By Alisha Moreland-Capuia, M.D., and Ebony Wortham, JD and CTIPP Board Members
“CTIPP embraces an anti-racist, public health framework by addressing the injustices that cause poor health and supporting the integration of promotion, prevention, resilience-building and healing activities. We recognize the importance of historical and intergenerational inequities that impact health across the lifespan as well as the health and welfare of families. We know that people are fundamentally resilient and we prioritize actions and policies that support and build on natural strengths and disrupt practices and policies that perpetuate harm. We believe that trauma-informed approaches address social and economic justice as well as healing.”
CTIPP is committed to ensuring that our policies and practices align with principles of diversity, equity, inclusion, and justice (DEIJ). With the support of our DEIJ committee, We are actively working to ensure that CTIPP’s agenda and priorities fully reflect this commitment.
Felitti, Anda and Nordenberg et al.’s seminal 1998 Adverse Childhood Experiences (ACEs) study demonstrated a deep connection between early chronic adversity and traumatic experiences and increased risk for chronic medical and mental health conditions, and substance use disorders in adulthood. (Felitti, Anda, Nordenberg et al., 1998)
There is consensus that early childhood trauma (and what happens in childhood) has implications for an individuals’ health trajectory throughout their lifespan. From a public health perspective and Benjamin Franklin’s words that “an ounce of prevention is worth a pound of cure” – the original ACE study was critical in highlighting that early, upstream intervention and prevention could increase individual, community and societal wellness.
Of note, the demographics of Felitti, Anda and Nordenberg’s early study included over 17,000 participants of which nearly 75% were white, educated, middle or upper class, and had health insurance/coverage. The original ACE survey queried participants on a range of psychosocial stressors spanning exposure to divorce, food insufficiency, limited access to clean clothes, exposure to family members with mental health and or substance use challenges, all forms of abuse, and family history of entanglement with the criminal justice system.
Over 65% of participants acknowledge having experienced at least one adverse childhood experience demonstrating that trauma can and does traverse class, race, socioeconomic status; trauma is ubiquitous and spares no one.
There have been several spinoff studies of the original ACEs study. One such spinoff is the Philadelphia Expanded ACE study conducted in 2012-2013 in Philadelphia with over 1700 adult participants from urban Philadelphia. (Philadelphia ACE Survey, 2012-2013)
The Philadelphia Expanded ACE Survey is also deemed a seminal study as the original ACE study did not include significant socio-environment, structural and historical factors referred to as “community-level-adversity” which can also contribute to and exacerbate childhood and adult trauma to include racism, discrimination, neighborhoods (zip codes), exposure to community violence and the foster care system.
The Philadelphia Expanded ACE study included a more racially diverse, urban demographic and showed an increase in ACE scores when community-level-adversity was accounted for. Moreover, the Philadelphia Expanded ACE study demonstrated the connection between the structural and historical impact of racism and the intensification of chronic stress and trauma in diverse, urban communities.
While racism and discrimination as a form of preventable trauma is not a new concept, it has not been widely appreciated in academic spaces until recent. In 1995, Dr. David Williams, now Harvard Professor, developed the “Everyday Discrimination Scale” (Williams et al., 1997), a tool that validly measures the chronic (physical and psychological) impact of what he coined as “everyday discrimination” in historically marginalized persons and communities. In brief, discrimination contributes to chronic stress and trauma. Several studies confirm racism and discrimination as trauma. (Williams et al., 2018; Carter et al. 2013; Bryant-Davis and Ocampo, 2006; Butts, 2002)
The original and initial trauma-informed principles framework included safety, choice, collaboration, trustworthiness, and empowerment. Cultural/historical/gender considerations were later added to the framework.
Dr. Williams’ work connecting discrimination and trauma was done before Felitti and Anda’s 1997-98 seminal ACE study. The Philadelphia Expanded ACE’s study conducted in 2012-2013, in many ways synthesizes the two studies and demonstrates a shift toward a broader model of trauma like the one from the RYSE center in 2015 (Image 1).
The RYSE 2015 model provides a more inclusive, comprehensive framework of trauma throughout the lifespan, showing racism, discrimination, generational and historical trauma + acute and ever-present social and structural racism and its impact on gene expression pre-conception through adulthood and its potential to accelerate early death. (Stephens, 2015; RYSE,2015)
In 2020, Bernard and colleagues introduced the concept of C-ACE with “C” standing for culturally informed. (Bernard et al. 2020) Bernard and colleagues cited and acknowledged the multiple studies on the psychological impact of exposure to racism in early childhood as a potentially traumatic event (PTE) and that PTE’s disproportionately effect Black youth, accounting for the mental health disparities and toxic stress observed in Black youth. Bernard and colleagues called for an extension of the ACE framework to intentionally acknowledge the psychological impact and trauma of racism in Black youth.
Antiracism as a term and idea can be appreciated in the literature as early as the 17th century with the Germantown Quaker Petition Against Slavery where German immigrants are said to have petitioned for equal human rights for all and this document is said to be one of the first American documents of its kind. (Johnson, 1988)
Historian Ibram X. Kendi has popularized the ideology and practice of antiracism in his book “How to be an antiracist”. (Kendi, 2019) Kendi’s work is a culmination of prior research that has demonstrated how historically and structurally racist systems, policies and practices perpetuate trauma within historically marginalized communities and do not support healing.
Being antiracist is acknowledging history, cultural and gender factors, recognizing and preventing re-traumatization, centering safety and ultimately it is about helping people, systems and society heal – all trauma-informed principles. If the foundation of antiracism principles are trauma-informed principles, then being fully trauma-informed requires that someone be fully antiracist and to be fully antiracist one must also be fully trauma-informed.
Bernard DL, Calhoun CD, Banks DE, Halliday CA, Hughes-Halbert C, Danielson CK. Making the “C-ACE” for a Culturally-Informed Adverse Childhood Experiences Framework to Understand the Pervasive Mental Health Impact of Racism on Black Youth. J Child Adolesc Trauma. 2020 Aug 11;14(2):233-247.
Bryant-Davis, T., & Ocampo, C. (2006). A therapeutic approach to the treatment of racist-incident-based trauma. Journal of Emotional Abuse, 6(4), 1–22. doi:10.1300/J135v06n04_01
Butts, H. F. (2002). The black mask of humanity: Racial/ethnic discrimination and post-traumatic stress disorder. The Journal of the American Academy of Psychiatry and the Law, 30(3), 336–339.
Carter, R. T., Mazzula, S., Victoria, R., Vazquez, R., Hall, S., Smith, S., Sant-Barket, S., Forsyth, J., Bazelais, K., & Williams, B. (2013). Initial development of the Race-Based Traumatic Stress Symptom Scale: Assessing the emotional impact of racism. Psychological Trauma: Theory, Research, Practice, and Policy, 5(1), 1–9. doi:10.1037/a0025911.
Felitti VJ, Anda RF, Nordenberg D et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACEs) Study. Am J Prev Med. 1998; 14: 245-258.
Johnson, H. B. (1988). The Germantown Protest of 1688 against Negro Slavery. Monatshefte, 80(3), 268–277. http://www.jstor.org/stable/30161607.
Philadelphia ACE Survey (2012-2013). Available at: https://www.philadelphiaaces.org/philadelphia-ace-survey Accessed January 25, 2022.
RYSE Center (2015). Adding layers to the ACEs pyramid: What do you think? Retrieved from https://www.acesconnection.com/blog/adding-layers-to-the-aces-pyramid-what-do-you-think [Google Scholar]
Stevens, Jane. Adding layers to the ACEs pyramid — What do you think? PACE’s Connection. April 7, 2015. Retrieved from https://www.pacesconnection.com/blog/adding-layers-to-the-aces-pyramid-what-do-you-think on January 25, 2022.
Williams, M. T., Printz, D. M. B., & DeLapp, R. C. T. (2018).
Assessing racial trauma with the Trauma Symptoms of Discrimination Scale. Psychology of Violence, 8(6), 735–747. doi:10.1037/vio0000212.
Williams, D.R., Yu, Y., Jackson, J.S., and Anderson, N.B. “Racial Differences in Physical and Mental Health: Socioeconomic Status, Stress, and Discrimination.” Journal of Health Psychology. 1997; 2(3):335-351.