Book Review – The Deepest Well by Dr. Nadine Burke Harris

This blog post is about childhood adversity and its connection to bad health outcomes and life outcomes. Adverse Childhood Experiences (ACEs) are common to about 2/3 of people in the U.S. ACEs are not specific to people of color, but we will outline how the ability to manage or mitigate the impact of ACEs may have related equity issues. Our developmental trajectory and physiology are affected in ways that are difficult to grasp and predict when specific kinds of adverse experiences are present in early childhood. The impact is far beyond those relating to behavioral and mental health that we may assume to be present. As the author, Dr. Nadine Burke Harris, puts it, ACEs are a “public health crisis hidden in plain sight.” (pg. 42)

The Context: How did the good doctor come to her conclusions about ACEs?

The insights provided by the author (who is a pediatric doctor) is based on her work in Bayview Hunters Point in San Francisco. It is based on her observation that community conditions in Bayview Hunters Point had an impact on health. The stats for Bayview Hunters Point (at the time that Dr. Harris began her work) showed that the number one cause of death in the community was violence while the number one cause of death in most of the 21 zip codes in the Bay Area was ischemic heart disease (17 zip codes) and HIV/AID (3 zip codes).  Ischemic heart disease is the most common cause of death in the country. Dr. Harris also noted that a child born in Bayview Hunters Point was 2.5 times more likely to develop pneumonia, 6 times more likely to develop asthma and 12 times more likely to develop diabetes compared to a child born in a more affluent zip code.

Dr. Harris noted that in communities like Bayview Hunters Point you don’t just need to address patient-specific needs, but also underlying conditions in the community such as: poor access to healthcare, poor quality of healthcare, poor access to healthy food, etc. In fact, when Dr. Harris opened her clinic’s doors in Bayview Hunters Point, there was only one pediatrician in the area to serve 10,000 children. (pages 8 thru 10)

What are ACEs? What are the health outcomes associated with ACEs?

The term ACES typically refers to a landmark study from 1998 by Vincent, Felitti, et.al, called “Relationship of Child Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences Study.” ACEs, as tracked in the study, include: experiencing verbal, psychological or physical abuse/neglect; experiencing sexual abuse; witnessing domestic violence against a family member; having a parent who had alcohol or drug use problems; having a family member who suffered from depression or who tried to commit suicide; parents being divorced or separated; and/or having a family member who was in prison (pg. 37). The study’s findings were based on an assessment of outcomes for more than 17,000 participants. Here are a few important findings:

• 67% of participants had at least 1 ACE (adverse childhood experience)
• 6% of participants had 4 or more ACEs
• A person with an ACE score of 4 or more was two times (2x) more likely to develop heart disease or cancer compared to a person with an ACE score of zero.
• A person with an ACE score of 4 or more was 3.5 times more likely to develop COPD compared to a person with an ACE score of zero.
• A person with an ACE score of 7 or more was three times (3x) more likely to develop cancer and 3.5 times more likely to have ischemic heart disease.

The over-simplified bottom line of the study: “childhood adversity makes people sick.” (pg. 38)  In addition, child adversity and physical health appear to have a dose response relationship: the higher the ACE score, the greater the risk to people’s health.

The ACE study is now almost 25 years old and there have been many follow-up studies that have all been pretty consistent in their findings. Findings of a study Dr. Harris conducted of patients at her clinic in Bayview Hunters Point include that: 67% had experienced at least 1 ACE; and 12% had experienced 4 or more ACEs, with participants having an ACE score of 4 or more being two times (2x) more likely to be obese and 32.6 times more likely to have been diagnosed with a learning or behavioral problem. (pg. 59)

Findings from other research studies suggest that:

• the life expectance of someone with an ACE score of 6 or more is 20 years less than a person with an ACE score of zero; (pg. 61)
• a person with 4 or more ACEs is 2.5 times more likely to smoke, 5.5 times more likely to be dependent on alcohol and 10 times more likely to use intravenous drugs; (pg. 70)
• a person who has an ACE score of 2 or more has twice the odds of hospitalization due to auto-immune disease compared to someone with an ACE score of zero; (pg. 73) and
• ACEs and high doses of maternal stress relate to premature birth, low birth weight and increased rates of miscarriage. (pg. 105)

What is going on in terms of child development?

It is difficult to imagine that something that happens in early childhood could have such a profound impact so many years down the road. Stress appears to be at the center of what is happening. Adverse experiences may cause an irregularity in the development of the immune response system. Exposure to chronic stress can inhibit the immune system when it needs to be activated (i.e., leading to more illness during childhood) and activate the immune system in ways that are unhealthy (i.e., leading to development of auto-immune diseases). The development of a deregulated immune system in early childhood doesn’t only affect someone in early childhood, it affects them for their entire life.

The body’s response to excess stress can also be maladaptive when it comes to a child’s physical development. It increases production of cortisol which in turn has an impact on production of other hormones that affect growth and development, including brain development. Elevated stress has the effect of decreasing growth hormones, sex hormones, thyroid hormones and insulin. Furthermore, stress depletes our dopamine levels (the energy to the brain that is provided by dopamine is substituted through the production of additional cortisol which serves as an alternative energy source). Fluctuating dopamine and cortisol levels affect how dopamine receptors behave and how we behave (i.e., when dopamine levels go down and cortisol levels go up, we crave things that will make us “feel good” by raising back up the dopamine level). Furthermore, relying on cortisol (instead of dopamine) for energy keeps your brain functioning, but the increased cortisol has been shown to create restlessness (due to increased adrenaline production) and weight gain (because elevated levels of cortisol have been shown to trigger weight gain in the abdominal area).

While these points are disconcerting, our awareness of how ACEs affect child development and health outcomes over time can push us (as individuals and institutions) to make decisions that are better informed. If you identify the process at work that is causing the adverse effect early, then you can also treat it early and, in so doing, produce a more beneficial long-term outcome for the individual.

Dr. Harris’ Case Notes

Dr. Harris shared information about patients that had experienced childhood adversity. One child who was a victim of sexual abuse exhibited slow growth (growth arrest), eczema, ADHD and asthma. The trauma on the child was just one factor. The impact that the knowledge of the abuse had on the parents (the caregivers) created additional stressors (i.e., feelings of guilt causing great stress for mom and alcohol abuse for the dad) that made it difficult for the parents to be as supportive as they might otherwise have been.

Two of Dr. Harris’ patients had weight issues because of sexual abuse. Donna had debilitating diabetes and weight problems. In Dr. Harris’ program, Donna had lost 100 pounds but later gained it all back. Through an examination of Donna’s adverse childhood experiences, clinical staff learned that Donna had experienced sexual abuse before the age of 10. Patty, another patient who had a sleeping/eating disorder (i.e., “sleep eating” triggered by sexual abuse) died at age 42 of pulmonary fibrosis, a disease attacking the lungs. Patty died of this disease even though she didn’t smoke and was not exposed to toxic substances like asbestos. (pages 31 & 32).

The Prescription: Prevent, Screen and Heal (pg. 124)

As Dr. Harris put it, what we have is “a public health crisis in plain sight” and that “we can’t treat what we refuse to see.” This is not an “us or them” proposition. (pg. 171) We are talking about childhood adversity, and that adversity can take many different forms because of the many types of stressors that may be at play. The good news is that regardless of what caused the adversity, the approach to treatment is the same.

Dr. Harris’ suggestion: to screen for ACEs universally. When children are faced with adversity, what they need most is a strong protective buffer. Ensuring early intervention is most likely to lead to establishment of a strong protective buffer for children that face adversity. And what does that protective buffer look like?

FOR CHILDREN FACING ADVERSITY: a strong protective buffer looks like a solid support network and strong loving relationships. Since we may be dealing with a stress response system that is disregulated, then we need to find ways to help children more effectively manage the stressors that they encounter. If we can encourage and support a positive (or tolerable) stress response instead of a toxic stress response (which involves a prolonged activation of the stress response system), then this can help create positive copying mechanisms (long term) and avoid other adverse developmental outcomes. (pages 52 to 55)

FOR ADULTS WITH A HISTORY OF ACES: The good news is that “it’s never too late to rewire your stress response system.” There are, of course, mental health interventions that can be pursued. These should ideally involve trauma-informed practices. Changes in our personal behavior can also help establish a more regulated stress response: more sleep; more exercise; better nutrition; and meditation. More consistency and patience will be necessary for adults since it will take longer for the impact of these changes to “take hold.” While these practices are good for everyone, if you know that you have a high ACE score, then such practices could be essential for ensuring better health outcomes and a longer life.

So, the solutions to this public health crisis are not “rocket science.” However, we must recognize that these supports are more than just “nice things to have” and that adequate financial resources to pursue these solutions are essential.

Relation to Racial Equity

Since this is an equity blog, I did want to note a few linkages between ACEs and race. The analysis gets a bit more abstract and complex (as is usually the case with racial equity because so many of the contributing factors are intersectional in their nature).

Living in poverty (which is much more common for people of color and children of color in Travis County, see http://dashboard.canatx.org/our-basic-needs-are-met/poverty/ ) and living in neighborhoods with “higher concentrations of families living in poverty” present more stressors for families and more challenges in ensuring “a strong protective buffer” for children. Dr. Harris uses the metaphor of one’s home being in a forest in which there is always the fear that a bear attack could occur. But for families living in poverty, they live in a part of the forest that has a greater number of bears (i.e., higher incidence of crime, lack of healthcare, greater unemployment, insufficient food, housing instability, etc.), and sometimes there are bears that actually live in your home with you (i.e., child abuse, domestic abuse, mental illness of a parent/guardian, parents being divorced, parent being incarcerated, parents with substance use disorder, etc.). Dr. Harris shares a great deal about community needs and challenges in the community that her clinic serves, Bayview Hunters Point, and how these underlying conditions should not be ignored in looking for solutions to address the impact of childhood adversity.

That’s a lot of bears (fears and stress) with which to contend, but this doesn’t even include the bear that is “racism” itself. Racism exposes children to direct mistreatment by others (because of their race) but also mistreatment by institutions that are supposed to serve their best interest. If the above-outlined effects of childhood diversity are not factored-in to health and educational assessments and interventions, then the needs of children experiencing adversity will not be served holistically (particularly if some of the underlying issues relating to childhood adversity are not addressed). Furthermore, if institutions know that certain sub-groups within our communities are suffering disproportionately and do not change their approach to addressing the identified problems, then it’s akin to saying “we don’t care enough about your suffering to change how we do things.” That feeling or sense of not being valued as a person is a heavy burden in and of itself.

In Conclusion

To reiterate an earlier comment, the response to ACEs as a public health challenge is not an “us vs them” situation. While it is easy to get caught up in addressing the suffering of a particular group, the fundamental message from Dr. Harris’ book is that ACEs don’t discriminate (like the flu or other viruses). If you have experienced a certain level of child adversity, then the health and life outcomes outlined above apply to you regardless of your race, income, gender, religion, sexuality, etc. As Dr. Harris puts it, “we all share a common enemy, and that common enemy is childhood adversity.” (pg. 195)

Raul Alvarez

CAN Executive Director