Ann McKnight has extensive experience in clinical social work and therapy. Methods and approaches she's learned about and shared to benefit her patients are the Enneagram, Cognitive Behavioral Therapy (CBT), Acceptance Commitment Therapy (ACT), mindfulness, centering prayer, mind-body research including sensory work, and Eye Movement Desensitization and Reprocessing (EMDR). She is certified in Brainspotting and Trauma Studies through Bessie VanderKolk's Trauma Center in Boston. In addition to her private practice, Ann speaks and teaches regarding a variety of topics, including Nonviolent Communications and this TEDx talk on Restorative Circles.
Dr. Barb: In a recent educational presentation, I heard about the connection between adverse childhood events and people's later experience of pain. This made me want to explore the effect of adverse child events (or ACEs) in more depth, and to share the effects of what many of us may experience, whether we know it or not. I contacted Ann McKnight, who was a guest here last year talking about brainspotting. Ann is a therapist who practices here in West Michigan. Welcome, Ann.
Ann: Thank you, Barb. It's nice to be back.
Dr. Barb: Yeah, well, I appreciate your time and expertise in speaking into this topic. It's really been quite recently that I've become aware of the term ACEs, or again, adverse childhood events, and it's fascinating to me what might result from that. So can you talk a little bit about it, what it is, and what we understand?
Ann: Yeah. The history of it, if I can give a little background on it, because the research is really not new, so I find it kind of interesting that all of a sudden it's coming more into public conversation. The research was done back in the 90s, and it started with two doctors, Felitti and Anda, who were doing some research on weight loss, because they realized that obesity was a huge problem and very expensive in our healthcare system. So they were trying some different treatments for people and in one of them, folks lost weight in a really dramatic way. And they were thinking, “Wow, this is wonderful.” Then lo and behold, for some of the people who were part of the test, they went back and started going back to their old eating habits, and their weight went up again. And the doctors were kind of wondering, “What is going on here?”
Isn't this what they wanted, to lose weight? And so they started asking some questions about these folks' history, and realized that they all had experienced adverse sort of chronic stressors in their upbringing before the age of 18. So then they went to Kaiser Permanente, which is a really large healthcare system out in California—I think it's the largest one in the country—and they got data from thousands and thousands, like tens of thousands of people, and realized there was a very high correlation between the types of experience that people can have in childhood and risk factors for things later in life, like not only depression and anxiety, but obesity, diabetes, cancer risk, heart disease, chronic diseases that involve chronic inflammation. So it really was kind of maybe too much for people to get their minds around when it first came out because it was such a different way to think about things. And it just kind of came back into the spotlight really, within the last ten years, that there's been more discussion in physician's offices and things.
Barb: So how often do you apply the ACE scores to what you do? Or does it actually apply to you as a therapist specifically? Does it help you? Is that a tool that can assist you?
Ann: Yes, definitely. I find it very helpful, and in fact I have folks fill it out before they come in for their initial session along with some other intake paperwork, because it's really good for me to know what risk factors they might have. I think about the current turbulence that we're in right now, and I think it's upsetting for everyone, but someone who has a higher ACEs score is definitely going to have a harder time regulating themself, a harder time finding a way to feel calm, and that's good information for me to know right from the get-go with folks.
Barb: So does a high ACE score correlate highly or not so highly with a struggle, a future struggle with mental health issues?
Ann: There is a high correlation, a staggeringly high correlation. I wouldn't say it's a certain cause, but I think these are questions that anybody who is struggling with depression and anxiety, these are things that we should be asking them right up front. In fact, I do believe that the healthcare system—everyone from pediatricians to family practice physicians—it would be helpful for them to ask these questions as well.
Barb: Is it simple enough to review what the questions are, what the points are for our listeners, or is it a fairly complex list?
Ann: Absolutely. No, it's really ten simple questions. And there's some arguments out there about, are these the only things that give people ACEs scores? I think that the general ballpark that we're looking at is experiences that people have had that are more than just one-time stressors. It's more than just a one-time upsetting event, but things that are more like chronic stress or toxic stress. So I'm happy to read the ten points to you.
Barb: I think that would be helpful for listeners to self-identify or further consider.
Ann: Yeah, okay. So the overall thing is prior to your eighteenth birthday:
- Did a parent or other adult in the household often swear at you, insult you, put you down or humiliate you, or act in a way that made you afraid you might be physically hurt? So that's a yes or no.
- Did a parent or other adult in the household often push, grab, slap, or throw something at you, or ever hit you so hard that you had marks or were injured?
- Did an adult or person at least five years older than you ever touch or fondle you or have you touch their body in a sexual way, or attempt or actually have oral, anal, or vaginal intercourse with you?
- Did you often feel that no one in your family loved you or thought you were important or special, or your family didn't look out for each other, feel close to each other, or support each other?
- Did you often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you, or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
- Were your parents ever separated or divorced?
- Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her; or sometimes often kicked, bitten, hit with a fist or hit with something hard; or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
- Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
- Was a household member depressed or mentally ill, or did a household member attempt suicide?
- And lastly, did a household member go to prison?
So those are the ten questions. And what folks do is add up their score. And what's really interesting, many people—I think it's maybe 63 percent of the population, 63 or 65 percent have one ACEs point, but the more ACEs points you have, your risk for all the things that I mentioned before increases. Once you get to four points, the risk for mental illness, depression, anxiety, risk for post-traumatic stress and so forth, and also physical illnesses goes up exponentially. So it's really kind of fascinating research and really quite clear. It's been tested over a long period of time on just a really huge number of people across socio-economic and class differences as well.
Barb: I was with a group of women not long after I had learned about this association between the ACE scores or the ACE events and pain and chronic pain. And so the group of women, we pulled up the test, and I think it was eight out of the ten had at least three to four of those.
Barb: Seemingly all “well-adjusted” adult women, high performers, high functioning. So I'm also curious as to what might differentiate those who have that exposure and go on to really do life well, and those who may go on and really have a bigger impact from a result of that?
Ann: Yeah. Boy, that's the big question, isn't it? Because there is such a variety in the way people walk through life with this. I think of it like other things, where I think our DNA and our family history and the environment that we grow up in have an impact on what things we're going to manifest. I think some families have more vulnerability for heart disease, let's say, and some people have or some families have more of a tendency to have intestinal problems, and some have more of a tendency to have mental health issues. So I think that may be part of it. I think goodness of fit of the social environment outside of the family home, around people, also can make a big difference.
It's not unusual for people who are really high achievers to have a very high ACEs score, because they have a lot of drive and a lot of energy, and they want to work really frantically not to have the life and the experiences that they grew up with. I'm thinking about somebody who I know who actually grew up in the Siege of Sarajevo, and he runs ultra marathons now because he uses all of that. That's his outlet for his traumatized energy, he would say. So, yeah, it's a complex little puzzle about why things work out for one person.
Barb: Yeah, and I'm sure it depends on then later in life, what event may occur that might trigger a spiral or something. Obviously so many factors at play there, but I'm wondering, is there some benefit of just awareness for individuals?
Ann: Absolutely. I've seen so many people—that's one great thing about providing just the information of the ACEs test—many people will say to me, “I've never heard of this,” or, “I didn't even know that existed,” or, “No one's ever asked me those questions before.” So then it gives us an opportunity to talk about how the experiences that really were not of their doing are really affecting how they experience life, and it can be a tremendous relief for them. I think women especially, and those of us who are in midlife, can have a lot of guilt about things or, "I don't measure up," and those kinds of thoughts. To see that maybe those thoughts didn't actually originate with you, maybe those are coming from some protective structures that you have in place in yourself to try to mitigate the impact of the experiences that you had when you were growing up. So it gives people a bigger context to understand why they may feel the way they do.
Barb: Yeah, it feels like a really basic stepping stone to moving forward more successfully, to have that perspective. So in your practice and in the past, we've talked about some areas that you focused on, the brainspotting and the EMDR, the eye movement and desensitization and reprocessing approaches. Are those tools specifically effective for those with the higher ACEs scores, or are those seen as completely separate, or can you talk about how you might bring those together?
Ann: Yeah, I would absolutely—I find brainspotting in particular—I actually really don't use EMDR that much anymore because I think brainspotting, in my experience, has been so much more effective and gentle with wider reaching help for people. But yes, definitely oftentimes when people live in those kinds of circumstances, they have what we would call post-traumatic experiences. So they have memories that are recurring or thoughts or feelings or emotions that when they're thinking about a past event, it feels like it's happening right now. Or they may have certain issues and situations in life where they find themselves getting triggered or reacting in ways that they don't like. Brainspotting is just such a wonderful way to get into that subcortical brain—the part that's beneath our consciousness where reactions come from—and to help integrate those experiences, so that even if they've had these traumatic experiences growing up, they can still find some freedom now, and find a sense of empowerment, and find that they feel like they have more of a sense of choice in their own life, and that they're living and acting and relating to people in a way that has a lot more integrity for them.
Barb: Is your management of patients different based on an ACE score?
Barb: Is your whole approach to helping individuals heal and become healthier going to depend on that ACEs score?
Ann: Yeah. I think if somebody has an ACEs score of four or more, that's certainly something we want to talk about. And one of the things that we want to talk about with that is that their cup is going to overflow, in not a good way, faster than other people. So if you have a higher ACEs score, you likely are going to have a lower threshold of tolerance, or you have much more discomfort around... it kind of looks like this, someone might be saying to themselves, “Wow, I am so angry about this,” or, “I'm really upset about this, and everybody else seems to be calm. What is my problem? Why is this such a big deal to me?” And it's just because their system has a preset, the way it uses cortisol, and the fact that their body has gotten used to that high level over time, and it just makes for more reactivity.
Barb: So understanding those people are at risk is important, but is there a then subsequent regulation that's successful for them to better manage that moving forward? And is that what you train them to do?
Ann: Yes. Yeah, we do some things in the office during sessions, and also there's just so many great things in normal life that people can use as resources for themselves. So the things that we all talk about in health care—yoga, mindfulness, all of that—I like to really talk with people just about the basics, just breaking it down in the simplest way.
Like thinking about your sympathetic and parasympathetic nervous system. So your sympathetic nervous system is when you have those physical sensations of tightness in your belly, or maybe shortness of breath, or your palms get sweaty, kind of those fear responses. Parasympathetic is when people are feeling a little bit more relaxed, and a little bit more at ease, a little bit more open, and just having people start to notice just their purely physiological reactions and how they can have an impact on those, without even needing to think or talk about issues or what's going on—whether that's through mindfulness that people can find some way to regulate through a breathing practice, through yoga over time, just through awareness— but bringing the focus to physiology. Oftentimes people who have a high ACEs score are stuck at some level in that sympathetic response, and we want to just help bring some flexibility to that.
So for one person it may look like they don't know how to play, or they don't have anything in their life that feels joyful to them, or they don't really know how to be creative or have a form of expression that suits them. So that may be something that works for one person. For another person, it might be physical activity, and really getting more connected with their body again, because oftentimes people who—women especially, who have higher ACEs scores—have learned to numb or disconnect from themselves, or they often just don't even know how they feel or what they feel. I ask a lot, “Where do you notice that in your body?” Or, “What do you notice happening in your body right now?” And that can be just a new way to look at things.
Barb: So do you have any favorite resources you could recommend for listeners who might want to understand or learn more about this?
Ann: Yeah, absolutely. There's a great TED talk by Nadine Burke Harris. Now, Nadine Burke Harris is really the person who I think brought this back into the spotlight of mainstream thoughts. She is a pediatrician, and last January she was sworn in—not in 2020, but in 2019—she was sworn in as the first surgeon general for the state of California because of her work around ACEs and bringing it into awareness. She has a really great book called The Deepest Well: Healing the Long-Term Effects of Childhood Adversity—great book, fun to read also—and then she has a TED talk that is also really interesting, and she kind of gives a nice summary of it. I also really like this book called Lost Connections by Johann Hari. He's not talking only about ACEs, but he does mention it in ACEs, along with a lot of other things, but the subtitle of the book is Uncovering the Real Causes of Depression and the Unexpected Solutions. That's one of those books that I would like to give out to every single human being, because I think it addresses some of the real concerns that we have in our society right now.
Barb: Well, great. Thank you for those very specific resources. I think that's something that if we haven't experienced it ourselves, we all know someone who has. So I think it's great to have something specific to reach for to learn more about it. So thanks for our time together today, Ann. I really appreciate this, and as we conclude our time together, I'd like to ask, where do you find fullness at this stage of your life?
Ann: Being an empty nester.
Ann: My husband and I are kind of having a blast with that right now.
Barb: Oh, great.
Ann: And that's been cool. Also it's been a really interesting time to kind of revisit my own self and my own family history, and it's just really nice in the middle of life to have some different questions around that and different things to explore. It just feels fun.
Barb: Good. Well, it is nice to kind of refocus, isn't it?
Barb: When you're a working mother, you don't always have all the space in your life to ask yourself some of the important questions. So it's great that you can carve that out for yourself now. So thank you for your time today, Ann.
Ann: You're so welcome. Thanks for having me, Barb.
Dr. Barb DePree, M.D., has been a gynecologist and women’s health provider for almost 30 years and a menopause care specialist for the past ten.