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

Summary

This script discusses the profound impact of childhood trauma, or Adverse Childhood Experiences (ACEs), on health outcomes throughout life. It reveals the correlation between high ACE scores and increased risks of chronic diseases, mental health issues, and early death. The speaker, Dr. Nadine Harris, emphasizes the need for routine screening and multidisciplinary treatment, advocating for a public health approach to address this widespread yet under-acknowledged issue.

Takeaways

• 🚨 Childhood trauma is a significant public health issue that increases the risk for leading causes of death in the United States.
• 🧠 High doses of childhood trauma can affect brain development, the immune system, hormonal systems, and even DNA transcription.
• 📊 The Adverse Childhood Experiences (ACE) Study revealed a strong correlation between the number of adverse experiences and negative health outcomes later in life.
• 💔 Exposure to severe trauma in childhood can triple the lifetime risk of heart disease and lung cancer and significantly reduce life expectancy.
• 👩‍⚕️ Doctors are currently not trained in routine screening or treatment for the effects of childhood trauma.
• 🏥 The establishment of the Center for Youth Wellness in San Francisco aims to screen, prevent, and heal the impacts of ACEs and toxic stress.
• 📈 The ACE Study showed that 67% of the population had at least one ACE, and 12.6% had four or more, indicating a widespread issue.
• 🔬 Science has begun to explain the biological mechanisms by which early adversity affects the developing brain and body, leading to increased health risks.
• 🏘️ The problem of childhood trauma is not limited to impoverished areas; it affects a broad spectrum of the population.
• 🌟 Recognizing childhood trauma as a public health crisis is crucial for developing effective interventions and treatments.
• 📣 There is a need for greater awareness and action to address the impact of childhood trauma on health, as it is a solvable and preventable issue.

Q & A

What significant discovery was made by the CDC and Kaiser Permanente in the mid-'90s?

The CDC and Kaiser Permanente discovered that childhood trauma significantly increases the risk for seven out of ten leading causes of death in the United States.

How does high-dose exposure to childhood trauma affect an individual's health?

High-dose exposure to childhood trauma can affect brain development, the immune system, hormonal systems, and even the way DNA is read and transcribed, leading to triple the lifetime risk of heart disease and lung cancer, and a 20-year difference in life expectancy.

Why are doctors not routinely trained in screening or treating the effects of childhood trauma?

The effects of childhood trauma have not been traditionally recognized as a medical issue, and thus, medical training does not typically include routine screening or treatment protocols for it.

What is the difference between the type of trauma discussed in the script and common, less severe setbacks like failing a test?

The trauma discussed in the script refers to severe or pervasive threats such as abuse, neglect, or growing up with a parent who has mental illness or substance dependence, which are significantly different from common setbacks like failing a test or losing a game.

What was the speaker's approach to addressing health disparities in Bayview-Hunters Point?

The speaker and California Pacific Medical Center opened a clinic in Bayview-Hunters Point to provide top-quality care regardless of the ability to pay, targeting health disparities such as access to care, immunization rates, and asthma hospitalization rates.

What was the surprising trend the speaker noticed regarding referrals for ADHD?

The speaker noticed that many children referred for ADHD did not actually have the disorder; instead, they had experienced severe trauma, suggesting that something else was going on.

What is the Adverse Childhood Experiences (ACE) Study, and what did it reveal?

The ACE Study was conducted by Dr. Vince Felitti and Dr. Bob Anda, and it revealed a correlation between a person's history of exposure to adverse childhood experiences and their health outcomes later in life, showing a dose-response relationship.

What are some of the common ACEs included in the ACE score?

Common ACEs include physical, emotional, or sexual abuse; physical or emotional neglect; parental mental illness, substance dependence, incarceration; parental separation or divorce; or domestic violence.

How does the hypothalamic–pituitary–adrenal axis play a role in the health effects of childhood trauma?

The hypothalamic–pituitary–adrenal axis is the body's stress response system. Repeated stress activation from childhood trauma can go from being adaptive to maladaptive, affecting the developing immune and hormonal systems and even the way DNA is read and transcribed.

What is the Center for Youth Wellness, and what does it aim to do?

The Center for Youth Wellness was created in San Francisco to prevent, screen, and heal the impacts of ACEs and toxic stress. It focuses on routine screening, multidisciplinary treatment teams, and educating parents about the impacts of ACEs.

Why has the issue of childhood trauma not been taken more seriously in the medical field?

The issue may have been marginalized because it was seen as not applicable to everyone or because it was easier to attribute health outcomes to bad behavior rather than acknowledging the impact of childhood trauma. Additionally, it may require a shift in perspective to view it as a public health crisis.

What does the speaker believe is the most important thing needed to address the issue of childhood trauma?

The speaker believes that the most important thing needed is the courage to acknowledge the reality of the problem and to recognize that it affects everyone, not just certain populations or neighborhoods.

Outlines

00:00

🧬 The Impact of Childhood Trauma on Health

This paragraph discusses a groundbreaking study by the CDC and Kaiser Permanente that links childhood trauma to a significant increase in the risk of leading causes of death in the United States. The exposure to trauma, especially in high doses, can affect brain development, immune and hormonal systems, and even DNA transcription. The speaker highlights that exposure to severe trauma, such as abuse or neglect, can triple the lifetime risk of heart disease and lung cancer and result in a 20-year difference in life expectancy. The paragraph emphasizes the need for medical professionals to be trained in recognizing and treating the effects of childhood trauma, which is currently not a standard practice.

05:03

📊 The ACE Study: Uncovering the Prevalence and Health Consequences

The second paragraph delves into the Adverse Childhood Experiences (ACE) Study, which surveyed 17,500 adults about their history of exposure to various forms of childhood adversity. Each 'yes' to questions about abuse, neglect, or household dysfunction resulted in a point on an individual's ACE score. The study revealed a strong correlation between higher ACE scores and poorer health outcomes, including increased risks of chronic obstructive pulmonary disease, hepatitis, depression, and suicidality. The speaker refutes the notion that these health issues stem from 'bad behavior' by explaining the neurobiological impacts of early adversity on brain development and the body's stress response system.

10:04

🏥 Transforming Clinical Practice to Address ACEs

In this paragraph, the speaker describes the transformation of their clinical practice after learning about the ACE Study. They established the Center for Youth Wellness in San Francisco to screen, prevent, and heal the impacts of ACEs and toxic stress. The center's approach includes routine screening for ACEs during physical exams, a multidisciplinary treatment team to reduce adversity and treat symptoms, and educating parents about the impacts of ACEs. The speaker also discusses the need for more aggressive treatment for patients with high ACE scores due to the changes in their hormonal and immune systems caused by early adversity.

15:05

🌟 The Movement for Change: Public Health and ACEs

The final paragraph calls for a public health movement to address the widespread issue of adverse childhood experiences. The speaker reflects on the lack of widespread action despite the clear scientific evidence and the significant impact of ACEs on health. They emphasize the need for courage to confront the problem and recognize that it affects everyone. The speaker envisions a future where the connection between childhood trauma and health outcomes is well understood, and untreated ACEs are seen as anomalies. The paragraph concludes with a call to action, urging the audience to be part of the movement for change.

Keywords

💡Childhood Trauma

Childhood trauma refers to distressing experiences that occur during one's early years, such as abuse, neglect, or growing up with a parent who has mental illness or substance dependence. In the video, it is highlighted as a significant factor that can dramatically increase the risk for many leading causes of death in the United States, affecting brain development and physiological systems.

💡Adverse Childhood Experiences (ACEs)

Adverse Childhood Experiences, or ACEs, are potentially traumatic events occurring in childhood that can have long-term negative effects on health and well-being. The script discusses the ACE Study, which correlates these experiences with a range of health outcomes, emphasizing their prevalence and impact on life expectancy and chronic diseases.

💡Dose-Response Relationship

The dose-response relationship in the context of the video refers to the correlation between the severity or frequency of ACEs and the negative health outcomes later in life. The higher the ACE score, the worse the health outcomes tend to be, as illustrated by the increased risk of chronic obstructive pulmonary disease, depression, and suicidality.

💡Neurological Impact

The neurological impact discussed in the video describes the effects of childhood trauma on the developing brain. It includes alterations in areas such as the nucleus accumbens, prefrontal cortex, and amygdala, which can lead to issues with impulse control, substance dependence, and fear responses, respectively.

💡Hypothalamic–Pituitary–Adrenal Axis

The hypothalamic–pituitary–adrenal axis, mentioned in the script, is the body's stress response system. It is activated in response to stressors and is connected to the release of adrenaline and cortisol. Chronic activation due to repeated stress or trauma can lead to maladaptive responses and contribute to health issues such as heart disease and cancer.

💡Toxic Stress

Toxic stress in the video is defined as the harmful stress that results from strong, frequent, and/or prolonged adversity without the support or buffering presence of a trusted adult. It can disrupt brain architecture and other physiological systems, leading to lifelong health effects.

💡Center for Youth Wellness

The Center for Youth Wellness, as described in the script, is an initiative created in San Francisco to address the impacts of ACEs and toxic stress. It focuses on routine screening, multidisciplinary treatment teams, and educating parents about the effects of ACEs, aiming to prevent, screen, and heal the impacts of childhood trauma.

💡Multidisciplinary Treatment Teams

Multidisciplinary treatment teams, as mentioned in the video, are composed of professionals from various fields working together to provide comprehensive care for patients. In the context of the Center for Youth Wellness, these teams work to reduce adversity and treat symptoms associated with ACEs using best practices.

💡Health Disparities

Health disparities refer to differences in the incidence, prevalence, diseases, and other health conditions between different population groups. In the video, the speaker discusses targeting health disparities such as access to care and immunization rates in underserved communities.

💡Public Health Crisis

A public health crisis, as defined in the video, is a situation where a health issue is so widespread and severe that it requires a coordinated societal response. The speaker argues that ACEs represent such a crisis, necessitating a public health approach to prevention and treatment.

💡Nation's Response

The nation's response in the video refers to the collective actions and attitudes of a country towards a significant health issue. The speaker critiques the lack of a robust response to the findings of the ACE Study, suggesting that there is a need for greater determination and commitment to address this public health threat.

Highlights

In the mid-'90s, the CDC and Kaiser Permanente discovered that childhood trauma significantly increases the risk for leading causes of death in the United States.

High doses of childhood trauma affect brain development, immune and hormonal systems, and DNA transcription.

Individuals exposed to high levels of childhood trauma have triple the lifetime risk of heart disease and lung cancer, and a 20-year difference in life expectancy.

Doctors are not routinely trained in screening or treating the effects of childhood trauma.

Childhood trauma includes severe threats like abuse, neglect, parental mental illness, or substance dependence.

The speaker's approach to treating patients changed after opening a clinic in an underserved neighborhood and noticing a trend of misdiagnosed ADHD.

The Adverse Childhood Experiences (ACE) Study revealed the prevalence of childhood trauma and its correlation with health outcomes.

ACE scores are calculated based on exposure to various forms of childhood adversity.

A higher ACE score correlates with worse health outcomes, including increased risks of chronic diseases and mental health issues.

The impact of childhood trauma on health is not just due to bad behavior but has a scientific basis in neurobiology.

Early adversity affects brain areas associated with reward, impulse control, and fear response, leading to high-risk behaviors.

The stress response system, governed by the hypothalamic–pituitary–adrenal axis, is compromised by repeated stress from childhood trauma.

The Center for Youth Wellness was created to address the impacts of ACEs and toxic stress through screening, treatment, and education.

Screening for ACEs allows for early intervention and tailored treatment plans for children at risk.

The movement to address ACEs as a public health crisis requires determination, commitment, and a change in clinical practice.

The speaker calls for courage to acknowledge the reality of childhood trauma and its widespread impact on health.

The future holds the potential for recognizing untreated childhood trauma as an anomaly, similar to the current view on untreated HIV/AIDS.

Transcripts

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)