Indre Viskontas: Good evening, and welcome to City Arts & Lectures. I’m Indre Viskontas, thank you so much for being here tonight. Tonight’s program is a benefit for 826 Valencia’s college scholarship program.
It is my great pleasure to introduce Dr. Nadine Burke Harris.
I haven’t even told you how great she is yet, though obviously many of you already know. She’s a physician, scientist, an advocate for children who have experienced adverse life events, and a successful entrepreneur, as the founder and CEO of the Center for Youth Wellness.
She got her medical degree at the University of California at Davis. Then her Master’s in public health at Harvard University. And then she did her residency at Stanford in Pediatrics. She could have chosen to practice anywhere with that kind of an academic pedigree. But she chose to go where she was needed most, in San Francisco’s Bay View District. Dr. Nadine Burke Harris.
Nadine Burke Harris: Thank you. Thank you very much.
Indre Viskontas: So you’re a pediatrician. You wrote a book about adverse childhood events. And it starts out with a story of a forty-year-old man.
Nadine Burke Harris: Yes. That was an interesting choice. And the reason I started “The Deepest Well” with a story of a 43-year old computer programmer who is you know, going about his regular life and then wakes up one day with a really severe stroke, was because in that story, and obviously it’s a true story, it was to highlight the point that when we talk about adverse childhood experiences, I think oftentimes for most of us we think about things like the increased risk of behavioral problems or the increased risk of becoming substance dependent or developing depression.
And I think what people don’t think about is the increased risk of things like cardiovascular disease, like heart disease and stroke, which affect so many Americans. And in that case, the team that treated that man, as they were, you know, doing his usual care, you know over and over again, what was said was “43 year old man, significant stroke, no risk factors.”
And yet he did have risk factors. The doctors and the medical team just didn’t know about it. And those risk factors had to do with the experiences that he had had in his childhood. An individual who has four or more adverse childhood experiences has two and a half times the risk of stroke as compared to someone who has zero ACEs.
And so it felt really important for me to start off with talking about the cardiovascular implications as well.
Indre Viskontas: And just the anomaly of someone who seemingly is so healthy brought down by a disease that we often consider something that happens at the end of life, you know or that–but also that we have very little control over. And this idea that, you know, there was something brewing inside of him that he didn’t know about for so long that could have had a part in the cause of the stroke.
Nadine Burke Harris: Yeah, that was exactly the point. It was something that his, you know, his doctor had never asked him about in all his years of going for his regular medical exams and for me, I think that the fact that we know now that childhood adversity leads to these changes in the way our stress response works, in the way that we release stress hormones and adrenaline and cortisol, the way that our you know, brain architecture develops, and the way we are wired down to a cellular level, to respond to adversity I think, for myself as a doctor and as a researcher who studies this, the impacts of early adversity on health, it just feels crazy to me that we still are not including this as a routine part of medical practice.
And I don’t know if it’s a little bit of a spoiler alert. If I’m allowed to say this, but I think for that man in that story with which I opened the book, I think no one would have ever have known, and in fact, it wasn’t part of his, you know, medical care, and the only way I knew about it was because I grew up in the same household that he did.
Indre Viskontas: He’s your brother.
Nadine Burke Harris: And he is my–so I’m sorry for anyone who hasn’t read the book yet. But so, you know, as I say in the book, as I and my family, we’re sitting in the Neurosurgical Intensive Care Unit at UCSF, and we were all sitting there praying for my brother as he was going through a life-saving medical procedure, and over and over and over again, I kept on hearing “43 year old man, no risk factors, 43 year old man, no risk factors,” and I just wanted to scream. I wanted to say “what do you mean no risk factors? What about all the science? What about all this research? Why are we not putting it to use?”
Right, it is past the day, right, where we need to be taking this–all of the stuff that’s sitting in medical journals, right, and and applying it to improve the health and well-being for real people every day.
Indre Viskontas: I mean, you went to some of the best schools that we have in the US. And yet, you know, as you mentioned this isn’t something that a lot of physicians even know about, let alone impart in their practice everyday. Why?
Nadine Burke Harris: Yeah, that’s a fascinating question. I have gotten that question a lot and there are a couple of reasons that jump out to me right away.
So, one has to do with the the original adverse childhood experiences study, which was done by the CDC, the Centers for Disease Control and Prevention, and Kaiser Permanente. Was done now two decades ago, and when that initial study came out, I think that–and I spoke with the principal investigators of that study, Dr. Vince Felitti and Dr. Robert Anda. And when they saw this incredible association between adverse childhood experiences and all types of health outcomes, I think a couple things happened.
I think number one, you know as doctors we always think that the science is going to speak for itself, and it turns out it doesn’t always, right. It actually needs people like me and like you and like every single member of this audience to be advocates. To shout it from the rooftops. To say that this association between early adversity and adverse health and life outcomes is something that we need to do about and we need to begin to demand for changes in practice. So I think that’s one piece.
I think another piece about it was that they found this association, but they hadn’t filled in all the gaps of exactly, okay, so, how is it that early adversity is associated with negative health outcomes? And how is it that it’s associated with so many negative health outcomes? Like that’s nuts, like that hardly seems reasonable. You know it’s like, okay I get that it’s associated with, you know, increased risk of depression, but why is it associated with, you know, increased risk of stroke?
Right so those pieces. And I think all of those contribute, and over the last two decades a lot of really smart science has helped to fill in the gaps and help us understand that the fundamental biological mechanism when you experienced adversity in childhood, is that it can lead to a disregulation or a loss of the normal systems and functioning of our basic stress response, our fight-or-flight response.
And that can lead to an overactive stress response, and that leads to changes in our neurologic system, our hormone system, our immune system. And that’s what leads to the increased risk of these different health outcomes. So we’re beginning to understand that piece.
But I think the last piece, the real reason that I think that we haven’t made more progress and that this hasn’t been incorporated into medical practice, is because it’s trauma. And trauma is scary. And we don’t want to–the nature of trauma in and of itself is aversive right? So we don’t want to look at it. We don’t want to talk about it, much less dive deeper into it to try and understand it. And I will tell you that when I first learned about this science, the first thing I did was started screening my patients for for adverse childhood experiences.
And when I started talking to my colleagues and say, “hey guys, you know, we got to ask, we have to do this,” there was a tremendous amount of fear. And a lot of doctors, a lot of my colleagues, say “okay we get it we get the science, we believe the science, but we’re worried that if we ask it’s going to traumatize patients even more. Right, or we’re worried that once we ask the question, it will unlock Pandora’s Box and we won’t be able to get through a day or finish a visit.”
Right, like I kind of made the joke a little bit that my colleague said they were afraid their patients wouldn’t tell them the truth, or worse, that they would tell them the truth. And I think those are very reasonable fears. But I also think there’s so much that we can do to overcome those issues. And in fact, every practitioner that I know that has started screening for ACEs–and you know everywhere I go where I’m talking to folks where they’re beginning to expand screening for adverse childhood experiences as a regular part of you know, the pediatric exam–the families say thank you for asking.
And that’s what we found–I mean listen, some folks are like, “huh? Okay. This is, I’m not sure why you need to know this, but okay.” And then once we explain that, you know, this is part of helping your doctor be able to understand risk factors to your child’s health and how we can be able to support you and protect your child’s health, I’ve had far far far more folks say thank you, thank you, thank you for asking, as opposed to any kind of negative reaction.
Indre Viskontas: I mean I think for a lot of us, it feels like there’s not much a pediatrician could do to help, you know in those kinds of situations, which is exactly why we need you to tell us what it is that you can do.
I mean, let’s start with the kind of getting us all on the same page in terms of understanding what constitutes an adverse childhood experience.
Nadine Burke Harris: Great question. So the term adverse childhood experiences refer to ten specific categories of adversities in childhood. And they include physical, emotional, and sexual abuse, physical and emotional neglect, or growing up in a household where a parent was mentally ill, substance dependent, incarcerated, where there was parental separation or divorce, or domestic violence.
So those are the ten traditional adverse childhood experiences. And what we now understand is that experiencing these adverse childhood experiences, or ACEs, can, in absence of adequate buffering caregiving relationships, can lead to this overactivity of the stress response, which is now known as the toxic stress response.
So when you hear me talk about toxic stress, I’m not talking about the line at Starbucks, which I think a lot of people, when they hear the term toxic stress–and I have to say sadly that was much more common, where especially in the media the term toxic stress would be misused–usually refer to the stressor, and it’s actually the stress response. It’s our biological stress response.
Sadly, I have to say the media has come a long way and gotten it a lot better over the last year. And the reason I say sadly is because they’ve had to. Because our government was giving children toxic stress through the policy of separating refugee children who have been through terrible amounts of trauma, right, from the one thing that the science shows us has the capacity to prevent long-term negative health outcomes, which is their trusted and nurturing caregiver.
And then, so these kids arrived at our border and swiftly we remove the one thing that could protect this child’s neurobiology and their physiology. And thank goodness for science and advocacy, because we know science alone is not enough. Fortunately, you know, the district court issued an injunction about that. But so the media’s had to to learn a lot more about toxic stress.
Indre Viskontas: So yeah, let’s talk about then toxic stress and how that’s different from, you know, the kind of stress that every kid, every adult goes through, you know, as you mentioned, Starbucks line. But you know, a lot of other, you know, kids go through all kinds of stressful events in their lives, how is toxic stress different?
Nadine Burke Harris: So, when I start talking about adverse childhood experiences and toxic stress, there is a certain subset of parents who always come up to me and say “oh my goodness,” you know, “how do I,” you know, “my child is–” whatever it is, you know. “Not doing enough, whatever, soccer.” I don’t know what it is. “How do I keep him from having toxic stress?”
And so the good news is that not all stress is bad. And in fact the way that we calibrate our biological stress response is by experiencing, especially in developing children, right, is by experiencing a certain amount of stress and being able to resolve it with you know, the adequate boundaries of a buffering caregiver.
So, you know, my husband and I have four boys and I don’t solve every one of my kids problems for them. Right, I allow them to experience a little bit because you know these kind of relatively manageable stressors that are, with adequate buffering caregiving, is what we call positive stress.
So the positive stress relates to brief increases in heart rate and blood pressure, you know and slight changes, increases in stress hormones, and then with adequate buffering the body returns back to normal.
There’s also something that’s called tolerable stress, which is in the face of more severe stressors, the body’s physiological response is more severe, more extreme. And so in the case of, for example, the death of a loved one, right, what we might see in kids is maybe a little bit developmental regression, some difficulty sleeping, maybe becoming more clingy, certainly having more emotional needs. And and that’s because of changes in their physiology. Higher levels of stress hormones that last for a longer period of time.
But with the adequate protection of nurturing caregiving, right, even in the face of a significant stressor, kids have the ability to regulate their stress response and have their biological systems return back to normal. And that is the tolerable stress response, where it’s a more severe, it’s more prolonged, but with that buffering caregiving, we can restore their physiology.
Toxic stress is when you have a severe or prolonged stressor. And in absence of that buffering caregiving system, and so that activation of the stress response is not only more severe and prolonged, but without adequate buffering caregiving systems, what we see is that it becomes more embedded with long-term changes to children’s developing brains, developing hormonal system, their immune system and ultimately it can lead to changes even in the way a child’s DNA is read and transcribed. And that is what is called by the American Academy of Pediatrics the toxic stress response.
Indre Viskontas: Yes. I think that you know, you touch on something that a lot of us parents worry about, you know, how much to jump in for the kid, how much to leave them apart. And you know the toxic stress instills, I think, a lot of fear in us. Is that every time you know a child really seems to have a lot of anxiety, you know, do we jump in? And yet, as you describe, this process of learning how to deal with stress, you know is something that they have to learn how to do.
It’s a little bit like, you know, you can think about a kid who’s allergic to peanuts, now the treatment is to give them small doses of peanut protein and hope their immune system learns that this is nothing to fear with these new therapies out there. Is that something that we should think about in terms of having a treatment profile for kids who are undergoing toxic stress in that same way? Or like is it, does it, is the work that we have to do sort of one step beyond that or one step away from that?
Nadine Burke Harris: Did you know that my son is allergic to peanuts?
Indre Viskontas: No, did you know mine is?
Nadine Burke Harris: No way. Oh my goodness. So what we’re learning more now when we think about the treatment for toxic stress–so there’s a couple of different things. And one of the things that’s really exciting to me is that our ability to assess and measure some of these things is just so much greater than they have been in the past. Right, so we have functional MRIs and we have the ability to look at proteomics and metabolomics and all these different ways of science assessing what’s going on in someone’s body.
And the more carefully we are able to characterize the physiology of toxic stress–at the same time when we think about how do we treat a toxic stress response in a child, some of it is the stuff that your grandmother could have told you. Right, it’s the presence of a–when I talk about the presence of a nurturing buffering caregiver, right, we now understand that there is that, you know, when we connect, when we get that warm hug from someone, when we’re in a healthy relationship with someone, one of the things that it does is it releases oxytocin, right?
And so we have a better ability to measure that it’s actually the oxytocin, and oxytocin directly inhibits the stress response, you know, the hypothalamic-pituitary-adrenal axis, and that it actually protects our cardiovascular system from the effects of stress. That it’s anti-inflammatory, that it delays cellular aging, all of the ways in which toxic stress impairs health, oxytocin essentially does the opposite, right.
And so what does that mean in terms of treatment? Well, it still means that good old-fashioned relationship is the best oxytocin delivery system that we have to date. That snuggle and that connection to to a caring adult is really important.
Although, I’m very excited because there is interesting research going on right now about oxytocin nasal spray, which I’m very excited about. But…
Indre Viskontas: Spray a hug in your nose.
Nadine Burke Harris: Exactly. But when we do a little–so it sounds very simple–but when we dive more deeply into that, there’s a lot for us to unpack and understand. For example, you know, I think that I’ve met a lot of parents who have even struggled in their parenting. Who have not been available or who have even frankly in some cases harmed their children, right. I still to this day, I don’t believe that I’ve ever met a parent who didn’t love their child or a caregiver who didn’t love their child.
And so many of our programs right now, or so many of the interventions that were working on, are targeted to, okay let’s teach this parent parenting skills, for example. And I think that we need to go a step further and say how do you teach this parent parenting skills, when you’re trying to parent, when you yourself have a toxic stress physiology, right? So if every time you’re faced with something that is super scary or super stressful or you know, whatever–cause I have never met a parent who’s like gosh, I’m really trying to hurt my child.
And you know what I hear is, my child was doing something that was either driving me crazy or scared me or makes me worried that they’re going to grow up and go out in the world and be at risk, right. And so I hit him, or I did, you know, whatever. It’s this activation of the stress response, coupled with, you know, limited choices and yes, there’s some educational component there.
But I think to be able to help parents understand when that, my own biology, right, is working against me, when my prefrontal cortex goes offline, right and my amygdala, my fear center is sounding the alarm and I am energized with all of these stress hormones that are telling me that I got to deal with this right now or else, right, how do we help them recognize–because parenting classes work great if you don’t have any of those obstacles, right?
But how do we help them recognize oh, that’s what’s going on with me. And then understand, okay, and now what do I do? How do I calm myself down? How do I regulate my own stress response? Because parenting is stressful.
You heard me mention earlier that my husband and I have four boys. Parenting is stressful. And so I think that recognizing the physiology that goes along with it and then giving people real tools of how they can really address, not only the situation, but also what their biology is in the situation, I think it’s absolutely critical for getting to breakthrough outcomes.
And I think there’s a lot more, as well. I mean, I think all of the science tells us that early detection and early intervention is our best chance at improving outcomes. Right, that those are the best outcomes we see. And I think that right now when it comes to toxic stress, I think a lot of folks have this myth that there’s nothing that can be done.
Right, folks come to me and they say, “oh well Nadine, you work in Bayview Hunters Point, and it’s you know, this really challenging neighborhood and how do you not give up hope? What makes you think that these–you know, we can make a difference, because, you know aren’t these kids too far gone? And you know, is it really even possible for us to make big strides in the treatment of toxic stress because the kids that I come into contact with, you know, it’s just so difficult, we work so hard, we put so much into them and it feels like you know, for some kids they do great, but for a lot of kids it seems like we’re just, you know, barely scratching the surface?”
And so I think that makes people think that there’s nothing that can be done about it. And I want to remind folks that even if we look at something like breast cancer, right, the later you detect it, right the more expensive and intensive the treatment has to be. So if you detect it at stage 4, right, that’s going to be this really really intensive difficult treatment. It’s going to cost a tremendous amount of money, and your survival rates are going to be lower. But if you catch it in stage 1, the survival is 90%. Right, and it’s a much less intensive and expensive intervention.
And that’s a big part of the reason why you will all see me, like I’m a woman on a mission, shouting from the rooftops, “we need to be doing universal screening for adverse childhood experiences as a routine part of every exam for every child in the United States of America, because let’s not wait for them to get to stage 4.” Right, let’s do early detection and early intervention.
And by the way, get the word out so that when parents and teachers and you know, anyone interacting with kids begins to see signs and symptoms, like hey, you know, I’m a little bit concerned about this child, we can get them in right away and get them good treatment when it’s more likely to be effective.
Indre Viskontas: You’ve done an excellent job in sort of painting us the picture of why, for a lot of people, life expectancy is tied to their zip code. You know, we know that this is the case especially in America. And you’ve also done a beautiful job of helping us understand why your book is titled “The Deepest Well.” So why don’t you tell the audience what is the well story that you’re really using here as the metaphor.
Nadine Burke Harris: So I’m, in addition to being a pediatrician, I’m also a public health nerd. Like I love–I’m a science nerd, but I’m also like, I love public health and actually using science to make people better on a large scale, like healthier on a large scale. And the story of the well is like the age-old public health parable that you learn public health school day one. And it’s essentially the story of a physiologist, sorry an epidemiologist and researcher, Dr. John Snow. Not Game of Thrones Jon Snow, different John Snow. Who was responding to the cholera outbreak in the SoHo neighborhood of London.
And as he was trying to you know, figure out why all these people were dying of cholera, and he mapped it out, and ultimately he figured out that all of these folks were were drinking from the same water source. And it was a well on Broad Street in Soho. And at the time, the theory of how disease was spread was the miasma theory. Right that it was spread through foul vapors essentially, through bad smelling air.
And so when he went and he presented the city officials with his theory, you know, he’d been reading this, you know, the crazy writings of some guy named Pasteur, who thought that maybe you know, infection could be spread by these little critters, that were called microbes, and they could be in the water, people thought he was totally nuts. But he convinced them to take the pump handle off of the well on Broad Street and when they did that the cholera outbreak in Soho subsided.
And it felt like a really powerful analogy because I think that in our society oftentimes if we’re just looking at the surface, if we don’t understand the root cause of a problem, then we’re going to continue to be treating the most obvious symptoms. We’re going to continue to be trying all of these these different things that are not effective if they don’t get to the root of the root.
And in our society a critical root cause is adverse childhood experiences and toxic stress. And so we need to go to the root of the root in order to be able to develop solutions that will actually work.
Indre Viskontas: And our society sometimes does such a bad job at helping those kids who are at risk, even because the symptoms that they show seem to fall under other diagnoses, like ADHD, for example. So, you know kids who have behavior and learning problems might have them because of an underlying disorder like ADHD, or they might have them as a result of toxic stress, and people in places where toxic stress is more common tend to also then be sort of labeled and be treated more poorly when they show these behavioral problems.
Nadine Burke Harris: Yes, you just decided to go there and get me started. That’s you know, this is something that is, it’s something that as a physician is deeply disturbing and frustrating to me. Which is that the purpose of a diagnosis is to inform a couple of different things. It’s supposed to give you a sense of what’s wrong. Right, and then it’s supposed to inform our treatment approach, and then ultimately inform the prognosis, right.
So for example, that’s why when a person has a diagnosis of, when someone has a cough right, it’s important to know whether it’s tuberculosis, or if it’s lung cancer, or if it’s the flu. Right, because the underlying cause is different, and that means that our treatment approach has to be different, and it means the prognosis is different, and that’s really important.
When it comes to the ADHD versus toxic stress question, the number one treatment in the United States of America for ADHD is stimulants. Right, Ritalin, Adderall, Strattera. Right, these types of medications. And when we look at the neurobiology, if you look at the functioning of the part of the brain that’s responsible for our executive functioning–so our attention, our focus, our impulse control–it looks like an inverted U, when we when we look at it relative to stress hormones.
So if you have too little stress hormones, then you can’t focus, you’re distracted, you’re inattentive, you have poor impulse control. And so for that reason, it makes all the sense in the world that you would give a stimulant to help the the prefrontal cortex, right this part of the brain with executive function.
But the problem is, if you keep going on that curve, on that inverted U curve, and if you have way too much stress hormones, then symptomatically you’ll look almost exactly the same: distracted, inattentive, poor impulse control. It’s like when you drink 20 cups of coffee, and you can’t focus to save your life. And in that case, right, adding a stimulant isn’t necessarily going to help. And in fact, in some cases it may even do harm.
And if that’s the case, then it’s far more likely that what you’re dealing with is a toxic stress physiology, in which case the treatment is to reduce the dose of adversity, to enhance the capacity of the caregivers in the child’s life to be a buffer to that stress, and, in the cases that we do need to use medication, because sometimes that’s the case, we actually use a non-stimulant medication that’s designed to regulate the stress response within the brain. And so in our clinic we use Guanfacine, in you know, other professionals sometimes use Clonidine.
But in any case, understanding what we’re dealing with, and not just lumping it all into ADHD, for me is critically important. Because it informs our treatment approach and it also, by the way, informs the prognosis, because if a child is experiencing toxic stress physiology and if they have high ACEs, isn’t it critically important for us, instead of just adding more medications to the mix or putting them on a stimulant, isn’t it critically important for us to understand, wow this child, their physiology is telling us that they’re being overwhelmed by the stress and adversity in their environment? And isn’t it critically important for us to try to figure out ways to intervene to reduce that adversity that they’re experiencing?
Right, because otherwise, even if we’re able to–and I’ve seen kids where they put them on a stimulant, and it doesn’t seem to help, so they add an anti-psychotic, and that also doesn’t seem to help, and so I you know, I’ve seen these kids they come in, they’re on four or five different medications, and when we identify what the actual issue is…
And this is a true story, I had a patient who went from being on four psychotropic medications right to, once we were able to identify the issue and really start treating the toxic stress–and in that case it meant working with the child and the caregiver, right? We were able to back them down off of all of their medications. We had them you know, just on one medication and then took them off. So really it’s about efficacy.
Indre Viskontas: And the timing of the stress seems to be critically important in terms of what the outcomes will be. So one of the other stories that sort of sticks vividly in my mind from your book is that of Diego. Tell us that story.
Nadine Burke Harris: So Diego is really the patient that opened my eyes and got me thinking more deeply about this issue. And got me asking the question of what am I missing?
So when I met him he was seven years old. He’s a little boy, 7 years old. And he came in to see me actually because his teacher was concerned that he might have ADHD, and so asked his mom to bring him in. And as I was doing his physical exam, the thing that struck me was that he was little. He was itty bitty. And when I you know, plotted his height and weight on the growth curve, I found even though he was seven years old, his height was the 50th percentile for a four year old. And I had to double check myself because I was like wait, maybe I got it wrong, or his date of birth was wrong.
And so immediately I was a little bit concerned about growth failure, why he wasn’t growing normally. And in addition to that he had asthma. He had some eczema, some sensitive skin. And then he had these behavior concerns. And when I sat down and I asked his mom about when his behavioral concerns began, she started to cry. And so I had Diego and his little sister step out of the room and go in the waiting room with my medical assistant.
And she explained that when he was four years old he had experienced a sexual assault at the hands of actually a tenant that they had taken in to help offset the rent, because they could no longer afford the San Francisco rent. And so someone who worked with Diego’s dad in construction came to rent a room from them in their house. And it wasn’t until Diego’s mom came home and found this man in the shower with her son that they even knew anything was going on. And you know, they called the police, they made the report.
But after that, and it, and when I went back and looked at his growth chart, what we saw was that he literally had growth arrest as a result of this trauma.
What was interesting for me about that experience was that now in hindsight, I can look back and say, wow, okay, well childhood adversity is associated with all of those things. With asthma, with eczema, with you know, behavioral problems, and with growth failure, but as I was treating him I said, oh he’s got asthma, I know how to treat asthma and I wrote the prescription and I gave it to Mom. Said oh, he’s got eczema, I know how to treat eczema, and I wrote the prescription and I gave it to Mom. And I think that if it hadn’t been for the growth arrest, right, it would have been easy to say, okay, well, he’s got behavior problems, we know how to treat that, you know, and write the prescription and send the family out.
But as I was trying to do this work up, and try to put all these pieces together, I was, I remember I was on the phone with the endocrinologist, the hormone doctor, and I said, “Let me ask you a question. Have you ever heard of this?” Because I mean way back in medical school, I had heard, you know heard of growth failure associated with psychological trauma. I said “have you ever heard of this?” And she was like, “yeah, absolutely. Absolutely.”
And that made me think to myself, if that can do this in this patient, and it’s so dramatic, how is the trauma and adversity that so many of my patients are experiencing every day, how is it affecting their developing brains and bodies? And that’s what got me asking these questions.
Indre Viskontas: So I have no doubt that very soon every pediatrician will be doing the ACEs questionnaire in their office because you are so compelling and you are such a passionate advocate. But what’s going to be the next step? What will they do once they find out that a child has a high score on this particular questionaire?
Nadine Burke Harris: Well, that’s exactly what we’re working on right now. So my organization, the Center for Youth Wellness, actually developed something called the National Pediatric Practice Community on ACE Screening, because it’s not enough for us to talk about it. We really have to be doing something about it and we have to be thoughtful and planful. But we’ve created this National Pediatric Practice Community to bring together pioneering practitioners who are learning together about how we screen for ACEs and then how we respond.
And I think that if you had asked me that question four years ago, I would have said, “oh, you know what, we’re going to develop this protocol, that’s what you know our team at the Center for Youth Wellness, we’re working on the protocol, and then when we find the answer, we’ll let everyone know.”
And what we now understand, and how my thinking has developed significantly, is recognizing that this National Pediatric Practice Community is part of the solution in terms of how we find the answers. Because there are protocols and services and interventions that we are piloting in our Center that we feel like are really moving the needle forward, but it’s going to take all of us.
There are doctors in New York and in Boston and in Phoenix, Arizona, who are also on the forefront of doing this work, and in advancing the science and advancing our protocols and advancing our response. And so getting more really really smart scientists and doctors and clinicians and mental health providers and social workers as being part of finding the solution is an important solution, if that makes any sense.
I mean when we look at, for example, where our nation went on childhood leukemias. Right, so 50 years ago, the mortality rate from childhood leukemia was 90%. Now we’re at an 85 percent cure rate. And the way that happened was they actually created something called the Pediatric Oncology Group, now called the Children’s Oncology Group, where folks all over the country were figuring out, okay, what are you doing that’s working? Share that with everyone else. What are you doing that’s working? Let’s figure out–are you seeing marginally improved outcomes? And together, all of these scientists coming together to share their experiences, to share their challenges, and to advance the field, led to this dramatic change.
And what’s even more fascinating to me, was that once they got to the you know, roughly a 60%, 65% cure rate, you know, I think most of us, we think that it’s because they develop new chemotherapy and they develop new, you know modalities and methodologies and all those things, which they did, but after just about that 65% rate, there actually weren’t more new medications or new drugs or new protocols. Most of the advancement was from doing the same things, but getting really smarter about how we’re doing it and what works for whom and taking the existing science and just applying it in much more rigorous and thoughtful ways.
So I think there’s a tremendous amount that we’re going to see happen in terms of the treatment of adverse childhood experiences and toxic stress.
Indre Viskontas: Well while I like the idea of the snuggle in a nasal spray, another great vehicle for oxytocin is music. So that’s something that I’m really passionate about. And I know, at least at Carnegie Hall, they have a project called the Lullaby Project, where they are teaching young parents to write music for their children, because it’s such a great bonding tool. Do you ever see kind of interventions like that, something that you know, could find their way into clinics, or you could have a prescription for music?
Nadine Burke Harris: Yes, so first of all, for the audience who doesn’t know that my interviewer today is not only an acclaimed opera singer, but a neuroscientist as well. Like all I can do is science. I have no musical talent.
But actually this was really fascinating for me in reading some of your work, because as I go through the world right, as we’re looking at how we develop interventions, one of the pieces that’s really fascinating and fun about science is to be able to say, “wow. This looks anecdotally like it makes a difference.” And then to dive into the science about why it makes a difference, right.
And interestingly at our Center, at the Center for Youth Wellness, we actually did a musical therapy intervention. I don’t know if I told you that. But it was really really powerful and we had actually a group in Bayview-Hunters Point that came in and was doing actually drumming and a music intervention with Native African instruments for our kids in our Center, and it was phenomenal.
Indre Viskontas: That’s awesome. Well, the synchronization is what you know, drives a lot of these oxytocin boosts that we see rhythming forever them together.
So let’s take some questions from the audience now. And as we’re turning up the lights and you’re thinking of all these great questions, let me just ask if there is something that you have seen in your patients that has changed as they become more kind of intertwined with technology in the Bay Area. Is there anything that you’ve seen that might mitigate or actually induce more stress when kids are given cell phones or you know engaged in technology?
Nadine Burke Harris: That’s a great question. I will say that…So, technology nowadays, I feel like a lot of it is dopamine manipulation tools, right. Like you–and I think that’s done intentionally, I think there’s actually research that goes into it. That makes you want to click or swipe or or do whatever it is.
And I also think that I’m really grateful that I’m not an adolescent in this time, right. Because when we combine the neurobiology of adolescent brain development with the way that–and I think that technology can be really positive, I don’t want to be saying that technology is the devil–but I think that the piece that, I think that kids are at greater risk because of the way that we interact with these tools that are designed to not only get our attention, but make us feel compelled to check them and interact in that way.
And the other piece that’s concerning to me is the–I think relating to a real human being is actually critically important. And that we learn a lot about how to be human and how to be healthy by relating to other healthy humans. And I feel like some of that is, if we’re not intentional, it’s very easy for that to get lost.
City Arts & Lectures: This question is coming from the center of the balcony.
Audience Member 1: Thank you. And well, thank you as well. I wanted to say, I read your book two months ago. And it really, I just wanted to say thank you, first of all for me and from all the people I know that you know, were really touched by your book. It helped me understand my father’s brain cancer. You know, my mother was always saying, you know, it was your grandmother who killed him, you know and all the questions of mental health that you’re really, you know, actually making us understand better.
And my question is really about I guess two issues that you touched upon, and both of you touched upon in your conversation, but for me that are sort of like two elephants in the room in a way, or two elephants in my head at least, when I read the book.
One is mental health, and you mentioned you mentioned a little bit you know, how we can move forward with like, you know addressing the ACEs. I feel and correct me if I’m wrong, but I just want to ask you to say something more about it if you can.
I feel like what your work is doing is really also dispelling the question that mental health is not as valuable, not as important, as physical health, and I feel like a lot of people are now listening to you know, issues of mental health, because now we can see, also thanks to your work, that it actually affects physical health as well.
And I guess you know, I wanted to ask you if you could, like say something about you know, how stigma of mental health still survives or maybe how you think your work can actually address that and change that.
And the second question, briefly, is really about what I see as actually the deepest of the deepest wells. Because we’re talking about how ACEs and childhood adverse experiences affect our health as adults, but also you did mention how in United States, you know, this also depends on your postcode in many ways, right? So our health depends a lot on the social economic background, racial and ethnic background as well.
And I guess the question is really how we can begin to address social economic inequality, also racial and ethnic based, in a moment like this of like crisis of you know, neoliberal capitalism. We see that with Trump as president, and the extreme inequality levels we’ve reached in this country. That I really see as, you know, impacting ACEs for a lot of people especially, you know, disadvantaged communities. So I guess mental health and the question of social economic inequality, I guess.
Nadine Burke Harris: Yeah, so that’s two questions there. And I think the first question, in terms of mental health, I…So we have made this distinction between mental health and then the rest of health or the rest of the body. The body doesn’t make that distinction.
And what I think is really fascinating and I think that part of the reason for my work, is even for example, when I talk with my adolescents, and I go through their ACE score and I’m sitting there with them in their appointment and I say, “because of what you’ve experienced, I believe that your body is making more stress hormones than it should. And that can look and feel like being quick to anger or having trouble controlling your impulses. Or getting sick easily when you feel overwhelmed.” And the most common answer that I get is, “oh you mean I’m not crazy?”
Right, is that I think that we put this judgment of oh, it’s all in your head or… And I think even medicine is guilty of this sometimes. It’s oh, there’s nothing real wrong with them, it must be a mental health problem. And I think that we’re beginning to understand more, and especially as science advances, that that’s not the case.
I think that in terms of the issue of the socio-economic and racial disparities in the US, particularly in relation to ACEs and toxic stress. So, absolutely without a doubt, there are–everything, I believe, in our society, in our culture, is related to race and socioeconomic status and other factors that define people’s circumstances.
And for example, if you are, you know, we’ve all heard the statistics that black boys are X many times, some ridiculous number, I think it’s five times as likely, to be kicked out of preschool, right, than white boys, when they did this big study.
And so what we see is that when kids or adults manifest the symptoms of toxic stress, right, when that’s filtered through the lenses of our society, number one, we can see different outcomes with the same fundamental behavior or the same, even the same cause for the behavior. We can see different outcomes. And as a parent of black boys that is terrifying for me.
And we also know that these conditions impact an individual’s risk of developing toxic stress. Listen, the Kaiser CDC study looked at these 10 adverse childhood experiences, but we know that there are also other risk factors for toxic stress, and we’re learning more and more about those all the time every day, right. So that also impacts people’s experiences, also dramatically impacts their outcomes.
And when I thought about, in terms of my little corner of the world, right, and figuring out, how do I use this science to try and restore some healing in the world? Because I originally came to this work in studying health disparities and trying to understand that and remedy health disparities.
I think one of the pieces that it’s really critical to understand, is that if we–one of the pieces about toxic stress, is that toxic stress affects everyone. Right, regardless of race or socioeconomic status or class or any of those things.
And for me, I believe deeply that when we are able to do a much better job at identifying and treating toxic stress, that there is a tremendous potential to lift everyone up. And I think that’s a big part of what drives me to this work, because I think there is a part of this work that has a tremendous equity lens as well.
City Arts & Lectures: This question is at the back of the orchestra.
Audience Member 2: Hi, I’m a child psychiatrist. And I treat children for trauma and PTSD through the age of six years. So young children. I think you’ve done a very important job in identifying this issue of the importance of ACEs, but I’d like you to talk about interventions from your perspective as someone interested in public health.
I know from my experience that treating these kids takes a great deal of effort and expertise and time per child. And we don’t have those resources. So I wondered if you are thinking about how pediatricians, pediatric practices, can devise interventions, how to advocate for more Mental Health Services, and also that in this country one half of the counties of the U.S. have absolutely no mental health provider period. So what do we do about that, since often those are going to be highly stressed communities?
Nadine Burke Harris: I think that’s a great question and it’s a great challenge. And I think that in fact…So one of the biggest challenges that we have, is that when when we look at the prevalence of adverse childhood experiences, right, one of the biggest shockers from the ACE study–right where they did this study in a population that was seventy percent Caucasian, college educated, and they found two thirds of them had experienced at least one adverse childhood experience, and one in eight folks had experienced four or more adverse childhood experiences. So there’s a couple of things right away. Like when you’re talking about two-thirds of the population, then you’re at a place where you rapidly outstrip our capacity for mental health services, right.
And in that also right, so it’s this huge challenge which feels scary and frustrating and daunting, and at the same time is a really important solution, right. Because when the original researchers, when Felitti and Anda, when they found out this information, their jaws were scraping on the ground. That number was so much higher than many folks had previously projected as the prevalence of childhood adversity.
And so what that means is a couple of things. It means that we need to have A, many more resources. So in many ways that’s our argument for more resources. Because we recognize that it’s a very widespread problem that we need to have a much better solution and infrastructure for dealing with.
But the fact that we need more resources shouldn’t preclude us from being able to act now. And just as an example of this, Vince Felitti, who is one of the co-principal investigators on the study, as a result he decided to incorporate the ACE screen, much as I did, incorporate the ACE screen into his intake for his patients at Kaiser.
And he was an adult medicine doc. And what they found–and they did this for a hundred and ten thousand patients–and what they did was that in the year following the incorporation of the ACE screen into their intake forms, what they found was that there was a 35 percent drop in ER visits, an 11 percent drop in sick visits to the doctor. And they actually–it was Kaiser–they actually didn’t make any changes to their mental and Behavioral Health Services. What they changed was the questions that they were asking from their patients.
And what Dr. Felitti told me was that his patients came to him, and what they said was, one patient in particular said “thank you so much for asking. I thought I would die, and no one would ever know.” It was a way in which having–and I think maybe especially a doctor ask these questions. And then what Dr. Felitti did was, believe it or not, here was this spectacular medical intervention that he did that reduced hospital, reduced ER visits, reduced sick visits—he listened. He listened to his patients.
So that’s just to say, I think we do need, and I agree with you, we do need tremendous amount more resources. And at the same time, that shouldn’t preclude us from acting now to do early identification and early intervention.
Indre Viskontas: Is there anything that we can learn from kids who are resilient in some way that even in the absence of a buffering caregiver–given this huge prevalence in people experiencing ACEs, you know–is there anything that we can learn about coping mechanisms that kids are already doing?
Nadine Burke Harris: Yeah. So there’s a tremendous amount that we can learn from who does well and who is more vulnerable. And this is work that’s underway right now, that folks are looking at. We’re looking at, some of it has to do with our genetics, right. We’re finding that certain genotypes confer a greater vulnerability, but also a greater, you know, the converse is that not having that genotype confers a greater resilience.
There’s Dr. Tom Boyce, who’s at UCSF, has done tremendous work around orchids versus dandelions. What we’re now understanding is that what we call, you know, orchid children, they have a higher vulnerability, but when they’re nurtured they actually flourish and are amazing. Right and you know some kids have more of what we call a dandelion physiology, which they’re able to tolerate a lot and you know, nothing really puts them off course one way or the other.
The thing that I think is the critical question is how we’re assessing resilience. And that is the piece that, when I talk to my colleagues, I think people often say, “oh well so-and-so had X many ACEs and he’s fine. Look at him. He holds down a job, right. He’s married and two kids. He’s doing great. He’s resilient.”
And that’s why I opened the book with the story of my brother who was doing great. Right, and then ended up with a major stroke at the age of 43. Resilience is not just absence of mental health pathology. When we’re talking about individuals with four or more ACEs, have double the risk for schemic heart disease, we need to do a much more rigorous job of assessing what we mean when we say resilience.
Indre Viskontas: So on that note, thank you so much for sharing your thoughts with us tonight.
Nadine Burke Harris: Thank you so much for inviting me. Thank you all for being here.
Indre Viskontas: And Dr. Burke Harris will be signing copies of her book “The Deepest Well,” just in the lobby area. Thank you.
Nadine Burke Harris: Thank you.