What Childhood Trauma Leaves Behind

Childhood trauma can leave lasting marks on the brain, body, and sense of safety—but it does not define a person’s future. 

In this episode of Road to Resilience, host Stephen Calabria speaks with Frank W. Putnam, MD, one of the country’s leading researchers on childhood trauma and maltreatment. Drawing on decades of clinical work and a landmark longitudinal study that followed abused girls from childhood into adulthood, Dr. Putnam explains how early maltreatment can shape mental health, physical health, development, and even biological aging. 

But the conversation is also about what helps people heal. Dr. Putnam discusses why safety is the foundation of recovery, how supportive relationships can change a child’s trajectory, and why resilience often begins with having options, stability, and someone who truly listens. 

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Visit https://www.mountsinai.org/clinical-trials to see if you're eligible to enroll in a clinical trial with the Mount Sinai Health System. Check out more episodes of Road to Resilience—as well as guest pictures, transcripts, and more—on the Mount Sinai website.

Transcript

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Stephen Calabria: [00:00:00] From the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm your host, Stephen Calabria, Mount Sinai's director of podcasting. 

On this episode, we welcome Frank W. Putnam, MD, who's regarded as one of the foremost researchers and clinicians on the health effects of violence and abuse

He's the co-author of a four-decade longitudinal study documenting the effects of childhood sexual abuse.

His new book, titled Old Before Their Time: A Scientific Life Investigating How Maltreatment Harms Children and the Adults They Become, discusses the study's findings and how our society responds to maltreatment.

We also hear about what can help these children and how resilience often begins with having options, stability, and someone who truly listens. We're honored to welcome Dr. Frank Putnam to the show

Dr. Frank Putnam, welcome to [00:01:00] Road to Resilience. 

Frank Putnam: Thank you very much for having me.

I'm looking forward to this discussion. 

Stephen Calabria: Now your new book, Old Before Their Time, chronicles how childhood maltreatment affects development and adult health. What inspired you to take on this kind of long-term investigation, and what was your most surprising discovery along the way?

Origins of a Landmark Study

Frank Putnam: I was looking for children who had dissociative identity disorder because I'd been working with adults who had dissociative identity disorder at the National Institutes of Mental Health in Bethesda. And all of them told me that they had been really, essentially multiple since childhood. In fact, they never felt that they were ever integrated in any way.

And so I thought, if that's true, I should be able to find children with this disorder. I was circulating actually a profile and asking therapists, foster parents, other people who were dealing with children, particularly who had disturbed behavior [00:02:00] if we could do a consultation on them.

I was seeing some very disturbed children. I didn't feel that all of them were dissociative by any means, but I felt that many of them had been pretty significantly altered by their experiences. So this was back in 1987? Actually it was started in about 1982. And so we knew so much less about trauma, childhood trauma at that time.

Most of the time all the therapists or the foster parents or the adoptive parents knew were that the child had been abused. And that was pretty much the extent of it. But I learned more from the children and I began to feel that we needed a prospective longitudinal forward looking study following abused children forward in time to understand what the implications of all these experiences were and their behavior.

And so I was fortunate to connect with a developmental psychologist, Penelope Trickett. Unfortunately penny died a few years ago. And we mapped out this study, [00:03:00] and we have now followed them, many of them for close to 40 years at this point in time.

They were ages six to 15 years when they came into the study. Now they're in their late forties and fifties. And we've seen them eight separate times for pretty extensive medical, psychological, social evaluations. And out of that, we've come up with a number of findings. 

Trauma and Accelerated Aging

Stephen Calabria: So your research suggests, from a top line perspective, that early trauma not only impacts psychology, but may accelerate biological aging. Can you explain how maltreatment gets under the skin, so to speak, in ways that affect both mental and physical health? 

Frank Putnam: Yes. This was always and a part of that scientific agenda was to look at processes such as puberty or another process called adanarchy, which is the coming online of the stress response systems or the adrenal glands, or to look at [00:04:00] cognitive development.

So we were following a number of processes that we knew something about the developmental curves of, and to see if they were accelerated in our maltreated children compared to our comparison children.

So we had a group of approximately a hundred sexually abused girls, abused by family members, and we had a comparison group that was matched on demographics and whether they were in one or two parent family homes and those sorts of things.

And so we were comparing, for example, the rate through puberty and found that the sexually abused girls started and completed puberty about a year earlier on average.

We saw there were differences in the cognitive development that we could pretty much determine by about age 12 or 14 and really played out into the late adolescents and early twenties. We could see a number of these systems and then fortunately, the genetic technology came along.

And last [00:05:00] few years, we've been able to look at changes in the DNA, a particular set of changes that are called epigenetic, which have to do with the structure and expression of the DNA not so much the actual coding of it, but how that DNA is expressed.

 All of these different looks came out to express the idea that these kids, the abused children, were aging faster and not so gracefully as our comparison girls. And we only did this with girls. We always wanted to do with boys, but never could find the funding for that. 

Poverty and Reporting Bias

Stephen Calabria: You touched upon socioeconomic factors. What role do those factors play in adolescent maltreatment? Is it common across the board? 

Frank Putnam: I think you have to take a lot broader picture than our research alone in this, because lots of people have looked at this and generally the factor that emerges as most predictive is poverty.

And so, once you control for poverty, any factors like race, for example, ethnicity, dropout, [00:06:00] and it's really a function of the poverty. However, there's a caveat here, which is that people from lower SES are more likely to be reported to CPS.

So there's real evidence that it exists across most SES groups, socioeconomic groups, but that there is maybe a bias towards reporting for lower income groups, plus they get more surveillance through home visiting kinds of programs and through other welfare programs.

So there are real caveats there, but socioeconomic status does seem to be a more powerful predictor, particularly of things like physical abuse and neglect, less so for sexual abuse. 

Gender Differences in Abuse

Stephen Calabria: Now, you mentioned that your study only included girls. Is there a discernible, statistically significant difference between how boys and girls tend to react to these kinds of abuses? 

Frank Putnam: Yes. And that's something that we don't know nearly enough [00:07:00] about. We know much more about sort of the impacts on females than we do on males. And to start off, one of the critical differences is patterns of abuse.

Girls tend to be abused in family situations. I'm talking about child sexual abuse primarily here, and tend to be abused by family members where boys tend to abused out of the home and abused more by coaches, teachers, boy scout leaders, those sorts of groups.

And we find in our own data, looking just at relationships among the girls, but also later in other studies, looking at relationships with your perpetrator, that's very critical in terms of many of the sort of outcome findings.

And probably the worst situation is maltreatment by your biological father, sexual abuse by your biological father for girls. It's not as clear, what that the worst case scenarios are for males because it's a different pattern of abuse.

And also we [00:08:00] don't see many males in the child protective service system or in the research areas after about age nine or 10. What we have later are retrospective accounts by adult victims, but we don't have a lot of kids coming in boys coming in after about age nine or 10. It's not that it's not happening to them, they simply aren't reporting it in the same way.

What Builds Resilience

Stephen Calabria: What have you learned about resilience, in individuals who have been impacted by childhood maltreatment?

Frank Putnam: We learned a number of things about resilience. One of the points that we make over and over again is that, relationships matter an enormous amount.

As I was mentioning, who your perpetrator is is very impactful, but also who is there to support you is extremely impactful.

And we find that, particularly for the girls, if they have older females who act as protectors and guidance, et cetera. That's a very important determinant of their outcome.

Now, other things that give you options [00:09:00] and resilience is, to some extent, really associated with having options to make choices about better things in your life.

And so some of those are intrinsic, having more education, higher iq, special talents, things that bring people to you, are associated with resilience, but really also being exposed to a wider set of outcomes that you can use as models.

Modeling is particularly important for children. And the unfortunate thing is if you grew up in an abusive family. You don't have a lot of really good models, external models. That's why programs like Big Brothers and Big Sisters are so important for many of these children. 

Stephen Calabria: A great deal of research indicates that children imitate what they see, and could that in part be an explanation as to why so many of these behaviors continue into adulthood for many people?

Frank Putnam: I think there is. You parent as you were parented, to some extent. But I think one point I [00:10:00] really wanna stress and make clear is that most abused children do not grow up to be abusive parents. Okay. I've looked at that very extensively.

I'm very interested in what are the factors that cross generations or lead to generational sort of increase of risk and, having looked at the literature, I mean, you can't really do the study in a sense, but you have to look at basic samples and how many of the abused kids grew up to become abusing parents.

And I found about 70 studies in a variety of languages looking at that and the number that kept coming up again and again was 70% do not become abusive parents, and about 30%, do become abusive parents in the sense that their children have histories of abuse.

They may not be the abuser themselves. It may be that they're in a relationship with an abuser, which is an important thing. But they will have children who are seen by the child protective [00:11:00] system.

So that number is, basically 70% turn out all right but that 30%, that's still about six times higher than seems like the spontaneous rate of maltreatment is for parents who have not never been abused themselves.

Stephen Calabria: While the violent behavior itself often doesn't continue, research shows that some children exposed to maltreatment demonstrate adaptive functioning across domains like behavior and social development. What are some specific examples of that? 

Frank Putnam: I what's really important is acknowledgement that these things happened to the child and that they're bad and that's one of the places that therapy plays with these children is to help them understand that the maltreatment is wrong because they don't really actually know that.

They grew up in these families and this is the way life is, and this is the way parents treat their children. And so having exposure to other [00:12:00] experiences that show them that this is not the way to behave or, or stuff, it, it depends, you know, 

I think we see a spectrum of human adaptability, but it really says that a lot of other input besides the negative input is very critical. That's coming from positive relationships with others like teachers and friends and coaches or whatever who help the children see the world in a larger way.

I think there's a hunger for better outcomes in all of the victims we work with. A, this is not what they want, it is just that they don't know what the options are and how to get out of it. And it seems like this is the way the world is constructed.

And then the other problem is that maltreated individuals end up being revictimized in other situations at much higher rates than individuals who do not have histories of maltreatment.

So we were seeing in our sample about two and a half times more [00:13:00] re-victimization, particularly by strangers, than we were in our comparison girls.

And there's about 15 plus studies that have found essentially the similar thing, that if you've been maltreated within a family context, your chances of being re-victimized by outsiders is at least two times, maybe three times higher than somebody who hasn't had those experiences.

Healing Through Safety and Therapy

Stephen Calabria: How do people heal, recover, and grow even when they have histories of early maltreatment? Are there particular pathways or mechanisms, be they psychological, or social that seem most important in recovery? 

Frank Putnam: We certainly do see evidence that people recover from these experiences, although I think they always leave some kinds of marks on the individual and certainly all the victims I know who become survivors still talk about the sense of injury, that happened to them.

But that has to do with the, probably the single [00:14:00] most important thing that seems to emerge is talking about the experiences, in terms of how they are affecting the person now, that's always where we start is, not what happened to you in the past.

We can talk about that at some point if that's what you want, but to talk about how it's affecting you now.

In one of the really important studies was called the Mother Child Study at the Minnesota mother child study at the University of Minnesota where they followed again, maltreated mothers and mothers were demographically at risk for maltreating their kids, and they followed the children into adulthood and they found that the best predictor of which mothers did not have abused kids, and again, wasn't necessarily that the mothers abused the children, but they were associated with perpetrators, who did, was that the mothers had told somebody about their maltreatment in some reasonable detail.

Did not have to be a therapist. It could be a best [00:15:00] friend, it could be a religious figure, but that they had spent some time talking about that experience and they had acknowledged that experience and they were not going to let this happen to their children, and so their vigilance for that was particularly increased. 

Stephen Calabria: Now you talk about that sharing and openness on the part of those mothers. Let's talk about the children and specifically the role of time.

If a child was to share that information at the time, is there evidence that they will wind up in a better place psychologically and emotionally down the road?

Frank Putnam: a lot depends on what the consequences of telling the child at the time is. What we have in terms of retrospective data, looking at adults who talk about I told somebody at the time this was happening to me.

Unfortunately a large number of adults will say that nothing was ever done so that's the first place we've failed these children.

But the most [00:16:00] important thing that we seem to find when we really acknowledge that this is a real thing that happened to the children is that, they are given a place of safety, that they feel safe and they are safe.

Even if they are technically safe, that is, the perpetrator is not likely to continue. If they don't feel safe or secure, they don't seem to get a lot better, so it's important for us to create safety.

And to have the child actually accept safety as that I am safe. And then that allows the child to begin to come out of defensive and reactive and anxious situation and begin to explore options.

Stephen Calabria: To follow that up, is resilience in the face of these things something that emerges immediately or more gradually over the lifespan, or does it just depend on the person?

Frank Putnam: That's a hard question that I don't know that we've really got good data. I think [00:17:00] clinically my impression is it's something that emerges over time.

I think about child development as trajectories. That is, you can't necessarily look at a child at one moment and make predictions about where that child is gonna be in five years or 10 years or something like that, in, in any very specific way.

It depends a lot on what the sources of support are around that child, how safe that child is. We see children, for example, that have been maltreated, they've been removed from the home, and they go through 10 or 12 foster home placements.

That is just destructive of attachment and relationships maybe as the abuse. And so that, that has a lot to do with resilience and outcome.

If they're fortunate and they really get a good, supportive situation and they feel safe and secure, their trajectory is usually pretty good.

I mean, I've certainly seen children who once they were [00:18:00] out of that situation really exhibited very quick healing and normalization of biological measures.

Not just that their behavior got much better, which was usually the tip off, that there's something going on with this child, they have very disturbed behavior.

So if they're fortunate to get into stable, secure situations, that's really, it's very optimistic.

Stephen Calabria: You mentioned the feeling that they're never safe. Victims of child abuse often struggle with a sense of agency because they lacked control during the trauma.

In your work, how have you seen survivors take back agency in their lives? 

Frank Putnam: I think the biggest single thing that I see as being important in agency is options.

That they see that they have different options, that they can exercise and that when they face situations, they know that they have more than one or two choices, [00:19:00] and that seems to be one of the things that, when we look at them and say what's really helped you, is the sense that I know more about other options that I can do.

That gives me agency.

They don't use the term agency so much, but it's like that gives me control of my life. So it's understanding that there's options out there, and that's again, often a function of relationships that they have with mentors of various types. 

We're learning so much more about therapy and I think for first time really have some effective therapies.

When we started this study back in the eighties, there really wasn't anything known about child maltreatment therapies and they were basically dumbed down, simplified adult therapies which were often not particularly effective.

Now we have more therapies that we can actually measure the outcomes in and there's a movement [00:20:00] in the child therapy world, particularly to what we call measurement based therapy, so that we look at outcomes and that often the therapist moves the child in the often, usually, adult caretaker, often a parent through the therapy with the child looking at their interaction and moves them on to the next step after they make certain criteria.

So this is true of something like parent-child interaction therapy.

What we see in the therapies is the children often get better pretty fast, and when they get better, and better, by that I mean typically, the terms of behavior which is the thing that most people complain about or get children brought into therapy is outta control behavior.

The parents also get better as the children get better. It's a very interesting thing. So we've looked at parent parental PTSD with parents who are working in a therapy model with their kids and as their kids improve, the [00:21:00] parents who aren't directly necessarily in a P-T-S-D therapy of their own, but also have often the same background of being maltreated.

They improve pretty significantly, also. So I'm really a big fan. Interventions that are intergenerational and include a parent and a child. And there, there are several of these on the market. Things like trauma focused CBT, for example, as well proven therapy. 

Long Term Risks and Protective Factors

Stephen Calabria: Is there a relationship between child maltreatment and later mental health or physical health problems? 

Frank Putnam: Yes. If you have a history of maltreatment or somebody who has a history of maltreatment they're at higher risk for depression, for anxiety disorders

and for PTSD. It's not clear that's true for schizophrenia.

But certainly, it increases risk for depression particularly in women.

So there's a seminal study in the child abuse maltreatment field called the ACEs Study and Stands for Adverse Childhood Experiences.[00:22:00] 

And it was a collaboration between the Centers for Disease Control and Kaiser Permanente. And they looked at adults and they looked at a list of traumas that they experienced.

I asked one of the collaborators there, what was the effect of maltreatment in terms of, mental problems like depression and so he did a statistical analysis, very large sample, thousands and thousands of cases in which he found that if you were to have eliminated maltreatment for women, you would've reduced the female load of depression by about 50% in the country.

Which would've made it essentially equivalent to what the male rates are. 'Cause right now the males have about half the rate of depression as females, but that is seemingly accounted for by the fact that females are much more likely to be the victims of sexual abuse. So that's an example of evidence that yes, having these [00:23:00] experiences does in fact increase susceptibility to mental health problems. 

Stephen Calabria: And is the relationship between that early trauma and later adverse behavioral or mental health outcomes a straight line, or is it more nuanced?

In other words, how predictable are the long-term effects of this kind of maltreatment?

Frank Putnam: For the individual, they're not predictable, what I tell people over and over again is, your ACE score is not your destiny.

What happens to you does not dictate that you're inevitably going to have these kinds of outcomes. It's more predictive if you're looking at a large group and then you're looking at sort of average outcomes.

And people with a lot of bases are more likely to have these outcomes. But any individual despite their ACE score is not doomed to have these particular kinds of outcomes.

Stephen Calabria: What protective factors has research identified that buffers the impact of maltreatment? For example, [00:24:00] supportive relationships, coping skills, or community? 

Frank Putnam: I think all of this actually. It's a pretty good list.

And then the certain aspects about what the trauma was, if I've emphasized the relationship, it's also when it started, how old was the individual?

How long did it go on how much force was used, intimidation, how much fear, intimidation were.

So there are a lot of factors that go into the abuse experience itself that are statistically important in terms of looking at outcome, say the tendency to have behavioral sorts of problems.

But there are all these other modifiers, as you pointed out, the community relationships. Really, education. Again, options, agency. These things are very important in positive outcomes. 

Stephen Calabria: Looking back on your career, what lessons has your research taught you about human potential for both suffering and for [00:25:00] recovery?

Frank Putnam: I think human potential is extraordinary. We certainly have seen remarkable outcome and I, I also, as I mentioned at the very beginning, got into working with children and maltreatment because I was working with a group of people who had dissociative identity disorder, in which you had the individual organized more like an us than an I.

That is, they were not as well integrated, but had a variety of different identity states or self states. It's not as rare as people actually think it is.

We did a major sort of survey of a general population, for example, of the us and found it was about 4% of people were probably had this form. And what you see there are some extraordinary abilities that are encapsulated in, some of those alter identity states that are absolutely amazing.

So my sense of what the human potential is it's really been expanded by working with this group. I've seen people [00:26:00] with extraordinary photographic memories and a variety of other kinds of skills that just seemed absolutely phenomenal.

I remember one case where she could write separate streams of thought with each hand and I actually talked with one, one of her professors who said she was freaking out all the other students in the class.

She was in a law class, so you can imagine how competitive they were. And they were seeing this person keeping two separate streams of notes. So I've seen a number of things where I've just amazed at what a human potential is in general, and it to some extent, brought to the surface by these different identity states.

But in general I've always operated on the principle that people wanted to do the right thing and be better and uh, to be happy and to heal. And I think that's very innate in, in the human condition. 

Hopeful Takeaways and Closing

Stephen Calabria: Finally, what gives you hope about our capacity as a society to address [00:27:00] and heal the wounds caused by early maltreatment? 

Frank Putnam: So I've been doing this about 50 years and I've seen an enormous improvement in our understanding of the problem and our willingness to acknowledge the problem. It's far from perfect as we see by events going on in our society right now.

But if you go back to the late seventies, early eighties when I really started doing this in depth, I think we've accepted trauma as something that has a lifelong impact with the idea of a biological impact, which was a heresy at one point, is now much more accepted.

It's recognized also to have much longer effects. People would think, get over it. It happened to you, a while ago. So I think that part of it is improved. And we know the sooner we start to work and provide safety and security and support, the [00:28:00] better they're gonna do on average. 

Stephen Calabria: That was it for my questions. Was there anything else you wanted to say? 

Frank Putnam: Well, I wanna reemphasize that these experiences are not inevitably, stigmatizing or dooming or that most people who have these do not go on to become abusive parents. Most people manage to make it, and the power of resilience is there. 

Stephen Calabria: Dr. Frank Putnam, thank you so much for being on Road to Resilience. 

Frank Putnam: Thank you for having me.

Stephen Calabria: Thanks again to Dr. Frank Putnam for his time and expertise. To find his book titled Old Before Their Time: A Scientific Life, Investigating How Maltreatment Harms Children and the Adults They Become, check out Amazon or wherever books are sold.

Want to get in touch with the show or suggest an idea for a future episode? Email us at podcast@mountsinai.org.

Road to Resilience is a production of the Mount Sinai Health System. It's produced by me, Stephen Calabria, and our executive producer Lucia Lee. From all of us here at [00:29:00] Mount Sinai, thanks for listening and we'll catch you next time.