This article discusses violence, suicide and child trauma.
Another week. Another mass shooting of children and teachers in America. In the wake of another indiscriminate mass-murder of children and their helpers, as a health care worker, I again find myself re-evaluating the purpose and role of my chosen profession.
Here I sit, on the other side of the world and still, somehow, the images reach me.
Kittens, laughing babies and the mesmerising handi-crafts in my social media are now gone.
They are replaced with images of texts from somebody’s child who believed they were having their last ever conversation with their parents. As a mother, thoughts of receiving a text like this from my own child continue to intrude in my mind…long after the image has disappeared. We are fond of saying: “I cannot imagine what it must be like”. But I have the opposite problem: I cannot stop imagining what it must have been like for those parents, and my heart shatters in ways that are unspeakable.
I see another image over and over. This one of children, just a few years older than my own, walking single file through the Florida school car park in such orderly fashion that I can’t help assuming they have drilled and prepared for this day countless times.
Seriously. You predicted this? And yet you still did nothing to stop it? the voice inside me screams. If only they would restrict the sales of automatic weapons, as we did here in Australia…then their children might live longer, I think to myself.
But sitting in another country, another context, another culture, makes it too easy to say this. I remind myself: guns and the notion of ready availability are deeply rooted in American culture, history and constitutional law. And, particularly, tied into profits and political interests. And, of course, none of us can solve a cultural problem by viewing it through a different cultural lens.
So, I must leave the US to its own devices. I am resigned to realising I will not solve another country’s problems today. America requires not only a legal change, but cultural one. And this sort of change can only happen from within. Without cultural context, my views are poorly informed and trite. And all that is left for me to do is to reflect on what this means for us, as a community of health workers, here in Australia.
To try and make sense, I follow the conversations on social media. There is, this time, something different. There is more of an angry groundswell than I have seen before. Most US commentary I read finally acknowledge: guns are the problem. The time has come. For some, however, the culprit is “not guns!” but “mental health!” (by which, I think they actually mean mental illness), or “toxic masculinity!”. In any case, I feel hopeful that there will be change – though the tradgedy is that it will be hard-won and have cost many lives.
I have seen so many references to Australia in these conversations. “Look to Australia!”. For in Australia we have similar problems caring for people with mental illness. And we have such toxic views of what “masculinity” should be limited to – yet our children are not regularly mass-murdered at school. Guns, and the way we deal with them in public policy is, unquestionably the reason for that.
For a split-second, I feel grateful. Grateful to live in a country where just over 20 years ago, in an act of extraordinary leadership, one of the most conservative politicians in Australian history removed automatic weapons from the equation. In an age of political cynicism, I doubt I will ever see again in my lifetime, a politician stand up and – without bothering with public opinion or placating the vocal media – simply did what was right for children, regardless of either political or short-term economic cost.
But my gratitude only lasts a moment.
Because a new story now slips its way into my newsfeed. A small article about suicide being the greatest killer of Australian children and teenagers. My cultural smugness about guns, eats a large serve of humble pie.
Psychologists know that aggression is aggression – whether directed inward or outward it is typically sourced from similar emotional roots. Unlike the mass shooting footage, this story appears in my newsfeed once, and then disappears. It seems our Australian children, and their version of death en-mass, don’t warrant a second-showing in Facebook’s algorithm of attention-worthy information.
I look up the figures. I find one report that shows the rate of suicide amongst 15-19 year olds in Australian is 13.4 per 100,000. That compares to gun deaths in the US, which in comparrison are reported around 2.9 per 100,000 in all age groups. America also does just slightly better than us in suicide rates which, for their children, historically sits at around 9 – 11 per 100,000. In fact, it is only in the past two years that the US rates have increased, and moved closer to ours (interestingly, coinciding with the shifts in the culture of American politics).
So, while we (rightly) parade our gun control laws here in Australia, we must remember that it only solved the problem of guns. It did not eliminate child deaths at the hands of violence. We may well be proud that our culture doesn’t allow our children to be mowed-down by other people’s children in mass shootings. But it seems we are still ignoring the other weapons and factors that somehow lead our children to turn their hatred inward, killing themselves at alarmingly high rates.
In the early media discussion about the investigation into children’s suicide, conducted by the Australian Children’s Commissioner Megan Mitchell, the link between suicide and earlier exposure to domestic violence is being given prominence. We often hear the statistic that one woman a week is killed by an intimate (or former intimate) partner. What we don’t hear is that in Australia:
“one child is killed by a parent each and every fortnight.
“Many young people are bystanders, witnesses and victims of family violence. In the more tragic cases, children can lose loved family members. Some children and young people feel so distressed by their exposure to family violence that they exhibit self-harm and suicidal thoughts.
“In the worst of cases, they become direct victims – they take their own lives, or are injured or brutally murdered.”
If we stop family violence, we will save lives – lives of men, women and children.”
The problem I have with the way that media (and government) reports some of these studies, is they often confuse the problem with the solution. No one who understands research disputes that family violence is one of the most dangerous conditions for children to find themselves in. And it is a rampant problem. In my daughter’s class of just 22 students, she has three friends we know of who have been exposed to extreme domestic violence. My daughter is only in grade three.
Uncontrolled gun policy is also extremely dangerous to children. We celebrate that no mass murders have occurred here in Australia for over two decades. But, while we no longer have a problem with guns, our problems with violence, self-harm, dying children and suffering are still well and truly with us. When we see these framed as “single-cause issues”, the public scream for money and action to solve [guns, domestic violence, drugs, mental health, etc] so it can be ‘fixed’. Yet all we do is displace the statistics, and trick ourselves into thinking we have enacted a solution.
However, I suspect when the Commissioner’s report is released in full next week it will reveal something different. It is likely that the report will highlight how domestic violence acts in more complex ways than simply being a straightforward pathway to suicide. The reason I predict this, is that there is now a groundswell of fairly overwhelming evidence that there are multiple potential sources of harm to children that are all associated with the sorts of consequences that we, as a community of health professionals, deal with every day.
Children are not born bad. We now know that several genetic vulnerabilities to personality or behavioural difficulties are either “activated” or “deactivated” by environmental conditions – particularly during pregnancy and the first year of life.
These environmental risks are not certainties – but cumulative. Simply, one or two risk factors are less likely to result in actual harm to a child than three, four or five.
For example, a child in a home experiencing family violence is less likely to experience long-term harm, if they are also living in a community with high levels of social capital and services that can counter balance the impacts of family violence (even if the violence itself cannot be stopped immediately).
In contrast, a child exposed to family violence who also lives in a community where there are few responsive/ high-quality services, few other adults with whom the child can form and access safe and secure relationships, where violence is normalised outside the home, and where many adults are experiencing substance abuse and/ or mental health issues, is at much higher risk of actually experiencing long-term harm. This is one reason that not all abused children are traumatised in exactly the same way.
The model of risk that is gaining increasing popularity is the Adverse Childhood Experiences (ACEs) model. This model recognises individual risk factors, but is based on more specific research highlighting the ways in which these risks accumulate, to increase the danger of long-term traumatic and developmental impacts. Based on available research, the ACEs model identifies the following as being harmful to humans when experienced during infancy and/ or childhood:
- Physical abuse
- Sexual abuse
- Emotional abuse
- Physical neglect
- Emotional neglect
- Mother treated violently
- Substance misuse within household
- Household mental illness
- Parental separation or divorce
- Incarcerated household member
Coordination centres for ACEs data (such as the World Health Organisation, and the Centre for Disease Control, are increasingly discussing data that strongly indicates ‘smacking’ (or spanking) may also be an ACE in and of itself. It is likely that other additional ACEs will continue to be added as more data is collated.
The instances recognised as ACEs are specific experiences that have significant, long-term consequences for human development, health, morbidity and mortality. Research is suggesting that these experiences are amongst the strongest predictors across all disciplines, of a wide range of life-long difficulty.
ACEs underpin human morbitiy and mortality:
Researchers believe ACEs have a ‘dose-response’. This means that “as the dose of the stressor increases, the intensity of the outcome also increases” (Centre for Disease Control, 2017). Cumulative ACEs scores have been identified as one the strongest known predictors of:
- Alcoholism and alcohol abuse
- Chronic obstructive pulmonary disease
- Foetal death
- Health-related quality of life
- Illicit drug use
- Ischemic heart disease
- Liver disease
- Poor work performance
- Financial stress
- Risk for intimate partner violence
- Multiple sexual partners
- Sexually transmitted diseases
- Suicide attempts
- Unintended pregnancies
- Early initiation of smoking
- Early initiation of sexual activity
- Adolescent pregnancy
- Risk for sexual violence
- Poor academic achievement
- Reported income
- Lowered educational attainment
Domestic violence, mental illness, drug use, obesity, liver disease, etc are all important issues. Each of them require specialist services with a sound understanding of the evidence underpinning (and the funding to provide) best-practice responses. However, they are all also outcomes of something far deeper: they are the different ways in which childhood trauma shows up.
By focussing on these single-issues alone, while ignoring the ongoing, underlying childhood trauma that forms their foundations, is increasingly irresponsible. Yes, let’s talk about suicide prevention here in Australia. Let America talk about gun control. But in doing so, let’s also give equal attention to the underlying issues of the massive rates of children in our community being exposed to unrelenting trauma, leading to these outcomes that we are dealing with.
Domestic violence (or abuse or neglect or mental illness) are not only concerning ‘in and of itself’ and by their nature. ACEs helps be more specific: abuse, neglect and violence are concerning because of the impacts they have on human beings.
These impacts can be broadly described as trauma.
There are, however, many experiences that traumatise children: the ACEs model illustrates that equally significant harm is associated with a number of other experiences as well – many of which are far less dramatic than the news stories we are accustomed to reading about. This does not negate the importance of monitoring for risk factors for potential abuse and neglect, but also indicates that addressing other risk factors (such as postnatal depression or financial distress), is equally important if we are going to be successful in crowding-out mental illness, violence, loneliness and human suffering at the foundations.
ACEs research also indicates that the presence (or ‘dose’) of three or more ACEs during childhood, is likely to have negative impacts or consequences observable over the lifespan. It is estimated that at least 20% of children experience three or more ACEs. This means that high proportions (20%++) of children (and, eventually, adults) are likely to have actually had their mental and physical health harmed as a result of their early childhood experiences.
This is not “soft science” – there is a parallel body of stunning neurological research illustrating the pathways through which early trauma impacts on the architecture of the developing brain and genetic structure. To make matters more complex, these genetic impacts can also be observed in future generations.
Part of the difficulty in using the ACEs model in health care, is that we are not typically trained to recognise ACEs in our basic training. Most ACEs are not dramatic, and are tricky-clever at remaining hidden within culturally accepted practices that normalise infant trauma.
Most ACEs will never be ‘noticed’ by neighbours or teachers or nurses, particularly those situations that do not fall into the specific ‘abuse and neglect’ categories that trigger mandatory reporting, let alone reach statutory intervention thresholds. Certainly, we have a long way to go before the public (and therefore politicians) are willing to invest in the sorts of preventative initiatives that are needed.
Let us remember that the child who killed at least 17 people in Florida last week, was abandoned and adopted as a baby, lost one parent through death, and was raised by a solo parent with little social or financial support. Some reports suggest he had been diagnosed with autism and that his adoptive mother struggled throughout most of his childhood to support his development. in turn, she died only last year. He had few social skills to connect with his community or mental health services, and was socially isolated. A life-time of trauma, beginning at birth, with no skilled or consistent intervention. And legal access to automatic weapons. Violence (whether by guns, cricket bats, or self-harm) is not “caused” by mental illness, any more than it is “caused” by diabetes. But we need to acknolwedge they are all built on the same foundations. Violence is simply one of the many possible points along the life-trajectory of the traumatised baby.
In hardcore medicine, the best, evidence-based ACEs initiatives are often seen as “fluffy” and receive little sponsor, government or donor support. Social support groups, financial relief, home visitors, mindfulness, play groups, drama and somatic therapies, cooking co-ops and other programs that build parent capacity are simply not as well-supported as programs and policy designed to “put out fires”. We wring our hands over the fires burning today, forgetting they were lit decades earlier by practices and social conditions that are still being used today.
And so, I reaffirm my commitment to inviting “softness” into my chosen profession – even though it is not yet taken too seriously by my many of my peers who specialised in the “hard” issues. I reaffirm my commitment to doing work which increases the love that babies experience, within their first year.
And, as it turns out, love really does win. Within each child’s ecology, there can be not only a wide range of risk factors, but conditions known as protective factors. Protective factors are those conditions in the individual-family-community that are known to (a) reduce the risk of harm and trauma occurring and/ or (b) buffer and mitigate against the impact of harm if it does occur or not noticed. Some researchers call these HOPEs (Health Outcomes of Positive Expeirences). HOPE is – like ACE’s – also cumulative and can, in many circumstances, completely cancel out and negate the presence of risk factors. Examples of HOPE in infancy and early childhood may include:
Child factors: early, secure attachment relationships.
Family and parent factors: warm and nurturing parenting, high engagement with the infant, knowledge of parenting and child development, parental age.
Community and environmental factors: neighbourhood social capital, adequate housing, low financial stress, concrete support and availability of responsive services.
Many of the HOPE factors can be described as love. Increasing the opportunities for babies to experience and feel the love their parents and families have for them. And increasing the ways that parents can know they are loved and supported by their community.
I get it. Many people find it’s hard to give serious weight to this simple love. In the face of the ‘big issues’ – guns, suicide, child abuse. But statutory child protection programs and other tertiary interventions only reach and respond to a relatively small number of children – those at the greatest risk of significant harm: there are so many more children experiencing ‘sub-threshold’ levels of risk and harm yet equally pervasive and harmful impacts of trauma.
Working to improve HOPE and promote love is what I do. Providing families with relevant supports that are palatable to them, and supporting their empowerment and education – is perhaps the most promising way available to help protect children in in difficult circumstances. My work in training and teaching health workers to deliver a program called the First Touch Program feels more important today that ever before. This is a small, humble, evidence-based program that uses infant massage and a range of other mechanisms – such as social support and something called “mentalisation” – to nurture parents in the love they have for their baby and, in doing so, empowers them to give their babies a foundation for HOPE.
As I look over the ACEs, and the increasing visibility of their consequences in our communities, I realise that the research is increasingly calling on us to give greater prominence to programs like our First Touch Program. Most of the known ACEs are underpinned by how we use touch to define our relationships with our babies and children. Those that are not directly related to touch, directly impact on the emotional and body availability of parents.
Together with my colleagues, we work in perhaps one of the most under-noticed, under-funded, under-valued sections of the health care community. Results of our work are not “seen” by the community (except in the media portrayals of Romanian orphanages or footage of premature babies born with drug addiction). But mostly people don’t see what we do simply because doing long-term prevention results in the absence of fires. A happy child who has healthy adaptive skills is not newsworthy. What we do is in many ways not complex. It has no complicated formulas. Yet it is not straightforward. To do this work we cultivate the skill of being present for parents without the ego-boost that comes with fixing, listening without judging, and honouring without needing. This is the art of supporting love. And it is in this little corner, doing this subtle, piece-meal work, that I know I have the most significant impact that I can.
Of course, the First Touch Baby Massage Program is just one of the many ways we can reduce ACEs and increase HOPE. To see real change in our communities, we must do better at all other HOPE-building activities:
- Offering evidence-based, non-stigmatising parent education and support programs that are palatable to parents, The First Touch Baby Massage Program is just one, Circle of Security is another…and there are many more;
- Increasing the capacity of our organisations to link families together and with their actual community (as distinct from “more services”);
- Screening for ACEs, and contributing to ACEs data collection initiatives in all sections of the health-care sector;
- Being willing to commit to eliminating financial and return-to-work stress on the people who need to be available for babies to develop the foundations for long-term health;
- Advancing discussion and education on the use of, and policies to protect positive, safe touch in homes, childcare, and schools;
- Providing education to staff on trauma-informed practice (such as the SMART model);
- Reconceptualising ‘behaviour management’ policies in our childcare and schools, to ‘relationship or community building’ policies and practices;
- Advancing discussion and supporting staff exploration of meeting attachment needs of pre-verbal children – particularly in families and child care settings; and
- Evaluating all practices, policies and incidents from a trauma-informed perspective.
My job is, in a nutshell, to promote the sort of love that changes lives. May yours be too.
If this article has raised any issues or distress for you please contact Lifeline on 13 11 14