Children who experience trauma tend to have health problems later in life.
Dr. Nadine Burke Harris explains why—and how we can help heal those wounds.
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When Dr. Nadine Burke Harris set up the Bayview Child Health Center in 2007, she immediately noticed an association between traumatic experiences and health outcomes in the children she treated.
“Day after day I saw infants who were listless and had strange rashes,” she writes in her new book, The Deepest Well: Healing the Long-Term Effects of Childhood Trauma. “Kids just entering middle school had depression. And in unique cases…kids weren’t even growing.”
Often, she discovered, these children had suffered “heart-wrenching trauma,” such sexual abuse, violence, or parental mental illness and incarceration. These are what researchers call “adverse childhood experiences”—or ACEs, for short. To understand what she was seeing in her clinic, Dr. Harris searched the scientific literature for evidence about the connection between experience and health—and discovered that the impact of an ACE went well beyond childhood, leading to more physical and mental illness in adulthood.
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We spoke with Dr. Harris about her new book and what we can do to mitigate the impact of adverse childhood experiences.
Jeremy Adam Smith: What is the origin of the term “adverse childhood experience”?
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Nadine Burke Harris: That refers to the 10 categories identified in the landmark 1998 study by Kaiser Permanente and the Centers for Disease Control and Prevention, which include physical, emotional, and sexual abuse; physical and emotional neglect; growing up in a household where a parent was mentally ill, substance-dependent, incarcerated; where there was parental separation or divorce, or domestic violence.
Many of us are familiar with the idea that exposure to trauma in childhood might affect your risk of being depressed or being an alcoholic, and that it might affect your behavior. However, this was the first large epidemiological study to document the association between adverse childhood experiences and heart disease, cancer, chronic lung disease, Alzheimer’s. This is the thing that’s so powerful about the adverse childhood experiences study—it really revealed this connection between childhood adversity and health problems.
JAS: How would an experience affect our health? What’s the mechanism?
NBH: In the two decades since the ACE study was published, we now understand much more about how ACEs affect health.
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When the original study was published, many folks assumed that, “Oh, okay, if you have a rough childhood you’re more likely to drink and smoke and do all the things that are going to ruin your health, so this, of course, makes a lot of sense… but it’s not really anything new. We already know that health-damaging behaviors are bad for your health.”
It turns out that that’s not completely right. When they did the logistic regression analysis—removing the effect of health-damaging behavior—it turns out that behavior only accounts for about half of the risk. The good news is that if you don’t do any health-damaging behaviors, that does reduce your risk—but the bad news is that you still have an increased risk.
We know that the fundamental mechanism is this activation of our body’s fight-or-flight response. When we experience something scary or traumatic, it releases stress hormones in our body like adrenaline and cortisol. These things have really important functions in our body. They raise our blood pressure, they raise our heart rate, they raise our blood sugar.
All of these things are really important and necessary if you are facing a mortal threat, like if you are in a forest and there’s a bear. These changes affect how our brains function. They activate the amygdala, which is the brain’s alarm to tell us when something scary is happening. And that turns down the effectiveness of the part of the brain that’s responsible for impulse control and judgment and executive functioning, which is the prefrontal cortex. When we activate our stress response, it also activates our immune system, because if you are in a forest and there’s bear, you want your immune system to be primed to bring inflammation to stabilize the wound This all was designed to protect our lives and protect our health.
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What happens when that bear comes home every night? When this system is activated over and over and over again? Well, it goes from being adaptive and life-saving to being maladaptive and health-damaging. Children are especially sensitive to high doses of adversity because their brains and bodies are just developing. So adverse childhood experiences are associated with changes in the structure and function of children’s developing brains, in their developing hormonal systems, and even in the way their DNA is read and transcribed.
JAS: Why would this affect adult health? You start the book by telling the story of Evan, who wakes up one morning and suffers a stroke. How could a bad childhood experience lead directly to Evan’s stroke?
NBH: The chronic inflammation piece is really important. That leads to the wear and tear on the lining on the inside of our arteries, which is part of the reason for why we see increased risk of cardiovascular disease. Adverse childhood experiences studies show that the more of these experiences you have, the greater the health risk. So, folks who have had four or more categories of adverse childhood experiences show two-and-a-half times the risk of stroke.
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When our stress response becomes over-activated in childhood, it changes the functioning of the stress response. Without intervention, these changes to levels of stress hormones will be lifelong—and those are the things that lead to increased inflammation and the changes to our cardiovascular system. For example, there are changes to hormones and proteins that our cardiovascular system uses to signal the health and to repair the lining of the inside of our arteries.
JAS: Not everybody who has an ACE will ultimately suffer a stroke. What do we know about people who seem more resistant to the impact of ACEs?
NBH: I hear it all the time: “I know someone who experienced a childhood trauma, and they’re fine.” That’s wonderful. We all know the one dude who smoked two packs of cigarettes a day for years who lived to be a hundred, right? People think of these anecdotal, individual stories and they’re like, “Well, that belies the whole premise.”
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That’s why we like science. That’s why it’s really important that they did this study of 17,500 people and that the study has now been repeated globally. We’ve got data from more than 20 countries around the world, and they all show the same thing: The higher your ACE score, the greater your health risk. Now, does that mean that someone could have a high ACE score and not have heart disease or a stroke or something along those lines? Sure. Does that mean that childhood trauma doesn’t put your health at risk? No.
Some people who smoke will get emphysema and other people will get cancer. Two different people will get two different types of cancer. But we know smoking dramatically increases your risk for all of these different health problems. That gives us really important information about how we can prevent those health problems by reducing the prevalence of smoking.
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JAS: What can physicians and health organizations do to address the impact of ACEs on both kids and adults? What needs to change from what’s currently being done?
NBH: This is a place where I think there’s a lot of good news, because there’s a tremendous amount of low-hanging fruit. Right now, there isn’t that much that we actually are doing, frankly. This is especially true for physicians. One of the most important things that we can do is routine screening, to do early detection and early intervention. All of the science tells us that early intervention improves outcomes.
There is a randomized controlled trial, published in 2015, of kids in institutionalized care—who had been removed from their home—and kids who were placed in homes with high-quality caregiving. They had MRIs at age two and then MRIs at age eight. And at age eight, those kids who had been randomized into high-quality nurturing caregiving, their brain’s structure was different than the kids who remained in institutionalized care. High-quality nurturing caregiving—safe, stable, nurturing relationships—can actually change the structure of children’s brains, and that is why early detection is really important.
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At the Center for Youth Wellness, we have set a goal to get every pediatrician in America to screen for adverse childhood experiences. Despite the fact that this research was published now two decades ago, still, today, only four percent of pediatricians are screening. There’s a lot of room for improvement there, so that we can get to a day when every doctor in America is screening for adverse childhood experiences.
JAS: Let’s say you’re an adult and you have an ACE? What should you do?
NBH: There’s a tremendous amount. On this front, I find this science incredibly hopeful.
One of the most important things an adult can do is just recognize what is going on. So, getting your own ACE score—that is the first step in the right direction. Number two involves figuring out whether you have an overactive stress response—and then understanding what situations activate your stress response.
Next, you have to put into place some of the evidence-based interventions that we know make a difference in toxic stress.
This is what I talk about in my book, The Deepest Well. Things like regular exercise, which helps reduce stress hormones, reduce inflammation, and enhance neuroplasticity. Things like having good sleep hygiene, which is really important for our immune system. Things like mindfulness meditation. One randomized controlled trial of meditation-as-intervention found that patients with chronic heart disease had better performance on an exercise treadmill test after the intervention. All of these kinds of interventions go a long way toward counteracting the biology of toxic stress.
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“I don’t think forgetting about trauma or blaming it is useful. The first step is taking its measure and looking clearly at the impact and risk as neither a tragedy nor a fairy tale but a meaningful reality in between. Once you understand how your body and brain are primed to react in certain situations, you can start to be proactive about how you approach things. You can identify triggers and know how to support yourself and those you love.”
JAS: What are the solutions for us as a society?
NBH: There’s an incredible amount that we can do. There are multiple levels where we can address the impacts of childhood trauma.
There are many schools across the country that are trying to be trauma-sensitive, understanding how to recognize the symptoms of toxic stress, how to differentiate a child having a fear response from one who is just being willful or difficult. There are a lot of kids right now who are being told that they are bad, who are being suspended or expelled, when really the underlying problem is a biological one, with the over-reactivity of their stress response.
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If you’re an employer, you can explore workplace policies that support parents’ ability to support their kids, like predictable work hours. Or employers can create a space for workers to practice self-care, to manage their own stress response. For the most part, mental health treatment is not covered in parity with health care. Many folks may have access to health care through their employer, but many, many people still do not have access to mental health care.
Finally, we need to invest in this work. We don’t receive any public funding at the Center for Youth Wellness. We had to invest public funds in addressing public-health threats, like HIV/AIDS or lead poisoning or tobacco. With HIV, it was the Ryan White Act; that required political will. We need folks to come together to demand greater investment in solutions for this public-health problem.
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Peacemakers, poets, and researchers agree: Forgiveness heals hurts and is good for the forgiver—even the young one.
It’s been more than four decades, but I still can’t forgive what they did to me that summer afternoon. I was 14, strolling in the mall with my two “friends,” Roger and Carson. I had introduced them to each other the week before and now they were jabbering back and forth, leaving me out except to occasionally tease me.
“Hey Hank,” said Roger. “Go in this store and see what the milkshakes cost.”
“We’ll wait here,” said Carson.
Dutifully, I did what my pals suggested. When I returned, they were gone. I looked up and down the pathways, I yelled their names, I waited for them to return. Finally, it dawned on me…I’d been ditched.
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Forty-two years later, Carson died of injuries caused by a motorcycle crash, the bad blood between us unresolved. Roger? I have 4,922 Facebook friends, but he’s not one of them. I delete his every request.
Revenge isn’t so sweet
Vengeance is a powerful emotion; the desire to hurt those who wrong us is a universal trait of human nature, claims Michael E. McCullough, author of Beyond Revenge: The Evolution of the Forgiveness Instinct. But it exacts a toll.
“An eye for an eye only makes the world blind” is an aphorism frequently attributed to Gandhi about what happens when nations battle over long-held grudges. As for holding on to individual hurts, research associates not forgiving with depression, anxiety, and hostility. Multiple studies find a higher rate of compromised immune systems and heart problems in adults who hold grudges. Conversely, children and adults who are able to let go of angry feelings when they’ve been wronged experience greater psychological well-being.
“Bitterness is like cancer,” the poet Maya Angelou told Dave Chappelle in an interview. “It eats upon the host. It doesn’t do anything to the object of its displeasure.”
No hard feelings
Forgiveness has roots as both a spiritual and a secular teaching in Western culture. In the last 40 years, it has become a subject of academic study as researchers have investigated the impact of forgiving—and not forgiving—on the relationships, health, and happiness of those who have suffered a range of traumatic experiences. But despite the evidence that forgiving is good for you, forgiveness has an image problem, which stems, say researchers, from a misunderstanding of what forgiveness is and isn’t.
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According to the American Psychological Association, forgiveness is a voluntary, deliberate change in feeling toward someone who has caused you hurt or harm; it involves letting go of negative emotions toward the offender and results in a decreased desire for retaliation or revenge.
It’s not saying that the offense was okay. Forgiveness is often thought to be a weak response that condones, minimizes, or excuses wrongdoing. These are all misconceptions, says Loren Toussaint, professor of psychology at Luther College and co-editor of Forgiveness and Health: Scientific Evidence and Theories Relating Forgiveness to Better Health.
Forgiveness doesn’t require that the other person apologize. And it doesn’t have to (and sometimes shouldn’t) result in reconciliation. Forgiveness simply means you’re letting go of feelings of resentment and vengeance. You’re refocusing your thoughts on positive emotions; perhaps even feelings of understanding, empathy, and compassion toward the person who hurt you.
“Forgiveness is not making up with a wrongdoer if they are likely to hurt you again,” explains Toussaint. “Forgiveness is about feeling better as a person.”
If your child is hurt by a sibling or a bully, it is critical that the hurt party is protected and the perpetrator is disciplined appropriately. But, assuming the offense is dealt with justly, when a child feels lingering anger and hurt, forgiving is what will help them recover—from that hurt, and maybe others as well.
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A study of six to nine year olds in Belfast conducted by Robert Enright, professor of educational psychology at University of Wisconsin–Madison, found that students who learned to forgive reduced their anger in general toward everyone, not just toward the person who harmed them.
Why forgiveness works for kids
When kids are wronged and don’t forgive, they remain “stuck” in the traumatic situation when they felt victimized. Every time they recall the hurtful event, they re-experience their stress response. If they dwell on their resentment, they continue to release stress chemicals, such as adrenaline, cortisol, and norepinephrine into their brains. This activates the amygdala and other primitive brain regions involved in survival emotions such as fear and rage. The result is an inhibition of the brain’s problem-solving ability, creativity, reasoning, and impulse control.
What happens in the brain when a person forgives is a very different picture. In University of Sheffield research using fMRI scanning, forgiveness exercises helped activate brain regions that feel empathy and make moral judgments. A University of Pisa study found that participants who contemplated forgiveness exhibited activation in five brain regions, indicating an increase in positive emotions, cognitive morality, understanding of the mental states of others, perception, and cognitive control of emotions. Although the research participants were young adults, studies indicate kids’ brains are wired similarly for moral reasoning and empathy.
Children who learn how to forgive also gain an edge academically, and the reason may be as simple as having more energy available to focus on constructive pursuits. Their brains aren’t fuming, recounting the hurt, and plotting revenge; instead, they’ve got a clean slate where they can organize information and think creatively.
A study conducted by Enright found that counseling sessions dedicated to teaching forgiveness had significant academic benefits for at-risk teenagers. Twelve middle school students who had each experienced life-altering hurts were tested before and after a 15-week program in Forgiveness Counseling, with astounding results. The kids showed measured improvement in written English, math, and social studies; in their attitude toward school and their teachers; and in their relationships with their parents and other kids.