How childhood trauma affects health across a lifetime

Summary

In this talk, the speaker elaborates on the profound impact that childhood trauma, or Adverse Childhood Experiences (ACEs), can have on health throughout a person's life. Initially discovered in a collaborative study by the CDC and Kaiser Permanente, ACEs have been found to increase risks for leading causes of death in the United States. These traumatic events can alter brain development, immune systems, and hormones, and even impact DNA transcription, leading to long-term health challenges such as heart disease, depression, and more. Despite the severe consequences, there's a gap in medical training regarding routine screening and treatment for childhood trauma. The talk emphasizes the need for a public health framework to address this issue and a movement to incorporate trauma-informed care into medical practice.

Highlights

• Childhood trauma is as significant as exposure to a severe health hazard. 🌊
• Medical practitioners often overlook the impact of childhood trauma. 🩺
• ACEs significantly relate to major diseases and early mortality. 💔
• Routine trauma screening is crucial in mining community health. 🔍
• Public health strategies can aid in managing and preventing trauma impacts. 🛠️

Key Takeaways

• Childhood trauma can raise the risk for numerous diseases and shorten lifespan. ⏳
• The Adverse Childhood Experiences (ACEs) study reveals high commonality and severe impacts of trauma. 📊
• Trauma affects brain development, hormonal balance, and immune function, altering health long-term. 🧠
• Despite its impact, trauma is under-addressed in routine medical practice. 💉
• Addressing trauma requires a public health approach and systemic change. 🏥

Overview

Childhood trauma, often underestimated, stands as a significant health hazard akin to any other severe exposure, influencing one's entire lifespan. During the mid-90s, a pivotal study by the CDC and Kaiser Permanente unearthed the substantial consequences of such adverse experiences, subsequently terming them as Adverse Childhood Experiences (ACEs). The findings illuminated how trauma could drastically elevate the risks for major illnesses, altering physiological functions deeply.

Despite the overwhelming evidence regarding the detrimental effects of trauma, there's a noticeable absence in routine medical screenings and interventions focused on these experiences. Many practitioners, including those aiming for equity in underserved communities, face surprises when they realize how many health challenges stem from these early adversities. The numerous cases initially attributed to common diagnoses like ADHD often reveal deep underlying trauma impacts when thoroughly investigated.

A broader movement advocating for the integration of trauma-informed practices in health provision is necessary. Public health models have adeptly tackled past challenges such as lead poisoning and HIV/AIDS, and a similar focus and commitment are essential for addressing the profound impacts of childhood trauma. Approaching ACEs as a public health crisis could unlock relevant strategies and interventions to curb long-term consequences and foster a more informed and supportive healthcare system.

Chapters

• 00:00 - 00:30: Introduction to the Discovery In the mid-1990s, the CDC (Centers for Disease Control and Prevention) and Kaiser Permanente made a significant discovery about a particular exposure.
• 00:30 - 01:30: Impact of Childhood Trauma The chapter titled 'Impact of Childhood Trauma' discusses how experiencing trauma during childhood can significantly increase the risk of developing serious health conditions later in life. It highlights that trauma can affect various bodily systems, such as brain development, the immune system, and hormonal systems, as well as influence the way DNA is read and transcribed. The chapter emphasizes that individuals with high levels of trauma exposure have a dramatically increased risk of major diseases, including heart disease and lung cancer, and may experience a reduction in life expectancy by as much as 20 years.
• 01:30 - 02:30: Types of Childhood Trauma This chapter discusses the issue of childhood trauma, emphasizing that today’s doctors are not routinely trained to screen for or treat it. It highlights that the trauma being referred to is not minor setbacks like failing a test or losing a game, but rather severe or pervasive threats impacting children.
• 02:30 - 04:30: Personal Story and Career Shift The chapter discusses the profound impact of personal experiences, such as abuse, neglect, or having a parent with mental illness or substance dependence, on an individual's physiology. Initially, these issues are viewed as social or mental health problems, referable to specialized services. However, a transformative event shifts this perspective, suggesting a deeper understanding is necessary.
• 04:30 - 05:00: Introduction to the ACE Study The chapter introduces the author's journey post-residency and their desire to make a significant impact in a community that truly needs it. This aspiration leads them to join California Pacific Medical Center, a prestigious private hospital, and collaboratively open a clinic in Bayview–Hunters Point, one of San Francisco's most impoverished and underserved areas.
• 05:00 - 07:00: Findings of the ACE Study The chapter titled 'Findings of the ACE Study' discusses the author's experience working as a pediatrician in a community with significant healthcare disparities. Initially, they were proud of improving access to quality care for over 10,000 children, regardless of their ability to pay, and successfully targeting health disparities such as access to care, immunization rates, and asthma hospitalization rates. However, they soon noticed a troubling trend among the children they served, which set the stage for further exploration into the findings of the ACE study.
• 07:00 - 09:30: Neurological Impacts of Trauma The chapter discusses the neurological impacts of trauma, particularly in children who are often misdiagnosed with ADHD when in fact their symptoms are due to severe trauma. The author highlights the importance of thorough history taking and physical examination to differentiate between ADHD and trauma-related symptoms. Many children referred for ADHD evaluation had actually experienced significant trauma, indicating a need for more careful assessment and understanding of trauma's impact on behavior and attention.
• 09:30 - 11:30: Stress Response and Health The chapter discusses a lesson from public health education about addressing the root cause of health problems. It uses the analogy of a doctor treating kids who developed diarrhea after drinking from the same well, emphasizing the importance of investigating the cause instead of just treating symptoms.
• 11:30 - 15:30: Center for Youth Wellness The chapter titled 'Center for Youth Wellness' begins with the author describing their quest for knowledge about the impact of adversity on the development of children's brains and bodies. The narrative unfolds as the author recounts a moment when a colleague introduced them to the 'Adverse Childhood Experiences Study', a research work that likely plays a significant role in understanding the effects of adversity on youth.
• 15:30 - 18:30: Public Health Movement Dr. Vince Feli from Kaiser and Dr. Bob from the CDC conducted the Adverse Childhood Experiences Study. They interviewed 17,500 adults about their exposure to adverse childhood experiences, and the study has significant implications for clinical practice and public health.
• 18:30 - 22:30: Social Perception and Challenges The chapter titled 'Social Perception and Challenges' explores the concept of 'Aces', which stands for Adverse Childhood Experiences. It lists these experiences to include instances such as physical, emotional, or sexual abuse, neglect, exposure to parental mental illness, substance dependence, incarceration, parental separation or divorce, and domestic violence. The chapter discusses how individuals earn a point for each 'yes' answer they acknowledge during an assessment of these experiences, cumulatively forming their 'A' score. The chapter explains the correlation found between these 'A' scores and various health outcomes, a discovery noted as particularly striking and significant, impacting the understanding of social perceptions and challenges linked to childhood adversities.
• 22:30 - 27:00: Hope and Future Directions This chapter discusses the prevalence and impact of Adverse Childhood Experiences (ACEs). It highlights that 67% of the population has experienced at least one ACE, and 12.6% (one in eight individuals) have experienced four or more ACEs. Furthermore, the chapter explains the dose-response relationship between the number of ACEs and health outcomes, indicating that as the number of ACEs increases, the risk for negative health outcomes also rises.

How childhood trauma affects health across a lifetime Transcription

• 00:00 - 00:30 in the mid90s the CDC and Kaiser Permanente discovered an exposure that
• 00:30 - 01:00 dramatically increased the risk for seven out of 10 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 tripled the lifetime risk of heart disease and lung cancer and a 20y year difference in life
• 01:00 - 01:30 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
• 01:30 - 02:00 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
• 02:00 - 02:30 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 bayw Hunter point one of the poorest most underserved neighborhoods in San Francisco now prior to the that
• 02:30 - 03:00 point there had been only one pediatrician in all of bayew 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
• 03:00 - 03:30 being referred to me for ADHD or attention deficit hyperactivity disorder but when I actually did a thorough history in 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
• 03:30 - 04:00 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 developed 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 what the hell is in this well so I
• 04:00 - 04:30 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
• 04:30 - 05:00 changed my clinical practice and ultimately my career the adverse childhood experiences study is something that everybody needs to know about it was done by Dr Vince feli at Kaiser and Dr Bob and 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
• 05:00 - 05:30 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 a scores against Health outcomes what they found was striking two things
• 05:30 - 06:00 number one aces are incredibly common 67% of the population had at least one ace and 12.6% one in8 had four or more Aces the second thing that they found was that there was a dose response relationship between Aces and Health
• 06:00 - 06:30 outcomes the higher your a 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 was two and a half times that of someone with an a 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 a score of seven or more had
• 06:30 - 07:00 triple the lifetime risk of lung cancer and three and a half times the risk of es schic heart disease the number one killer in the United States of America well of course this makes sense you know some people looked 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 these things that are going to ruin your health this isn't science this is just bad
• 07:00 - 07:30 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 accumbent the pleasure and reward center of the brain that is implicated in substance dependence it inhibits the prefrontal core cortex
• 07:30 - 08:00 which is necessary for impulse control and executive function a critical area for Learning and on MRI scans we see measurable differences in the amydala the brain Spar 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
• 08:00 - 08:30 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 ORF flight response how does it work well imagine you're walking in the forest and you see a bear immediately your hypo thamus
• 08:30 - 09:00 sends a signal to your pituitary would send 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 is what happens
• 09:00 - 09:30 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 fect brain structure and function
• 09:30 - 10:00 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
• 10:00 - 10:30 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 that if my patient has an a score of four she's two and a half times as light likely to develop hepatitis or
• 10:30 - 11:00 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 with zero acis I know that when she's in my exam room for our patients who do screen positive we have a multi-disciplinary treatment team that works to reduce the dose of adversity and treat symptoms using best practices including home visits care coordination Mental Health Care
• 11:00 - 11:30 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 system
• 11:30 - 12:00 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 bayew I figured the minute that everybody else heard about this it would be routine screening multidisiplinary 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 as simply best
• 12:00 - 12:30 clinical practice I Now understand to be a movement in the words of Dr Robert block 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
• 12:30 - 13:00 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 toolkit to come up with solutions from tobacco to lead poisoning to H IV AIDS the United States actually has
• 13:00 - 13:30 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
• 13:30 - 14:00 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 Asus study was done in a population that was 70% Caucasian 70% college educated but then the more I talk to folks I'm beginning to think that maybe I had it completely backwards
• 14:00 - 14:30 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
• 14:30 - 15:00 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 is clear early
• 15:00 - 15:30 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 a score and whose behavioral symptoms go unrecognized whose asthma management is not connected and who goes on to develop high blood pressure and early heart
• 15:30 - 16:00 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
• 16:00 - 16:30 us I believe that we are the movement thank you