SALT LAKE CITY — Long after they've stopped crying, children separated from their parents at the southern border of the U.S. could suffer long-lasting consequences of trauma, including addiction, disease and possibly dementia.
So could your children, if they’ve been affected by more common adverse events, such as substance abuse, divorce or a serious illness that incapacitates a parent.
For the past 20 years, researchers have learned that "what happens in childhood doesn't stay in childhood," as the authors of a new book published by the American Academy of Pediatrics say.
“The way the body adapts to ongoing stress is useful in the short term, but can be really damaging in the long term,” said Dr. Andrew Garner, who with Dr. Robert A. Saul, wrote “Thinking Developmentally."
But this doesn't mean all children who endure traumatic circumstances will be damaged adults.
"No matter what kind of adversity you look at, most of us will ultimately be resilient," said Megan Gunnar, director of the Institute of Child Development at the University of Minnesota in Minneapolis.
Research into neuroplasticity — the brain's ability to adapt throughout life — has shown that long-established habits of thinking and behavior can be changed. And Gunnar suspects there's a specific window during which the brain of a child traumatized early in life might recalibrate how it responds to toxic stress: puberty, the time of significant hormonal change.
But the most important factor in how a child overcomes trauma is the consistent presence of a stable and nurturing parent, which is why the United States' policy of separating children from detained migrant parents has child-development experts so upset.
Border agents separated more than 2,000 children — some as young as 3 years old — from their parents or caregivers between April and June 20, when President Donald Trump signed an order rescinding that part of his "zero tolerance" immigration policy; about 500 had been reunited as of June 30.
Biology of attachment
Newborns don’t recognize their parents right away, but around the time they start crawling, they have a desperate desire to be with their parents, as any parent who’s tried to leave a toddler with a babysitter knows.
That attachment occurs in all primates and exists for good cause: to ensure that the child stays close to the people most invested in keeping her alive.
“We’ve evolved so that these systems get really revved up about the time we could walk away from our parent,” Gunnar said. “At around 7, 8 or 9 months, the baby begins to say, ‘I don’t care if my babysitter reads the story better than anyone else. I want you reading the story because you are the person I’ve formed this incredible bond with. That is their safe place.”
So long as the parent is near or accessible, the child can quickly recover from a stressful event, such as getting vaccinations.
“You can go to the doctor with a 15-month-old, and they’ll get shots in both legs and they’re going to scream their heads off, but if your relationship with the child is secure and you’re there and available, if I measure it, you won’t see much of a stress response at all. They’ll cry, but the body won’t kick in this defensive hormonal system. And we’ve recently discovered that this lasts until puberty,” Gunnar said.
For older children and adolescents, a mother who has a strong bond with her child doesn’t even have to be present every moment to mitigate the effects of a mildly stressful event. In one study in which children had to give a speech in front of other people (“one of the best stressors we know that we can do ethically," Gunnar said), being able to talk to the parent after the speech, even only on the phone, enabled the children’s stress levels to quickly return to normal.
Short-term stress, whether a vaccination or a speech, can be good for a child, said Garner, clinical professor of pediatrics at Case Western Reserve University in Cleveland.
“Some adversities can be positive, in the sense that the stress response is brief, usually because there’s a nurturing relationship there to help the child turn off the stress response. That can actually help build resilience for the future,” he said.
When the parent is missing for a longer period, however, “we’re removing the primary source of stress regulation,” Gunnar said.
“And the very removal of that parent is another stressor. We’re kicking in all the biology that will potentially change the way the brain functions,” she said.
Why toxic stress endures
Dr. Vincent J. Felitti, an internal medicine doctor, is widely acknowledged as the first person to show the link between early trauma and poor outcomes later in life.
Felitti was supervising obese people on a liquid diet in the 1980s when he discovered that one of his patients, a woman who had lost more than 100 pounds but regained 37 pounds in three weeks, had been sexually abused as a child.
"In short order, it became clear that obesity was not her problem, it was her solution to problems we knew nothing about," Felitti said.
After he learned another woman he was treating also had a history of sexual abuse, Felitti began interviewing others in the program and learned that more than half of 186 patients had a history of sexual abuse. Additional surveys by other physicians replicated the findings.
The discovery led to a long-term study of more than 17,000 people that is known as the "ACE Study" — ACE is an acronym for adverse childhood experiences.
Participants were asked if they had experienced any of 10 types of adversity in childhood in three categories: household dysfunction, abuse or neglect. Felitti and his co-investigator were flabbergasted by the results. Although the subjects were largely well-educated and middle-class, two-thirds reported experiencing at least one of the adverse events, and 87 percent reported two or more.
Those with the most adverse experiences in childhood had the greatest number of physical and mental problems later in life.
Now retired from clinical practice and living in San Diego, Felitti said there are three reasons childhood trauma shows up as biomedical disease a half-century later.
The first is that people with unresolved trauma employ coping mechanisms as adults, “all of which have distinct short-term benefits but many of which have major long-term detriments,” Felitti said. These coping mechanisms include overeating and drug and alcohol addiction, all of which are major factors in disease.
Secondly, early trauma seems to dampen immune function and keep the body in a constant state of inflammation.
“It’s been discovered in the past decade, that under conditions of chronic, major, unrelieved stress, such as adverse childhood experiences, there is chronic hyperstimulation of multiple areas of the brain, one of which is involved in immune system function,” Felitti said.
Gunnar, at the University of Minnesota, noted that in one animal study, baby monkeys who were taken from their mothers, had weakened immune systems for the rest of their lives even though they were returned to their mother after two weeks and then lived in normal conditions.
The third factor Felitti described is epigenetics, the study of how a person’s environment and experiences can affect the functioning of genes.
When we are repeatedly exposed to stress, a process called DNA methylation occurs, changing how the gene works. When the brain is always on high alert, preparing for the next onslaught of stress, a gene's “on-off” switch can get stuck on “on" as a defensive mechanism, and researchers believe this effect can pass to another generation.
The field of epigenetics was new when Felitti and his co-investigators began their research so they did not consider epigenetic effects in the ACE Study, which ended two years ago after 20 years of followup study of more than 17,000 people originally enrolled.
What are the solutions?
When Felitti first presented his theory, at a gathering of the North American Association for the Study of Obesity in 1990, he was met with criticism from some people who said his patients must have been making up stories about past abuse to cover for their “failed lives.”
However, when the physician, who was chief of Kaiser Permanente’s Department of Preventive Medicine, partnered with researchers from the Centers for Disease Control and Prevention and studied more than 17,000 people for 20 years, his findings were hard to refute.
Since then, hundreds of other studies have been done on the biological effects of childhood trauma and confirmed Felitti’s theory, including one report published earlier this year that suggests a connection between early trauma and dementia in rats may translate to humans.
Although it's not been proven, Felitti believes the mere act of talking about trauma can help reduce some of its effects.
He said outcomes could be improved if physicians know not just how patients are sick, but why they are sick, and that patient health surveys should ask about adverse events.
Any effort to incorporate discussion of past trauma into routine doctor visits is difficult because of liability and privacy issues, as well as what Felitti describes as the resistance of non-psychiatrists to delve into psychiatry. But there are other, simpler things that Americans can do to help heal the wounds of traumatized children.
In Minneapolis, Gunnar has been studying children who were unable to form stable relationship early in life, such as children adopted from orphanages. She believes that hormonal changes might open up a window for the brain to recalibrate its response to stress if the child's later environment is supportive and non-threatening.
The most important thing, Gunnar said, is to ensure the child has a secure, lasting relationship with a parent or caregiver who is consistent and supportive.
"That relationship piece is the core critical thing," she said.
Garner, in Cleveland, believes that in the case of the migrant children separated from their parents, rebuilding that bond is the most important task, even though it may be difficult because the children, depending on their age, may be angry and oppositional with the parent.
"The relationship is the foundation for how we build resiliency, how we learn things. We learn things in the context of relationships," he said.
Another way to help ramp down the biological response to stress is to quickly re-establish routines.
“Routines make the world predictable and safe, so kids know what’s going to happen. That also decreases the stress response,” Garner said.
Once the primary relationship is strong and routines are established, the parent or caregiver can help the child learn that there is nothing wrong with negative emotions like fear or anger, but that there are positive ways of dealing with them, such as immersing themselves in something they enjoy, such as drawing, reading, playing an instrument or taking part in a sport.
“If we can channel that energy into something constructive, now we’re really cooking with gas,” Garner said.
Garner’s new book "Thinking Developmentally" cites a study about the effect of physically stroking infants whose mothers were experiencing postpartum depression, thus putting the babies at risk for epigenetic changes. Infants who were stroked by their mothers 5 and 9 weeks after birth had fewer epigenetic changes, offering more evidence of the importance of touch and supportive parenting, which Felitti believes many American children don’t get.
He remembers being skeptical about a report he heard a decade ago about the importance of making eye-to-eye contact with newborns. But when he tried it with his grandchild, he was astonished at the effect it had on the baby, and said that small things, such as speaking to newborns regularly, help create the bond that will help the child be resilient if trauma later occurs.