How childhood trauma affects health across a lifetime | Nadine Burke Harris | TED

In the mid-'90s, the CDC and Kaiser Permanente discovered an exposure

that dramatically increased the risk for seven out of 10 of the leading

causes of death in the United States. In high doses, it affects

brain development, the immune system, hormonal systems, and even the way our DNA

is read and transcribed. Folks who are exposed in very high doses have triple the lifetime risk

of heart disease and lung cancer and a 20-year difference

in life expectancy. And yet, doctors today are not trained

in routine screening or treatment. Now, the exposure I'm talking about is

not a pesticide or a packaging chemical. It's childhood trauma. Okay. What kind of trauma

am I talking about here? I'm not talking about failing a test

or losing a basketball game. I am talking about threats

that are so severe or pervasive that they literally get under our skin

and change our physiology: things like abuse or neglect, or growing up with a parent

who struggles with mental illness or substance dependence. Now, for a long time, I viewed these things in the way

I was trained to view them, either as a social problem --

refer to social services -- or as a mental health problem --

refer to mental health services. And then something happened

to make me rethink my entire approach. When I finished my residency, I wanted to go someplace

where I felt really needed, someplace where I could make a difference. So I came to work for

California Pacific Medical Center, one of the best private hospitals

in Northern California, and together, we opened a clinic

in Bayview-Hunters Point, one of the poorest, most underserved

neighborhoods in San Francisco. Now, prior to that point, there had been only

one pediatrician in all of Bayview to serve more than 10,000 children, so we hung a shingle, and we were able

to provide top-quality care regardless of ability to pay. It was so cool. We targeted

the typical health disparities: access to care, immunization rates,

asthma hospitalization rates, and we hit all of our numbers. We felt very proud of ourselves. But then I started noticing

a disturbing trend. A lot of kids were being

referred to me for ADHD, or Attention Deficit

Hyperactivity Disorder, but when I actually did

a thorough history and physical, what I found was that

for most of my patients, I couldn't make a diagnosis of ADHD. Most of the kids I was seeing

had experienced such severe trauma that it felt like something else

was going on. Somehow I was missing something important. Now, before I did my residency,

I did a master's degree in public health, and one of the things that they teach you

in public health school is that if you're a doctor and you see 100 kids

that all drink from the same well, and 98 of them develop diarrhea, you can go ahead

and write that prescription for dose after dose

after dose of antibiotics, or you can walk over and say,

"What the hell is in this well?" So I began reading everything that

I could get my hands on about how exposure to adversity affects the developing brains

and bodies of children. And then one day,

my colleague walked into my office, and he said, "Dr. Burke,

have you seen this?" In his hand was a copy

of a research study called the Adverse Childhood

Experiences Study. That day changed my clinical practice

and ultimately my career. The Adverse Childhood Experiences Study is something that everybody

needs to know about. It was done by Dr. Vince Felitti at Kaiser

and Dr. Bob Anda at the CDC, and together, they asked 17,500 adults

about their history of exposure to what they called "adverse

childhood experiences," or ACEs. Those include physical, emotional,

or sexual abuse; physical or emotional neglect; parental mental illness,

substance dependence, incarceration; parental separation or divorce; or domestic violence. For every yes, you would get

a point on your ACE score. And then what they did was they correlated these ACE scores

against health outcomes. What they found was striking. Two things: Number one, ACEs are incredibly common. Sixty-seven percent of the population

had at least one ACE, and 12.6 percent, one in eight,

had four or more ACEs. The second thing that they found was that there was

a dose-response relationship between ACEs and health outcomes: the higher your ACE score,

the worse your health outcomes. For a person with an ACE score

of four or more, their relative risk of chronic

obstructive pulmonary disease was two and a half times that

of someone with an ACE score of zero. For hepatitis, it was also

two and a half times. For depression, it was

four and a half times. For suicidality, it was 12 times. A person with an ACE score

of seven or more had triple the lifetime risk

of lung cancer and three and a half times the risk

of ischemic heart disease, the number one killer

in the United States of America. Well, of course this makes sense. Some people looked at this data

and they said, "Come on. You have a rough childhood,

you're more likely to drink and smoke and do all these things

that are going to ruin your health. This isn't science.

This is just bad behavior." It turns out this is exactly

where the science comes in. We now understand

better than we ever have before how exposure to early adversity affects the developing brains

and bodies of children. It affects areas like

the nucleus accumbens, the pleasure and reward

center of the brain that is implicated

in substance dependence. It inhibits the prefrontal cortex, which is necessary for impulse control

and executive function, a critical area for learning. And on MRI scans, we see measurable differences

in the amygdala, the brain's fear response center. So there are real neurologic reasons why folks exposed

to high doses of adversity are more likely to engage

in high-risk behavior, and that's important to know. But it turns out that even if you don't

engage in any high-risk behavior, you're still more likely

to develop heart disease or cancer. The reason for this has to do with

the hypothalamic–pituitary–adrenal axis, the brain's and body's

stress response system that governs our fight-or-flight response. How does it work? Well, imagine you're walking

in the forest and you see a bear. Immediately, your hypothalamus

sends a signal to your pituitary, which sends a signal

to your adrenal gland that says, "Release stress hormones!

Adrenaline! Cortisol!" And so your heart starts to pound, Your pupils dilate, your airways open up, and you are ready to either

fight that bear or run from the bear. And that is wonderful if you're in a forest

and there's a bear. (Laughter) But the problem is what happens

when the bear comes home every night, and this system is activated

over and over and over again, and it goes from being

adaptive, or life-saving, to maladaptive, or health-damaging. Children are especially sensitive

to this repeated stress activation, because their brains and bodies

are just developing. High doses of adversity not only affect

brain structure and function, they affect the developing immune system, developing hormonal systems, and even the way our DNA

is read and transcribed. So for me, this information

threw my old training out the window, because when we understand

the mechanism of a disease, when we know not only

which pathways are disrupted, but how, then as doctors, it is our job

to use this science for prevention and treatment. That's what we do. So in San Francisco, we created

the Center for Youth Wellness to prevent, screen and heal the impacts

of ACEs and toxic stress. We started simply with routine screening

of every one of our kids at their regular physical, because I know that if my patient

has an ACE score of 4, she's two and a half times as likely

to develop hepatitis or COPD, she's four and half times as likely

to become depressed, and she's 12 times as likely

to attempt to take her own life as my patient with zero ACEs. I know that when she's in my exam room. For our patients who do screen positive, we have a multidisciplinary treatment team

that works to reduce the dose of adversity and treat symptoms using best practices,

including home visits, care coordination, mental health care, nutrition, holistic interventions, and yes,

medication when necessary. But we also educate parents

about the impacts of ACEs and toxic stress the same way you would for covering

electrical outlets, or lead poisoning, and we tailor the care

of our asthmatics and our diabetics in a way that recognizes that they may

need more aggressive treatment, given the changes to their hormonal

and immune systems. So the other thing that happens

when you understand this science is that you want to shout it

from the rooftops, because this isn't just an issue

for kids in Bayview. I figured the minute

that everybody else heard about this, it would be routine screening,

multi-disciplinary treatment teams, and it would be a race to the most

effective clinical treatment protocols. Yeah. That did not happen. And that was a huge learning for me. What I had thought of as simply

best clinical practice I now understand to be a movement. In the words of Dr. Robert Block, the former President

of the American Academy of Pediatrics, "Adverse childhood experiences are the single greatest

unaddressed public health threat facing our nation today." And for a lot of people,

that's a terrifying prospect. The scope and scale of the problem

seems so large that it feels overwhelming to think about how we might approach it. But for me, that's actually

where the hopes lies, because when we have the right framework, when we recognize this to be

a public health crisis, then we can begin to use the right

tool kit to come up with solutions. From tobacco to lead poisoning

to HIV/AIDS, the United States actually has

quite a strong track record with addressing public health problems, but replicating those successes

with ACEs and toxic stress is going to take determination

and commitment, and when I look at what

our nation's response has been so far, I wonder, why haven't we taken this more seriously? You know, at first I thought

that we marginalized the issue because it doesn't apply to us. That's an issue for those kids

in those neighborhoods. Which is weird, because the data

doesn't bear that out. The original ACEs study

was done in a population that was 70 percent Caucasian, 70 percent college-educated. But then, the more I talked to folks, I'm beginning to think that maybe

I had it completely backwards. If I were to ask

how many people in this room grew up with a family member

who suffered from mental illness, I bet a few hands would go up. And then if I were to ask how many folks

had a parent who maybe drank too much, or who really believed that

if you spare the rod, you spoil the child, I bet a few more hands would go up. Even in this room, this is an issue

that touches many of us, and I am beginning to believe

that we marginalize the issue because it does apply to us. Maybe it's easier to see

in other zip codes because we don't want to look at it. We'd rather be sick. Fortunately, scientific advances

and, frankly, economic realities make that option less viable every day. The science is clear: Early adversity dramatically affects

health across a lifetime. Today, we are beginning to understand

how to interrupt the progression from early adversity

to disease and early death, and 30 years from now, the child who has a high ACE score and whose behavioral symptoms

go unrecognized, whose asthma management

is not connected, and who goes on to develop

high blood pressure and early heart disease or cancer will be just as anomalous

as a six-month mortality from HIV/AIDS. People will look at that situation

and say, "What the heck happened there?" This is treatable. This is beatable. The single most important thing

that we need today is the courage to look

this problem in the face and say, this is real

and this is all of us. I believe that we are the movement. Thank you. (Applause)