Toxic Stress Is The Hidden Public Health Crisis California's New Surgeon General Wants To Solve
Our brains grows so much in the first few years of life that any trauma we experience during that time can affect our health forever.
California's new, first-ever surgeon general, Dr. Nadine Burke Harris, has made the link between childhood adversity and long-term health the focus of her work.
She was sworn in by Gov. Gavin Newsom last week and calls her new role a "dream job."
Harris has built her career as a Bay Area-based pediatrician and the founder of the Center for Youth Wellness in San Francisco. She's also the author of The Deepest Well: Healing the Long-Term Effects of Childhood Adversity, and is known for giving this popular TED Talk.
I spoke with her about how she developed a passion for this type of work, what she hopes to accomplish in her new job and what families can do now to protect kids from toxic stress. The conversation below has been edited for clarity.
PN: At the center of your work is a study on Adverse Childhood Experiences or ACEs. You say this is something that everyone should know about but it has a few parts. Break it down for our audience.
NBH: The Adverse Childhood Experiences study was a big study that was done by the Centers for Disease Control and Prevention and Kaiser Permanente. And in it they asked about 17,500 adults about their histories of 10 categories of what they call the Adverse Childhood Experiences - those include things like abuse and neglect, or growing up in a household where parent was mentally ill or substance dependent, or where there was domestic violence. And what they found were to really major things. One is that Adverse Childhood Experiences are super common. Two thirds of the population had experienced at least one and one in 8 folks had experienced four or more of the 10 traditional Adverse Childhood Experiences.
But the other thing that they found was that the more ACEs a person had the greater than risk for not just the stuff that you'd expect, like, you know, mental health issues or substance use, but really medical problems like heart disease and cancer and Alzheimer's. And so this really was a surprise, I think, to a lot of folks. And it begun to put together the link between early adversity and increased risk of some of our biggest health problems today.
PN: As you mentioned, this is extremely common, but I think when people hear about, you know, adverse experiences in trauma and toxic stress, they may think, "Oh, that's not me."
NBH: Yeah, that's right. That's so common. I think that most folks when I first start talking about Adverse Childhood Experiences, they're thinking about you know, someone else in a different circumstance and usually in a different zip code.
But once you start talking about what the Adverse Childhood Experiences actually are, which include things like you know emotional abuse, having a parent or caregiver who often you yelled at you or swore at you or didn't make you feel like you were loved or cared for, or even witnessing domestic violence or having parents who were separated or divorced — all of these things we now understand how how it works is that they activate the body's stress response. And when that stress response is activated, and kids don't have a caring adult to buffer their stress response that can lead to over-activation over the long term and then that can lead to harm in our bodies.
PN: Yeah, actual physical health problems. I think that's something that's really surprising to people. And this wasn't something that was always part of your practice as a pediatrician. How did you come across it? And how did it change the way that you treated your patients?
NBH: When I finished my pediatrics residency at Stanford, I opened a clinic in in partnership with a local hospital in one of the most underserved neighborhoods in San Francisco. That's always been kind of part of my DNA — serving vulnerable communities. But what I was noticing was I was doing a great job with the immunization rates and counseling kids and families about obesity and doing all of the protocols that we're taught as pediatricians to do, but I was seeing lots of kids who were coming to see me for ADHD, or attention deficit hyperactivity disorder. And it was like an unusual amount. It was it was a bizarrely high rate.
What I found was that the kids who were having the worst outcomes were also the kids who had really the most severe histories of adversity. They were kids dealing with parents who were substance dependent or who were experiencing mental illness or who were experiencing domestic violence at home. The correlation was just so strong. And it was wasn't just their behavior, it was also their health.
I will not forget, as I was sitting down with a little girl trying to work on her asthma triggers working with her mom, you know, what is it that you notice tends to trigger your daughter's asthma. And this mom said to me, I noticed that my daughter's asthma tends to act up every time her dad punches a hole in the wall. And so as a doctor, I was just like, "wow."
That's when I started diving into the research and that's when I came across the Adverse Childhood Experiences study and then now the hundreds of other studies that have validated the same thing.
PN: You founded the Center for Youth Wellness in San Francisco, a national leader in raising awareness about ACEs. And it's really your vision that there would be universal awareness among pediatrician about ACEs. What difference would that make in treatment?
NBH: We understand that when kids are exposed to high doses of adversity, that can lead to an overactive stress response. And those stress hormones that bathe a child's brain and body can affect their development. The development of their brain, their hormonal system, their immune system, even the way their DNA is read and transcribed.
But the good news is that all of the research tells us that early detection and early intervention improves outcomes. The earlier that we can identify these things, then we have an opportunity to take advantage of cool science like neuroplasticity, the ability of brain cells to make new connections — these things can can really improve outcomes for kids.
Kids come into my office as a pediatrician and I check their height, I check their weight, I check their blood pressure, I ask about how much milk they're drinking and how many times a day they're going to the bathroom. And yet Adverse Childhood Experiences are such a critical risk factor that affect children's health in a really substantial way.
PN: Once you ask those questions, then what? What did you do for that little girl who had asthma once you realize that connection to the stressors in her life?
NBH: So that's the that's the big question that I think a lot of people are nervous about. Before physicians implement any screening, they receive training, they have a protocol to say, "OK, if we identify a concern or risk here are the resources that we're going to plug our families into." And there are a lot of things that really make a difference. Mental health intervention, excellent treatments like parent-child interactive therapy, for example.
One of the things that's really important is that they support both the child, which is kind of obvious, but also the caregiver, because the two parts of the equation is the stress on the child and the the adults ability to be a buffer to that stress is critical.
There are other things as well things like mindfulness, that's shown by evidence to help to strengthen the part of the parasympathetic nervous system that calms your body down when your stress response is activated, regular exercise, good nutrition.
PN: In my work as a reporter, I've been doing a lot of stories lately focused on the social determinants of health focusing on black infant mortality and how the experiences of black moms affect birth outcomes. And something that's been striking to me is that it really does seem that this this focus on social determinants of health and early interventions is sometimes seen as innovative. It's not something that policy makers are always focused on why do you think that is?
NBH: Well, to be honest, I don't understand.
PN: Yeah, this is what you do, so you don't get that mindset?
NBH: Yeah, it doesn't make a ton of sense to me. One of the things that I'm really, really excited about is being at this first surgeon general of California, it's not only my dream job, but it's my dream job in a dream administration. We're very fortunate to have an administration where the governor and his team is very focused on ensuring that every child has access to a healthy start. What we see is that this administration is really, you know, putting their money where their mouth is when we when they say giving every child a healthy start as a priority and health equity is a priority and looking at the social determinants is critical. And so I'm really excited to be able to be doing this work in this role in the great state of California.
PN: So let's talk a little bit more about that role of surgeon general. On a national level it may not be very visible and may not have that much power, but what do you hope to accomplish? What's your vision?
NBH: What I'm really going to be focused on as surgeon general is addressing toxic stress as a health crisis in the state of California, and really looking at, across our health care programs, how we can better support our existing infrastructure and then look at what else is needed to be able to address toxic stress as a major risk factor for negative health and behavioral outcomes.
In addition, focusing on this vision and this promise of making sure that every Californian can have a healthy start. Listen, we know that an ounce of prevention is worth a pound of cure. And when we look at how do we address some of our biggest challenges, we recognize that the investments that we make an early developmental screening, giving kids a healthy start is absolutely critically important.
And then, as I mentioned health equity. California is such an amazing state where we have all this scientific expertise, we have the the fifth largest economy in the world, and so the idea that some communities are having poor health outcomes in such a persistent way is just unacceptable.
PN: You'll be using your new platform to reach young families across the state what do you what do you want to say to parents about toxic stress now and what what they can do for their their their own children now?
NBH: I think one of the biggest myths that we have to bust is the idea of like, "Oh, you know what, whatever happened in my childhood, it happened so long ago. And, you know, is there really anything that I can do about it now, anyways?"
And what the science is showing us is that it's never too late to begin healing. It's never too late to start regulating an overactive stress response and to put in some of these things into practice and the things that we know make a huge difference a sleep, exercise, nutrition, mindfulness, mental health and healthy relationships.
As I'm talking to families, and especially families with young kids across the state, one of the things that's really common is folks are saying, "Yeah, some of that stuff did happen in our household, but I didn't realize that that could affect my child's health."
And so really helping to to raise awareness because I'm a physician, but if we think that we're going to solve this problem only in the doctor's office, we're out of our minds. It's around creating communities, raising awareness among not only healthcare providers, but teachers and police officers and judges and the person at the supermarket; everyone in our society absolutely needs to understand how children's environments — whether that's a safe and buffering environment, or whether that is a scary environment — literally gets under their skin and every single one of us has an opportunity to be a healthy buffer for a child.
PN: I focus specifically on children ages 0-5 in my reporting and it always is just shocking to me how often people kind of silo early childhood from the rest of life. Of course it's connected!
NBH: What's amazing, especially with the advancement in the sciences, we used to think of heart disease as an adult disease, because you're diagnosed when you're an adult. But what we're now understanding is, for example, an individual with four or more Adverse Childhood Experiences is twice as likely to develop heart disease as an individual with zero ACEs. The origins of things that we have previously thought of as adult diseases we now understand begin in childhood. And that means that the investments that we make in childhood and having a healthy start for every child actually have a much bigger impact then we previously thought.
PN: I've heard you speak before about how often you meet young doctors or med students who are inspired to go into the field because of your work and your very popular TED Talk about ACEs. What do you imagine that you could inspire now with your new position as surgeon general?
NBH: This is one of the things that I'm most excited about because when we think about responding to Adverse Childhood Experiences and toxic stress as as a public health issue, this is not something that's done by one individual or one organization, or frankly, even one state.
When we look at other public health crises like HIV/AIDS, like lead poisoning — what we see is that it's really the advancement of a field. It's people coming together folks choosing to decide, you know what, I'm going to do my PhD thesis on this topic instead of whatever else I could do it about. I'm going to be part of the solution and helping to understand how the stress response works and what happens when it when it becomes over-activated. I think the role of inspiring folks to be part of the solution is, I think, one of the most exciting parts of my job.
Editor's note: A version of this story was also on the radio. Listen to it here on KPCC's Take Two. It starts at 15:00.