functions in a dose response manner. So the more ACEs, the more of an impact on health kits are shown to have. Having one has maybe an impact, but a smaller impact. And then as they experience a second or third or fourth or more than that, they are experiencing kind of in a stepwise fashion, greater health impacts. Sort of a cumulative effect of all of that.
TH

One of the things I liked about your paper was, it had several different aspects to it. And, another one of them was the relationship between ACEs and adaptive functioning. And because people may not have heard the term adaptive functioning before, can you, first of all, just in layman’s terms explain what it is, and then just sort of, what’s the literature about what we know even prior to the study going into the study about ACEs and adaptive functioning in kids?

 

LDG

Yeah, absolutely. So, adaptive functioning is sort of just the basic way that kids are functioning on a day-to-day basis. You know, their ability to communicate effectively with maybe their parents or their teachers or peers, ability to do kind of age-appropriate daily living skills like getting dressed in the morning, grabbing a snack after school, being able to kind of organize the things that are within their control.

And so, when kids are doing really well in terms of their adaptive skills, they can maybe be a little bit more independent. They might seem to be kind of functioning at an age-appropriate level. Parents can be less hands on. And then, if kids are struggling with those skills, they might need a lot of support, might have a lot of support or accommodations in school. Their parents are kind of doing some of those things for them on a day-to-day basis and might not be able to be as independent as you might expect for their age.

And so, we might expect that when kids are having greater experiences of ACEs, they might be sort of struggling in terms of their adaptive skills. They might have less ability to do some of those age-appropriate daily living skills. They might need more support, or they might not have had those skills modeled for them. If there’s a lot of household dysfunction, they might not know how to prepare a healthy snack, or might not know how to go and brush their teeth or communicate in an appropriate way.

 

TH

In fact, I think that sometimes for caregivers, and especially I think in a CAC setting, what may drive a caregiver to agree to therapy, for example, may be that absence of good functioning, even more than their understanding of the ins and outs of mental health and mental health treatment and trauma and all that. Just like, my kid doesn’t seem like they can get out of bed and get themselves dressed and they’re not functioning well at school. They’re fighting with their siblings all the time or whatever it is, but it’s behavioral often.

 

LDG

Yeah, and those kids who are struggling behaviorally are the ones who are kind of right up in your face. They need the support. You couldn’t go without supporting them. So they might be pulling for more teacher involvement. The families have to get more involved. And when kids are on the other end of the spectrum and maybe internalizing a little bit more or they’re quieter, sometimes you hear kids with trauma, they’re told they’re really mature for their age because they’re doing all of those things on their own.

The reality might be that they didn’t have another choice. It was kind of a sink or swim situation where they had to prepare a snack for themselves and their sibling, or they didn’t have somebody to get them up in the morning for school, or they switched to foster care, kinship care, back to biological parents so many times that they had to structure their own routines. And so you’re right, it can go the opposite way. When kids seem to be doing really well, parents might think that they’re doing well and they might not need all of this extra support or they can prioritize different things.

 

TH

Well, we’re going to get more into the point you’re raising right now because that was an interesting, don’t want to get too far into it yet, but that was an interesting finding from the study. But, I want to now pick apart one other thing in terms of terminology and what we’re talking about for the audience before then we’re just going to dive into your study. And that is when we talk about treatment engagement, what exactly are you talking about? And you looked at a particular aspect of it in the study. So, can you talk about that as well?

 

LDG

So, treatment engagement can kind of capture a few different things. It could be when they’re in treatment, how much they’re participating or engaging with the various tasks being asked of them. And, the piece that I looked at was just sort of basic attendance numbers. So, we wanted to standardize this variable. And so we had a cut point of from the start of treatment, six months out, what was kind of the rate of how kids were attending therapy sessions.

And, it’s not a perfect variable, but we really wanted to try and do as much as we could to standardize. So of course, some families over the course of six months might have had an appointment scheduled every single week. Some families might have been maybe less on top of calling in and scheduling an appointment. And so they had an appointment scheduled every other week or maybe once a month. And so we created a percentage. So of the number of appointments scheduled, how many did they attend? So we could sort of see the rate of attendance across that six month period, which hopefully was long enough to give us a sense of, you know, the start of treatment, what things were looking like as they were really diving into the of treatment.

 

TH

Now we’ve set the stage with all of this very helpful background context, but now let’s turn to the study itself. What were the three research questions that you were most interested in learning about? What were your hypothesis?

 

LDG

Yeah, absolutely. We set out to look at factors that related to treatment attendance in children, you know, specifically at this CAC. So, we knew it was a sample of children who had experienced trauma. We know that trauma treatment works. Treatment can help kids to build skills or to cope with big emotions after experiencing something scary or upsetting. But this attendance and engagement piece is a major barrier, especially for kids in these high-conflict, high-stress families or kids involved in the welfare system. And so, our three big questions were, you know, do ACEs or adverse childhood experiences predict therapy attendance? How do these adaptive skills, you know, do they help children stay engaged or how do they help children stay engaged in treatment? And then also, just how common were ACEs in this rural CAC population?

There’s not a whole lot of research coming out of CACs. It’s a tricky, kind of messy, real-world setting. And so, we wanted to kind of document the population that was being seen here, what sorts of services were happening and what traumas had these kids experienced.

 

TH

I appreciate you pointing out that the CAC, and especially a rural CAC population, is somewhat unique in its own way. While every state is different, every CAC is serving slightly different population. At the same time, it was interesting when I was reading the demographic breakdown of both the caregivers and the kids. There were just some unique aspects of that. Do you want to talk a little bit about what your subject pool looked like?

 

LDG

Yeah, absolutely. So, this was a sample of kids who were coming to the CAC seeking treatment. A lot of the kids had done a forensic interview after being victimized. So, kind of in collaboration with law enforcement, being able to come in for kind of a child appropriate interview to ask about the things that had happened to them. And then because we offer treatment at our center, many of the kids stayed right there for treatment. And so, this was really a highly traumatized population. Many of the kids weren’t just really coming in after being traumatized by a dog bite or something like that. And so, on average, kids in this sample, on average, the kids were about nine. We see the full range of the age spectrum. So, little ones up to teenagers. And so, kids on average were about nine years old and had already experienced almost five ACEs on average.

So, even for the young ones experiencing multiple traumatic events, maybe they had a parent who was struggling with substance misuse, and then they were removed from their home, placed with another caregiver, experienced domestic violence or, you know, had been abused or neglected because of those ongoing substance use concerns. And so, kids were really highly traumatized, much more than the average you might expect for the general population of children, which is about one to two ACEs for kids. And so, really looking at a unique population that doesn’t show up in research that often. It’s hard to access them and hard to get them in for regular treatment.

So, I was really excited to be able to not only work with them, but be able to do some research here in that setting. And so, they’re really in this high-risk category. They’ve experienced all of these traumas and they are also kind of showing signs, showing symptoms of being in distress, having externalizing or internalizing symptoms. And for many of the kids, the conflict is ongoing, it’s chronic. They hadn’t necessarily landed in a safe or stable place yet. And so, sometimes these traumas were ongoing.

 

TH

One of the things I thought was interesting that you pointed out in the paper is that because the average age was nine and you would capture ACEs until someone’s 18, it’s even a higher level when you think about it in that way, that half their childhood remains. So, the importance of making sure that additional ACEs aren’t layered onto the already very high level, you know, that they’ve experienced.

I thought one of the things that was interesting as well, were some of the caregiver data because honestly, they’re a group that’s experiencing a lot of stress themselves. In the data, I just kind of jotted down a few notes from the table that you included, but one in five of the caregivers were grandmothers. So, that was very interesting. We certainly see lots of grandparent caregivers, but that’s a particularly, I think, high level. 50% had a high school education as their highest level of educational attainment. 50% were employed. Almost two-thirds were below the state median income level, which is already low, I believe, if I’m remembering right about West Virginia.

Can you just talk a little bit about that? Because I was thinking, you know, it’s challenging enough to support a child who’s had a traumatic experience or more than one. But, when you also are dealing with caregivers who are under incredible stress themselves, I think it’s all the more challenging.

 

LDG

Yeah, I think just the makeup of these caregivers was really interesting because many of them weren’t the biological parents. A lot of the kids in the state because of this kind of devastating impact of the opioid crisis, they had been removed from their home with their biological parents, placed into the foster care system, which at a point became really overwhelmed. And, so many kids went into these kinship caregiver placements where they’re placed with a grandparent, an aunt or uncle, someone maybe they know but haven’t lived with.

And then sometimes, and especially with these grandparents, they’re kind of getting the second wind of caregiving. They raised a child who is having some difficulty raising their kids. And then they, maybe at 60 or 70 are having a three-year-old, or a four-year-old, or siblings placed with them.

And not just kids who are doing really well, but kids who are having some significant mental health issues.

It’s a big ask for grandparents. It places a lot of stress. And many of these families, like the data showed, weren’t affluent. They didn’t have this endless supply of resources or transportation to make it to this center every single week or the finances to be able to support additional medical appointments, therapy appointments. It was a big ask for a lot of these caregivers.

And a lot of the work, especially for young children, takes that intergenerational sort of dyadic approach too, where we’re asking them to try out some different parenting strategies, which is hard when it’s a caregiver who’s raised many generations of kids before. It can be a big ask not just to get them there, but also to show up and be present in these appointments too.

 

TH

I was thinking as you were talking about what a gift it is that these grandparents, despite all the things that we’re talking about, were willing to take on the caregiving role for such young children overall and who had experienced traumatic events and as you point out might very well be acting out or withdrawn or whatever. I mean, all children require lots of care, but children who’ve been highly traumatized may well need additional care. And that’s a lot to ask of individuals who are older, and also experiencing their own stressors.

So, I think it, you know, to be honest, I was surprised by the level of engagement because it’s somewhat remarkable actually given all of that, everything that you laid out and described, I mean, it might not be where we want it, but it’s still, I think people obviously want their grandchildren and whoever they were providing care for, if they were foster parent or anything else.

They were willing to go to great lengths, it seems to me overall, to try to get them the treatment and care they needed to the extent that they could. I’m wondering, as we talk about ACEs, one of the things you had in the paper, which I thought was really helpful, was a chart that just showed by percentage broken down boys versus girls, the percentage of the subjects that had experienced those particular ACEs. And I have to tell you, it was, I’m not going to say surprising. I’ve been around a while, but it was very concerning just the sheer high level of it.

ACEs can also be things like natural disasters and other things like that, right? These are not the ones that were showing up at very high levels, I shouldn’t say unfortunately. We don’t want people to have a tornado hit their house either, but it is more the case that they were experiencing things like child sexual abuse, child physical abuse, exposure to a caregiver that had a substance abuse issue and other kinds of domestic violence. You go down the list of particularly concerning things. And, I wonder if when you saw the list and the breakdown, was there anything that surprised you about it? Was there anything where you were like, well, I wasn’t quite expecting that?

 

LDG

Starting off in this work, I was surprised by a lot of it. I think there’s sort of that shocked reaction or feeling maybe even overwhelmed by just the nature of doing trauma-focused work with kids. And, I think the more we see, especially since the pandemic, the more we see these kind of changing rates of child abuse and ACEs in kids, a lot of research showed increases or hidden ACEs that were happening and not being properly identified and sort of reported, and managed in the same way that we saw pre-pandemic.

It was all new for me, and a lot of it was surprising, but really getting to see the families and getting to work with them, it was what I was seeing. Anecdotally, in the cases I was working with, clinically these were what all of the families walking through the door were having trouble with. And, it was that same pattern over and over again. And I think also speaks to a strength of some of the values of Appalachian families too, that there were so many relatives and grandparents and family members who were willing to show up and be that caregiver for these kids who were kind of caught in this cycle. And again, speaks to a strength of that population and the family, the strong value of family in this region of the country.

And also, it could kind of be a motivator for families too. There was something about this child being important to them that made them step up to the plate. And, I think that that was really powerful to witness and kind of harnessing and tapping into that over the course of therapy was something that helped families keep coming too.

 

TH

You know, even sort of acknowledging that a child advocacy center population is by its very nature going to include a population that’s heavily traumatized, right? You were brought to a CAC because there’s going to be an investigation of child abuse and particularly sexual abuse and severe physical abuse for most of them. But I think what I was somewhat surprised by was, and it’s certainly not unique to West Virginia, but West Virginia was the epicenter more or less of the opioid epidemic.

But, the high levels of exposure to substance abuse, 45% of girls in the study and even higher level, 64% of boys lived with a caregiver or a person who was abusing substances. For boys, 93% lived with one or no parents. Not quite as high, but also high levels for girls. High levels of individuals who lived with somebody who had been to jail or had experienced the loss of a friend or relative, which I am wondering if those numbers being as high as they are were because of fatal overdoses. You saw in girls, I don’t know, 40% and boys, maybe 25% had experienced that loss of a friend or relative.

What to me, the thread that was running through all of that was these were kids who are not just experiencing this sort of tenuous existence, right? Because if you were another one that was living with someone who had depression, suicidality, or a severe mental illness. They’re living in situations that are somewhat tenuous because of those things. But there’s also a lot of grief and loss that threads through it as well.

And, I was just curious about your own impression of that. Were you seeing that manifesting outside the data as well? just, in reading these, seeing these very high percentages, I was thinking, you’re not just dealing with the trauma of child sexual abuse. You’re dealing with a whole lot of losses and other things that are going to show up in therapy.

 

LDG

I think that is really what came to the forefront. I think for a lot of kids, especially young kids, we as adults see them go through something horrific and we think that that must be all they’re thinking about and all that’s going on for them, kind of the core of their symptoms and the stress they’re feeling. It is important and it does have a huge impact on them.

And sometimes, when kids are young, it’s almost harder on the caregivers or the family to watch their child go through something like that, or harder for a grandparent to step in and kind of feel the weight, the true weight of what happened. And, what really has an impact on kids is that they can’t see their parent anymore. They can’t, they’re not in that home where maybe there were some things going wrong, but they felt it was what was normal for them. They felt loved by their parent, and now they’re not able to see them anymore. They don’t have a good understanding of what addiction means or looks like.

Sometimes kids even get scared. A caregiver might explain, ‘mommy was taking medicine, or mommy was sick.’ And so, they themselves might get scared to take Tylenol, or if they get a cold, they’re wondering, their brain is filling in all of the gaps of, ‘what does that mean if I’m sick too?’ And so, it’s really that ripple effect, the loss of their caregivers being displaced, the home that they knew was changed and taken away from them maybe quickly, or something like they walked in on a parent who had overdosed. And so, that was really scary.

And now, they don’t really know that that’s forever, that this loss is permanent. These big traumas happening in the midst of all of these other really significant changes in their life and that as kind of a constellation of factors that has an impact on their life.

 

TH

As you were talking, I was thinking about, I had been talking to someone from West Virginia and they were saying that one of the things that was particularly hard on the kids that they were serving is that they would see a parent overdose. And then, they’d be given Narcan and brought back and that would happen over, and over, and over. And so, the terror of thinking, you know, your parent has died, and then they sort of miraculously live.

And then, you’re scared it’s going to happen again, and then it happens again. And I think all of that is something we have to be thinking about when we’re thinking about the practical implications of what we’re dealing with clinically with these kids because it’s many of the things that are listed here in your chart came out very high are chronic conditions. They’re not one-time episodes that a child might be exposed to. They may be essentially the environment they’re being raised in.

 

LDG

And, I think it speaks to the intergenerational nature of this trauma in these communities too, that sometimes parents don’t even realize, or caregivers may not realize, what this looks like or they themselves weren’t raised in an environment that was kind of healthy and supportive of their social and emotional development.

So, then when they become parents, they might have limited resources to pull from in terms of what they’re supposed to do, how they discipline a child, how they support them when they’re sad, or when they’re going through something difficult, or when a family member is lost. And so, that kind of keeps them in this cycle where that stress increases and their reserves for managing stress and accessing social support is taxed or limited.

So, it continues on with their kids where they’re not able to manage some of those high-risk behaviors or some of heightened symptoms that are showing up in their kids. And then, you know, maybe it causes a relapse, or it leads them to a point where they can no longer care for their kids. It continues on, and is really challenging for families to manage all of those things.

 

TH

So ultimately, what did you learn about the relationship between ACEs and treatment engagement itself?

 

LDG

I think there was kind of a big finding that came out. We found that children with this higher trauma exposure attended therapy less consistently. That was something we hypothesized that when there’s more stress, more dysfunction, more trauma happening in the home, it makes them show up for therapy less often.

But then, the surprising finding for us was that when kids had high levels of adaptive skills, they seemed to be more high functioning, more resilient. They were actually more likely to disengage from treatment when those ACEs were high. So, when there’s more trauma and more of those adaptive resilient skills, it led to less therapy attendance. So, they were showing up less often. And, that was really surprising for us. We thought that when kids seem to be doing okay, when maybe the stress was lower because kids were functioning well, they would be able to show up for therapy.

We thought that maybe what was happening here was that when kids seemed to be doing okay, they seemed to be showing some indicators of resilience. It almost masked the need that they had. Families, again, they grew up in this environment where there’s high levels of trauma. They were part of the trauma potentially. And so, families saw their child doing okay, doing well, getting ready for school in the morning, and helping out with their siblings, and they stopped coming to therapy, which is a big problem, right? We can’t help kids, we can’t help them benefit from these evidence-based treatments that we know work when they’re not coming long enough to receive the benefits and to be engaged in treatment.

 

TH

You know, I have to say I found that a very interesting finding, but not a surprising one. And I’ll tell you why, just because of some data we collected. So first, we asked CAC directors, why do you think kids are not following through on treatment completion? Why do you think they’re dropping out? Why do you think that your engagement rates are low or where they are anyway, whether or not they were low?

And they gave us this litany of, as you can imagine, transportation, childcare, like they went down this very long list, right? And those practical things, this is a few years ago, were high, high, high on the list. Okay. So then, in our outcome measurement surveys, we surveyed caregivers and we said sort of the same question, like if for whatever reason you didn’t follow through on the referral that you received to therapy, why not? And, the number one thing was I didn’t think my child needed it.

So, I think, you know, we have been working for a long time to say, you’re trying to solve the wrong problem, CAC director. You think at once the bus token or the gas card is there, you’re there. Whereas, we need to listen to what parents are telling us and caregivers, which there’s a persuasion piece of this. If somebody isn’t familiar with therapy or maybe they had a bad experience themselves with therapy as an adult or something else, that attitude, no barrier is more important in some ways than the other factor.

So, when I read your paper, I was like, that is so interesting because it’s so similar to our own experience when we were kind of probing on questions of engagement. And, I feel like caregivers are very honest, you know, in terms of just going, ‘I didn’t think they needed it or whatever it was.’

 

LDG

And, I could see it happening in my clients too. I think about families where maybe kids were placed with an aunt and an uncle, and they have their own kids in the home and a kid coming in who experienced this neglect, but took on a of a parentified role helping out with their siblings.

And, of all of the kids in the home, the kid who’s maybe the oldest, experienced this trauma the longest, but it’s helpful and kind and able to almost be another mother figure to their younger siblings. They seem to be doing okay. So, when you have to prioritize, you have to pick and choose what you have time for. They maybe get the short end of the stick, and it’s not malicious, but it’s because they have so much else going on. There’s so much on their plate. The kids are being placed with them almost overnight, and they have to pick and choose something, right?

 

TH

And to your point in the paper, the other issue is that we shouldn’t assume that a caregiver automatically knows the lifelong impact of ACEs, right? They can very easily, if they have a background, a professional background in this. If the child seems to be functioning well, their viewpoint might be unless and until they don’t seem to be functioning well, they’re fine. You know, ‘we’ve been supportive,’ you know, ‘we’ve encouraged them, they’re active in their church,’ whatever.

I think that you raised a really important point in the paper, which is there’s an educational role here that we have with these caregivers to talk about the fact that somebody seems to be functioning fine now, doesn’t necessarily negate all the potential impacts of the ACE exposure.

 

LDG

Yeah. And I think, like you said, that’s a huge takeaway for us. It helps us to know that early on when we have families here in the door, and we can give them information, it’s important to let them know, how much of an impact these ACEs have. Even if everything seems to be okay right now, what we know is that, these kids long-term, they have these significant impacts on their health, their mental health, their functioning overall.

And so, even though these kids have been incredibly resilient and learn to adapt to these challenging environments, we need to support them, even if it feels proactive. And, we know it’s not proactive because they’ve already experienced these ACEs. It’s okay to keep them in therapy. It’s okay to take that preventative approach prior to this increase in symptoms or before something really goes wrong or goes bad in that child’s functioning.

And so, you know, helping caregivers to take that trauma-informed understanding of their child’s behavior and not to misinterpret what these adaptive skills mean, what this resilience factor means for their child. We need to be able to get them into treatments that we know will be helpful, or at least stay connected. So that way, when symptoms do increase over time, they can stay connected and reinitiate in therapy.

 

TH

One of the things that, and the paper didn’t get at this, so I’m just talking about it. But, one of the things that I think sometimes people don’t think about is that you’re teaching kids in therapy lifelong skills and at different developmental stages, things can crop up. And, if they already know those skills, and they’re prepared to deal with some of that, I mean, they might need to go back to therapy as a booster shot, but they might actually be able to use some of the skills that they’ve learned.

And so, when you cut that short, you’re really preventing someone from learning some of what they may need that will reduce the likelihood that they’ll be abused in the future, because we know they’re more vulnerable to that over their lifespan. There’s just a lot of, I think, downstream implications that without scaring anybody or making it sound too negative that we can try to impart.

I did also want to talk to you, though, just for a second about, you also pulled apart the data about children who were exposed to substance abuse, essentially, in a very specific way, and looked at their ACEs scores separately, even from all the others. I thought this was so interesting because we know that substance abuse is a big driver within neglect and kids coming to the attention of social services. I’m just wondering if you could talk a little bit about that.

 

LDG

By and large, substance use was a major ace in this sample. And so, when we saw kids who were impacted by substance use, they are coming in with a specific profile. That’s one of many ACEs that are coming up in their experiences. And, for kids who hadn’t experienced that substance exposure, sometimes they are looking a little different. Maybe it’s a different family structure. And so, thinking about, even from a biological standpoint, when we know kids are exposed to substances in utero, that can have a major impact on their ability to regulate, their functioning, their cognitive factors.

And so, helping kids to have an understanding of the things that have kind of gone on in their history. They might even be more likely to engage in substance misuse as they get older. And so, helping them to have more holistic understanding of what it looks like, what their background is, an understanding of their story. What it means is that their parents had been exposed to substances, or that growing up they might have been exposed to these substances in their caregiving system, their parents, and helping families to be able to talk about that. What does it mean? What does it not mean? How to have a consistent story that is age-appropriate and makes sense for those kids.

 

TH

I was thinking when I saw the data at that particular subset of, and we’re only talking about one subject pool, so we don’t want to generalize too much here, but that they had a higher ACE score on average than the rest of the kids, all things being equal. And, that made sense to me in the sense that, if you think about caregivers who might be impaired, that brings with it exposure to lots of things, right?

Some of the loss we talked about of somebody overdoses, it could involve, it could bring somebody to the attention, not just of CPS, but of law enforcement and they could become system involved. Also, just the environment. Some of the researchers I’ve had on here in the past have talked about the link between neglect, for example, and substance abuse as a part of that and child sexual abuse just in terms of it’s hard to appropriately monitor what kids are doing and who they’re with, if you’re impaired.

One of the things that I was really thinking about is that’s a real point of intervention, you know, not just for CACs, but as a society. If we want to reduce ACEs overall, a good place to start might be pressing on this powerful lever about making sure that folks who would like substance abuse treatment have the ability to actually get access to it.

 

LDG

Yeah, absolutely. Like you’re saying, this caregiver supervision piece is a huge factor in ACE exposure. So, when kids are not adequately supervised, whether that’s because a parent’s working or because they might have a limited capacity because of substance use, it plays a major role in maybe the unsafe people they’re around, the other factors they’re exposed to, the parents’ ability to meet their basic needs, get them to the doctor’s office or get them to school on time.

And, it creates this web of ACEs that happen for these kids. Not only do they have a parent who has substance use problems, but they’ve also now been experiencing neglect or a parent who maybe is less regulated or more hot and cold than they might usually be when they’re sober. And so, now they’ve experienced physical abuse or they’ve been around unsavory people who have exposed them to, you know, like child sexual abuse material, or, they’ve been around substance use in the home. And so, maybe they accidentally got into something, or something happened, or a sibling got hurt and that in and of itself was scary and traumatic.

It’s a key and a critical point of intervention when we’re thinking about kind of the substance use service package for families. We have to think about kids too. Not only are these ACEs prevalent in this population, but again, that in utero exposure, that in and of itself leads to these secondary behavioral problems, cognitive learning, developmental problems. And so, when we think about adult substance use, we have to remember the kids that are so impacted by caregiver substance use.

 

TH

I found this whole study just fascinating. I really have appreciated the opportunity to talk to you about it. I hope you continue to partner with CACs long into the future and continue to use them as a place to conduct important research as this is. Is there anything else that I should have asked you and didn’t, or anything else you wanted to make sure that we talked about today?

 

LDG

I think, like you said, I hope to be able to collaborate for a long time in doing this important work with researchers from the CAC and from West Virginia University. And, I think a piece that maybe is missing from this study is what these kids look like long term. Does it really have an impact if they’re staying in treatment longer? What’s the optimal level of treatment for these kids, and how can we really help them?

How can we know what the appropriate package is for these kids who’ve experienced this high level of ACEs? And yeah, I hope to be able to continue to do some of this research and ask some of those questions. I’d also like to thank my collaborators from the Monongalia County CAC, especially Dr. Laura Capage, the center’s fearless executive director. She was a wonderful mentor to me.

I miss getting to work at the CAC with all of them. I think the staff and the volunteers there are, they’re just incredible. They’re on the ground doing all of this really hard work, working with some of these really challenging cases where this trauma is kind of chronic and ongoing. And yeah, it was a privilege to have worked there for the four years that I did. And, I would also love to thank my co-authors, Dr. Hannah Elias, Sharon Phillips, Sydney Parker, Samantha Frenzisi, Taylor Schultz, and then of course my mentor, Dr. Sharon McNeil.

 

TH

You mentioned three or four studies you’d like to do in the future. So, you just come on back anytime when one of them gets published. Thank you so much, Lindsay.

 

LDG

Thank you so much.

 

TH

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