In the mid-90s the CDC and Kaiser Permanente discovered an exposure that dramatically increase the risk for 7 out of 10 of the leading causes of death in the United States in high doses and effects brain development the immune system hormonal systems and even the way our DNA is read and transcribed folks who are exposed in very high doses of triple the lifetime risk of heart disease and lung cancer and a 20 year difference in life expectancy and get doctors today are not trained in routine screening or treatment Double Exposure I’m talking about is not a pesticide or packaging chemical its childhood trauma okay what kind of trauma my talking about here I’m not talking about failing a test or losing a basketball game I am talking about threats that are so severe or pervasive that they literally get under our skin and change our physiology things like abuse or neglect or growing up with a parent who struggles with mental illness or substance dependence now for a long time I view these things in the way I was trained to do them either as a social problem refer to Social Services or is it mental health problem refer to Mental Health Services and then something happened to make me rethink my entire approach when I finished my residency I wanted to go someplace where I felt really needed some place where I could make a difference so I came to work for California Pacific Medical Center one of the best private hospitals in Northern California and together we opened a clinic in Bayview Hunters Point one of the poorest most underserved neighborhoods in San Francisco no prior to that point there had been only one pediatrician in all of Bayview to serve more than 10,000 children so we hung a single and we were able to provide top quality Care regardless of ability to pay it was so cool we targeted the typical Health disparities access to care immunization rates asthma hospitalization rates and we hit all of our numbers we felt very proud of ourselves but then I started noticing a disturbing Trend a lot of kids were being referred to me for ADHD or attention deficit hyperactivity disorder but when I actually did a thorough history and physical what I found was that for most of my patients I couldn’t make a diagnosis of ADHD most of the kids I was seeing her.
Such severe trauma that it felt like something else was going on, how I was missing something important now before I did my residency I did a master’s degree in public health and one of the things that they teach you in public health school is that if you’re a doctor and you see a hundred kids that all drink from the same well and 98 of them develop diarrhea you can go ahead and write that prescription for dose after dose after dose of antibiotics or you can walk over and say what the hell is in this well so I began reading everything that I could get my hands on about how exposure to adversity affect the developing brains and bodies of children and then one day my colleague walked into my office and he said Doctor Burke have you seen this in his hand was a copy of a research study called the adverse childhood experiences study that day changed my clinical practice and ultimately my career adverse childhood experiences something that everybody needs to know about it was done by doctor Vince politi at Kaiser and dr. Bob Fonda at the CDC and together they asked 17 and a half thousand adults about their history of exposure to what they called adverse childhood experiences or Aces those include physical emotional or sexual abuse physical or emotional neglect parental
Mental illness substance dependence incarceration parental separation or divorce domestic violence for every yes you would get a point on your Ace score and then what they did was they correlated these a scores against Health outcomes what they found was striker two things number one uses are incredibly common 67% of the population had at least one ace and 12.6% 1 8/2 four or more Ace the second thing that they found was that there was a dose-response relationship between Aces and health outcomes higher your Ace score the worse your health outcomes for a person with an a score or four or more their relative risk of chronic obstructive pulmonary disease with two and a half times that of someone with an ace score of 0 for hepatitis it was also two and a half times for depression it was four and a half times for suicidality it was 12 times a person with an ace score of 7 or more had triple the lifetime risk of lung cancer and three and a half times the risk of ischemic heart disease the number one killer in the United States of America well of course this makes sense you know some people look at this data and they said come on you know you have a rough childhood you’re more likely to drink and smoke and do all the things that are going to ruin your help this isn’t science it turns out exactly where the science comes in We Now understand better than we ever have before how exposure to early adversity affect the developing brains and bodies of children it affects areas like the nucleus accumbens the pleasure and reward center of the brain that is implicated in substance dependence it inhibits the prefrontal cortex which is necessary for impulse control and executive function a critical area for Learning and on MRI scans we see measurable differences in the amygdala
The brains fear response Center so there are real neurologic reasons why folks exposed to high doses of adversity are more likely to engage in high-risk behavior and that’s important to know but it turns out that even if you don’t engage in any high risk behavior you’re still more likely to develop heart disease or cancer the reason for this has to do with the hypothalamic-pituitary-adrenal axis the brains and body’s stress response system that governs our fight or flight response how does it work in the forest and you see a bear immediately your hypothalamus sends a signal to your pituitary to your adrenal glands that says release stress hormones adrenaline cortisol and so your heart starts to pound your pupils dilate your Airways open up and you are ready to either fight that bear run from the bear and that is wonderful if you’re in a forest and there’s a bear but the problem is what happens when the bear comes home every night and this system is activated over and over and over again and it goes from being adaptive or life-saving to maladaptive or health damage it children are especially sensitive to this repeated stress activation because their brains and bodies are just developing high doses of adversity not only affect brain structure and function the affect the developing immune system develop a hormonal systems and even the way our DNA is read and transcribed so for me this information through my old training out the window because when we understand the mechanism of a disease when we know not only which pathways are disrupted
But how did his doctors it is our job to use the science for prevention and treatment that’s what we do do in San Francisco we created the Center for Youth Wellness to prevent screen and he’ll the impact of a we started simply with routine screening of every one of our kids at their regular physical because I know that was my patient has an ace score of 4 she’s two and a half times as likely to develop hepatitis or COPD she’s four and a half times as likely to become depressed and she’s 12 times as likely to attempt to take her own life as my patient was 0asis I know that when she’s in my exam room for a patient who do screen positive we have a multidisciplinary treatment team that works to reduce the dose of adversity and treat symptoms using best practices including home visits care coordination Mental Health Care nutrition holistic intervention and yes medication when necessary but we also covering electrical outlets or lead poisoning and we tailor the care of our asthmatics and are diabetics in a way that recognizes the aggressive treatment given the changes to their hormonal and immune systems so the only thing that happens when you understand this science is that you want to shout it from the rooftops because this isn’t just an issue for kids
In Bayview figured the middle heard about this it would be routine screening your multidisciplinary treatment teams and it would be a race to the most effective clinical treatment protocols yeah that did not happen and that was a huge learning for me would I have thought of as simply best clinical practice I Now understand to be a movement in the words of dr. Robert Bloch the former president of the American Academy of Pediatrics adverse childhood experiences are the single greatest on address Public Health threat facing our nation today pay for a lot of people that’s a terrifying Prospect the scope and scale of the problem seems so large that it feels overwhelming to think about how we might approach it but for me that’s actually where the hope lies because when we have the right framework when we recognize has to be a Public Health crisis then we can begin to use the right tool kit to come up with solutions from tobacco to lead poisoning to hiv-aids quite a strong track record with addressing public health problems but replicating those successes with Aces and toxic stress is going to take determination and commitment and what I look at what I Nations response has been so far I wonder why haven’t we taking this more seriously at first I thought that we marginalize the issue because it doesn’t apply to us right that’s an issue for those kids in those neighborhoods which is weird because the data doesn’t pair that out the original Aces study was done and a population that was 70% Caucasian 70% college educated but then the more I talked to folks I’m beginning to think that maybe I had it completely backwards if I were to ask how many people in this room grew up with a family member who suffered from mental illness
I got a few hands would go up and then if I were to ask how many folks had a parent who maybe drink too much or who really believe that if you spare the rod you spoil the child I bet a few more hands would go up even in this room this is an issue that touches many of us and I’m beginning to believe that we marginalize the issue because it does apply to us maybe it’s easier to see in other zip codes because we don’t want to look at it we’d rather be sick fortunately scientific advances and frankly economic realities make that option less viable everyday the science is clear early adversity dramatically affects Health across a lifetime the day we are beginning to understand how to interrupt the progression from early adversity to disease and early death the child who has a high Ace score and who’s behavioral symptoms go unrecognised whose asthma management is not connected and who goes on to develop high blood pressure and early heart disease or cancer will be just as anomalous as a 6-month mortality from HIV AIDS people will look at that situation and say what the heck happened there this is treatable this is beatable the single most important thing that we need today is the courage to look this problem in the face and say this is real and this is all of us I believe that we are the movement thank you.