TN family fights for answers year after teen dies in DCS lockup

130811104755_dcs fatal lockupKendall Oates spent most of his short life as a typical upper-middle-class Brentwood kid, playing hockey and his Xbox, treated to expensive birthday parties and attending the best public schools Williamson County has to offer.

But a scuffle with his father landed him in the juvenile justice system, where the 17-year-old - who had never been in serious trouble before - was placed with some of the state's most violent juvenile offenders.

His mother spent more than a year trying to persuade the Department of Children's Services to release him. Five days before his homecoming, he died in a place where family, friends and even a judge said he did not belong.

Kendall suffered a seizure at Nashville's Woodland Hills Youth Development Center, where DCS records show he may have lain sick or dead for hours, undetected by a security guard who was supposed to check on him every 15 minutes but did not.

DCS was required to administer anti-seizure medication to Kendall, but an autopsy performed the day he died, May 25, 2012, found no trace of the medicine in his bloodstream.

Kendall also did not have his lifesaving anti-seizure wristband, which he was required to wear at all times. Kendall had used the device to stop previous seizures, swiping the band over his chest at the onset of symptoms to activate an implanted seizure-regulating device, similar to a pacemaker. Kendall's wristband was discovered after his death in a guard's booth, out of reach.

In the months before his death, a Williamson County judge issued two separate court orders urging DCS to place the teenager in a 24-hour residential medical care facility that could better monitor his seizures.

After his death, one Woodland Hills staff member noted in DCS records that Kendall "should have been in a different facility because of his medical condition."

Kendall's mother, Diane Oates, is devastated. A former IBM executive, Oates had dedicated herself full time for more than a year trying to get Kendall out of DCS custody.

"I've been thinking that if that was Kendall's day to die, why did it have to be there?" she said. "Kendall should have been with me."

When a child dies in DCS custody, the agency conducts its own investigation and authorities outside the agency review the evidence DCS provides for possible prosecution.

DCS closed its internal investigation, finding the teenager died of natural causes.

 

Read More at : wbir.com.

How Could You? Hall of Shame-Kendall Oates 2012 case-Child Death

How Could You? Hall of Shame-India-Grace HomeThis will be an archive of heinous actions by those involved in child welfare, foster care and adoption. We forewarn you that these are deeply disturbing stories that may involve sex abuse, murder, kidnapping and other horrendous actions.

From Nashville, Tennessee, Kendall Oates, 17, died on May 25, 2012 after suffering “a seizure at Nashville’s Woodland Hills Youth Development Center, where DCS records show he may have lain sick or dead for hours, undetected by a security guard who was supposed to check on him every 15 minutes but did not. ”

“Kendall Oates spent most of his short life as a typical upper-middle-class Brentwood kid, playing hockey and his Xbox, treated to expensive birthday parties and attending the best public schools Williamson County has to offer.

But a scuffle with his father landed him in the juvenile justice system, where the 17-year-old – who had never been in serious trouble before – was placed with some of the state’s most violent juvenile offenders.

His mother spent more than a year trying to persuade the Department of Children’s Services to release him. Five days before his homecoming, he died in a place where family, friends and even a judge said he did not belong.”

DCS was required to administer anti-seizure medication to Kendall, but an autopsy performed the day he died, May 25, 2012, found no trace of the medicine in his bloodstream.

Kendall also did not have his lifesaving anti-seizure wristband, which he was required to wear at all times. Kendall had used the device to stop previous seizures, swiping the band over his chest at the onset of symptoms to activate an implanted seizure-regulating device, similar to a pacemaker. Kendall’s wristband was discovered after his death in a guard’s booth, out of reach.

In the months before his death, a Williamson County judge issued two separate court orders urging DCS to place the teenager in a 24-hour residential medical care facility that could better monitor his seizures.

After his death, one Woodland Hills staff member noted in DCS records that Kendall “should have been in a different facility because of his medical condition.”

Kendall’s mother, Diane Oates, is devastated. A former IBM executive, Oates had dedicated herself full time for more than a year trying to get Kendall out of DCS custody.

“I’ve been thinking that if that was Kendall’s day to die, why did it have to be there?” she said. “Kendall should have been with me.”

When a child dies in DCS custody, the agency conducts its own investigation and authorities outside the agency review the evidence DCS provides for possible prosecution.

DCS closed its internal investigation, finding the teenager died of natural causes.

Family hardships

Kendall was weeks away from turning 18 when he was taken into DCS custody in 2011. The teen had been moody and angry, frustrated that his friends were getting their driver’s licenses and new cars.

Kendall couldn’t drive until he had been seizure-free for six months, but that hadn’t happened since the eighth grade, when Kendall experienced his first seizure after suffering a blow to the head playing field hockey in the school gym.

His parents divorced just after Kendall started high school, entering into what would become a years-long dispute over custody and finances. His mother moved out of the family’s home into a nearby apartment. Then Diane Oates got laid off from her job as an IBM project manager, moved to live with her parents in Alabama and began visiting Kendall and his younger sister on alternating weekends.

Those family hardships – a divorce, a job loss – affected everyone in the family, but they hit Kendall especially hard, his parents said.

Kendall couldn’t stop thinking about brain surgery to stop the seizures. But his father, Gary Oates, said brain surgery was not an option.

In March 2011, Gary Oates called police to report an outburst at his home. It followed several fights Kendall had gotten into at school. Oates reported that Kendall had slammed doors and smashed his father’s cellphone. Oates, a courier for FedEx in Nashville, later amended his complaint to say that Kendall also had lunged at him.

Had Kendall’s blowup happened just a few weeks later, he would have turned 18 and been subject to the adult court system, where consequences for a first-time offender are typically light – ranging from court-ordered community service to counseling or probation, and an expunged record.

But for minors, such offenses bring DCS involvement. With Oates’ consent, DCS asked a Williamson County juvenile judge to remand Kendall into state custody, where he would spend more than a year.

It was a decision Diane Oates said she didn’t learn about for weeks. DCS records noted her address as “unknown” at the time Kendall was placed into custody. Diane Oates said someone could have reached her. State child support records, divorce records and her ex-husband had her home address.

She disagreed with the decision to place her son in state care and began petitioning juvenile court and contacting DCS to release Kendall to her.

Meanwhile, Kendall grew frustrated at having been removed from his home, dis-enrolled from his Brentwood high school and placed in a group home for wayward boys at a time when his friends were going on dates and taking family trips to visit colleges, according to juvenile court records.

Kendall began hitting his head against the wall until he bled. Later, he pulled out the staples used to stitch his wounds. He threatened suicide. He got into fights. He suffered a series of seizures and had to be rushed to the hospital.

In June 2011, Williamson County Judge Sharon Guffee ordered DCS to take Kendall for a medical evaluation regarding his seizures. She noted, “The Court recommends a … residential treatment facility to address the child’s mental and physical illness and for the protection of the child and others.” One month later, she issued another order, again telling DCS that Kendall belonged in a medical facility that could keep round-the-clock watch. Also, she urged DCS to communicate with his mother, juvenile records provided to The Tennessean by Diane Oates showed.

But by December 2011, DCS had transferred Kendall from a group home to Woodland Hills, a high-security facility surrounded by barbed wire and reserved for teenage boys who have committed multiple or violent felonies ranging from drug offenses to armed robbery to rape.

Guffee said confidentiality rules barred her from commenting on Kendall’s case. But, she noted, there has been an “ongoing conflict” between DCS and judges over where kids are placed, because state law gives the agency full authority over such decisions.

“Juvenile courts have virtually no say over where these children get placed,” said Guffee, noting that part of the problem was DCS funding.

DCS data obtained by The Tennessean show waiting lists for children in DCS’ juvenile justice system needing beds in medical facilities or other treatment centers have doubled in the past two years. Four successive years of budget cuts have eliminated 38 percent of DCS’ juvenile program budget.

Other teens inside Woodland Hills said Kendall was different from the other teens at the facility.

John Foster, a former Woodland Hills inmate who estimated he had more than 30 convictions ranging from drugs to assault by the time he was 18, remembers seeing how Kendall interacted with his mother during a visit.

“A few days before he died, I saw him kissing his mom,” Foster said.

“Sometimes you see a guy hug his mom, but you never see any of the guys kiss them,” he said. “He was cool and all, but he wasn’t that tough. He just seemed different, like he shouldn’t have been there.”

DeCari Cradle, 19, who was in Woodland Hills for drug-related offenses, said he and others tried to protect Kendall.

“A lot of us watched out for him because we knew he had seizures and sometimes he was feeling so bad about wanting to get out, he’d bang his head into the wall,” Cradle said.

A DCS caseworker noted in Kendall’s records that she once found Kendall in the gym banging his head against the wall repeatedly.

“He reported he is just sad and he wants to go home,” the caseworker noted, saying he seemed to feel better after a phone call from his mother.

‘God, please don’t let the child die’

DCS records, police reports, 911 audio files and personnel records obtained by The Tennessean detail witnesses’ accounts of what happened at Woodland Hills on the day Kendall died.

On the morning of May 25, after breakfast and a routine anger management training for kids at the facility, most of the other youths in Kendall’s dorm went outside to a party rewarding good behavior. But between 7:45 and 8 a.m., Kendall told friends he was tired and returned to his room. The Read Dormitory, where Kendall lived, was quiet and mostly empty.

Shortly before 11 a.m., when the party was over and the teens were heading to lunch, one of them noticed that Kendall was missing. He told Calvin Gooch, the guard on duty. Two teens then went to check on Kendall through the rectangular window in his locked door. Kendall was lying on his bed and didn’t appear to be moving, they reported.

The guard followed them to Kendall’s room and unlocked the door. Kendall “looked like he had already been gone for a while, his eyes were glistening like they had glue on them and his lips were ashy, his body seemed real stiff,” one of the teens later reported. Gooch sounded a “Code Blue” and a senior security guard rushed to the room, followed soon after by two nurses.

The senior security guard performed CPR, repeating, “God, please don’t let the child die” between chest compressions. Nurses took over CPR, then paramedics. But Kendall never revived. He was taken by ambulance to Vanderbilt University Medical Center, where he was declared dead a short while later.

Gooch first told internal DCS investigators that he had checked on Kendall regularly as he was trained to do, by doing a “visual check” through the window of their locked rooms. Gooch said he “has never been trained to see a child sleep a certain way, if the student is in the cell they just write that the student appears to be sleep.” DCS investigators noted the guard “appeared to be very remorseful and tearful during the interview.” The records noted that Gooch should have checked on Kendall every 15 minutes.

After examining video monitoring tapes inside the facility, checking logs, and in interviews with teenagers at the facility, DCS investigators concluded that Gooch made no checks on Kendall for 2½ hours between 8:15 a.m and 10:56, when he sounded the Code Blue, according to a termination memo addressed to Gooch in his personnel file.

Instead, Gooch sat at a guard station about 20 feet away from Kendall’s room, left for a 24-minute break, returned and at one point read the Bible at his desk with other youths.

Gooch was fired from DCS in February. His termination memo notes he “failed to conduct a physical count of the students upon your return from break at 10:23 a.m. You further stated you did not hear any noises or sounds coming from K.O.’s room. You were aware that K.O. had a history of seizures because you were present on another occasion when K.O. had a seizure.”

DCS declined to take specific questions about the death of Kendall Oates, instead issuing a statement on July 25 that addressed only the security guard’s role.

“We were aware that this young man was having medical issues, and we were working hard to address them,” the statement said. “This is not how we regularly do business. We have policies, procedures and protocols in place that we use every single day to ensure the safety of the youth in our care. … Once we learned the officer had not followed policy and procedure, we terminated his employment at DCS. He was marked for no-hire at DCS.”

Gooch appears to be the only DCS staffer disciplined in connection with Kendall’s death. But others inside the agency raised questions about whether any Woodland Hills security guard should have been responsible for monitoring a child with a serious medical condition.

After Kendall died, DCS records show an unnamed Woodland Hills staff member told internal investigators that the teen “should have been in a different facility because of his medical condition because it is hard to focus on one child and keep an eye on him all the time.”

Police records also show that the DCS nurse on duty reported that Kendall had been given his anti-seizure medication at 6 a.m. that day. Another unnamed nurse told DCS internal investigators later that Kendall had gotten the medication at 6:30 a.m.

An autopsy found no trace of Clonazepam, the anti-seizure drug, in his system.

“I would expect had he taken the drug it would be there,” said Deputy Chief Medical Examiner Adele Lewis, who performed Kendall’s autopsy. “Clonazepam has a pretty long half-life – it hangs out in the blood anywhere from 20 to 50 hours. There was no evidence of him having taken his Clonazepam in his blood.”

DCS records also show that a medical wristband Kendall was required to wear at all times to regulate his seizures was instead in a booth out of reach.

DCS emails obtained by The Tennessean show that DCS has ongoing challenges in keeping its juvenile facilities adequately staffed with medical personnel.

A week after Kendall’s death, DCS nurse Patricia Slade sent an email to several DCS officials about nursing shortages at Woodland Hills and the New Visions facility for girls. Slade noted nurses had to cover double shifts each week.

“We just don’t have enough bodies to staff the clinics,” she wrote. “This has been a problem for several weeks and I’m afraid will continue to be a problem. … Any suggestions are welcome.”

Father sues DCS

For months after Kendall died, DCS attorneys denied separate requests from Kendall’s parents to review their son’s records and medical information.

DCS’ top lawyer, Doug Dimond, noted in a February email to Diane Oates that he could turn over Kendall’s records only with Kendall’s consent – because Kendall had turned 18 in DCS custody and was no longer a minor. “I’ve got to follow the law that governs record release,” Dimond wrote.

With Kendall’s death, the records would be kept permanently sealed from his parents.

Oates said she read Dimond’s email, looked up at the photo of Kendall hanging on the wall above her computer and wept.

The parents got their first glimpse of DCS records when The Tennessean obtained copies of records of more than 200 children who died or nearly died in a 3½-year span after being brought to the agency’s attention. Those files were released under court order beginning in May.

Gary Oates filed a wrongful death lawsuit against DCS. He told The Tennessean he believes the agency deliberately delayed its response to his records request to avert a lawsuit. Such wrongful death lawsuits must be filed within one year of a death. Oates’ lawsuit came two days before the anniversary of Kendall’s death on May 25, 2012.

“DCS has been giving me the runaround,” Oates said. “Now I know why. Nobody checked on him like they were supposed to. Kendall should be alive right now if they had. And they stalled me. They stalled me, so I wouldn’t know, so I couldn’t sue them.”

Diane Oates said it was agonizing for her not to know the details of her son’s last hours.

“How long was he lying there by himself before they found him?” she asks herself.

A bitter divide

Losing their son has worsened the acrimony between his parents, who were married for nearly 20 years.

Diane Oates says she will never forgive her ex-husband for agreeing to place their son in DCS custody.

Today, Diane Oates sits in a minimum-security federal prison in Florida. Five months after Kendall’s death she pleaded guilty to cashing in her children’s Social Security checks when they did not live with her. Her children were entitled to the benefit when Diane Oates qualified for federal disability payments, said her attorney, Jesse Montagnino, who cited client confidentiality rules in declining to specify the disability. In May she began serving a 10-month sentence. Oates said in a telephone interview she did not trust anyone else with the money and had saved it for the children.

Gary Oates reported her to federal authorities.”

TN family fights for answers year after teen dies in DCS lockup

A version of this column originally appeared in www.reformtalk.net.

Change comes, slowly, to Florida’s juvenile justice system

prisons2-300x336[1]The Florida House on Friday unanimously passed a bill securing teenagers from abuse by personnel in lock-ups run by the Department of Juvenile Justice-- but for lots of supporters, the Legislature should be putting even more protections in place, reports Margie Menzel of the News Service of Florida.

The Dream Defenders, a youth team concentrated on juvenile justice concerns, called today for protection from arrests at school for small occurrences. The group also called for an end to pepper spray and solitary confinement in jails run by Florida counties and to stop putting teenagers in the adolescent justice system for violation first offenses.

Florida incarcerates more young people per capita than any of the 10 most populous states. In 2012, more than 58,000 were detained-- a rate 40 percent higher than the national average.

So members of the Dream Defenders presented a sit-in this week at Gov. Rick Scott's office and contacted the Legislature to provide their bills a hearing, however the measure that passed Friday had not been on their radar display.

DJJ had asked Rep. Gayle Harrell, R-Stuart, to recruit the costs (HB 353) after the death of Eric Perez of a cerebral hemorrhage at the Palm Beach Regional Detention Center in 2011. Since they thought Perez was faking his illness, a 2012 examiner general's report found that agency workers didn't call for aid. A grand-jury report was caustic, however discovered criminal fees could not be filed against the personnel since there was no basis in state law. So HB 353 expands the definition of child abuse to consist of young people in DJJ detention facilities.

DJJ Secretary Wansley Walters said the bill was needed but the occurrence itself was "an outlier-- and it was quickly handled. Which certainly sends a message.".

Because Perez' death, DJJ has actually developed an annual audit to evaluate its staff members for compliance with treatments and laws, and a tool to screen potential employees for their ability to deal with apprehended young people. The Palm Beach lock-up's telephones were reconfigured so teens could make free calls to lawyers, probation officers and the state abuse hotline.

"We will not allow children being abused," Walters stated. "We will not endure children being overlooked. Too many children have had that experience and discovered their means into our system, and our system will refrain that to them.".

She indicated the Milton Girls Juvenile Residential Facility, which was closed last winter after a former guard was accuseded of child abuse for her treatment of a 15-year-old inpatient. A DJJ security video appeared where Shannon Abbott appeared to slam the girl into a wall, toss her to the ground and pin her. Although Abbott filed an occurrence report stating the teen had withstood, the video did not appear to support her, and she was found guilty last month.

"I think there was a culture there that was really being concealed and being concealed from our division," Walters said. "But it has actually emerged, and luckily police has gotten included and people are being held accountable-- after the truth, because within a few months of that event, that program was closed. And that will be our technique throughout our system.".

Perhaps the greatest concern for proponents, however, is exactly what the Southern Poverty Law Center's David Utter calls "state-sanctioned child abuse down in Polk County.".

That would be SPLC's top legal priority, SB 506 by Sen. Arthenia Joyner, D-Tampa, which would repeal a 2011 law (SB 2112) that enables Florida counties to run their own adolescent justice facilities. 3 counties now do so-- Polk, Seminole and Marion-- but just Polk utilizes pepper spray on juveniles.

SPLC has actually brought a federal claim against Polk County and Sheriff Grady Judd for the practice, which Judd strongly defends.

"Why would you rather us fight these kids-- a few of them well over six foot and 200 pounds-- why would you desire us to fight them on a concrete floor and take the possibility of hurting them or us when they're so incorrigible they won't de-escalate, when an easy spray from the pepper spray de-escalates most chances for there having to be a physical fight?" Judd asked.

He said pepper spray rapidly diminishes, whereas lots of supporters state it should not be used on juveniles due to the fact that their brains aren't fully established.

"The overwhelming view in Florida and the rest of the nation regarding using pepper spray in juvenile settings is at odds with Sheriff's Judd's practice," wrote Magistrate Judge Mark A. Pizzo last month. "He would be smart to establish a plan for reducing the juvenile-on-juvenile violence and limiting the use of pepper spray.".

Judd likewise stated Polk County abides by the Florida Model Jail Standards, which are different from the DJJ requirements, which housing juveniles at the prison-- independently from adult inpatients-- saves Polk County millions of dollars.

Seminole County also runs its own adolescent detention center, and Major Scott Ballou informed an audience at the panel discussion "Kids are Different: Youth in the Justice System" last month at St. Petersburg College that the expense was certainly a factor.

"(Senate Bill) 2112 was born of years of aggravation over detention expense repayment," Ballou stated. "I can inform you the last time we paid, the per diem rate was $282 per day per child-- and that's insane.".

Seminole County has cut the daily ordinary lot of incarcerated youths from between 40 and 50 to 15, he said.

"That's why we wanted to do it. It had not been to abuse children by any stretch of the creativity," Ballou said. "Because of neighborhood control, we have a great deal of choices on detention avoidance.".

Joyner's bill rescinding SB 2112 hasn't been heard, nor has its House companion by Rep. Mia Jones, D-Jacksonville.

Neither has SB 660/HB 603, requiring police force to issue civil citations and offer diversion programs for newbie offenders who commit misdemeanors.

Neither has SB 1374/HB 1039, intended to reduce exactly what the Dream Defenders call the "school-to-prison pipeline" by needing schools with zero tolerance policies to state to police just serious hazards to school safety.

 

A version of this column originally appeared in saintpetersblog.com.

Child Abuse And The Most Important Public Health Study Ever

Pensive ParakeetDavid McCollum was an emergency room doctor that came to the realization that almost all the injured and seriously ill patients passing through his hospital emergency room doors had been abused as children.  These people were leading dangerous lifestyles, often suffered from chronic illness, and met early death.

When I met him, he spoke passionately about the Academy on Violence and Abuse www.avahealth.org and all the work being done by medical professionals to identify the impact of Adverse Childhood Experiences (ACEs) on human beings throughout their lives.

Dr McCollum’s observations mirrored my own experience as a CASA volunteer guardian ad-Litem for Hennepin County, as so many of the *tortured children I removed from horrible circumstances went on to lead painful, dysfunctional lives.

Interviewing people for my book INVISIBLE CHILDREN I came to know professionals in many different fields that agree with the Academy’s findings.

Educators have a hard time teaching (or managing) abused or neglected children, the juvenile justice system is filled with youth that have suffered through violent and toxic home lives**, and our criminal justice system is now the greatest in the industrialized world if measured by violent crime statistics or the fact that we have more of our citizens incarcerated per capita (and in sheer numbers) than any other industrialized nation in the world.

The medical community correctly points out that this is a giant public health issue that needs resolution if this nation is ever to regain its higher order ranking in the quality of life indices that we have lost over the decades.

This short powerful article from the Huffington Post, clearly articulates the depth and scope of the work done by the Academy on Violence and Abuse and will change the way most people view how their community should reach out to at risk children.  This short video gives a snapshot of the ACE study.

*The World Health Organization defines torture as “Extended exposure to violence and deprivation”.  Every child I worked with as a CASA volunteer guardian ad-Litem suffered from Extended Exposure To Violence and Deprivation.

** Former MN Supreme Court Chief Justice Kathleen Blatz has stated that “90% of the youth in the juvenile justice system have passed through child protective services” and that the “difference between that poor child and a felon, is about eight years’.

Buy our book or donate  Watch Our Video Follow us on Twitter http://twitter.com/KidsAtRisk

From the Huffington Post;

The Adverse Childhood Experiences Study — the Largest Public Health Study You Never Heard Of

Posted: 10/08/2012 8:53 am

“Adverse childhood experiences” has become a buzzword in social services, public health, education, juvenile justice, mental health, pediatrics, criminal justice, medical research and even business. The ACE Study – the CDC’s Adverse Childhood Experiences Study – has recently been featured in the New York TimesThis American Life, and Salon.com. Many people say that just as you should what your cholesterol score is, so you should know your ACE score. But what is this study? And do you know your own ACE score?

The ACE Study – probably the most important public health study you never heard of – emerged from an obesity clinic on a quiet street in San Diego.

It was 1985, and Dr. Vincent Felitti was mystified. The physician, chief of Kaiser Permanente’s revolutionary Department of Preventive Medicine in San Diego, CA, couldn’t figure out why, each year for the last five years, more than half of the people in his obesity clinic dropped out. Although people who wanted to shed as little as 30 pounds could participate, the clinic was designed for people who were 100 to 600 pounds overweight.

Felitti cut an imposing, yet dashing, figure. Tall, straight-backed, not a silver hair out of place, penetrating eyes, he was a doctor whom patients trusted implicitly, spoke of reverentially and rarely called by his first name. The preventive medicine department he created had become an international beacon for efficient and compassionate care. Every year, more than 50,000 people were screened for diseases that tests and machines could pick up before symptoms appeared. It was the largest medical evaluation site in the world. It was reducing health care costs before reducing health care costs was cool.

But the 50-percent dropout rate in the obesity clinic that Felitti started in 1980 was driving him crazy. A cursory review of all the dropouts’ records astonished him — they’d all been losing weight when they left the program, not gaining. That made no sense whatsoever. Why would people who were 300 pounds overweight lose 100 pounds, and then drop out when they were on a roll?

The situation “was ruining my attempts to build a successful program,” he recalls, and in typical Type-A fashion, he was determined to find out why.

The mystery turned into a 25-year quest involving researchers from the Centers for Disease Control and Prevention and more than 17,000 members of Kaiser Permanente’s San Diego care program. It would reveal that adverse experiences in childhood were very common, even in the white middle-class, and that these experiences are linked to every major chronic illness and social problem that the United States grapples with – and spends billions of dollars on.

In 1985, however, all that Felitti knew was that the obesity clinic had a serious problem. He decided to dig deep into the dropouts’ medical records. This revealed a couple of surprises: All the dropouts had been born at a normal weight. They didn’t gain weight slowly over several years.
“I had assumed that people who were 400, 500, 600 pounds would be getting heavier and heavier year after year. In 2,000 people, I did not see it once,” says Felitti. When they gained weight, it was abrupt and then they stabilized. If they lost weight, they regained all of it or more over a very short time.

2012-10-05-AVAFelitti.jpgBut this knowledge brought him no closer to solving the mystery. So, he decided to do face-to-face interviews with a couple hundred of the dropouts. He used a standard set of questions for everyone. For weeks, nothing unusual came of the inquiries. No revelations. No clues.

The turning point in Felitti’s quest came by accident. The physician was running through yet another series of questions with yet another obesity program patient: How much did you weigh when you were born? How much did you weigh when you started first grade? How much did you weigh when you entered high school? How old were you when you became sexually active? How old were you when you married?

“I misspoke,” he recalls, probably out of discomfort in asking about when she became sexually active. Although physicians are given plenty of training in examining body parts without hesitation, he says, they’re given little support in talking about what patients do with some of those body parts. “Instead of asking, “How old were you when you were first sexually active,” I asked, “How much did you weigh when you were first sexually active?’ The patient, a woman, answered, ‘Forty pounds.’”

He didn’t understand what he was hearing. He misspoke the question again. She gave the same answer, burst into tears and added, “It was when I was four years old, with my father.”

He suddenly realized what he had asked.

“I remembered thinking, ‘This is only the second incest case I’ve had in 23 years of practice’,” Felitti recalls. “I didn’t know what to do with the information. About 10 days later, I ran into the same thing. It was very disturbing. Every other person was providing information about childhood sexual abuse. I thought, ‘This can’t be true. People would know if that were true. Someone would have told me in medical school.’ ”

Worried that he was injecting some unconscious bias into the questioning, he asked five of his colleagues to interview the next 100 patients in the weight program. “They turned up the same things,” he says.

Of the 286 people whom Felitti and his colleagues interviewed, most had been sexually abused as children. As startling as this was, it turned out to be less significant than another piece of the puzzle that dropped into place during an interview with a woman who had been raped when she was 23 years old. In the year after the attack, she told Felitti that she’d gained 105 pounds.

“As she was thanking me for asking the question,” says Felitti, “she looks down at the carpet, and mutters, ‘Overweight is overlooked, and that’s the way I need to be.’”

During that encounter, a realization struck Felitti. It’s a significant detail that many physicians, psychologists, public health experts and policymakers haven’t yet grasped: The obese people that Felitti was interviewing were 100, 200, 300, 400 pounds overweight, but they didn’t see their weight as a problem. To them, eating was a solution. (There’s a reason an IV drug user calls a dose a “fix”.)

One way it was a solution is that it made them feel better. Eating soothed their anxiety, fear, anger or depression – it worked like alcohol or tobacco or methamphetamines. Not eating increased their anxiety, depression, and fear to levels that were intolerable.

The other way it helped was that, for many people, just being obese solved a problem. In the case of the woman who’d been raped, she felt as if she were invisible to men. In the case of a man who’d been beaten up when he was a skinny kid, being fat kept him safe, because when he gained hundreds of pounds, nobody bothered him. In the case of another woman — whose father told her while he was raping her when she was 7 years old that the only reason he wasn’t doing the same to her 9-year-old sister was because she was fat — being obese protected her. Losing weight increased their anxiety, depression, and fear to levels that were intolerable.

For some people, both motivations were in play.

Felitti didn’t know this at the time, but this was the more important result — the mind-shift, the new meme that would begin spreading far beyond a weight clinic in San Diego. It would provide more understanding about the lives of hundreds of millions of people around the world who use biochemical coping methods – such as alcohol, marijuana, food, sex, tobacco, violence, work, methamphetamine, thrill sports – to escape intense fear, anxiety, depression, anger.

Public health experts, social service workers, educators, therapists and policy makers commonly regard addiction as a problem. Some, however, are beginning to grasp that turning to drugs is a normal response to serious childhood trauma, and that telling people who smoke or overeat or overwork that these are bad for them and that they should stop doesn’t sway or convince them when those approaches provide a temporary, but gratifying solution.

Ella Herman was one of the people who participated in the obesity clinic, but had dropped out because any weight she lost, she regained. Herman owned a successful childcare center in San Diego. Herman said she was sexually abused by two uncles and a school bus driver; the first time occurred when she was four years old. She married a man who abused her repeatedly and tried to kill her. With the help of her family, she fled with her children to San Diego, where she later remarried.

“I imagine I’ve lost 100 pounds about six times,” she recalled. “And gained it back.” Every time she lost weight and a man commented on her beauty, she became terrified and began eating. But she never understood the connection until she attended a meeting at which Felitti talked about what he’d learned from patients. At this time, Herman was just over five feet tall and weighed nearly 300 pounds.

“He had a room full of people,” she said. “The more he talked the more I cried, because he was touching every aspect of my life. Somebody in the world understands, I thought.”

Herman later sent a letter to Felitti. “I want to thank you for caring enough about people to read all those charts and finding out what happens to all of us who are molested, raped and abused in childhood,” she wrote. “…I suffered for years. The pain became so great I was thinking of jumping off the San Diego Bay Bridge….How many people may have taken their life because they had no program to turn to? How many lives can be saved by this program?”

Part Two: What do you do when you’ve got something important to tell the world, but the world thinks it’s stupid?

For Part 2, go here; and for Part 3 go here.

A version of this column originally appeared in www.invisiblechildren.org.