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  • In the mid-'90s,

  • the CDC and Kaiser Permanente

  • discovered an exposure that 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 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 a 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 underserved 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 when 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 100 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 something that everybody needs to know about.

  • It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC,

  • and together, they asked 17,500 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 ACE 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.

  • Sixty-seven percent of the population had at least one ACE,

  • and 12.6 percent, 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 of 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.

  • Some people looked at this data and they said, "Come on.

  • 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 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 and executive function,

  • a critical area for learning.

  • And on MRI scans,

  • we see measurable differences in the amygdala,

  • the brain's 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 hypothalamicpituitaryadrenal axis,

  • the brain's and body's 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.

  • (Laughter)

  • 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 threw 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 that if my patient has an ACE score of 4,

  • she's two and a half times as likely to develop hepatitis or COPD,

  • she's four and 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 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 impacts 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, multi-disciplinary 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 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 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 hopes 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 marginalized the issue

  • because it doesn't apply to us.

  • That's an issue for those kids in those neighborhoods.

  • Which is weird, because the data doesn't bear that out.

  • The original ACEs study was done in a population

  • that was 70 percent Caucasian,

  • 70 percent 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 am 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 a 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

  • and 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)

In the mid-'90s,

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B1 US TED health adversity childhood score public health

【TED】Nadine Burke Harris: How childhood trauma affects health across a lifetime (How childhood trauma affects health across a lifetime | Nadine Burke Harris)

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    unickname posted on 2015/08/30