the deepest well | Reflections & Notes

Nadine Burke Harris, M.D. the deepest well: Healing the Long-Term Effects of Childhood Adversity. Mariner Books, 2019. (251 pages)


REFLECTIONS


I have often wondered if I read books, not to discover the world, but to discover myself. Becoming more informed has been a way for me to become more aware of who I am, and my place in the universe. the deepest well has confirmed this thesis, and is now an incredible and indelible part of my journey of discovery, for which I am truly thankful.

For several years I have pontificated the various maladies that plague my psyche. Having participated in counseling and therapy, and various soul-searching events and programs, I could see various incremental changes and improvements. But nothing was as insightful to me as the number 5. Five. That’s my ACE (Adverse Childhood Experiences) score. For some reason, that number – along with Dr. Burke’s explanations – has really helped me frame my personal experience, healing pathways, and given me a framework for understanding the care work that I do in my profession. (I so wish I had this information when I was a youth pastor for so many years, working with kids who, I now understand, to have been suffering from ACEs.)

Dr. Burke not only brilliantly weaves personal narrative with scientific explanation, but she also explicates the vast implications understanding ACEs has for how we see personal and public health in the first place. Like shifting from miasma theory to germ theory, ACEs have the potential of creating another paradigm shift that may forever change how we think about – and therefore treat – personal and public health. Once again, we are faced with substantive data that breaks down the traditional bifurcations we make, and forces us to contend with the interconenctive tissues that make up individuals and society as one whole entity.

Tears, hope, science, humanity, transparency, and professionalism. I highly commend this book to you for your personal discovery.


NOTES


Introduction

Twenty years of medical research has shown that childhood adversity literally gets under our skin, changing people in ways that can endure in their bodies for decades. It can tip a child’s developmental trajectory and affect physiology. It can trigger chronic inflammation and hormonal changes that can last a lifetime. It can alter the way DNA is read and how cells replicate, and it can dramatically increase the risk for heart disease, stroke, cancer, diabetes––even Alzheimer’s. (xv)

I DISCOVERY

1. Something’s Just Not Right

What if the cause of these symptoms––the poor impulse control, inability to focus, difficulty sitting still––was not a mental disorder, exactly, but a biological process that worked on the brain to disrupt normal functioning? Weren’t mental disorders simply biological disorders? (5)

After years of schooling, I had faith in the dominant academic view: if you improve people’s access to quality health care, you will move the needle toward better health. (10)

But I also took away a larger lesson: If one hundred people all drink from the same well and ninety-eight of them develop diarrhea, I can write prescription after prescription for antibiotics, or I can stop and ask, “What the hell is in this well?” (12)

2. To Go Forward, Go Back

Corticosterone is a stress hormone––its equivalent in humans is cortisol––… (19)

If the toads-to-be were exposed to corticosterone late in development, it did speed up metamorphosis, allowing for the adaptive, timely leap out of (19) pond. But if the toads were exposed to the steroid early in development, it actually inhibited their growth. And it had other unexpected negative effects, such as decreasing immune function, diminishing lung function, causing osmoregulatory problems (high blood pressure), and impairing neurological development. If the tadpoles were exposed to corticosterone for a prolonged period, the same problems occurred. The tadpoles’ stress response to overcrowding was adaptive, but only if it happened at the right time during development. (20)

In fact, early exposure often led not only to irreversible developmental changes but, eventually, to death. For instance, levels of corticosterone can have an impact on levels of thyroid hormone, which regulates metabolism. In the case of the tadpoles, corticosterone knocked out the thyroid hormone completely, which is why those tadpoles didn’t grow and develop to the metamorphosis stage. Corticosterone also affects the production of surfactant, which plays a key role in lung development, allowing them to absorb oxygen out of the air. (20)

If you have the right amount of each hormone, they all work together to keep the body functioning normally, but if you change one of those levels the delicate interplay gets thrown off. This kind of hormonal imbalance can have direct and indirect effects. (20)

Back in the day on the savanna, a major purpose of cortisol was to help the body manage that long-term stress. Maintaining homeostasis is the key to survival, so cortisol shows up when the body detects a change in the environment that threatens to push it off balance. (21)

a major effect of cortisol is an increase in blood sugar. The brain needs enough blood sugar to be able to think and plan, so this extra punch of cortisol helps to keep blood sugar on an even keel, despite a shortage of gazelle BBQ. The steady stream of glucose swimming in your veins also helps fuel your muscles, so in the event that you do see a gazelle, you have the energy to chase it down. Cortisol also helps maintain normal blood pressure by regulating the body’s water and salt levels. And it inhibits growth and reproduction, because if you are living through a food crisis, it’s not a good time to be doing any optimistic long-term family planning;… (21)

The difference between the ancient adult human surviving a bad hunting season and the tadpole getting a lethal dose of stress is the timing and duration of the exposure to the stress hormone. (22)

…the effects of a stress dose of steroids on a child were not only known but codified in the hospital’s protocols for care. Medical protocols are put in place when the side effects of a certain medication are so predictable that it’s worth setting up a system for addressing them. (23)

If their systems were flooded with stress hormones just like Sarah’s or the tadpoles’, it stood to reason that their bodies, including their blood pressure, blood sugar, and neurological functions, might react in similar ways; all could be seen as side effects of stress hormones. It made biological sense that a high dose of stress hormones at the wrong developmental stage could have an outsize impact on my patients’ downstream health. (24)

3. Forty Pounds

cf. “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: the Adverse Childhood Experiences (ACE) Study,” by Dr. Vincent Felitti, Dr. Robert Anda, and colleagues.

What if he had been looking at this all wrong? He, as a doctor, had perceived a patient’s weight to be the problem. What if it was actually a solution? What if his patient’s weight was a psychological and emotional barrier, something protecting her from harm? (35)

Dr. Felitti’s initial insight about the link between childhood adversity and health outcomes led to the landmark ACE Study. This was a prime example of doctors thinking like detectives, following a hunch and then putting it through it scientific paces. (35)

Their aim was to identify two things: (1) the relationship between exposure to abuse and/or household dysfunction in childhood and adult health-risk behavior (alcoholism, smoking, severe obesity), and (2) the relationship between exposure to abuse and/or household dysfunction in childhood and disease. (36)

Felitti and Anda sorted their definitions of abuse, neglect, and household dysfunction into ten specific categories of ACEs. (37)

  1. Emotional abuse (recurrent)
  2. Physical abuse (recurrent)
  3. Sexual abuse (contact)
  4. Physical neglect
  5. Emotional neglect
  6. Substance abuse in the household (e.g., living with an alcoholic or a person with a substance-abuse problem)
  7. Mental illness in the household (e.g., living with someone who suffered from depression or mental illness or who had attempted suicide)
  8. Mother treated violently
  9. Divorce or parental separation
  10. Criminal behavior in household (e.g., a household member going to prison) (37)

First, they discovered that ACEs were astonishingly common––67 percent of the population had at least one category of ACE and 12.6 percent had four or more categories of ACEs. (38)

The original ACE Study was done in a population that was 70 percent Caucasian and 70 percent college-educated. The study’s participants, as patients of Kaiser, also had great health care. (39)

A critical piece of their findings was the dose-response relationship;… The ACE Study strongly establishes a dose-response relationship, which is an important step toward demonstrating causality. A person with an ACE score of seven or more has triple the lifetime odds of getting lung cancer and three and a half times the odds of having ischemic heard disease, the number one killer in the United States. (40)

So what gives? Why hadn’t I heard of this study before? (40)

The first has to do with a misconception concerning the ACE Study itself, the belief of some that the increased risks had everything to do with behavior. (40)

It turned out that “bad behavior” accounted for only about 50 percent of increased likelihood for disease. In a way that’s good news, because it means that if a person is exposed to ACEs and he is careful to avoid smoking, physical inactivity, and other health-damaging behaviors, he’s still more likely to develop heart or liver disease. (41)

In the United States, the culture puts a lot of stock in personal responsibility. The lifestyle choices you make do have a huge impact on your health; so-called bad behavior does result in increased risks to your health, and there’s no disputing that. But the ACE Study shows us, yet again, that it’s not the whole story. (41)

| The second reason I hadn’t heard of Felitti and Anda’s work in medical school, and maybe the most potent, is that this is scary, emotional stuff. It’s one thing to take a cold, calculating look at your cottage-cheese consumption over the past decade, but it’s another to revisit trauma and abuse. (41)

The last reason why the ACE Study didn’t catch fire in the medical and scientific communities in 1998 can be best explained as scientific gaps. The study showed that adversity was bad for your health, but although Felitti and Anda had exposed the what, they were unable at the time to answer the how. (42)

Identifying and  demonstrating that the stress-response system was the biological mechanism behind adversity’s role in health was going to be the fun part. (42)

II DIAGNOSIS

4. The Drive-By and the Bear

…the body remembers. … We all have a stress-response system, and it is carefully calibrated and highly individualized by both genetics and early experiences. … When it’s in good working order, it can help save your life, but when it’s out of balance, it can shorten it. (48)

Stress Response

Here are the main players involved.

  • The amygdala: the brain’s fear center
  • Prefrontal cortex: the front part of the brain that regulates cognitive and executive function, including judgment and mood and emotions
  • Hypothalamic-pituitary-adrenal (HPA) axis: initiates the production of cortisol (longer-acting stress hormone) by the adrenal glands
  • Sympatho-adrenomedullary (SAM) axis: initiates the production of adrenaline and noradrenaline (short-acting stress hormones) by the adrenal glands and brain
  • Hippocampus: processes emotional information, critical for consolidating memories
  • Noradrenergic nucleus in the locus coeruleus: the within-the-brain stress-response system that regulates mood, irritability, locomotion, arousal, attention, and the startle response (49)

But what happens when you can’t experience safety in your cave because the bear is living in the cave with you? (52)

Living with the Bear
(aka Dysregulated Stress Response)

It turns out that cortisol has a predictable daily pattern: it’s high in the morning to help wake you up and get you ready for the day and then gradually decreases, reaching its lowest point in the evening, just (52) when you need to go to sleep. As a result, it’s possible to determine if someone’s cortisol pattern is disrupted. (53)

We all know that adversity, tragedy, and hardship are a part of life. As much as we’d like to shield our children from illness, divorce, and trauma, sometimes these things happen. What the research tells us is that those daily challenges can be overcome with the right support from a loving caregiver. (53)

The main issue is that when the stress response is activated too frequently or if the stressor is too intense, the body can lose the ability to shut down the HPA and SAM axes. The term for this is disruption of feedback inhibition, which is a science-y way of saying that the body’s stress thermostat is broken. (53)

Healthy development of the stress-response system requires that a child experience both positive and tolerable stress. This allows the SAM and HPA axes to be calibrated to react normally in the face of stressors. But for every ACE a child has, the risk of tolerable stress tipping over into toxic stress increases, as the system responds more frequently and intensely to multiple stressors. (55)

| Just like tadpoles, children are particularly sensitive to repeated stress activation. High doses of adversity affect not only the brain structure and function but also the developing immune system and hormonal systems, and even the way DNA is read and transcribed. (55)

5. Dynamic Disruption

If you want to understand how a child’s stress response is working, try walking into the examination room with a tray full of needles and telling him it’s time for shots. … Coincidentally, this natural stress-response provocation challenge gave us an opportunity to test the second, equally important ingredient for toxic stress––the caregiver’s ability to act as a buffer. The kids who had the worst responses were also the ones whose caregivers were the least likely to hug, kiss, sing to, or otherwise soothe their child. (57)

Currently, ADHD is a diagnosis based entirely on symptoms. If you remember, the criteria include inattention, impulsiveness, hyperactivity, but the Diagnostic and Statistical Manual of Mental Disorders doesn’t say a word about the underlying biology. What it does say is that if these same symptoms are associated with a different mental disorder, like schizophrenia, then it’s no longer ADHD. Similarly, if we see impulsivity and hyperactivity but discover that those symptoms are caused by a brain tumor, we can’t diagnose ADHD. (60)

We know from the research that the life expectancy of individuals with ACE scores of six or more is twenty years shorter than it is for people with no ACEs. For a patient with a high ACE score, it may not be the obesity that shortens his or her life but the underlying toxic stress that the obesity is signaling. To treat the root of the problem I had to look at both stories my patients’ symptoms were telling me: the story on the surface and the story underneath. (61)

I began asking about exposure to adversity for all of my patients to better understand their health risks. Just like height, weight, and blood pressure, the ACE score became another vital sign for my regular medical exams. (61)

The crazy thing is that many busy physicians do their entire assessment of ADHD based on behavioral symptoms alone, without a stethoscope even touching the patient’s chest. (64)

There wasn’t (and still isn’t) a clear set of diagnostic criteria or a blood test for toxic stress, and there is no drug cocktail to prescribe. My biggest guide for what symptoms might be toxic stress-related was the ACE Study itself, but I knew that the number of diseases and conditions it accounted for might just be the tip of the iceberg. … A disrupted stress response doesn’t affect only the neurological system, it affects the immune system, the hormonal system, and the cardiovascular system as well. Because everyone’s biological and genetic makeup is different, how that dysregulation manifests itself will be similarly diverse. (65)

Toxic Stress and the Brain

The Alarm (aka the Amygdala)

I Don’t Know Karate but I Do Know C-razy (aka the Locus Coeruleus)

The Conductor (aka the Prefrontal Cortex)

Memory Bank (aka the Hippocampus)

Vegas, Baby! (aka the Ventral Tegmental Area, VTA

When your body’s stress-reponse system is overloaded again and again, it messes with the sensitivity of your dopamine receptors. … The biological changes in the VTA that lead people to crave do-(69)pamine stimulators like high-sugar, high-fat foods also lead to an increase in risky behavior. The ACE Study shows that there is a dose-response relationship between ACE exposure and engaging in many activities and substances that activate the VTA. (70)

Hormonal Harmony

But cortisol isn’t the only bad guy here; the hormones leptin and ghrelin are also increased with activation of the stress response. Together they intensify appetite and work with cortisol to do their worst for your waistline. (71)

…it’s not just because they subsist primarily on a diet of fast food that they are overweight. It’s not just that they are living in a food desert… (71) … Those things compound the problem, to be sure, but they are not the whole story. Our data suggested how powerful the underlying mechanism of toxic stress can be––that the metabolic disruption was also an important driver. If you grow up in a food desert, of course it’s going to be difficult for you to be healthy. But if you also have higher cortisol levels that are driving you to crave high-sugar, high-fat foods, it’s going to be that much harder for you to choose broccoli over French fries. (72)

Foreign Relations: Toxic Stress and the Immune System

The word cytokine literally means “cell movers.” They (72) prod your body to make more white blood cells, which fight off infection and activate different types of cells to do things like make antibodies and eat bacteria. The immune system also stimulates inflammation (like when a bug bite gets all red and swollen). Like everything else in the body, what’s important in the immune system is balance. (73)

Just as the brain or the nervous system is not fully developed when a child is born, the immune system is also still developing well after (73) birth. (74)

What is so powerful about the follow-up ACE studies like the one Dube did is that they show a strong correlation between autoimmune diseases and exposure to something environmental and specific––childhood adversity. (75)

The consequences of toxic stress are not just neurologic and hormonal; they are also immunologic, and those symptoms are much more difficult to spot. (75)

6. Lick Your Pups!

Every second in the first years of life over one million new neural connections are formed, so if an infant isn’t getting enough fats and proteins needed to make healthy brain connections, that can have significant impacts. (78)

How is it that ACEs are handed down so reliably from generation to generation? For many families, it seemed that toxic stress was more consistently transmitted from parent to child than any genetic disease I had seen. (79)

Meaney and his team looked at two groups of rat mothers and rat pups. They noticed that after the pups were handled by researchers, the moms would soothe their stressed-out pups by licking and grooming them. This is basically the human equivalent of hugs and kisses. What was fascinating was that not all moms did it to the same extent. Some moms exhibited high levels of licking and grooming behavior toward their pups. Other moms displayed low licking and grooming behavior, which meant they didn’t give as many sloppy kisses and embarrassing hugs when their pups were having a rough day. (81)

| Here’s the part that made me sit up straight in my chair: Researchers observed that the development of the pups’ response to stress was directly affected by whether the mom was a “high licker” or a “low licker.” They found that pups of high-licker moms had lower levels of stress hormones, including corticosterone, when they were handled by researchers or otherwise stressed out. … The licking and grooming behavior that occurred in the pups’ first ten days of life predicted changes to their stress response that lasted for the entire lifetime. Even more startling, the changes continued into the next generation, because female pups who had high-licker moms became high lickers themselves wen they had their own kids. (81)

What they found was that the rat moms were, in fact, handing down a message to their pups that changed the way the pups’ stress responses were wired, but the mechanism, the how of the changes, turned out to be not genetic, but epitgenetic. (82)

| Many people still think of genes and the environment as very separate things:… …but as science gets more and more advanced, there is less and less to argue about. Scientists can now say pretty definitively that there is no separating the two. In fact, we now know that both environment and genetic code shape both biology and behavior. (82) …with the advances in science, we are finally able to see that there is a vital synchronicity that determines what we look like, how our bodies work, and ultimately who we are. (83)

What scientists have discovered is that baked into the cells are both the genome (your entire genetic code) and the epigenome, another layer of chemical markers that sit on top of your DNA and determine which genes get read and transcribed into proteins and which ones don’t. The term epigenetic actually means “above the genome.” These epigenetic markers are handed down from parent to child along with the DNA. (83)

| One way to think about it is this: The genome is like the musical notes in sheet music and the epigenetic markers are like the notations that tell you how loudly, quietly, quickly, or slowly to play the notes. (83)

As your body tries to adapt to the stress of your experiences, it turns certain genes on or off, particularly genes that regulate how you’ll respond to stressful events  in the future. That process of the epigenome working with the genome to respond to your environment is called epigenetic regulation and it’s critical to our understanding of why toxic stress is so damaging to our lifelong health. (83)

There are a handful of processes that are responsible for epigenetic regulation, but the two that we know the most about when it comes to the genetics of stress are DNA methylation and histone modification. In DNA methylation, a biochemical marker called a methyl group is attached to the beginning of a DNA sequence. That marker prevents the gene from being turned on; it acts like a Do Not Disturb sign hanging on a hotel doorknob. It tells the DNA housekeeping team not to come in and translate that genetic sequence into proteins, essentially rendering that part of the genetic code silent. (84)

| Histones are like a chastity belt for the DNA. They are proteins that keep the genetic material locked up, preventing the DNA transcription machinery from getting to it. When certain biochemical markers are attached to the histones, the histones are then modified––they change shape and become more open, allowing the DNA to be read and transcribed. (84)

…the key to keeping a tolerable stress response from tipping over into the toxic stress zone is the presence of a buffering adult to adequately mitigate the impact of the stressor. (85)

…telomeres protect DNA strands, making sure that every time it is replicated by cells, the copy is true to the original. Telomeres are very sensitive to the environment, which means that, like good car bumpers, they always take the first hit. Anything biochemically harmful (like stress) is going to damage the telomeres much more than the DNA. When the telomeres are hurt, they send signals to the rest of the cell letting it know that the bumpers have taken too many hits and that the cell should respond. The cell reacts in two major ways. The first is that when the telomeres get too short (too many bad parallel-parkers in the neighborhood), the cell can become senescent, which is science-y word for old. This means the cell retires and doesn’t do its job anymore. (87)

The response a cell can have to  damaged and shortened telomeres other than senescence is that it can become precancerous or cancerous. When that happens, it means the ability of the cell to copy its DNA correctly has been compromised, and it begins coding for mutations that say, “Keep making cells forever!” This causes the cells to replicate uncontrollably and grow into a tumor that continues to grow and grow and grow. Simply put, if there is too much damage to your telomeres and they become excessively shortened, it can lead to premature cellular aging and disease or cancer. (88)

…the science is new, but it suggests that even if you start out with shorter-than-normal telomeres, you can still slow decline by increasing your telomerase with things like meditation and exercise. (89)

The research on epigenetic regulation and telomeres reinforced what I already suspected–early detection is critical. Now more than ever, I believed if we could identify those at risk for toxic stress by screening for ACEs, we had a better chance of both catching related illnesses early and treating them more effectively. (90)

Even in areas much better off than Bayview, toxic stress was essentially invisible to the health-care system. (91)

…between 55 and 62 percent of the population have experienced at least one category of ACE, and between 13 and 17 percent of the population have an ACE score of four or more. The states with the highest rates of ACEs among young children were Alabama, Indiana, Kentucky, Michigan, Mississippi, Montana, Oklahoma, and West Virginia. Left unchecked, the effects of ACEs and the toxic stress they create were being handed down by well-meaning parents in families all across the country and, undoubtedly, around the world. (91)

III PRESCRIPTION

7. The ACE Antidote

integrated behavioral health services. That simply means having mental-health services available at the pediatrician’s (or primary-care clinician’s) office. (99)

…Dr. Alicia Lieberman at the University of California, San Francisco, a renowned child psychologist who specialized in child-parent psychotherapy (CPP). This type of therapy focuses on children from birth to five years old and is built on the notion that to help young kids experiencing adversity, you have to treat the parent and (99) child like a team. (100)

After years as a clinician, Dr. Lieberman came to understand that children’s need to create a story or narrative to confusing events is actually very normal. Children are compelled to give meaning to what is happening to them. When there is no clear explanation, they make one up; the intersection of trauma and the developmentally appropriate egocentricism of childhood often leads a little kid to think, I made it happen. (101)

While techniques based on meditation practices began with religious sects thousands of years ago, they are now being used by an unlikely successor–the medical community. From cardiologists to oncologists, doctors have begun incorporating mind training into their clinical treatments. (111)

Meditation was shown to be associated with reversing the narrowing of arteries, which for patients suffering from ischemic heart disease can be nothing short of lifesaving. In another study involving breast and prostate cancer patients, researchers found that meditation was associated with decreased stress symptoms, increased quality of life, and improved functioning of the HPA axis. Other studies have shown that meditation decreases cortisol levels, enhances healthy sleep, improves immune function, and decreases inflammation–all critical parts of keeping our biological systems balanced and able to mitigate the effects of toxic stress. (112)

The more I read, the more it made sense to me. If stress can negatively affect the way the body works at a basic chemical level, then I could see how taking on a calming practice could positively change those same chemical reactions. While stress activates the fight-or-flight system (also called the sympathetic nervous system), meditation activates the resting-and-digesting system (also called the para-sympathetic nervous system). (112)

cf. Mind Body Awareness (MBA) Project.

Sleep, mental health, healthy relationships, exercise, nutrition, and mindfulness–we saw in our patients that these six things were critical for healing. As important, the literature provided evidence of why these things were effective. Fundamentally, they all targeted the underlying biological mechanism–(114) a dysregulated stress-response system and the neurologic, endocrine, and immune disruptions that ensued. (115)

8. Stop the Massacre!

We could prevent not only adverse health outcomes but also adverse social outcomes. (121)

If ACEs were affecting not only health but social outcomes, I wasn’t going to be able to work only the medical-community angle. I would need to talk to folks in education and criminal justice to learn more about how toxic stress related to the problems they were seeing. (122)

cf. Tipping Point Community; the Center for Youth Wellness (CYW)

It occurred to me that the trauma that is endemic in communities like Bayview isn’t just handed down from parent to child and encoded in the epigenome; it is passed from person to person, becom-(132)ing embedded in the DNA of the society. … That realization caused me to look at this obstacle as a symptom of a community plague by trauma as opposed to a sign that I was destined to fail. (133)

9. Sexiest Man Alive

…the newborn screening test was expanded even further; it now identifies more than twenty-nine conditions that can lead to long-term neurological damage. The Guthrie test has been used in more than seventy countries and is responsible for helping countless children reach their God-given potential. (138)

Eventually, I realized that what we were doing at the clinic was an informal version of a practice I had learned on the oncology ward at Stanford, referred to as multidisciplinary rounds. In the pediatric oncology unit, there were understandably some really high-needs patients. Every week a group would meet that included the head oncologist, the social worker, the therapist, the child-life specialist (someone who helps kids through painful procedures), and a nephrologist (kidney doctor) or whatever specialists were needed for that particular case. (139)

…childhood adversity is associated with a variety of diseases and con-(142)ditions in children that can be observed as early as infancy. In babies, exposure to ACEs is associated with growth delay, cognitive delay, and sleep disruption. School-age children show higher rates of asthma and poorer response to asthma rescue medication (such as albuterol), greater rates of infection (such as viral infections, ear infections, and pneumonia), and more learning difficulties and behavioral problems, and adolescents exhibit higher rates of obesity, bullying, and violence, smoking, teen pregnancy, teen paternity, and other risky behaviors such as early sexual activity. (143)

If they had never manifested any behavioral symptoms, chances are–even if they developed asthma, or an autoimmune disease, or any of the other significant immunological consequences of toxic stress–the underlying problem would likely have gone undetected and untreated. Guthrie had shown that the only way to radically move the needle on patient outcomes is to screen universally, because otherwise you are relying on chance: The chance that Lila’s symptoms would get bad enough that her doctor asked more questions. The chance that this particular doctor had (143) heard about ACEs and knew to ask those questions in the first place. How much damage could be done while you were waiting for the right questions to be asked, the right tests to be run? … That is why an ounce of screening is better than a pound of cure. (144)

All the science about the development of the neuro-endocrine-immune system tells us one thing: intervening earlier is better (and I mean way, way, way better). (144)

The prenatal and early childhood periods offer special windows of opportunity because they represent “critical and sensitive periods” of development. A critical period is a time in development when the presence or absence of an experience results in irreversible changes. (144)

sensitive period is a time when the brain is particularly responsive to a stimulus in the environment, but unlike critical periods, the window doesn’t totally close at the end of the sensitive period; it just gets a lot smaller. (145)

There are two types of neuroplasticity, cellular and synapticSynaptic plasticity is a change in the strength of the connection across the junction from one brain cell to the next (the synapse). It’s kind of like changing your voice from a whisper to a shout. Cellular plasticity, however, is a change in the number of brain cells that are talking to each other, the difference between one person shouting and a whole stadium shouting. While synaptic plasticity is lifelong (it’s how an old dog learns new tricks), cellular plasticity happens most rapidly in the first years of life. About 90 percent occurs by the time a child turns six, but the rest of it stretches out until about age twenty-five. (145)

…estrogen; …progesterone; …oxytocin; … All of these hormones stimulate synaptic plasticity, biochemically enhancing the ability to learn and adapt to one’s environment. (146)

More good news–there are things that you can actually do yourself to boost your synaptic plasticity; sleep, exercise, nutrition, and meditation all enhance the process. … We know that the earlier we start, the more tools we have–young children are the most vulnerable to adversity, but they also have the greatest capacity for healing when the interventions are begun early. And we also know that it’s never too late to use biology to our advantage for healing. (146)

First, the new one was on paper (or a tablet), something that a parent was able to fill out before I came into the exam room. Second (and this was the real innovation), on the new one, we listed the ten ACEs and specifically asked the patient’s parents not to tell us which of them their child had experienced, only how many. At the bottom of the page, the caregiver wrote the total number, and that’s the ACE score. We call this our “de-identified” screen because it doesn’t identify the individual ACEs, and it goes a long way to solving two of the biggest challenges–time (previously, a positive screen took a very long time to unpack) and the sensitive information we’re asking for. (147)

The other important thing that the CYW ACE questionnaire did was go beyond the traditional criteria developed by Felitti and Anda and ask about additional risk factors for toxic stress. We don’t call them ACEs because they are not from the ACE Study and we don’t have the large body of population data to tell us odds of disease, but our experience in Bayview told us that our patients faced other adversities that repeatedly activated their strese-response systems. (148)

  • Community violence
  • Homelessness
  • Discrimination
  • Foster care
  • Bullying
  • Repeated medical procedures or life-threatening illness
  • Death of caregiver
  • Loss of caregiver due to deportation or migration

In our teen screener, we also include the following:

  • Verbal or physical violence from a romantic partner
  • Youth incarceration

…the preliminary data indicates that stressors at the household level (the traditional ACEs) seem to have a greater effect on health than stressors at the community level. This was a surprise to many in the field (myself included), but the data suggests that if a child grows up in a stressful community environment but has a well-supported and healthy caregiver, he or she is much more likely to stay in the tolerable stress zone as opposed to the toxic stress zone. (149)

Around the time that I was seeing Lila, we made our screening protocol available for free online. We knew that getting folks to do things differently was really hard, which was why we set the goal for one thousand downloads over the next three years. To my surprise and our collective delight, over twelve hundred clinics and practitioners in fifteen countries downloaded the tool in just one year,…they all said that they would never go back to not screening. It’s like a bell you can’t unring. (153)

…we went a step further, creating a network for pediatricians around the country to learn together about how to screen, what to do with a positive screen, and how to advance the care o children with toxic stress faster. It’s my hope that our National Pediatric Practice Community on ACEs will bring us closer to the day when ACE screening is a universal part of health care. I believe in my core that we will get there. (153)

10. Maximum-Strength Bufferin’

“The impact of interventions for toxic stress may not be quite as dramatic in adults as it is in our kids, but it still can make a big difference. This might sound simple, but I cannot overstate this: The sin-(167)gle most important thing is recognizing what the problem is in the first place.” (168)

…it became clear to me that these hidden ACEs were hindering not only the people experiencing them but also the movement that CYW was trying to catalyze by perpetuating the myth that adversity was a problem for only certain communities. … ACEs and toxic stress thrive on secrecy and shame, both at the individual level and at the societal level. We can’t treat what we refuse to see. By screening for ACEs, doctors are acknowledging that they exist. By being open about ACEs with friends and family, people are normalizing adversity as s part of the human story and toxic stress as a part of our biology that we can do something about. (171)

| Toxic stress is a result of a disruption to the stress response. This is a fundamental biological mechanism, not a money problem or a neighborhood problem or a character problem. That means we can look at one another differently. We can see one another as humans with different experiences that have triggered the same physiological response. We can leave the blame and shame out of it and just tackle the problem the same way we would treat any other health condition. We can see this problem for what it really is, a public-health crisis that is as indiscriminate as influenza or Zika. (171)

IV REVOLUTION

11. The Rising Tide

cf. Dr. Alan Guttmacher

…researchers at the University of Calgary (180) launched a study, recruiting over four thousand patients from primary-care clinics and asking about ACEs as well as health status and mental-health measures. Much like the original ACE Study, the population was 83 percent Caucasian and 82 percent college-educated. What the researchers found was that the numbers fell within a few percentage points of Felitti and Anda’s results–demonstrating that Alberta was as affected by ACEs as anywhere else. People with high ACEs were (again) shown to be at much higher risk for depression and anxiety and also to have a greater risk of asthma, autoimmune disease, food allergies, cardiac disease, chronic obstructive pulmonary disease (COPD), migraines, fibromyalgia, reflux disease, chronic bronchitis, stomach ulcers–and the list goes on. (181)

I knew that the doctor’s office wasn’t the only place that needed fundamental understanding of toxic stress. This statement opened a hornet’s nest: one woman in particular wondered, as I heard later, whether ACE screening in schools could be used to label low-income kids and stigmatize them even further. (182)

cf. Dr. Pamela Cantor; Turnaround for Children

The communities near Ground Zero were equipped with more resources, which meant adults were far more able to act as effective buffers, keeping the kids’ stress out of the toxic zone and into the realm of tolerable. Whether it was a teacher, a religious leader, a grandparent, or a coach, the children closer to Ground Zero had many more sources of buffering that could help stabilize them in moments of acute  trauma, even if it was severe. (184)

| What Dr. Cantor saw through the research was that poverty itself reduces the resources available to even caring, dedicated parents to be effective buffers for their kids. Not only were children in poverty experiencing a greater incidence of trauma, they were more likely to develop toxic stress because their source of buffering was constrained by the daily existential stresses that families were under. That was what was affecting their ability to thrive and learn in school. (184)

The breakthrough from Dr. Cantor’s perspective ultimately came with a shift in how they looked at solutions. She saw that educators often lifted up one practice as the solution to the problem. After being in the education world fifteen years, Dr. Cantor had seen how account-(186)ability and measurement was now the thing, how expectation was the thing, how a great teacher in every classroom was the thing. (187)

| It hit her that in medicine, she hadn’t been trained to ask, What is the thing? Her training told her to ask herself: What explains the symptoms we’re seeing? And usually the answer was more complicated than just one thing. (187)

So, Turnaround came up with a framework it called Building Blocks for Learning that worked to develop in children the foundational skills of attachment, stress management, and self-regulation, and then layered the other skills for learning on top. by ensuring the development of these skills in an order that makes sense for learners’ biology, Turnaround was building on decades of neuroscience telling us that it’s not enough to “step on the gas” by providing enriched environments to support learning for children. You also have to release the “brake” (the inhibitory effect of the amygdala on cognitive function) by supporting attachment, stress management, and self-regulation. (188)

…ACEs weren’t just at the root of a public-health crisis in America, they were at the root of our public-education crisis as well. (188)

“What’s the serum for helping a community to stay together and not be dismantled? I have families that now commute back to my program from Antioch–forty-five miles away. What’s the serum for that? Dr. Martin Luther King told us that it does not cost America anything to have me drink at the same water fountain as you. It does not cost America anything to have me sit at the front of the bus. But it is going to cost something to make sure that we have educational equality, equity in jobs, housing. So we are gathered here, and this is a beautiful gathering, but we are missing a whole other group of people. Because to manage stress, the stress that my clients come into the office with, I don’t have a serum, there’s no pill, there’s no research question to help me help them. We keep talking about stress, stress, stress, and let’s study, study, study, when the axiology of black people is relationship. We all know that. We need to bring them up on the agenda and bring other (190) people into the space. Especially the people that this impacts. We’re at meeting number five hundred that I’ve been to, brother, and they are not here.” – [Jenee Johnson, the Director of the Black Infant Health Program (BIH) in San Francisco] (191)

I agreed with much of what she had said, but here statement that the people affected by stress weren’t here was dead wrong. I knew that for a fact. (191)

When you are black or brown and living in America, there are more threats and stressors inherent in your experience; in other words, you live in a part of the forest where there are a lot more bears. Race is never easy to talk about, but exposure is exposure is exposure–that was a big part of what Jenee had been saying, and she was right. (192)

Think about it like this: We all live in a forest with different kids of bears. There is a large group of bears that populate a part of the forest called Poverty, and if you live there, you’re going to see a whole lot of bears. There’s also a part of the forest called Race, where a different cluster of bears hang out. And there is another bear neighborhood called Violence. If you live near any of these bear dens, your stress-response system is going to be affected. But here’s the important part – it is affected in the same way no matter which bear you tango with. Unfortunately, a lot of people (like my patients) live in a place (192) in the forest where the neighborhoods of Poverty, Race, and Violence overlap, and for them, it’s wall-to-wall-to-wall bears. (193)

“It’s not just dat it doesn’t cost Americah anyt’ing for us to drink at di same watah founten. We mus’ show dat it costs Americah bilyons of dollahs in cardiovasculah disease and cyan-sah and housing and educya-shon for us to drink at diff’rent watah fountens!” (194)

“We need to make dat argument! We mus’ hexplain to ev’ry person dat if dey are in Appalachia, if dey are living in Middle Americah, if dey are living in Kentucky and dy believe dat dey have it hard – we mus’ mek sure dat ev’ry single person knows dat dey cyan get strong solu-shons – for poor white folks and for de peer-ent who brought her child and her syuitcases to you – dat we are in a united struggle about de effects of adversity on de developing brains and bodies of children. And when we all get behind dat, den we will have solu-shons that will lif’ ev’rybody up!” (194)

Why were people so resistant to the science of adversity and to giving a basic fact of our biology a name and a number? Because when you bring it down to the level of cells, the level of biological mechanisms, then it is about all of us. We are equally susceptible and equally in need of help when adversity strikes. And that is what a lot of folks don’t want to hear. Some want to stand back and pretend that this is just a poor-person problem. Other stake fierce ownership of the problem and say, “This is killing my community,” but what they also mean is It’s killing my people more than yours. (194)

But everyone is really saying the same thing: I am suffering. (195)

| It is easy to get stuck on your own suffering because, naturally, it is what affects you most, but that’s exactly the mentality that is killing black people, white people, and all people. It perpetuates the problem by framing it in terms of us versus them. Either we get ahead or they get ahead. That leads quickly to a fight for resources that fragments efforts to solve the same damn problem. (195)

…the science shows us that it is not us against them. In fact, we all share a common enemy, and that common enemy is childhood adversity. The approach to treatment for the homeless child standing with her mom holding their bags at a Black Infant Health Program meeting is the same approach you use for the family in Pennsylvania where the dad hasn’t work in five years because the plant closed down and for the little girl in rural China whose mother had to leave her to find work in Beijing and for the families in Montenegro and Serbia who lived through civil war … It’s the same fundamental approach to treatment for us all. If we begin to understand that, then maybe we will stop being so Balkanized in our response to the problem and be able to come up with solutions that work for everyone. Because, as my dad used to say in his Jamaican patois, “That rising tide, she lif’ up all di boats, mon.” (195)

12. Listerine

These combined efforts were all base don a simple frame shift – that exposure to germs, not foul air, causes disease and death. Once that was accepted, people were free to get creative about limiting exposure and transmission and about ultimately treating the infections that did occur. But just as important as any individual intervention was the recognition that both approaches were necessary to achieve transformative change. All the antibiotics in the world won’t solve the problem if people continue to dump raw sewage into the water supply. Similarly, even with the most advanced sanitation practices, some people will still get sick, so we need ways to treat infections. (210)

| I spend a lot of time with folks who ask, “What do ACEs and toxic stress have to do with me?” My medical colleagues say, “Isn’t this a social problem?” And policymakers wonder, “How can we even talk about toxic stress if we don’t have a cure?” The answer to all three of these questions is that understanding the mechanism of how ACEs lead to toxic stress gives us a powerful tool to shape both our medical response and our public-health response. And everyone has a role to play. (210)

When we understand that the source of so many of our society’s problems is exposure to childhood adversity, the solutions are as simple as reducing the dose of adversity for kids and enhancing the ability of caregivers to be buffers. From there, we keep working our way up, translating that understanding into the creation of things like more effective educational curricula and the development of blood tests that identify biomarkers for toxic stress – things that will lead to a wide range of solutions and innovations, reducing harm bit by bit, and then leap by leap. The cause of harm – whether that’s microbes or childhood adversity – does not need to be totally eradicated. The revolution is in the creative application of knowledge to mitigate harm wherever it pops up. Because when you know the mechanism, you can use that understanding in countless ways to drastically improve the human condition. That is how you spark a revolution. You shift the frame, you change the lens, and all at once the world is revealed, and nothing is the same. (222)

13. In the Rearview

I believe that when we each find the courage to look this problem in the face, we will have the power to transform not only our health, but our world. (222)

Epilogue

Appendix 1
What’s My ACE Score?

[.pdf]

Prior to your eighteenth birthday:

  1. Did a parent or other adult in the household often

            Swear at you, insult you, put you down, or humiliate you?

                        or

            Act in a way that made you afraid you might be physically hurt?

                        Yes      No                                                                                If yes enter 1 ___

 

  1. Did a parent or other adult in the household often

            Push, grab, slap, or throw something at you?

                        or

            Ever hit you so hard that you had marks or were injured?

                        Yes      No                                                                                If yes enter 1 ___

 

  1. Did an adult or person at least five years older than you ever

            Touch or fondle you or have you touch their body in a sexual way?

                        or

            Attempt to actually have oral, anal, or vaginal intercourse with you?

                        Yes      No                                                                                If yes enter 1 ___

 

  1. Did you often feel that…

            No one in your family loved you or thought you were important or special?

                        or

            Your family didn’t look out for each other, feel close to each other, or support each other?

                        Yes      No                                                                                If yes enter 1 ___

 

  1. Did you often feel that…

            You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?

                        or

            Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

                        Yes      No                                                                                If yes enter 1 ___

 

  1. Were your parents ever separated or divorced?

                        Yes      No                                                                                If yes enter 1 ___

 

  1. Was your mother or stepmother…

            Often pushed, grabbed, slapped, or had something thrown at her?

                        or

            Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?

                        or

            ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

                        Yes      No                                                                                If yes enter 1 ___

 

  1. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

                        Yes      No                                                                                If yes enter 1 ___

 

  1. Was a household member depressed or mentally ill, or did a household member attempt suicde?

                        Yes      No                                                                                If yes enter 1 ___

 

  1. Did a household member go to prison?

                        Yes      No                                                                                If yes enter 1 ___

 

Now add up your “Yes” answers: ___

This is your ACE Score.


CYW ADVERSE CHILDHOOD EXPERIENCES QUESTIONNAIRE
(ACE-Q) CHILD
To Be Completed by Parent/Caregiver

Today’s Date:

Child’s Name: ____________________________________        Date of Birth: _____________________

Your Name: ______________________________________        Relationship to Child: _______________

Many children experience stressful life events that can affect their health and well-being. The results from this questionnaire will assist your child’s doctor in assessing his or her health and determining guidance. Please read the statements below. Count the number of statements that apply to your child and write the total number in the box provided.

Please DO NOT mark or indicate which specific statements apply to your child.

1) Of the statements in Section 1, HOW MANY apply to your child? Write the total number in the box.

Section 1. At any point since your child was born…

  • Your child’s parents or guardians were separated or divorced.
  • Your child lived with a household member who served time in jail or prison.
  • Your child lived with a household member who was depressed, mentally ill, or attempted suicide.
  • Your child saw or heard household members hurt or threaten to hurt each other.
  • A household member swore at, insulted, humiliated, or put down your child in a way that scared your child, OR a household member acted in a way that made your child afraid that she or he might be physically hurt.
  • Someone touched your child’s private parts or asked your child to touch their private parts in a sexual way.
  • More than once, your child went without food, clothing, or a place to live, or had no one to protect her or him.
  • Someone pushed, grabbed, slapped, or threw something at your child, OR your child was hit so hard that your child was injured or had marks.
  • Your child lived with someone who had a problem with drinking or using drugs.
  • You child often felt unsupported, unloved, or unprotected.

2) Of the statements in Section 2, HOW MANY apply to your child? Write the total number in the box.

Section 2. At any point since your child was born…

  • Your child was in foster care.
  • Your child experienced harassment or bullying at school. Your child lived with a parent or guardian who died.
  • Your child was separated from her or his primary caregiver through deportation or immigration.
  • Your child had a serious medical procedure or life-threatening illness.
  • Your child often saw or heard violence in the neighborhood or in her or his school neighborhood.
  • Your child was often treated badly because of race, sexual orientation, place of birth, disability, or religion.

About VIA

www.kevinneuner.com

2 comments

  1. Alison Youssef

    What intriguing research. My ACE score is 5 and I think it’s probably played a role in my eating habits, stress levels and weight. The body is incredibly complex, especially when it comes to the mind-gut connection (IIRC the gut actually creates 90% of serotonin). Child abuse/neglect and physiology are probably connected in ways we don’t even know of yet.

  2. Pingback: When The Body Says No | Reflections & Notes | vialogue

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