The first time I met Anthony,1 it felt like a kick in the stomach—literally. He was sitting on an exam table in my clinic, and as I leaned in close to examine him, he got scared, lost control, and wham! He got me. Anthony’s mother brought him in not just for his rash, but also because she had heard that we had a different way of doing things at the California Pacific Medical Center’s Bayview Child Health Center.
I founded the clinic in 2007 to address health disparities in the Bayview-Hunters Point neighborhood of San Francisco. Bayview is home to thousands of families struggling every day to make ends meet. Many San Franciscans are not even aware that Bayview exists, let alone that it is home to the highest density of children in the city, many of them in women-led households.
Over and over again, I heard stories in the clinic such as the one from Anthony’s mom. Her child had a rash and she was worried about it, but what she was really worried about was his behavior. At age 6, he was struggling to sit still in class and frequently interrupting the teacher. Sometimes he lost control and would hit, kick, or run out of the classroom. She was worried about having to leave work so often to talk to school officials. Her son was a sweet kid, but he had been through a lot. His dad had struggled with sobriety, there had been domestic violence, and his dad was now out of the picture. While his mom was grateful that the drama had ended, she missed having someone to help with Anthony, and every month it was a challenge to make ends meet.
As a physician, I could see that the stress of poverty was affecting my patients in a very direct way, the question was, how? I immersed myself in research on how stress and trauma affect the developing brains and bodies of children. What I found validated the clinical picture that presented itself to me daily, and it transformed my frustration into hope.
The first big insight came when I found the Adverse Childhood Experiences, or ACEs, Study.2 It turned out that I was not the only one making connections between childhood stress and bad health outcomes. Dr. Vincent Felitti at Kaiser San Diego and Dr. Robert Anda at the Centers for Disease Control and Prevention conducted the ACEs study. Together, they completed a survey of more than 17,000 adult patients for what are called “adverse childhood experiences,” including abuse, neglect, exposure to domestic violence, and household dysfunction such as parental substance use, mental illness, incarceration, or divorce. Using the study data, they correlated the number of ACEs against health outcomes. What they found was striking.
First, ACEs are incredibly common. Sixty-seven percent of the study population had experienced at least one ACE, and 12.6 percent had experienced four or more. Second, there was a dose-response relationship between ACEs and health problems later on. That means that the higher the ACEs score, the worse the health outcomes are later in life. A person with four or more ACEs has a relative risk of chronic obstructive pulmonary disease (COPD) that is an astonishing 260 percent of the risk for someone with no ACEs—more than two-and-a-half times the risk. For hepatitis, it was 250 percent of the risk; for depression it was 460 percent. If a patient had seven or more ACEs, their relative risk of ischemic heart disease, the number one killer in the United States, was 360 percent—more than three-and-a-half times the risk of someone who had never undergone adverse childhood experiences.
Since the publication of the original ACEs study in 1998, dozens of studies have corroborated the dose-response effect. Most important, the studies have started to point to a mechanism for how it works, which is where the hope lies. Understanding the mechanism of a biological problem is critical to targeting effective interventions.
Here’s what we know so far. The principal actor in the link between ACEs and disease is the hypothalamic-pituitary-adrenal, or HPA, axis governing the body’s “fight-or-flight” response. That’s the familiar heart-pounding feeling we get when we experience what we perceive to be a sudden threat to our survival. The HPA axis releases a surge of stress hormones, including adrenaline and cortisol, which creates a cascade of chemical reactions in the brain and body. When activated occasionally—say, when someone in the next car suddenly slams on the brakes, or a dog comes from out of nowhere and growls and snaps—this system bypasses our thinking brain, the prefrontal cortex, and activates the primitive reactions that can get us out of the way of a mortal threat.
The problem comes when the system is overtaxed by repeated, intense, or chronic stress. That cascade of chemicals and reactions goes from saving one’s life to damaging one’s health. As it turns out, children are particularly vulnerable to the harmful effects of chronic stress and trauma and the resulting bath of stress hormones, because their young brains, nervous systems, and organs are just developing.
Anthony’s behavior put him at higher likelihood of failure in school and all of the associated social risks. But his high ACE score told me that he was also at higher risk of COPD, heart disease, hepatitis, autoimmune disease, and cancer. Science points to two reasons for this.
First, the effect of trauma on the ventral tegmental area, or VTA, of the brain’s nucleus accumbens—the reward and addiction center—dramatically increases the chance he will engage in high-risk behaviors such as smoking, substance use, and early sexual activity. These behaviors can result in poor health.
But second, and more surprisingly, even if Anthony somehow manages to avoid all of those negative outcomes in his life, the data show that he is still at an increased risk for chronic disease. Why? It turns out that the HPA axis—that brain system squirting out all the fight-or-flight stress chemicals—is also closely involved with the immune system. That means that people exposed to chronic stress in childhood show increased signs of chronic inflammation in adulthood. Chronic inflammation is a driver of such ailments as heart disease and COPD.
So if biology is destiny, what could I do about that in my clinic? As it turns out, quite a bit.
The first step for healing young children exposed to trauma and chronic stress is what we call dyadic or two-generation work. That means looking at the parent and child as a single unit to be treated, then engaging, educating, and empowering caregivers to be buffers between their kids and the stressors they face. Therefore, at our clinic, we provide many single mothers with the appropriate counseling, social connections, and community resources to help them overcome their own challenges for the sake of their kids’ health.
One of the most effective ways of doing this is something called Child-Parent Psychotherapy, or CPP, developed by Dr. Alicia Lieberman at the University of California, San Francisco.3 CPP helps parents address their own often-traumatic histories so that they can establish healthy attachments to their children and break the intergenerational cycle of trauma. Other promising interventions include teaching both mothers and kids practices such as mindfulness—meditation—and biofeedback, which help them with self-regulation so that they can calm the overactive fight-or-flight response. In addition, a healthy diet and regular exercise are key to giving the brain the good hormones necessary to regulate mood and behavior.
I referred Anthony to my colleague at California Pacific Medical Center, Dr. Ruby Ng, who is trained in biofeedback. She hooked him up to electrodes that measured things such as heart rate, breathing, and the hair that stands up on the back of his arms, and then she stressed him out! She gave him tasks that frustrated him, and at the same time, he got the chance to see a screen that showed how his body was reacting to the stress. Then she showed him how to bring the reactions back under control with breathing techniques and other tricks, and he watched his heart rate and other markers calm down on the screen. It was a cool game for a 6-year-old boy. It was HPA axis rehab!
I have continued to follow Anthony over the years, and he is doing so much better that it makes my heart ache for all of my patients who don’t have access to these therapies. Ninety percent of our patients are covered by Medicaid, which doesn’t pay for biofeedback. But seeing such improvement in Anthony and other kids like him has transformed my clinical practice.
Today, I work with the hopeful urgency of a doctor on the frontier of medicine. We recently created the Center for Youth Wellness in San Francisco to pilot and evaluate multidisciplinary interventions that heal the impacts of Adverse Childhood Experiences. One of our goals is to share best practices in ACE treatment with others around the country. We are also working on the policy level to get these therapies reimbursed so that all kids who need them have access to resources that go to the heart of their problems.
All in all, this convergence of basic science, clinical research, and public health is reframing a problem so common that it was hidden in plain sight: Chronic stress and trauma are toxic to our children. We now know the targets to go after—early childhood brain development, HPA axis regulation, and chronic inflammation—and that creates opportunities for intervention. We have an obligation to our kids, to their caregivers, and to our society to advance the standard of practice to meet the state of the science.
This is an excerpt from The Shriver Report: A Woman’s Nation Pushes Back from the Brink, in partnership with the Center for American Progress. Download the full report here for FREE from January 12th – January 15th.
 The patient’s name and identifying details have been changed in the interest of confidentiality.
 The Adverse Childhood Experiences Study, “What is The ACE Study?”, available at http://acestudy.org (last accessed September 2013).
 University of California, San Francisco, “Alicia F. Lieberman, PhD,” available at http://psych.ucsf.edu/faculty.aspx?id=322 (last accessed September 2013).