in the mid-90s the cdc and kaiser
permanente discovered an exposure that
dramatically increased the risk for
seven out of ten of the leading causes
of death in the United States in high
doses it affects 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
have triple the lifetime risk of heart
disease and lung cancer and a 20-year
difference in life expectancy and yet
doctors today are not trained in routine
screening or treatment now the exposure
I'm talking about is not a pesticide or
packaging chemical it's childhood trauma
okay what kind of trauma am i 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 viewed these
things in the way I was trained to view
them either as a social problem refer to
social services or as a 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
someplace 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 understand
neighborhoods in San Francisco now 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
shingle 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 what 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 had experienced such
severe trauma that it felt like
something else was going on somehow 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 affects
the developing brains and bodies of
children and then one day my colleague
walked into my office and he said dr.
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 the adverse
childhood experiences study is
thing that everybody needs to know about
it was done by dr. Vince felitti at
Kaiser and dr. Bob andhe at the CDC and
together they asked seventeen 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 or domestic
violence for every yes you would get a
point on your a score and then what they
did was they correlated these ace scores
against health outcomes what they found
was striking two things number one aces
are incredibly common 67 percent of the
population had at least one ace and
12.6% one in eight had four or more aces
the second thing that they found was
that there was a dose-response
relationship between aces and health
outcomes the higher your ace score the
worse your health outcomes for a person
with an ace score or four or more their
relative risk of chronic obstructive
pulmonary disease was two and a half
times that of someone with an ace score
of zero 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 seven 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 yeah you
a rough childhood you're more likely to
drink and smoke and do all these things
that are going to ruin your health this
isn't science this is just bad behavior
it turns out this is exactly where the
science comes in we now understand
better than we ever have before
how exposure to early adversity affects
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 an 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 stress response
system that governs our fight-or-flight
response how does it work well imagine
you're walking in the forest and you see
a bear immediately your hypothalamus
sends a signal to your pituitary which
sends a signal to your adrenal gland
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 or 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 damaging 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 they affect the
developing immune system developing
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 then as doctors it is
our job to use this science for
prevention and treatment that's what we
do so in San Francisco we created the
Center for youth wellness to prevent
screen and heal the impacts of aces and
toxic stress we started simply with
routine screening of every one of our
kids at their regular physical because I
know though if my patient has an ace
score of four 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 zero aces I know that
when she's in my exam room for our
patients 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
interventions and yes medication when
necessary but we also educate
parents about the impact of aces and
toxic stress the same way you would for
covering electrical outlets or lead
poisoning and we tailor the care of our
asthmatics and our diabetics in a way
that recognizes that they may need more
aggressive treatment given the changes
to their hormonal and immune systems so
the other 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 I figured the minute that
everybody else heard about this it would
be routine screening yet
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 what I had thought of a
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 unaddressed public
health threat facing our nation today
and 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 this 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 the United States actually has
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 when I
look at what our nation's response has
been so far
I wonder why haven't we taken this more
seriously you know 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 bear that out
the original ASA study was done in a
population that was 70 percent 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 bet a few
hands would go up and then if I were to
ask how many folks had a parent who
maybe drank too much or who really
believed 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
every day the science is clear early
adversity dramatically affects health
across the lifetime today we are
beginning to understand how to interrupt
the progression from early adversity to
disease and early death and 30 years
from now the child who has a high ace
score and whose behavioral symptoms go
unrecognized whose asthma management is
not connected and who goes on to develop
high blood pressure an early heart
disease or cancer will be just as
anomalous as a six 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
[Applause]