Growing up in adversity can take a big toll on health later in life—and perhaps even for future generations. Public health officials are beginning to act.
In the mid-2000s, Dr. Nadine Burke Harris opened a children's medical clinic in the Bayview section of San Francisco, one of the city's poorest neighborhoods. She quickly began to suspect something was making many of her young patients sick.
Earlier this year, thanks in part to her advocacy, California allocated more than $105 million to promote screening for"Adverse Childhood Experiences" —10 family stressors, first identified in the late 1990s, that can elicit a"toxic stress response," a biological cascade driven by the stress hormone cortisol that is linked to a wide range of health problems later in life.
The research is so fresh that many clinicians are still debating the best way to tackle the problem, most significantly whether the science is mature and the interventions effective enough to implement universal screening. And the details of California's approach to screening are controversial in the world of public health. But there is broad consensus, at least, about one thing.
When Felitti asked her if anything unusual had happened in her life around the time the dirty pots and pans began to appear, one event came to mind. An older, married man at work had told her she looked great and suggested they have an affair. After further questioning, Felitti learned Patty had first started gaining weight at age 10, around the time her grandfather began sexually molesting her.
At least one person was intrigued by his findings. Robert Anda, a researcher at U.S. Centers for Disease Control , had been studying chronic diseases and the counterintuitive links between depression, hope and heart attacks. He knew firsthand what it was like to deal with colleagues who considered his work flaky. Anda and Felitti got to talking.
The results went beyond these common trauma-related health risks. The study also linked childhood trauma to a host of seemingly unrelated physical problems, including ischemic heart disease, cancer, chronic lung disease, skeletal fractures and liver disease. Much of the research has focused on how ACEs affect the functioning of the hypothalamic-pituitary-adrenal axis, a biological system that plays a key role in the mind-body connection. The HPA axis controls our reactions to stress and is crucial in regulating an array of important body processes including immune function, energy storage and expenditure—even our experience of emotions and mood.
However, when the emergency goes on for a long time—perhaps over an entire childhood of abuse—the resulting high levels of cortisol take a big and lasting toll. In 2009, Bruce and her colleagues demonstrated a possible explanation for the discrepancies. Since morning cortisol levels play such an important role in getting well-functioning individuals ready for the day, they sought out a group of 117 maltreated 3- to 6-year-old children transitioning into new foster care placements in the United States. The researchers then trained the children's caregivers to collect saliva samples before breakfast.
One of the most important findings to emerge recently is that the experience of childhood adversity, by itself, does not appear to be enough to lead to toxic stress. Genetic predispositions play a role. But even among those predisposed, the effects can be blunted by what researchers call emotional"buffering"—a response from a loving, supportive caregiver that comforts the child, restores a sense of safety and allows cortisol levels to fall back down to normal.
Scientists have since documented many biochemical mechanisms by which emotional buffering can help inoculate children exposed to adversity to long-term consequences, and how chronic overactivation of the HPA axis can interfere with development—or, as one widely cited scientific paper put it, can have an impact akin to"changing the course of a rocket at the moment of takeoff.
While these findings help explain the link to chronic diseases, Harris Burke and other public health officials believe they also provide the basis for some of the most promising interventions in the clinic today. Not surprisingly given her background, Burke Harris looks to pediatric caregivers and other doctors to lead the effort to detect and treat patients suffering from toxic stress.
The specifics will vary on a case-by-case basis, and will rely on the judgment and creativity of the doctor to help adult caregivers design a plan to protect the child—and to help both those caregivers and high-risk adults receive social support services and interventions when necessary. In the months ahead, the protocols and interventions will be further refined and expanded.
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