Children often get referred to Marcy Kane's mental health agency because of behavior: They're not listening, they're failing in school, they've kicked other kids or are having headaches and stomach aches.
Sometimes the symptoms suggest anxiety or attention deficit hyperactivity disorder.
But often, the root cause is something else: sexual abuse, domestic violence, the loss of a parent, surviving a car accident, or another form of trauma.
"Trauma is missed all the time because the lay person doesn't really recognize the connection between a child or adolescent's misbehavior and how that misbehavior can be a result of a traumatic incident that happened to them," said Kane, a psychologist and vice president for child services at Waterbury-based Wellmore Behavioral Health.
Childhood trauma is common, affecting the majority of young people at some point in their lives. It's misunderstood. Many children suffering from post-traumatic stress get misdiagnosed, or receive treatment that focuses on their symptoms without addressing the underlying cause.
It's linked to a wide range of problems later in life, including both mental and physical illnesses.
It's also treatable.
And in the wake of the massacre at Sandy Hook Elementary, there's a growing interest among school personnel and mental health professionals in better understanding and addressing trauma.
"Childhood trauma, in public health, is probably considered today the single greatest preventable cause of mental illness," Dr. Ken Spiegelman, a Manchester pediatrician, told an audience of school nurses at a recent training session on trauma.
The presentation included this quote, from Dr. Steven Sharfstein, former president of the American Psychiatric Association: "Trauma is to mental health as smoking is to cancer!"
"It's really, from my perspective, a public health crisis," said Robert Franks, vice president of the Child Health and Development Institute of Connecticut and director of the Connecticut Center for Effective Practice. He developed the training presentation, which is aimed at increasing health professionals' understanding of the effects of trauma.
Since the Sandy Hook shooting, Franks has trained close to 900 school nurses and school personnel. Interest in the topic has been "monumental," he said.
"Newtown has raised awareness. The children who were directly impacted in those communities clearly are suffering," Franks said. "But we have children in our communities across Connecticut every day who are living in neglect or abuseful situations or in neighborhoods of high crime or violence, or experiencing deaths of loved ones in their communities due to violence or due to natural causes. So we have kids that every day are exposed to trauma."
"This is actually raising our schools' awareness that we need to identify these kids and get them help," he said.
'A Pandora's box'
Victoria was 11 when she finally told her devastating secret: Her father was sexually abusing her.
What followed felt like a roller coaster.
"It was almost like a Pandora's box had opened," said her mother, Lynn. (The Mirror is not using their real names to avoid identifying them.) "There were so many mixed emotions coming out of her."
She had complex feelings toward her father. She was confused about why it had happened. She wondered how her mother didn't know what was going on.
Sometimes she threw things and trashed her mother's house. She cut herself and made suicidal overtures.
National statistics suggest that about 70 percent of young people will experience at least one potentially traumatic event by the time they reach 18, Franks said.
Most will get over the experiences with support and resources to help cope. But about 20 to 25 percent will develop chronic symptoms from the exposure to trauma, Franks said. The symptoms can include irritability, changing mood, aggression, hypervigilance, an exaggerated startle response, or decreased responsiveness.
Often, they end up misdiagnosed, or receive treatment that fails to address the cause of the problem.
"The implications for pediatrics is as many as two out of three children treated in pediatric practices are likely to have experienced a traumatic event," Spiegelman, the Manchester pediatrician, told the school nurses during his presentation. "And I'm willing to say humbly, myself, most of us never find out about them."
Spiegelman now asks his patients and their parents, "Has anything scary or uncomfortable happened in your life in the past year?"
The question is like extending a welcome mat to make them comfortable discussing serious issues, he said.
"Unless you establish that relationship or allow the kids to feel comfortable talking about this, they never will, and neither will their families," he said.
School nurses might find that their "frequent fliers" -- kids who show up frequently with nonspecific complaints like stomach aches or headaches -- are dealing with trauma, Spiegelman said.
Linda Kelly, a school nurse in Watertown, knows that. She sees between 50 and 80 children a day, and at least half of the issues are related to mental health. Some she knows need attention more than medical care.
"There's no real physical findings," she said. "You know that they need just a little time out, they need to talk, they need a drink of water."
Manchester school nurse Linda Hodgkins sees similar dynamics.
"You do see a lot of kids in the nurse's office with these vague types of symptoms, and sometimes you just have that sense that they've been through something very difficult," she said.
A lot of what's known about the effects of childhood trauma comes from obesity research that took an unexpected turn.Dr. Vincent J. Felitti was conducting a study of weight-loss techniques. But participants were dropping out. Curiously, it was those who were losing weight.
Exploring further, Felitti found that many of the patients who dropped out had been sexually or physically abused as children. For them, obesity had been a form of protection against sexual attention or physical abuse. Losing weight made them uncomfortable.
"It became evident that traumatic life experiences during childhood and adolescence were far more common than generally recognized, were complexly interrelated, and were associated decades later in a strong and proportionate manner with outcomes important to medical practice, public health, and the social fabric of the nation," Felitti and Dr. Robert F. Anda, an epidemiologist, wrote in a chapter of a 2009 book on trauma.
They teamed up to lead a study of adverse childhood experiences, using information from more than 17,000 people covered by Kaiser Health Plan in California, a middle-class group. They came up with eight categories of adverse childhood experiences, including sexual abuse, physical abuse, having an incarcerated household member, having a household member who abused drugs or alcohol, having a mother who was treated violently, and having a household member who was mentally ill. They later added two more categories for physical and emotional neglect.
Their findings: Childhood trauma is very common. Only one third of the people in the study reported none. Of the rest, close to 90 percent had at least two different types of adverse experiences, and 11 percent had childhood experiences that would fit into five or more of the categories.
And, their research indicated, childhood trauma is strongly linked to mental health problems later in life, as well as physical ones.
The researchers assigned people one point for each category in which they had an adverse childhood experience, and called it their "ACE score."
As people's ACE scores rose, so did the incidence of a wide range of problems: risky behaviors like smoking or alcoholism, medical conditions like chronic obstructive pulmonary disease, liver disease and heart disease, and mental health issues including chronic depression and suicide attempts.
A man whose ACE score is 6 or more has a 4,6000 percent higher chance of using intravenous drugs than a man with a 0, they wrote, suggesting that "the basic cause of addiction is predominantly experience-dependent during childhood and not substance-dependent."
Although some of the link between adverse childhood experiences and medical problems could be explained by risky behavior like smoking or drug use, the researchers found that even if they corrected for risk factors, there was still a link between ACE score and coronary disease.
They suggested that the deeper link could be related to the biological effects of adverse childhood experiences. In young children, exposure to violence or other chronic stress can change the way the brain and hormonal systems are wired, with potentially lifelong consequences.
"In the context of everyday medical practice, we came to recognize that the earliest years of infancy and childhood are not lost but, like a child's footprints in wet cement, are often life-long," Felitti and Anda wrote.
But there's good news.
"Trauma actually is very treatable. As quickly as it's recognized and treated, you can have very, very good outcomes," Kane, the psychologist, said. "It's really when trauma goes unrecognized and unaddressed for many years that it becomes more difficult and it really becomes more disruptive to somebody's individual life and their success into adulthood."
The method clinicians who work with trauma now commonly use is known as trauma-focused cognitive behavioral therapy. It's an evidence-based method that's relatively short-term, lasting months, not years.
For Victoria, the therapy took less than 6 months.
She learned coping skills to handle triggers that evoked the abuse. One was a code word to signal to her mom when she needed help: "Paris Hilton," the name of a celebrity she doesn't like.
"If I heard that, I knew that I just needed to drop what I was doing and help her out," Lynn said. "We would go in her room, close the door, cry, curse, whatever it took. and talk about 'why?' and 'how could he do this?' and 'why me?' and 'I just want to feel better.'"
As a parent, Lynn was involved in the therapy. She didn't sit in on the sessions but would find out what her daughter learned and whether the session had been particularly tough. The therapist, Karen Stevens, would tell her how she could support Victoria when they left.
In addition to teaching coping skills, the therapy focuses on processing the traumatic event by "telling a story." It helps the person organize what happened, talk about and process it, and use coping skills to gain control over his or her body and emotions, Kane said.
She likened it to learning to ride a bicycle: You're scared at first, but you learn how to pedal, catch your balance, put your feet down when you think you might fall. "Once you learn those things and you practice those things, it almost becomes second nature and it's not scary any longer cause you know how to do it," she said.
Stevens, a psychiatric clinician at the Charlotte Hungerford Hospital Center for Youth and Families, said children face internal turmoil from carrying a traumatic experience with them.
"Our goal as part of the trauma treatment is to really unpair the overwhelming emotions that go along with the trauma and the event," she said. "So yes, it may be an experience that is part of their life experience, but it doesn't define them."
Victoria is now 17, set to graduate from high school in June. She's guarded, but she has good relationships with her peers and has avoided the sort of risky behavior that can be typical among teens dealing with traumatic experiences. She wants to be a therapist or work in corrections, so she can make a difference.
Lynn now works at the center where her daughter received therapy, helping other parents.
"She learned quite quickly through the therapy that this wasn't stamped on her forehead, which I think was probably one of the hard things for kids, is that they think that now everybody knows this happened to them," she said.
But her daughter has confided in other people who have been through similar experiences, as a way to help.
"It just happens so often," Lynn said.
Follow Mirror health reporter Arielle Levin Becker on Twitter @ariellelb.