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Before several hundred people at Evanston Township High School on Feb. 13, Nadine Burke Harris, M.D., explained her journey in determining that the emotional and physical symptoms that many of her young patients were exhibiting were due to adverse childhood experiences (ACEs), such as abuse, violence in the home, or a parent suffering from mental illness. Many people in the audience were early childhood educators, social workers, psychologists, teachers and interested community members. The event was sponsored by the Family Action Network.
After starting a health clinic in Bayview Hunters Point, one of the poorest, most underserved neighborhoods in San Francisco, Dr. Harris said she often referred patients for Attention Deficit Hyperactivity Disorder (ADHD), many of whom had “poor impulse control,” “difficulty with attention,” or were “quick to anger.”
But after looking more deeply into the children’s history and physical symptoms, Dr. Harris said she thought something else was going on. “All of these kids were being exposed to really high doses of adversity,” she said. As examples, she said one child’s parents went through a very acrimonious divorce, where one of the parents discharged a firearm. Another child witnessed an attempted murder in the home.
One 10-year-old patient had asthma, which recurred despite treatment. When Dr. Harris asked the mother if she noticed anything that triggered the asthma attacks, the mother said, “It tends to act up every time her dad punches a hole in the wall.”
When she saw “patient after patient who was exposed to incredible doses of adversity and who were also manifesting some of the worst systems,” she questioned what was the “biological mechanism I’m seeing play out in front of me.”
An explanation came, she said, when a colleague gave her a copy of the 1998 Adverse Childhood Events study that was a collaboration between the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente’s Health Appraisal Clinic in San Diego. The study asked 17,500 adults about their exposure to or experience of 10 types of ACEs as children, including emotional, physical, or sexual abuse; violent abuse of their mother; living with an adult who had a drinking problem or used street drugs, or who was mentally ill, or who had been in prison; or whose parents had separated or divorced.
The study found that exposure to ACES was fairly common. Two-thirds of the participants were exposed to at least one ACE. About 12% were exposed to four or more ACEs.
A key finding of the study was that the higher the number of ACEs a person was exposed to as a child, the worse the person’s long-term health outcome. Dr. Harris said that people who had four or more ACEs were twice as likely to develop heart disease, two-and-a-half times as likely to have a stroke, and four times more likely to develop chronic lung disease.
These findings were the same for persons from different socioeconomic backgrounds, and different races or ethnic groups.
Dr. Harris explained how an adverse childhood experience could impact a person’s physical health. If a person sees a bear in the woods, she said, it turns up the person’s brain stress response system and also activates the immune system’s response, she said. These are both defensive mechanisms.
The problem, said Dr. Harris, is “what happens when that bear comes home every night. And the system is activated over and over and over and over again. It can actually lose its ability to turn itself off normally. And it goes from being adaptive or live-saving to being maladaptive or health-damaging.
“Children are especially sensitive to this repeated activation of the stress response because their brains and bodies are just developing. High doses of adversity can actually change the structure and function of children’s developing brains, but not just their brain, but also their developing immune system, their developing hormonal system, even the way their DNA is read and transcribed.”
Dr. Harris and her colleagues did their own study of 702 patients at the Bayview clinic to determine if ACEs had a more immediate impact on a child’s life. In their study, they found that 67% of the children had at least one ACE, and 12% had four or more.
She said she was surprised the percentage was not higher, but thought it might be explained because the average age of patients in their study was eight years old, and the 10 ACEs in the CDC study did not include some adverse child experiences that became recognized in subsequent studies, such as living in extreme economic hardship; witnessing or being a victim of neighborhood violence; experiencing racial discrimination, or the death of a parent, or the deportation of a family member.
Dr. Harris said they found a strong connection between the number of ACES a child experienced and a learning or behavioral problem. “Our patients with four or more ACEs were two times as likely to be overweight or obese, and 32.6 times as likely to be diagnosed with a learning or behavioral problem,” she said.
Viewed another way, Dr. Harris said, 51.2% of the children who had four or more ACEs had a learning or behavioral problem. In contrast, only 3% of the patients who had zero ACES had a learning or behavioral problem; and 21% who had 1 to 3 ACEs had a learning or behavioral problem.
“I had a profound aching in my heart for all of the kids who were struggling in school and being told they had ADHD or a behavioral problem when their problems were directly correlated with toxic doses of adversity.”
She said, though, she saw hope in the data that showed students who have zero ACEs had a minimal likelihood of being diagnosed with having a learning or behavioral problem. Since then, she said, she has been dedicated to “making sure that more of our kids stay in the zero ACEs category,” and making sure that “kids who are exposed to ACEs get the appropriate treatment and evidence based care that they need.”
“When we do early detection and early intervention, kids do better,” said Dr. Harris. “It’s unequivocal. There’s improved brain structure and function on MRIs, reduced stress hormones, reduced markers of inflammation. We are talking about healing that goes all the way down to the DNA.”
Dr. Harris identified several things that can be done. First she said it is important to increase awareness about ACEs, and there needs to be universal prescreening for ACEs. She said only 3% of pediatricians in the country do prescreening for ACEs.
Second, she said, “All of the science shows us that safe, stable, nurturing relationships and environments are healing for children. Healthy relationships are powerful. She said the community needs to enhance the ability of caregivers to be “buffers.”
Finally she added, “Things like good old fashioned mental health interventions still work; integrating primary care and behavioral health; and things like regular exercise, mindfulness, meditation, certain types of nutrition, an regular sleep can mitigate the effects of stress.
“When we understand that the source of so many of our society’s problems is exposure to childhood adversity, the solution is as simple as reducing the dose of adversity for kids.”
In Evanston, School Districts 65 and 202 are attempting to address the impact of ACEs and trauma and are working with partners in the Evanston Cradle to Career initiative to do so. Erie Family Health Center is also focused on this issue.