The US medical system isn’t particularly good at preventing illness. Once someone is sick, doctors hopefully know how to treat them. But historically, there’s been far less focus on preventing people from needing treatment in the first place.
That’s finally starting to change, thanks to a growing movement in the health-care community that looks to address the environmental and behavioral causes of many common diseases. Prevention, experts say, will save money (though it’s unclear how much) and lead to an improvement in many people’s quality of life. As the saying goes, “an ounce of prevention is worth a pound of cure.”
Nowhere is that shift more visible than California, where governor Gavin Newsom recently created the position of surgeon general to focus on the “early warning signs and childhood determinants” of diseases and poor health outcomes.
Pediatrician and child health advocate Nadine Burke Harris will be sworn in to this position today (Feb. 11). She plans to use her decades of experience treating childhood trauma to lead the state’s push ”for a system that promotes health instead of managing sickness.” Quartz spoke with Harris about why stress affects kids so much, what caregivers can do to help, and what she plans to do about it.
This interview has been lightly condensed and edited for clarity.
Nadine Burke Harris: The term “adverse childhood experiences” comes from the landmark research study that was done by the [Centers for Disease Control and Prevention] and Kaiser Permanente now two decades ago. It asked about 10 categories of adverse childhood experiences: Physical, emotional, and sexual abuse; physical and emotional neglect, or growing up in a household where a parent was mentally ill; substance dependence; incarceration, where there was parental separation; divorce; or domestic violence.
What they found were two things that were critically important: One, is that ACEs are incredibly common. Two-thirds of the population has experienced at least one, and one in eight folks has experienced four or more.
The second was that there was what we call a “dose-response relationship” between ACEs and negative health outcomes. So, for example, a person with four or more ACEs has double the risk for ischemic heart disease, has more than double the risk for cancer, more than double the risk for stroke, and three times the risk for chronic lung disease. What we’re now understanding is that exposure to high doses of adversity, especially in childhood, activates biological pathways and they release stress hormones that can affect brain development, the development of the immune system, the development of hormonal systems, and even the way that our DNA is read and transcribed. These long-term changes are what’s now known as “toxic stress.”
What routine screening of all children for ACEs allows us to do is to be able to do what the science shows makes the biggest difference, which is early identification and early intervention. And that’s what we plan to do here in the state of California.
Generally, what the science shows us makes a difference in improving outcomes is … sleep, exercise, nutrition, mindfulness, mental health, and healthy relationships. Because, as we’re talking about raising awareness, one of the biggest myths that we have to bust is that if you have experienced childhood adversity, there’s nothing we can do about it.
What the science shows, for example, is that high-quality, nurturing caregiving improves outcomes; it improves brain development, it improves immune functioning, it improves our epigenetic regulation. These things make a difference, and that’s why early detection and early intervention is so important. And so what we’re seeing reflected in the governor’s proposed budget is, for example, $100 million for home visiting and black infant health programs. Home visiting is one of the nationally-recognized, evidence-based programs that improves outcomes and leads to better health down the line. And when we talk about better health, we’re also talking about lower healthcare costs. So we’re seeing that, for every dollar that we’re investing in these early childhood prevention programs, they yield dividends with greater dollars down the line.
This is the type of visionary investment that really brings California in line with the science of how critical the early years are and how important it is for us to be doing as much as we can to […] invest in a healthy start for kids.
Take the example of Lila in my book [The Deepest Well]. When Lila came into my office, she had no outward signs [of ACEs]. Her only thing was that she was small. And she had been getting the number-one treatment for her diagnosis, which was “failure to thrive.” And in her case, her ACE score of seven for this 3-year-old girl helped me recognize that the root cause of her failure to thrive wasn’t inadequate calories; it was that her body was making so many stress hormones that that was interfering with her growth. And so that allowed me to prescribe a different course of action, and in that case it was child-parent psychotherapy.
In the case of Lila, what we saw is that within six months, she was back on the growth curve. In that case, the treatment was more effective and also more efficient than the previous treatment. But this is certainly a capacity we need to develop throughout our practitioners across the state because this is an emerging science.
When it comes to public education around ACEs and toxic stress, I think one of the key messages is that it’s never too late to begin healing. Number two, I think that it’s critical to empower caregivers with the knowledge that … we are the most important antidote to toxic stress. We biologically have the capacity to calm our children’s stress response, but in order to do that, we have to … have our own stress response in healthy working order, and so that means that sometimes we have to do work on ourselves. And the same sleep, mindfulness, exercise, nutrition, mental health and healthy relationships that we recommend for kids is just as important for adults. We have the opportunity to break the inter-generational cycle of adverse childhood experiences and toxic stress.
Self-care isn’t selfish. It’s absolutely critical and we have to put our own oxygen mask on first. My husband and I are parents to four boys and it’s hard. As parents, we want to put our kids first all the time. But we have to be well.
Number one, raising awareness. That’s a big piece. I think there’s still a lot of awareness-raising that needs to happen about ACEs and toxic stress.
Number two, with the AB-340 legislation, California is moving towards universal screening for ACEs for kids receiving Medicaid, and so the implementation of that is something that I plan to be very closely invested in and really helping to work with the governor’s office and our legislators in terms of, how are we implementing this in a way that allows clinicians to provide the best care to their patients to address this public health crisis? Raising awareness, advancing the practice, and advancing the science; I think those are really the three big roles that I see myself playing.
Read more from our series on Rewiring Childhood. This reporting is part of a series supported by a grant from the Bernard van Leer Foundation. The author’s views are not necessarily those of the Bernard van Leer Foundation.