When violence and mental illness stem from adverse childhood experiences.
Eddie Bocanegra grew up in Chicago’s mostly Mexican-American Pilsen neighborhood in the 1980s and early 1990s, at a time when violent crime was peaking nationally and locally, with nearly 1,000 murders per year in the city of Chicago. His world was rocked by domestic violence at home, constant fighting among his neighbors and their parents, bullying in school and street violence among gangs in the evening.
Then, at 13, one afternoon while on his way to a baseball game, he saw someone shot multiple times and killed.
“The following year, I got involved in a street gang, both for protection and identity,” Bocanegra said. “The gangs — believe it or not — they do contribute to people’s identity in terms of a sense of belonging. Being part of a gang gave me a voice. Because I was part of this big group, nobody would mess with my home, and more importantly, because I was the oldest of five, nobody would mess with my siblings.”
At age 18, a friend of Bocanegra was shot and paralyzed — and he retaliated. “I killed somebody. Those were the facts,” he said, which resulted in 14 years behind bars. “As regretful as I am, it doesn’t change the facts. In prison, I saw so many things. I knew I had done wrong. I knew I didn’t want to come back from prison the way I went in.”
After leaving prison, Bocanegra worked for the anti-violence organization CeaseFire, for which he was heavily featured in the 2011 documentary, “The Interrupters,” and he now works as co-executive director of youth safety and violence prevention at the YMCA of Metro Chicago. As such, Bocanegra is at the front lines of understanding why young people sometimes behave violently, much of which traces back to the piling up of adverse childhood experiences (ACEs), according to many in the youth and mental-health fields.
The causes and effects of ACEs have been exhaustively documented in the federal Adverse Childhood Experiences Study, which has tracked 17,000 mostly white, middle-class Kaiser Permanente policyholders since the mid 1990s, drawing connections between their childhood adversities and mental health and violence-related issues as they reached young adulthood. Jane Stevens, founder and editor of the ACEsTooHigh.com news site and ACEsConnection.com social network, has called the ACEs study “the largest, most important public health study you’ve never heard of.”
A collaboration that brought together Dr. Robert Anda of the federal Centers for Disease Control and Prevention, Vincent Felitti of Kaiser Permanente and Laura Porter of the Washington-based Family Policy Council, the ACEs study asked questions about childhood abuse and neglect, mental illness, incarceration, domestic violence, divorce or death of a parent, and substance abuse. Of the 17,000 adults surveyed, two-thirds had experienced at least one such trauma, and 87 percent of those with one ACE had experienced at least two.
Stevens doesn’t think many youth workers have heard about this study, but she and others believe its conclusions are vital for those in the field to understand, so they can understand the youth with whom they work.
“A lot of people think that when kids act out, they’re doing it intentionally — the whole ‘willful defiant disorder’ and ‘willful behavior’ that gets kids kicked out of school,” she said. “Their behavior is a symptom of stress that they’re experiencing. It’s not aimed at anybody in particular; it just erupts. The best thing is definitely not to take it personally, and instead of saying, ‘What’s wrong with you,’ say, ‘What happened?’ ”
The ACEs study and its implications also help to explain young people who withdraw. “The natural response to stress is to fight, or run away or freeze up,” Stevens said. “Kids who withdraw or are labeled, ‘they’re not engaged’ or ‘they don’t care.’ That’s probably not true. If they’re in a group, they may be overwhelmed by the noise or activity because it’s triggering some other stress that happened in their household. Understanding the range of behaviors that a kid will experience as a result of being under toxic stress is critical for being able to help kids.”
The study presents a visual in the form of a pyramid (see graphic below) that shows the progression from adverse childhood experiences to the progressively more severe negative outcomes that occur if those ACEs are not addressed. The bottom layer of the pyramid is the ACEs themselves, and immediately above that is social, emotional and cognitive impairment, followed by the adoption of health-risk behaviors, then disease, disability and social problems, and lastly the higher likelihood of early death.
“[The study] really changed how people think about the kids who are involved in violence,” said Brad Stolbach, a pediatric psychologist at the University of Chicago’s Comer Children’s Hospital. “It changed how they think about them and what kinds of interventions are going to help, if they think about it from a trauma perspective, in terms of, ‘What has this child experienced?’ ”
Kathy Colbenson, CEO of Atlanta-based CHRIS Kids (see sidebar), which serves foster children ages 6 to 17, young adults ages 18 to 24 who have aged out of foster care, and their families, illustrated the concept of trauma-informed care through the example of a boy who kept getting suspended from school for fighting.
Knowing that he had suffered abuse and instability, Colbenson asked for his side of the story, and he said: “They hit me first.” But the school kept saying, “He’s decking people in the hallway. I say to him, ‘Show me what you mean?’ He stands up, walks toward me and … bumps into me. He was calling that, ‘hitting me.’ ”
The boy took the accidental contact as an intentional slight unless the person apologized, Colbenson said. “If they didn’t say they were sorry, he would deck them.” It turned out he had lived in his dad’s car for two years and had been sexually abused during that time — and his mother had been killed when she got hit by a truck after her car broke down, not long after she left a service station without getting the car fixed because the boy and his brother had been fighting. “He blamed himself for his mother’s death,” Colbenson said. “This little boy had carried this with him.”
Taking care of traumatized youth
A traumatized person will go into “fight, flight or freeze mode,” explained Stevens. “There is no reasoning with that kid.” Recent neurobiological research has shown how trauma can damage the structure and function of the brain, she said. “That’s not to say you can’t change that brain to be healthy — you can. But you can’t further traumatize it.”
Researchers are beginning to realize that it’s erroneous to describe the behaviors of young people who have experienced multiple ACEs as disorders. “This is, in fact, the normal response to traumatic behaviors,” Stevens said. “We’re shifting from blaming the victim to changing the environment. … Kids usually act out because parents are causing stress. [Parents] don’t know better; they never had their own ACEs dealt with. If you don’t intervene, it’s passed on.”
Stevens added, “You’re trying to change the environment so they feel safe.”
Youth workers need to be trained to recognize behaviors as reactions to traumatic stress and understand how to deal with it, Stevens said, as well as how not to deal with it. Those who lose their cool don’t help matters and are probably reacting to their own stresses, she said. Training is available online and in person, and it’s often tailored to one’s level of knowledge and/or focused on one’s type of job function.
“People who go into helping professions tend to have higher ACE scores,” Stevens said. “They can be triggered by what has happened to a child, or how a child acts. If you are not cognizant of those triggers you yourself are not going to respond well. And you may even take a kids’ behavior personally, when a kid hasn’t a clue as to how his or her behavior is affecting” the youth worker.
The University of Chicago’s Stolbach said youth workers need to understand that those who grow up like Bocanegra did are adapting to their environments and surviving as best they can — and stop relating to them as a “problem” that needs to be solved. “This person has been injured, and you may not know the specific details, but if you pay attention, if you communicate with them a little bit, you can understand: what are the things that can trigger this kid? What are the things that are going to scare them?” he said.
Validate, don’t label
Considering and validating a young person’s adverse experiences can have a powerful effect on them — and their relationship with the youth worker, Stolbach said. “What’s going to make them feel safe? Then, facilitate that,” he said. “And just communicating to them that you don’t believe they deserved whatever it is that’s hurt them.”
Youth workers should look for opportunities to get youth to open up, Stolbach suggested. For example, he remembers talking to a young person who had been shot and asked whether he had been in the hospital before. The youth responded it was his first time being shot. Stolbach then asked, did he know other people who had been wounded by gunfire. The kid listed people he knew and talked about what they had been through, medically, which led to a discussion about his own fears.
“A lot of times, we’ll jump to, ‘Why did you do what you did?’ Or, ‘What are you going to do so this won’t happen to you again?’” Stolbach admonished. “Instead of trying to understand what must have been going on for you. It’s not that there’s no value in future-focused skill-building or decision-making, but it’s not where you ought to start. You shouldn’t start with the assumption that the problem is, this kid doesn’t know right from wrong, or this kid doesn’t know how to manage social situations. In fact, a lot of kids … have a lot of skills, a lot of strengths. Those strengths and skills might be deployed in a way that, in the big picture, is not pro-social.”
It’s essential that youth workers understand that context, Stolbach said. “A lot of times it is just being open, … conveying some basic respect initially. A lot of kids have a very sensitive meter for how someone is viewing them and whether they’re being respected or disrespected,” he said. “If you come across in a way that says, ‘You’re a human being, and I want to try to help you if I can … and I want to try to get to know you,’ that can go a long way.”
If youth workers exclude and marginalize those dealing with past traumas, that only underscores those traumas, said Dr. Elena Quintana, executive director of the Institute of Public Safety and Social Justice at The Adler School of Professional Psychology in Chicago, who instead urges a more trauma-informed approach.
“It’s saying, we care about you, but we want you to be accountable. We want you to be a pro-social part of the community,” Quintana explained. “That’s what adults should be offering young people, instead of just saying, ‘We’re going to come down on you, and we’re going to come down on you hard.’ … You want them to have the opportunity to develop emotional maturity and some sense of conscientiousness.”
The National Crittenton Foundation, a national umbrella for 27 direct-service agencies that serve marginalized girls and young women, implemented a pilot of the ACEs-aware, trauma-informed approach, then rolled it out nationwide in May 2011. It’s been empowering for them just to know that the foundation is collecting such data, said Jeannette Pai-Espinosa, president of National Crittenton.
“The young women we work with, and the vast majority of youth who end up in foster care, or juvenile justice, or homeless — these are generational patterns. To break that cycle, it begins with childhood adversity. …Unless we get to the root, we’re never going to break the cycle.”
Girls and young women tend to focus trauma inwardly and act out through negative coping methods like drug abuse and smoking, which often means it takes longer for their trauma to be noticed, Pai-Espinosa said. “We just focus on them as the issue, which they’re not,” she says. “It really has changed the frame for them, particularly if they are young mothers, understanding how they can increase their children’s potential for success, by not exposing them to these negative factors. It’s a very different perspective for them, particularly if they were born into families where they didn’t have a positive environment.”
Taking care of staff
As a co-executive director at the YMCA-Chicago, Bocanegra has had the opportunity to develop his staff, and he’s realized that many in the youth field, like himself, have come from tough backgrounds and carry around their own trauma. An unscientific survey of nine staff members showed multiple ACEs for most of them, and an average age of first being exposed to violence at around 8, he said.
Those realizations led to some questions. “The same people we’re asking to be in the front line, doing this work, how are they being taken care of?” Bocanegra has asked himself, and challenges other youth agency leaders to do the same. “Are they doing anything to minimize their trauma? … There is no way that myself or other outreach workers who have been in prison or experienced trauma can just stop the trauma.” Hearing about their youth’s traumas triggers their own experiences. “Many of us have maladaptive behaviors. There’s a reason they’re smoking weed. There’s a reason they can’t sleep,” Bocanegra said.
At CeaseFire, Bocanegra participated in one-on-one biweekly meetings to help staff members process what they hear from the kids they serve. “Most of them have come from the community,” he said. “It’s really challenging a taboo because seeking a therapist in low-income communities is really taboo.”
Working for the YMCA appealed to Bocanegra because it’s becoming a trauma-informed organization, he said, suggesting that to become more effective in addressing ACEs, youth agencies hire more people who can relate to those issues, while investing in them to ensure they’re dealing with their own pasts.
If organizations don’t invest in their staff in that regard, they are likely to experience burnout. “Burnout is just another word for secondary trauma,” Stevens said. “Having to deal with so much trauma will traumatize you. You have to know what your limits are and how to be focused on your own wellness. That means taking breaks. That means making sure you eat right, you get enough sleep, you get exercise, you do meditation. All of those things physiologically will push back on the physiology of trauma that’s being built up.”
National Crittenton has faced the same issues with its staff, Pai-Espinosa said. “We talk a lot about staff being traumatized by their exposure to the stories of these young women, but the question is, is that third-party traumatization, or is it triggering an old trauma? We’re giving people the tools to recognize that in themselves.”
CHRIS Kids also pays attention to staff members’ personal experiences of and how those might affect their care-giving, Colbenson said, whether from their own ACEs or secondhand from youth in their care. Otherwise, Colebenson said, “where does all that emotion go? … It’s hard to hear what horrible things some of these children have lived through. How do you do that, and how are you supported in doing that? … Part of being a trauma-informed organization is paying attention not just to your clients but to the staff.”
Taking trauma-informed approaches will make society safer because youth agencies and others with whom youth interact will notice the impact of ACEs sooner, Colbenson said. “How in the world will children cope with [ACEs] if they don’t get help to cope?” she said. “It’s like a toothache: It starts small, and if you don’t address it, it gets bigger, and then you lose your whole tooth. If you don’t manage and treat diabetes, you lose your feet, your eyesight and, eventually, your life.”
Bocanegra, no stranger to trauma, finally found a semblance of inner peace while in jail, given the time to reflect on his actions and past, along with the therapeutic nature of art and writing, both of which he spent a lot of time doing. And these outlets continued through his work with CeaseFire and, now the YMCA. Through a conversation with his brother, who had done two tours of duty in the Iraq War, Bocanegra came to accept that he had post-traumatic stress disorder.
“I realized at that moment that prisons have become these back doors for mental institutions,” he said. “Art was therapeutic for me. It was very calming for me. I was constantly writing. And then I came home and I started volunteering. I wanted to find a way to give back.”
Ed Finkel is a writer, editor and Web content manager with 20 years of professional experience.