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In August 2013 we published an article, “Synergistic Childhood Adversities and Complex Adult Psychopathology” (Putnam et al., 2013), in the Journal of Traumatic Stress (JTS) showing that certain combinations of childhood adverse experiences (commonly called ACES) are “synergistic” in that when they occur together they increase a person’s risk for complex mental health problems significantly more than the sum of their individual risks. Sort of a 1 + 1 = 3 effect. Men and women had overlapping profiles of synergistic ACES with sexual abuse in females and poverty in males showing synergy with the greatest number of other ACES. 

The impression that synergy among certain combinations of ACES multiplied risk for negative adult outcomes is not new, having been described by John Bowlby, Arnold Sameroff and others decades earlier. The JTS paper serves as an empirical validation of their prescient observations. For us, the results also posed a question, “If certain combinations of ACES are synergistic, then what are the clinical and policy imperatives?” 

The JTS paper necessarily required lengthy methodology and results sections that limited discussion of the clinical and policy implications, which must be considered within a larger context of relative risk, available resources, and current approaches to treatment and prevention. The challenge was to reach audiences, who need this information, ranging from Head Start teachers to elected officials to judges to medical and mental health providers to the general public. No journal article could reach these diverse audiences. Another medium with greater outreach was needed. Why not try social media?

Previously we had a modest response to a deck of PowerPoint slides on the costs and consequences of childhood trauma, initially drafted to brief U.S. Senator Edward Kennedy and his staff in 2008. Several of the 2008 slides are still routinely included in other people’s presentations. Drawing on this experience, we constructed a PowerPoint “narrative” highlighting the public health implications of cumulative trauma and synergistic interactions among ACES. This allowed the inclusion of other relevant research as well as comparisons of the life-long effects of ACES with other public health problems receiving greater national attention. 

The PowerPoint narrative, “Opportunities to Change the Outcomes of Traumatized Children”, is free and available to anyone to download at CANarratives.org along with a pdf version and a short list of URLs for relevant resources. Once downloaded, slides can be copied individually or in groups for use in other presentations. The slides are locked to keep graphics and text from becoming “ungrouped” and perhaps inadvertently scrambled when copied and pasted. Although each slide includes the website URL, there are no copyright restrictions. Instead users are encouraged to include any and all slides in their presentations as well as to share them with others.

The next step was to get the word out. Fortunately CANarrative.org contributors have been able to disseminate it to organizations and institutions whose missions are significantly impacted by cumulative and synergistic childhood trauma. By spreading the word through these professional and personal networks, we estimate that (as of this draft) we have had about 10,000 unique views. 

To date, CANarrative.org has been disseminated through list serves and websites reaching pediatricians, psychologists, psychiatrists, infant mental health professionals, social workers, psychoanalysts, and child trauma treatment trainers. It has been posted on Facebook pages and tweeted about. University presidents, deans and course directors have sent it their faculties, colleagues, and students. Police chiefs, family court judges, and juvenile justice administrators are circulating it. Parts of the narrative will be included in a range of courses starting in the fall and included in upcoming national and international conference plenaries and presentations. 

The Narrative has been given directly to state and federal elected officials as well as congressional and administrative staff. It was cited in the LHHS Appropriations Subcommittee Markup Report. 

The committee appreciates SAMSHA’s ongoing support of the National Child Trauma Stress Network. A recent report, Childhood Adversity Narratives, makes clear that childhood trauma is an all-encompassing and costly national public health problem contributing directly to serious mental and medical conditions. The Committee encourages SAMHSA to more broadly disseminate information regarding evidence-based interventions for the prevention and treatment of childhood trauma so more children can benefit from proven practices.
Given the information highlighted by the Narrative, one question is routinely asked: “why aren’t we doing more to reduce and prevent a major cause and contributor to a host of costly public health problems?” Especially since we have proven, cost-effective interventions available. One answer is that there is insufficient public awareness both of the scope of the problem of childhood adversities and trauma and existence of effective, scientifically proven interventions to address it. 

The Narrative is a specific effort to increase public awareness with the hope that it will inform public opinion of the costs and life-long consequences of childhood adversity as well as important opportunities to change the outcomes of traumatized children. Only then, when sufficient public education generates demand for action, can we respectfully request that elected officials provide the resources to scale up proven interventions commensurate to the magnitude of the problem.

The Narrative concludes: Christof Wieland, the German man of letters, wrote in 1798 that public opinion was

“ . . . an opinion that gradually takes root among a whole people; especially among those who have the most influence when they work together as a group. In this way it wins the upper hand to such an extent than one meets it everywhere... It then only requires some small opening that will allow it air, and it will break out with force. Then it can change whole nations in a brief time and give whole parts of the world a new configuration.” (p. 14, Boorstin, 1975)

About the Authors

Frank W. Putnam, MD, is Professor of Psychiatry, University of North Carolina at Chapel Hill, and Professor of Pediatrics Emeritus, Cincinnati Children’s Hospital Medical Center. His interests include intergenerational transmission of risk and large-scale dissemination of evidence-based practices. A former ISTSS Board member, the Frank Putnam Research Scholars Program was named in his honor.

William Harris, PhD, is Chairman, Children’s Research and Education Institute. His interests include childhood trauma, child development, poverty and politics.

Alicia F. Lieberman, Ph.D., is Irving Harris Endowed Chair in Infant Mental Health, Professor and Vice Chair for Academic Affairs, University of California San Francisco, and Director of the Child Trauma Research Program, San Francisco General Hospital. Her interests include early childhood trauma, child-parent psychotherapy outcome research and dissemination, mental health disparities, cultural issues in trauma treatment.

Karen T Putnam, PhD, is Adjunct Instructor, Department of Psychiatry, University of North Carolina at Chapel Hill. Her interests include synergy among risk factors and the role of trauma in the heterogeneity of psychiatric illness.

Lisa Amaya-Jackson, MD, MPH, is Associate Professor, Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine. Her interests include disseminating & implementing child-trauma evidence-based interventions and decision-making guidelines on use of EBTs to create a trauma-informed mental health workforce. 


Putnam, KT, Harris, WW, and Putnam, FW (2013). Synergistic childhood adversities and complex adult psychopathology. Journal of Traumatic Stress, 26:435-442.

Boorstin, DJ (1975). Democracy and Its Discontents: Reflections on Everyday America, Vintage Books.