Measuring trauma

The most common measure of nonmilitary trauma is a short survey of “adverse childhood experiences,” known around the world as the ACE test. The index consists of simple but intrusive yes-or-no questions: When you were growing up, did a parent or adult in the house beat you? Beat each other? Did any of them verbally or sexually abuse you? Emotionally ignore you? Were any of them alcoholics? Drug users? Incarcerated? Mentally ill?

Compared to someone with zero “yes” answers, a person with four or more is six times more likely to struggle with depression; seven times more likely to grow up alcoholic; 10 times more likely to inject street drugs; and 12 times more likely to attempt suicide. They’re far less likely to hold a job and more likely to end up homeless.

Children with high scores tend to enter adulthood without the normal ability to manage stress, navigate relationships or practice delayed gratification. Further, those with an ACE score of four or higher are twice as likely to have heart disease, twice as likely to be diagnosed with cancer. They’re more likely to miscarry or give premature birth, and more vulnerable to diabetes, strokes and liver disease. For those who score six or higher, life expectancy drops 20 years.

“If I grow up in a chaotic situation, I don’t know how to be calm,” Pittman-McGee says, describing a person with a high ACE score. “I know how to be chaotic.”

In the United States, from 2009 through 2015, 32 states and the District of Columbia carried out ACE surveys, according to the U.S. Centers for Disease Control and Prevention. Nearly 30 nations conducted ACE surveys, according to the World Health Organization in Switzerland.

What's your ACE score? Start the quiz

What's your ACE score? Start the quiz

The results: No social class, ethnicity or geography spares their children.

“This is a human phenomenon, which is global,” says Robert Anda, a public health physician who co-created the survey.

Just as universally, ACE scores spike in environments of concentrated poverty, widespread economic uncertainty and high unemployment. Surveys carried out across Milwaukee lay bare entire neighborhoods where scores of four or higher are more the norm than the exception.

One survey of African-Americans and Latinos in the city, conducted by the Black Health Coalition of Wisconsin, found that more than one in three carried a four-plus ACE score. Separately, statewide ACE surveys showed that nearly two-thirds of Wisconsinites who grew up with an incarcerated adult have at least three additional ACEs — landing them in the four-plus category in a state with the highest rate of black incarceration in the country.

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Lad Lake uses ACE tests to screen children before admitting them for residential treatment. The percentage scoring four or higher: 70. The percentage with none: 0.

“Trauma is to mental health as smoking is to cancer,” says Steven Sharfstein, past president of the American Psychiatric Association.

After the fiery riots last summer in the city’s Sherman Park neighborhood, Franklin Cumberbatch, project manager at Bader Philanthropies, could see the toll on children’s faces.

“I’ve looked into their eyes,” Cumberbatch says. “They have no feelings. They are numb.”

Trying to forget

Larry Davis scores a nine out of 10 on the ACE test.

His grandmother moved to Milwaukee from North Carolina in the 1960s, chasing the same opportunities that lured Belinda Pittman-McGee’s parents.

A single woman from a sharecropping family with her daughter in tow, Davis’ grandmother found work at engine-maker Briggs & Stratton. The first years were good; her daughter attended Catholic school and learned ballet.

Milwaukee Journal Sentinel files Engine makers at Briggs & Stratton Corp., shown in 1981. The company was a major employer in the city's urban center in Milwaukee's industrial heyday. Since then, it shuttered factories inside the city limits as it expanded production sites elsewhere.

But as time went on, Davis’ grandmother began taking on extra shifts as a hedge against losing her job. Extra shifts meant more time away from home. Her daughter became pregnant as a teenager.

Davis was the fourth child. His mother developed a drug dependency and was unable to provide proper care.

Today, Davis, 27, is finishing up a master’s degree in public health policy. He’s already studied with some of the city’s top ACE researchers, and has worked around the country as a youth counselor and child welfare advocate. He’s contributed thousands of hours of public service.

“I don’t think the American dream is the picket fence and the house anymore,” he says. “It’s changed. It’s building yourself from the ground up.”

He is sometimes invited to share his turnaround story.

He describes the night he spent at the Milwaukee Secure Detention Facility, when he had a conversation with God, asking for help. That came after being arrested for driving the car for a burglary, for which he calls himself an unwitting accomplice. Which came after a harsh Wisconsin winter sleeping in a car, drinking to fall asleep. Which came after dropping out of high school. Which came after bouncing around several middle schools. Which came after spending childhood weekends at emergency “respite care” homes where his foster mom dropped him off because she “had a social life to keep up.” All of which came after being removed by authorities from his mother at age 3.

In an interview, Davis grimaces when he’s prompted to go further in his story.

He finally mentions that, as a youngster, he needed to make his own meals after school or go hungry. He recalls classmates labeling him “Foster,” and needling him for wearing ragged clothes and missing field trips because he couldn’t pay the fee. There were nights using candlelight because the electric bills hadn’t been paid.

And then Davis shuts down. “See,” he finally says, “I forced myself to forget this.”

Like former frontline soldiers who repress combat experiences, forgetting is a common survival strategy — sometimes as a psychologically healthy way to move forward with a new sense of identity and purpose. But that collective silence has become part of the problem as well, keeping trauma experiences hidden behind stigma, pain and shame. Danieli calls it “social denial.”

“Trauma is perhaps the most avoided, ignored, belittled, denied, misunderstood and untreated cause of human suffering,” says Peter Levine, an American psychologist and author.

Economic consequences

Until recently, the economic impact of trauma has been just as invisible.

The CDC estimates the economic burden resulting just from child abuse and neglect in the United States at $124 billion.

“ACEs are the leading determinant of public health spending,” and a major driver of incarceration and child welfare costs, says Jennifer Jones of the Alliance for Strong Families and Communities. She has overseen six statewide ACE surveys in Wisconsin since 2009, more than any other state has conducted.

Shifting priorities into preventive programs “would save on the deep-end cost” of incarceration, public medical care and mental health facilities, Jones says.

When Joe and Eva Rogers settled in, after uprooting from Arkansas, 43% of black Milwaukeeans drew paychecks as industrial laborers — assembly line workers, punch press operators, forklift drivers. No other city came close, not even Detroit.

Today, the city sets the national extremes of distress. Milwaukee leads all 100 of the nation’s biggest metro areas in an index of concentrated poverty created by the Federal Reserve Bank of Cleveland. In the Annie E. Casey Foundation’s annual report on the well-being of children, which examines the nation’s 50 biggest cities, Milwaukee is the only large city to land in the bottom five in such key categories as: percentage of children in single-parent families; children in poverty; children in low-income families; and children in which the head of the household has no more than a high school degree or equivalent.

In a 2014 study on upward mobility in the 50 largest cities, Milwaukee had “lower rates of mobility than any developed country for which data are currently available.” The study was conducted by Raj Chetty, a Stanford University economics professor who grew up in the Milwaukee area.

“You’re kind of stuck in Milwaukee,” Chetty says. “And it’s hard to achieve the American dream.”

Given the scope of the city’s challenges, some are astonished that Milwaukee’s neighborhoods aren’t in even worse condition.

Belinda Pittman-McGee talks about her move to Milwaukee as a child before she founded Nia Imani Family Inc. 22 years ago. The center provides transitional housing for homeless women and their children.

“You look at the communities and they should be a lot worse off, believe it or not, than people would think,” says Patricia McManus, president of the Black Health Coalition of Wisconsin. “I don’t think our communities get enough credit for resilience.”

One of the most common strategies to coax that resilience out of trauma victims is to help them create a different narrative for their own lives — a process called re-scripting. The objective is to map out a future that moves beyond the auto-repeat memories of the past.

Pittman-McGee takes that concept literally at Nia Imani, handing out writing assignments to residents.

“At times when I was sober, I was depressed and suicidal,” one woman recently wrote. “I was cutting myself with razors and glass to feel some kind of life.”

In careful print, the young mother continued, diary-style: “It may take me a couple more months or a couple more years, but forgetting everything is just not an option anymore. Death is not an option.

“When I look at my babies, all I can see is success for them. No matter how many setbacks I have and how many demons try to stop me, I will rise and that’s a promise to myself and my boys.”

This year marks the 50th anniversary of Milwaukee's open housing marches, which focused attention on a knot of persistent urban problems. This project is part of an ongoing series of stories, videos and other special features that will examine how far Milwaukee has come – and the work that remains to be done.

How the Journal Sentinel reported this series

In reporting “A Time to Heal,” the Journal Sentinel collected data on multiple Adverse Childhood Experience studies in the city of Milwaukee, as well as studies done across Wisconsin, in numerous other states, at the national level and in other countries.

More than 100 people were interviewed for their knowledge of trauma research, behavioral science, public health, urban sociology, economics, law enforcement, community development and welfare.

To create census-tract maps showing how the economies of Milwaukee and other cities have evolved since 1970 – the nation’s industrial peak – the Journal Sentinel used U.S. Census Bureau data provided by the Minnesota Population Center's National Historical Geographic Information System.

Statistical advice was provided by Charles Franklin, professor of Law and Public Policy at the Marquette University Law School and data experts at Milwaukee’s Hunger Task Force.

John Schmid is an economics reporter at the Journal Sentinel. He can be reached at john.schmid@jrn.com and @GlobalMilwaukee.

Credit: Interactive design by Gurman Bhatia, Kevin Crowe and Andrew Mollica