of their career, and he found that quite a few of them had had adverse child events. So he made that association between those and the PTSD they initially had. Okay, well, what do we do? As I mentioned before, we had this longitudinal prospective study we were doing on police. We did a few studies in 1999, but in 2004 we surveyed the entire Buffalo Police Department and we ended up with 462 police officers. Our goal was to look at cardiovascular disease and stress and the effect of stress on cardiovascular disease among police officers, and along the way we looked at many other things. The first study was done in 2004, the first major study was done in 2004. We did preliminary studies prior to that, and it went out to 2020, and during that time we looked at sort of the prospective movement, if you will, of cardiovascular disease and psychological difficulties along the way, along these years. We looked at, in terms of stress, we looked at the dysregulation of the HBA axis, the hypothalamus pituitary adrenal axis in the body, which as you know is sort of an axis which secretes cortisol, and which is kind of known to be a stress hormone. We looked at the dysregulation of cortisol, in other words, we could measure by using saliva samples in these police officers, we used diurnal samples and we used awakening samples and we looked at those in terms of how they became dysregulated in officers and whether they remained dysregulated over time, and whether or not that was going to eventually lead to disease, and by disease I meant we looked at subclinical cardiovascular markers in the police, in particular the brachial artery, we looked at brachial reactivity in the police, and we looked at carotid thickness in the police over time, and we associated that with the cortisol dysregulation, and we did find associations with that, by the way. So, those are things we were really after. The other things we were after were psychological factors, post-traumatic stress disorder was very strong on our list, depression was strong, hopelessness was strong, and some of these other things as well. The sample was derived from the Buffalo Police Department, originally we had 462, from that sample we took a smaller sample of completed data for our present study on adverse disease. We used regression coefficients and controlled for age and gender and race and ethnicity and alcohol use and a few other things. Adverse Child Events is a 10-item yes-no questionnaire, developed by Philedia originally in 1998. Five of the questions deal with physical abuse, sorry, sexual abuse and emotional neglect. Emotional neglect being, we don't love you type emotional neglect. Like, you're no good kid, get away from me, you know, maybe we don't want you in this family, that sort of neglect. Post-traumatic stress disorder, we used the PTSD checklist by Weathers, and that basically is a 17-item, the PCL-5 is derived from the DSM-5, Diagnostic and Statistical Manual in American Psychiatric Association Version 5. And for depressive symptoms we used the Epidemiological Studies Depression Scale, hopelessness, the Beck Hopelessness Scale. And the various statistical methods we used were descriptive, took care of confounders, associations, linear regression, and we did some adjustments for age, gender, and so forth. Well what did all of this bring for us? The mean age of our sample was 48. This is kind of almost the average age of police in the country, in our U.S., it's a little older, but it's in that range. 28% were women, 67% were married, had degrees, 53% were patrol officers. Most of the people that were in our study were patrol officers, and these are the officers essentially that do the work, they're the ones, nothing against supervision, but the patrol officers go out there every day in the street and deal with the crime and the trauma and everything else that the officers have to deal with. And a lot of them had a good time on the job, they were on the job for over 15 years. The overall age score was 1.6, and interestingly, the age score for female officers was higher than it was for males. In fact, it was significantly higher for female officers than it was for males. Which I found kind of interesting, I think that's an indication that women in policing have a more difficult time with stress, and probably with past abuses in a physical sense, in a sexual sense as well. And we did find that to be true here, and I'll show you that in a minute. Well, what kind of abuses did they officers have? Primarily, the biggest abuse they had was divorces of the parents. This was very upsetting for a lot of children, as many of you know, and I don't have to tell you this, that divorce can really disrupt things in any family. And apparently, this was a big one for the police officers. Being humiliated was next, fear of being injured or hurt by one's parents. Being grabbed, being pushed, living with a problem, drinker. The alcohol abuse situation among police officers is rather significant, and it's a problem for a lot of officers out there who can't cope with the stress of the job, eventually they turn to maladaptive coping techniques, and one of those techniques is binge drinking or drugging out when they come home, and just, you know, just not drugging out with alcohol or just not, you know, being able to cope anymore, like giving up. So I think you see that because of the stress of this job. Not having support in the family, and there were a few others, bodily harm, sexual abuse, and so forth. So these were, in terms of a scale, you know, divorce seemed to be the highest, but then humiliation was next, and so forth and so on. If you look at the data, it tells us, it's kind of gibberish here, but what it tells us essentially is that if you, if we associate ACE scores, adverse scores with PTSD, for example, for every unit standard deviation in the ACE score, there's a 70% deviation in PTSD. So there's a big increase in PTSD if you've experienced ACEs. As far as depressive symptoms, and again, these are symptoms, 29% greater for every unit of ACEs, and depression, 14% higher for every unit of ACEs. Hopelessness was the only one that was not significant in that association, and if we look at it graphically, it looks like this. As the ACEs score go up, and you can see that on the graph there, as the ACEs score go up, the PTSD goes up significantly, depressive symptoms go up significantly, and hopelessness goes up, but not significantly. So there are associations, and in this sample, we did find associations between the ACEs, the adverse events, and the sort of mental difficulties among our police officers in Buffalo. Overall, women officers, again, women officers had significantly higher mean in the total number of ACEs than males did, and they were higher in male officers in each separate item of the 10 items of the ACE measure. Almost 20% of the women reported being sexually fondled as children. So this has a significant impact, I believe, on anybody, on anyone who has gone through such a terrible experience, and I think it has affected the policewomen here in our study. Okay, in sum, ACEs were positively and significantly associated with PTSD, post-traumatic stress disorder, depressive symptoms, and hopelessness to some degree. Women officers had higher percentages of physical and sexual contact, including insults, laughs, injuries, and being touched and bonded sexually. Divorce, well, again, that was the highest. What does that matter? Only 38% reported divorce was the highest adverse event they had as a child. What the research shows is that, again, up here it shows that the child's ability to deal with divorce, to regulate emotions after a divorce, are affected, and that dysregulation of the ability to deal with that sort of emotion can affect your ability to deal with stress, because that's a whole stressful situation when you lose your dad or your mom, or they're fighting in front of you all the time, and that sort of thing is going on. So you lose that ability to deal with future stress. Now, when you become a cop, when you become a police officer, you go out there and you're going to be stressed to no end. It's not an easiest job as it looks. I think sometimes you'll get the wrong impression about police officers. There's a lot of negative talk against cops and so forth, and a lot of bad things have happened in our society with police, but that's not the general police officer. The general police officer is really a good person who does their job, and they deal with a lot of stress, and they deal with a lot of trauma, and believe me, the trauma that you experience as a police officer for a period of 20 to 25 years is a lot. It's very high. Officers probably experience two to three trauma events a month on their job on average. The dead bodies, the abused kids, the horrible crimes that they see, the human misery that they see every day, and that's part of this job, so not being able to deal with that job because of something that may have happened to you in your former life can affect you in some way, and sometimes the children blame themselves for the divorce, and that too can have an impact on future health, mental health, because it's internalized, you know, everything was my fault, and so forth and so on. Again physical abuse, and these are just research things that I've looked at. Some meta-analysis said that emotional abuse had the strongest association with depression followed by sexual abuse as well. Women may be more susceptible to depression because, again, they were sexually abused at an early age, and the real hurtful part about that is generally it was someone close to the young woman, a family member, an uncle, a father, a brother, you know. That probably had the most impact upon the woman in our sample. Of course it's a limited study, again, we'd like to look at it over time to see if these things sort of hang in there over periods of time, but it's cross-sectional. It's a small sample, and, you know, we don't know about, the thing about ACEs that we don't know is how they occur, in other words, are they simultaneous, are all these things happening at the same time in a family, are you getting abused, you know, are you getting, everything's happening all at once at the same time, are they happening in stages, or are they happening over a period of time. These are things that are important to know when you look at adverse events. We don't know the exact age of the abuse that took place, we know there were less than 16, and of course a bias in recall is always evident in self-report sorts of studies. PTSD can, again, affect attention and interpretation, and can exacerbate emotional regulation. Now you don't want that to happen in police officers, again, especially those on the road, and in fact we, you know, some of our studies that we've done, our ancillary studies we've done upon PTSD, using brain imagery, found that if you have higher levels of PTSD, essentially, it can affect your ability to make decisions, because of neural transmission is essentially, in some cases, blocked by post-traumatic stress disorder, and the ability to reason out something, or to make a decision on something, can be affected by higher levels of PTSD, and we did find that in one of our studies most recently. Looking at what an officer does every day is important as well, and, you know, some police officers have this job of sitting in front of a computer and tuning in to pornographic and child exploitation websites, and gathering evidence to prosecute these people who abuse children, sexually abuse children. They do this all day long, so they're sitting there for, you know, 8 to 10 hours a day looking at this stuff, and, you know, I think it's important they be evaluated for being sexually abused as a child, and also for that sort of job that they should be evaluated every month or so on their psychological health. I think that's important to look at, and we do see that. Other things they do, of course, is to catch these people. And they do catch these people, is to prosecute them, and they have to gather evidence from these websites, and sometimes they'll go in and they'll act as a child, you know, or a young woman, or a young girl, in order to bring out these people, in order to get and arrest them. So it's a tough job. That's a very difficult job, and, of course, we want to do a larger sample on our women officers, because they, too, are suffering from this. Now, I don't mean to tell you that, you know, adverse child events are the only thing that affect officers and their mental health. That's not true. I think it's one of the things. Perhaps we should screen officers for that when they initially come into police work. Right now, we do give psychological testing to police officers, the MMPI, the MMPI-2, the CPI, there are various psychological tests that they do give police officers when they come in, to measure things like depression, PTSD, schizophrenia, you name it, all the psychological things. And then they go to a psychologist for an interview, and the psychologist talks about this. And I think it's important for the psychologist at this point to talk a little bit about these events. I think, I just have a strong opinion that they are something that can affect them in later life. So maybe that will be part of the screening technique that we do use presently. A lot of the screening techniques we use as well are good in the beginning, but what happens to police officers over time is very interesting to me as well. As we see them change from, in terms of psychological health, we also see them change in the way they act, the way they are, basically. And family members we talk to say, well, you know, they're not the same person they were when I married them five years ago, and they became a cop, they kind of became a different kind of person. So these are very interesting things that we need to look at at police. And why is that true? Should they be attested again in terms of psychological health? Should we take better care of them? And we don't. We don't. Officers who do have mental difficulties are essentially afraid to come forward. Much like firefighters that Judith talked about. This is a stigma attached to mental disease, and they're going to feel that, well, my comrades are going to not trust me, and my supervisors are not going to like me anymore, and they're not going to trust me, and I'm going to lose my job, I'm going to lose my badge, so forth and so on. They're not going to come forward. They're going to try to eat it, try to stuff it inside them, and do something with it. You know, it doesn't work. It doesn't work for them. So okay. We wrote a paper on this, and that's the source that we used on this, and my aunt was supposed to be along here with me, but she couldn't make it, so. Okay. What time is it? Excuse me. I guess that's it. I really don't have any much more to say, and if anybody has any questions, yes, sir? Thanks for a really interesting presentation. My name is Mike Levine. I have the- Mark, I'm sorry. I'm kind of hard of hearing. Oh, okay. I don't want to get that close, because COVID's not that far in the past. I need the microphone. My name is Mike Levine. I'm an occupational physician in Virginia. I have the honor of taking care now of one police department. I've been active in our public safety medicine group, and was the primary author or editor of our mental health chapter, and your work was figured in that. Thank you. This is interesting to me, but I am struggling a little bit with how it's useful to me as a clinician, and let me ask you a question to start with. You showed us a graph of the differences with hopelessness, depression, and PTSD, and I wonder if you had a cohort of ice cream men and women, would it show the same thing? The relationship between A-score and depression and PTSD, and I would argue it probably would, and- Would it be the same in women? Is that what you're saying? Ice cream. You know, people who sell ice cream- Ice cream? Yeah. If you pick the happiest people in the world who sell ice cream, right? And you looked at the correlation between depression and PTSD, and the A-score. Oh, I see what you're saying. Okay? So what I'm saying is that the important thing, I think, is what percentage of police officers have a high A-score, and is there any way that we can really use that A-score as a screening test? I would argue it would just confuse things. Well, yeah, I think we could use it as part of a screening test. I mean, we do a pretty- I don't know if you do screening on officers, but it's pretty thorough, as you might know, by psychologists and by testing. Personally, I would say to include it. I mean, it's like prior trauma. People who have prior trauma have these same sort of things going on in their life, and I think this is part of that. I would like to see it. It's not done now, but I would like to see it as part of a psychologist interview, maybe not the testing, but that interview is very important after the initial testing to find out about the person's life, and whether or not they're suited to be a cop, and some people are not. Yeah, well, I mean, there's a lot of places where you would test an officer, right? If you're- ideally, you would test them at time of hire, right? And then you might test them after a critical incident, or a fitness for duty issue came up, and then I would wonder, how does it really contribute to what you do with the officer? Does it inform treatment in some way to know that they had a high ACE score? I don't know. I don't know either. I'm not sure what you would make out of that, but generally, we don't test them after a traumatic event, but they do go to critical incident briefings, or maybe see a psychologist after an event like that. Sometimes it's mandatory, sometimes it's not, but I think it's important to address the trauma after an event like that in some way, and I think the critical incident debriefings that officers do, do help to some degree, but they're not- they've been proven not to be really that effective, but at least they're something, you know? I think a face-to-face meeting with a psychologist is a better deal than a critical incident debriefing, but my opinion- yes, sir? So this is outside of the scope of the study that you presented, but I was wondering if you know if there's anything in the literature regarding adverse childhood events leading someone to become a police officer, such as, you know, their childhood events led them to want to be in a position to protect the vulnerable, to defend the vulnerable, anything like that? Yes. Yes, and in fact, I was thinking along those lines that, you know, why do you want to become a police officer? You know, to right a wrong? I mean, maybe I think that's what you're saying here. This is what happened to me, and I don't want it to happen to anybody else, so I guess in a sense that's a positive motive to become a police officer, and that may be a driving force to get people to come into that profession. That's a very good point. Do you know if there's anything in the literature about that? I don't. No, I don't know. Sorry. I want to thank the last two docs for stealing part of my question, but first of all, great presentation. Very good on the scientific rigor. I think that's outstanding. Along the lines of the last question, did you consider a placebo group to see if a high ACE score contributed to a child's pursuit of a career in law enforcement? I'm just curious if that has any reality to it or validity. Yeah, that's an interesting question, to consider the placebo group. That would be a good experiment. I think that would be interesting to see what kind of profession do these people go into in general if they've been victims of ACEs. I don't know of any studies that have looked at that, but not sure. My wife did a quick stint as an elementary school nurse, school nurse, and I think maybe a lot of these folks go into elementary school teaching. That's cool. How are you doing? Across the country, it's become virtually impossible to fill numbers in police academies across the country. In New York City, where I came from, I serve as an honorary surgeon for the NYPD. They've dropped standards. Most recently they had a mile and a half run that they dropped. People are up in arms. Are we dropping psychological standards? What will the consequences of that be? On the other side of the coin, as honorary surgeon, I've been approached by people who have failed the psychological. They've come to me with things, and I really wanted to say this to you, do you love your father more than your mother? I've heard that over and over again. How do I answer that question? In summary, are we dropping standards? What are we going to do? Are you familiar with something called The Chief? It's a civil service newspaper. If you look in The Chief, there's a whole industry built around appealing these psychological decisions. What are your thoughts going forward? We're having a crisis, especially in New York. Here's the situation. It's become extremely difficult for departments to hire police officers. I think that's motivated them to lower standards. I know one department that recently lowered the standard of education into equivalency of high school, which has been done in the past, but they moved it up to two years of college and then maybe a bachelor's degree, which I think is essential to have. If you're going to be a cop, you need a little wired view of the world, then you get in high school, I think. I think the standards have been lowered in terms of physical standards. I can't speak for all departments in this country, but just from my own knowledge, you're right, you're right, the appeals have increased. I went to the psychologist, he said I wasn't qualified to be a police officer. I don't believe that. I'm going to fight it. I'm going to get a lawyer and try to do it anyways. A lot of times the lawyers win. Sometimes we get people who are officers that really shouldn't be police officers. Maybe that's why we sometimes get in trouble with law enforcement. I'm surmising what I know about this job and what I've experienced on this job for 23 years. I understand what the job's all about. That's what I'm seeing. Hopefully that's answerable. I mean, physical standards too. I don't know if you remember a few years back there was an incident in Atlanta where a suspect took control of the officer's taser and then they fired on that suspect. The response from the mayor is, oh, our guy's got to get tougher, but I don't know, we're not in a, we're in trouble. Did you say suicide? No, this was a famous case in Atlanta a few years back where a suspect took, police had an interaction with a suspect and a taser was taken out. They took control of the taser, the perp took control of the taser, fired the taser at the police and the police fired back, killing the perp and just, it didn't go over. So the mayor's response was, oh, our cop's got to be stronger. I don't know. It's not a good time to be a police officer. Well, it's interesting. I really don't know how to comment on that. I hear you. Yeah. You know, in terms of, we do, in terms of suicide, I think, I thought I heard you mention it, but we do study that in law enforcement and our last epidemiological study we did on that, we looked at 1.4 million workers in the United States using the National Occupational Mortality Surveillance Study and we found that if you're a member of the law enforcement profession, you have a 54% greater risk of dying by suicide than the average American worker in this country. So I mean, to me, that tells you how stressful this job is and what it does to the people that work this job over time. So on that happy note, I thank you for attending. Oh, I had one more comment. Oh, did you have a question? Sorry. I'm sorry. I just had a comment. I'm a retired San Juan occupational physician, retired from the Postal Service and just working part-time elsewhere, but I'm also on the Health, Wellness, and Recreation Committee for the town that I live in, which is Hyattsville, Maryland, a suburb of D.C., and we have mental health wellness check-ins for our police officers, which we've started. So once a month, the individual police officers meet virtually with a counselor. They get to choose the counselor. They're introduced to all. They get to choose the counselor. They can change if they want to. And so we're doing that, those mental health wellness check-ins, and the police officers really appreciate it, and I think it's very important to them. It's confidential. All of the interactions are confidential, but we just find that we have a better functioning police department, I believe, because of this. And they also have had mental health first aid for police officers so that when they approach people who may be dangerous, they learn how to talk them down, and we've had some really good outcomes with some fairly dangerous people who really, you know, may have been having mental health issues, actually, and so our police officers are able to deal with them better, and then they also can, in their monthly check-in, they can talk about their feelings, how they felt about it, and whatever other issues they may be having, whether it's on the job or at home. Mental health check-ups are an interesting concept, I think, that's recently came into policing, and what it is essentially is that every year you go and you talk to a counselor or a peer support officer, one of your own that's trained in counseling, and you talk about the past year. It's like going to a doctor or a dentist every year, and you go over your problems, and if you've had none, that's great. If you did, well, let's talk about it. Maybe we can get some help, but it's not a check-out, it's a check-in, you know, because people think, well, I'm going to get chucked out, well, no, it's not. It's a check-in, and it's confidential, like you mentioned. That's very important for the police because, again, the stigma of mental health, very strong in this particular occupation, but yeah, it works very well, and I think the first aid program is good as well. Having a peer support counselor, well, we can't call them counselors, we call them peer support people in police departments, is good because officers, much like the firefighters, officers will go talk to another police officer more so than they'll talk to a mental health professional, and, you know, it's easier for them to do that. If they have a small problem, they get that done. The peer support person generally has networked into psychologists and psychiatrists that they trust to talk to the police officer and get the officer help. So they work very well, and it's good to see they're doing that. I think it's a very good program. Well, thank you again, appreciate it.

Longitudinal study

Adverse childhood events

Mental health outcomes

Cortisol levels

Women officers

Stigma

Police recruitment