Delivery of Care

California looks to lead nation in unraveling childhood trauma

As Rhode Island seeks to ramp up investment in early childhood education, what can be learned from the approach that California is taking, putting a renewed focus on toxic stress?

Illustration by Caitlin Hillyard/KHN illustration, Getty Images, courtesy of Kaiser Health News, reprinted with permission of KHN

Under the leadership of California's new surgeon general, Dr. Nadine Burke Harris, renewed focus has been put on strategies to address toxic stress. The illustration above is entitled: Unraveling ACES.

By Anna Maria Barry-Jester
Posted 3/11/19
Three years ago, an initiative to develop a toolkit in Rhode Island to help pediatricians diagnose toxic stress stalled out when push back from doctors raised concerns about the lack of established protocols for treating childhood trauma. In California, with the appointment of Dr. Nadine Burke Harris as the state’s surgeon general, there is a push to incorporate screening for toxic stress, the same way that some pediatric practices in Rhode Island are now screening for mental health and behavior health symptoms. The question is: can the toxic stress screening toolkit in Rhode Island be revived, following California’s example.
Why is the discussion of toxic stress missing from the forums and discussions that are part of BrainweekRI this week, given the groundbreaking neurosciences research being conducted at Brown? Are there ways to link the work being done with health equity zones in Rhode Island with a better understanding of toxic stress screenings as a community enterprise? What are the ways that neurological damage from lead poisoning and other toxins such as mercury are similar to the damages caused by toxic stress, resulting in epigenetic changes? When will the Hassenfeld Child Health Innovation Institute add toxic stress as a core emphasis? Would the Brown Medical School be willing to invite Dr. Nadine Burke Harris to give a talk about her work as California’s newly appointed surgeon general? What is the connection between the diseases of despair – the high rate of deaths from alcohol, suicide and drugs, particularly in the demographic age group of 25-34 in Rhode Island – and toxic stress, related to economic and family disruption?
In October of 2015, ConvergenceRI sponsored a day-long workshop on toxic stress at Rhode Island College, bringing together neuroscientists, pediatricians, housing experts and community advocates in the hope of shaping a collaborative strategy to address toxic stress. Despite the enthusiastic response to the conversation, what happened next was somewhat predictable: many of the participants went back to their respective silos, perhaps protective of their programs in a time of greater competition for diminishing resources as well as decreases in state funding. In the four years since then, conversations about a collaborative approach to combating toxic stress have all but disappeared from the health and social services radar screen.
Now, as the state wrestles with ways to boost investment in early childhood education, access to daycare, and improved parenting resources, it would seem to be an appropriate time to revisit strategies of how best to implement the toxic stress diagnostic toolkit in Rhode Island.

SAN FRANCISCO, Calif. – Imagine identifying a toxin so potent it could rewire [the brain of a child] and erode his [or her] immune system. A substance that, in high doses, tripled the risk of heart disease and lung cancer and reduced life expectancy by 20 years.

And then realizing that tens of millions of American children had been exposed.

Dr. Nadine Burke Harris, California’s newly appointed surgeon general, will tell you this is not a hypothetical scenario. She is a leading voice in a movement trying to transform our understanding of how the traumatic experiences that affect so many American children can trigger serious physical and mental illness.

The movement draws on decades of research that has found that children who endure sustained stresses in their day-to-day lives – think sexual abuse, emotional neglect, a mother’s mental illness, a father’s alcoholism – undergo biochemical changes to their brains and bodies that can dramatically increase their risk of developing serious health problems, including heart disease, lung cancer, asthma and depression.

“[Nadine] has probably single-handedly done more to elevate this issue than anyone else,” said Dr. Mona Hanna-Attisha, the pediatrician known for documenting the rise in children’s blood lead levels in Flint, Mich., after the city switched its water supply. [Dr. Mona Hanna-Attisha will be speaking in Rhode Island on April 11, as part of the Reading Across Rhode Island program highlighter her new book, What the Eyes Don’t See.]

With Burke Harris’ selection as the state’s first surgeon general, California is poised to become a vanguard for the nation in embracing the research that traces adverse childhood experiences, or ACEs, to the later onset of physical and mental illness.

In pockets across the country, it’s increasingly common for schools and correctional systems to train staff on how academic and behavioral problems can be rooted in childhood trauma. Burke Harris envisions a statewide approach whereby screening for traumatic stress is as routine for pediatricians as screening for hearing or vision, and children with high ACEs scores have access to services that can build resilience and help their young bodies reset and thrive.

As California’s surgeon general, she will have a powerful bully pulpit — and the firm backing of a new administration with deep pockets. In his first weeks in office, newly elected Gov. Gavin Newsom has made clear he intends to devote significant resources to early childhood development.

He has named several recognized experts in child welfare, along with Burke Harris, to top posts, and is promoting child-centric policies that include extended family leave [see link to story below] for new parents, home nursing visits [seek link to story below] for new families and universal preschool [see link to story below]. In his first state budget proposal, released last month, Newsom called out ACEs by name and committed $105 million to boost trauma and developmental screenings for children.

“It should be no surprise to anyone that I’m going to be focusing on ACEs and toxic stress,” Burke Harris said in a phone interview just days into the new job. “I think my selection is a reflection of where that issue fits in the administration’s priorities.”

A game-changing study
Adversity is the sort of thing we intuitively understand, at least to some extent. Having a parent who struggles with addiction or mental illness is hard on kids, as is growing up in a neighborhood marked by poverty, gun violence or drug abuse.

A 1990s study [see link to study below] laid the groundwork, however, for an understanding of adversity that suggests it poses a pervasive threat to public health.

During interviews with patients at a Kaiser Permanente obesity clinic in Southern California, Dr. Vince Felitti was shocked at how many said they had been sexually abused as children. He wondered if the experiences could be connected. [Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.]

As head of the Department of Preventive Medicine at Kaiser Permanente in San Diego, he had access to a huge pool of patients to try to find out. Together with the Centers for Disease Control and Prevention, he surveyed more than 17,000 adult patients about 10 areas of childhood adversity. Among them: Did a parent or other adult in your household physically abuse you? Emotionally abuse you? Sexually abuse you? Go to prison? Was your mother regularly hit? Did you often go hungry? Were your parents divorced? The researchers scored each patient, assigning a point for each yes, and matched up the responses with patients’ medical records.

What they found was striking. Almost two-thirds of participants reported experiencing at least one kind of adversity, and 13 percent – about 1 in 8 – said they had experienced four or more. Those who reported experiencing high doses of trauma as children were far more likely to have serious health problems as adults, including heart disease, stroke, cancer and diabetes. And the higher their ACEs score, the worse their health was likely to be.

This extended to mental health, as well: Adults who reported experiencing four or more ACEs were 4.6 times as likely to have clinical depression and 12 times as likely to have attempted suicide.

In the 20 years since, scientists have built on the research, replicating the findings and digging into the “why.” In the simplest terms, traumatic events trigger surges in cortisol, the “stress” hormone. When those surges go unchecked for sustained periods, they can disrupt a child’s brain development, damage the cardiovascular system and cause chronic inflammation that messes with the body’s immune system.

And where children really get into trouble is when they also are missing the best-known antidote to adversity: a nurturing and trustworthy caregiver. Without that positive stimulation, children can end up with an overdeveloped threat response and a diminished ability to control impulses or make good decisions. Children with high ACEs scores are more likely to develop attention deficit hyperactivity disorder, known as ADHD, and cognitive impairments that can make school a struggle. They are more likely to grow into adults who drink to excess, are violent or are victims of violence.

The research is compelling, because it has the potential to explain so many intractable health problems. What if some portion of Generation ADHS really has PTSD? [see link below to story] What if obesity and hypertension are disorders with roots in childhood experiences, and not just what we eat for dinner?

‘What Happens To You Matters’
Until now, Burke Harris’ professional epicenter has been Bayview-Hunters Point in San Francisco. It’s a vibrant community with a history of activism, but also deeply impoverished, and blighted by pollution and violence. It was there that Burke Harris, at her pediatric clinic, noticed that many of her young patients with serious medical conditions also had experienced profound trauma. And patients who had experienced serious adversity were 32 times more likely to be diagnosed with learning and behavioral problems than kids who had not.

When a colleague introduced her to the ACEs study, she saw her patients written between its lines. Though these problems might be concentrated in Bayview, they certainly weren’t confined there. This was a health crisis transcending race, class and ZIP code.

In the years since, Burke Harris has worked to advance ACEs science though her work at the clinic and her nonprofit research institute, the Center for Youth Wellness. She regularly travels the country to train fellow pediatricians in trauma screening and treatment. She has written an acclaimed book on the issue, “The Deepest Well,” and her TED talk [see link below] on the topic has been viewed nearly 5 million times online.

Now, she’ll be directing her singular focus back on California. She plans to start with a statewide tour to hear from doctors and other health leaders about barriers to increasing pediatric screening and care. She’ll also be talking about the science of ACEs. “It’s Public Health 101 that raising awareness is a critical form of primary prevention,” she said.

But even with the funding included in Newsom’s budget, there are challenges to standardizing trauma screening. For one: In medicine, it’s common practice that you screen only for what you can treat. Many doctors – even those persuaded by research on adversity – have raised concerns about the lack of established protocols for treating childhood trauma. What can a pediatrician, with her 15-minute time slots and extensive to-do list, do about the ills of an absent parent, or a neighborhood riddled with gun violence?

In general, experts working on the issue say a critical ingredient in helping kids heal is ensuring they find and develop healthy relationships.

“All of us want to feel seen, heard, understood and supported,” said Alicia Lieberman, a researcher at the University of California-San Francisco who specializes in early childhood trauma. Involving parents is an essential aspect of treatment, particularly because so many have experienced trauma themselves. “It has to start with an acknowledgment that what happens to you matters.”

Researchers have found early success in seemingly simple interventions: Therapists coaching parents by filming and playing back positive interactions with their child; therapists working with teachers on how to support their students. Key to success, said Pat Levitt, chief scientific officer at Children’s Hospital Los Angeles, are quality programs that start early and recognize the role of relationships.

At her clinic, Burke Harris coordinates with a team that wraps a child in care, treating mind and body. When a patient scores high on the adversity scale, she can send them down the hall to a therapist; connect them with classes on meditation, nutrition and exercise; involve the family in counseling; and aggressively monitor for and treat any physical manifestations.

Most clinics aren’t set up for this staff-intensive approach.

Dr. Andria Ruth, a pediatrician with the Santa Barbara Neighborhood Clinics in California, is among those researching how to “treat” adversity within a more traditional doctor’s office. Her research team is randomly assigning patients who screen positive for trauma into one of three groups. One group is assigned a navigator who connects the family to services for basic needs, such as food and housing. A second group also sees a behavioral health therapist at their child wellness visits. The third group receives both those services, and gets home family visits from therapists.

Ruth has a healthy skepticism about what’s possible, but she and her colleagues are convinced childhood trauma does pose a potent health threat: None of them felt comfortable including a control group that wouldn’t receive any services.

In the big picture, these experts say, addressing the fallout of traumatic stress will require a broader paradigm shift, to a system that recognizes that bad behavior can be a physical symptom rather than a moral failing. Gov. Newsom has signaled a move in that direction: In January, he said he would transfer the Division of Juvenile Justice out of the Department of Corrections, which runs the state’s prison system, and into the Health and Human Services Agency.

Garnering that kind of official backing is a powerful boost, said Jason Gortney, director of innovation at the Children’s Home Society of Washington, that state’s oldest and largest nonprofit dedicated to child welfare. His organization has lots of programs with promising results, he said, but connecting them to state agencies that aren’t used to working together is a challenge.

With Burke Harris crusading from the surgeon general post, Gortney said, he and fellow advocates across the country are hoping California can provide a beacon.

“Maybe California can show some of the other states how to do this,” he said.

This story is reprinted with permission of Kaiser Health News. It was first published on California Healthline, a service of the California Health Care Foundation. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

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