Nadine Burke Harris, MD with Kristin Leong: Healing the Long-Term Effects of Childhood Adversity

Transcript by Haley Freedlund

Jini Palmer: (00:03) Welcome to Town Hall Seattle’s Science Series. I’m Jini Palmer. In this episode, renowned pediatrician Nadine Burke Harris discussed the connection between toxic stress during childhood and lifelong illness. She spoke with Town Hall’s Community Programs Curator, Kristen Leone, about her new book, The Deepest Well: Healing The Longterm Effects of Childhood Adversity.

Kristen Leone: (00:30) Thank you, thank you. Welcome Dr. Burke Harris. Welcome to all of you here today. To begin, I would love to see who is in our audience today. Please raise your hand if you are a doctor. Any pediatricians in that group? Excellent, welcome. Raise your hand if you are a social worker. Thank you. Raise your hand if you are mental health professional. Yes. Thank you. Raise your hand if you are a teacher. Raise your hand if you work with children. Raise your hand if you think you might know somebody that has at least one ACE in their life. Well welcome. We’re thrilled to have all of you here today with us. I wanted to begin the event by going through Dr. Burke Harris’s Adverse Childhood Experience questionnaire. And for this, please, you don’t have to raise your hand. And in fact, you should not. But go ahead and you can think for yourself, if this counts as a 1 for you, or you can think of a child that you love, if it counts for a 1 for them. But go ahead and keep a running score in your mind. And that will be your ACE score.

Number one: your child’s parents or guardians were separated or divorced. Number two: your child lived with a household member who served time in jail or prison. Number three: your child lived with a household member who was depressed, mentally ill, or attempted suicide. You saw your child or heard household members hurt or threatened to hurt each other. A household member swore at, insulted, humiliated, or put down your child in a way that scared your child or a household member acted in a way that made your child afraid that he or she may be physically hurt. If someone touched your child’s private parts or asked your child to touch their private parts in a sexual way. More than once your child went without food, clothing, a place to live, or had no one to protect him or her. Someone pushed, grabbed, slapped, or threw something at your child, or your child was hit so hard that your child is injured or had marks. Your child lived with someone who had a problem with drinking or using drugs. Your child often felt unsupported, unloved, and/or unprotected. At any point, since your child was born, your child was in foster care. The child experienced harassment or bullying at school. Your child lived with a parent or guardian who died. Your child was separated from his or her primary caregiver through deportation or immigration. Your child had a serious medical procedure or life-threatening illness. Your child often saw or heard violence in the neighborhood or in his or her school neighborhood. Your child was often treated badly because of race, sexual orientation, place of birth, disability, or religion.

If this room matches the research that Dr. Burke Harris found, 67% of us have at least 1 ACE score, and 1 in 8 of us has 4 or more. It would seem that we’re all drinking from this well. I would love to begin with the title of your book, The Deepest Well: Healing The Longterm Effects of Childhood Adversity. The metaphor of the well runs through the entire book. Can you talk to us more about how you arrived at that title? Did you know that that would be the title from the beginning?

Dr. Nadine Burke Harris: (05:01) So the book actually had a slightly different working title, and initially, the working title was just The Well. And that idea came as a double meaning between The Well as the source of the problem and also The Well in terms of the opportunity for all of us in terms of well being. And ultimately, we ended up going with The Deepest Well because it was really important to communicate how fundamental the issue of childhood adversity is to so many of the fundamental things in our society that we’re all grappling with. And it feels like oftentimes we are each feeling like it almost seems insurmountable, and yet, it’s so critical for us to recognize the source of the problem and begin to tackle the root of the root. And when we do that, it feels like we can be much more effective.

KL: (06:24) The first time I encountered your work was actually a few years ago when I was still a classroom teacher, and the study that is at the core of this book was presented to us. And we were sort of bowled over by the prevalence of early adverse childhood experiences in many of our students’ lives. And we were presented with this data and then left to think about, “These are many of your students. In fact, these are most of your students, if the data translates.” And then we were left to our own devices about what to do with that information. You took that same study and this has been your work. Doing something with that information. What is your hope with this book? What is your hope will come out of this?

NBH: (07:11) So it’s not just my hope. It is my fundamental belief that we can use this science and this information to transform the way our society responds to childhood adversity. And I think a big part of that is, one of our biggest obstacles is simply myth and misinformation. And that is why I wrote The Deepest Well, because we have this kind of intuitive sense, and it’s this false sense that, “Oh, well, sure. Lots of us have been exposed to childhood adversity.” The first myth is like, “This is what happens to those people, right? That doesn’t happen in our neighborhoods.” It’s like, “Um, sorry, the data took care of that. 67% of Americans. Right?” So this is not ‘those people’. I don’t know who ‘those people’ are. The second piece was, “Oh, okay. Sure, everyone’s exposed, but you know, oh well. I had childhood adversity and I pulled myself up by my bootstraps. Look at me. I am whatever I am.” And that’s not what the research shows. What the research shows is that some people will develop behavioral symptoms, but some people will develop heart disease. Some people will have a stroke. Some people will develop asthma, or diabetes. And when you look at, if we’re only counting the people who have behavioral problems, and we’re only saying, “These are the folks that are affected by childhood adversity.” And we’re not counting the rest? Then we are missing this massive opportunity for folks to begin to recognize not only how it’s affecting themselves and their loved ones, but also the fact that we are all drinking from the same well, right?

KL: (09:27) You bring up this idea of “pulling yourself up by your bootstraps.” It’s such an American idea. That combined with the medical community also had some resistance. You said in your book, one physician in the audience after you presented insisted that patient’s stories of abuse or fabrications meant to provide cover for their failed lives. When I hear attitudes like that, combined with this idea that we should all just pull ourselves up from our bootstraps, you’re up against some pretty heavy-duty resistance to this work. Did you know going in that you were going to be facing a lot of pushback to this?

NBH: (10:11) So that comment was originally made to Vince Felitti, who was the original researcher for the Adverse Childhood Experiences study. A funny thing when I first started this work? When I read this research, I figured, “Oh my God, well people just don’t know about it! But the minute I say something, everyone’s going to be like, ‘Yes! Let’s do routine screening! Multidisciplinary care! Let’s do it!'” That did not happen. Crazy thing. And there were some huge headwinds. That’s a big part of the reason why I started the Center for Youth Wellness, this whole concept of all of these myths. The thing about me which, I think, makes me very well suited for this work, is two things. Number 1, I’m hopeful. Number 2, I’m a science geek. So I’m just like, “Okay, we are going to lay out the data. Because this is not something that we just made up. There’s ridiculous amounts of evidence now. And in fact, our team at the Center for Youth Wellness reviewed over 16,000 research articles to pull together a lot of the science that is in this book. Our team worked incredibly hard. At this point, I feel like using that science and that data and making sure that this is an unimpeachable argument, we’re just laying out the facts, is part of beginning to do some of this myth-busting.

KL: (12:09) The arc of your book begins that way. The first half of the book, it does feel undeniable. By a few chapters in, you’re like, “Yes, like this is obviously a problem. And this is obviously a very simple and actionable solution.” You fill us with case studies and statistics and data, and it seems undeniable. What I’m struck by with the power of this book is that you start there, but then it arcs to arrive at that other part of you that is that hopeful, very human, mother and human being. And the impact, I think, of this book, is that it really does combine that science geek side of you with that hopeful, optimistic human side of you. Was that planned from the beginning? Did you outline that out? Did you know that you had to lead with the science? Lead with those statistics?

NBH: (13:09) That’s a great question. It wasn’t that intentional. As a doctor and a researcher, my inclination is always to lead with the science. In fact, there was a way in which that I think, for myself, up until this book, the focus of my work has been putting the science forward. And in the process of writing this book, I’ve really come to this understanding that this is us. This is all of us. And by the time I got to the end of the book, I think I felt more comfortable putting more of myself as a mom and as just a human being into the book. And that felt very vulnerable. At the same time, I think I’m asking every person in this room, every person across this country, to go on this journey with me. And in doing so, I think it was really important to recognize that it’s going to be a personal and difficult and vulnerable journey for all of us. So that’s why I ended up including more of myself in there.

KL: (15:03) At one point you talk about the necessity of bringing in mindfulness into the Center in Bayview, and you were looking for someone to help lead that with your patients. And you said that you didn’t want to have someone named Moonbeam come in and talk about some chakras and bring in some crystals. And I get it. Was there fear with bringing that personal side of yourself into this book? Because your TED Talk is absolutely staggering. It’s so powerful. But what this book has that the TED Talk doesn’t is that personal side of your story. Was there fear for you in writing this, and sharing that side of yourself with not only your readers, but with the medical community?That you would become Moonbeam?

NBH: (15:53) That’s probably part of the reason why I kind of lead with the science, a little bit. Because by the time you get to Moonbeam, you realize I’m not totally – you know, it’s not 100% crystals and chakras. I think when I talk about things like meditation as an important intervention for this work, I also talk about randomized control trials in which one group is randomized into meditation and the other one is randomized simply into health education. And of these patients with heart disease, the patients who are randomized to meditation had better performance on their EKG, had better performance on their cardiac stress tests, and had improved heart functioning. Right? So even when I’m talking about something like meditation, I’m talking about it because that is what the research shows.

KL: (16:56) Indeed. I want to hear a little more about Sister J, which is an incredible story in this book.

NBH: (17:05) For those of you have not read this–

KL: (17:07) She is an amazing character. And when you talk about that, all of us are included. All of us are drinking from this well, this woman is really pushing back very hard against the creation of the Center, which is an interesting criticism, because it’s like she sees you as the enemy, in a way, that’s taking advantage of the children. Right? Which is a different kind of – she doesn’t question the science, she doesn’t–

NBH: (17:41) I don’t think that was actually it.

KL: (17:43) Oh.

NBH: (17:43) So I think Sister J– so for those who haven’t read the book yet. When we were getting ready to start the Center for Youth Wellness in Bayview-Hunters Point in San Francisco, a very underserved neighborhood, there was this tiny pocket of resistance. And it was some fierce resistance. And what’s in the book is an understatement of what happened. I’m just going to say that much.

KL: (18:10) It’s a testament to grassroots activism is what it really is.

NBH: (18:14) It is. But, can I say? It won’t give it away. So one day, one of my team members, right? Because my team is hustling, we gotta get permits for this building, we’re trying to get this up and running. And one of my team members is out in the community. And there is Sister J, passing out flyers. And these flyers, the headline is “STOP THE MASSACRE: Dr. Burke wants to experiment on our children.” I am not joking. I wish that I had kept this flyer just for historic purposes. And it was crazy. I mean, you can imagine for me as a community pediatrician, working in an underserved neighborhood, and especially as a Black woman, as a Black doctor, knowing the history of what the medical community has done in Black communities. And here I am. I’ve dedicated my life to serving this community, to improving the health of our children. And this woman is now taking that historical fear, that historical trauma, and using it against me because she heard that a foundation had raised some money for us to open the Center. And frankly, I think she thought we were deep pockets. And this is a person who has done incredible activism in many positive ways in the community, but any activism she does, some of it ends up in her pocket. And that process was heartbreaking and discouraging. And it’s the type of thing that makes you want to say, “Forget this. I’m going to go work across town. And by the way, I’ll get paid better.” But the lesson that I took from that, that was so powerful to me, that actually redoubled my commitment to this community is, “Oh, this is community trauma. This is trauma happening at the community level.” And I recognized it because I was going to bed at night and I couldn’t sleep. My heart is pounding. I’m thinking, “Oh my God, is this really going to stop this center from being built?” And when I recognize that that endemic community trauma is actually part of the system and the cycle, and that there was a lot that we could do to be part of breaking the cycle in this community, that is what kept me going.

KL: (21:25) That story is also such powerful evidence of the kind of caregiver that you are, because you end up meeting Sister J with empathy. Could you share a little bit about what you realized about her own story?

NBH: (21:38) Well, it’s so funny, right? This is the case, and we almost want to call it ironic, but it’s not ironic. It’s actually causal. This is how it works. So I went to Sister J’s home to sit down with her and hopefully, knowing that we were both advocates for this community that we both love, maybe I could reason with her. Because she had appealed our building permits. As I sat down with her and we had tea in her house, I was at her house for over two hours, I got an almost zero words edgewise. In fact, when I had arrived at her house, she handed me her business card and it said, “Sister J: Community Icon.” Right? I’m not joking. That’s real. That’s what her business card said, ‘Community Icon’. We sat down and she went through, for that two hours, and told me all about her life. And it was one of those – she was like the African American matriarch. You guys can get a picture of what I’m talking about. You sit and you listen. And she spoke and I listened. And as she was talking about her life and how she had grown up in the South and then came to San Francisco and all of her experiences, the thing to me that was so ironic was that by the time she finished just regularly telling me the story of her life? In my mind, I was doing a mental tally, and she had probably eight adverse childhood experiences. And it’s like, “Yeah, this is how this is transmitted. right. And it also helped me understand that that’s a big part of why I was dealing with the resistance that I was dealing with, and how important, again, this healing is on a community wide level.

KL: (24:06) In an ideal world, pediatricians and also teachers would have the time and training to be able to listen like you did with Sister J. To all of the stories of the children that we care for. But of course there’s never enough time and there’s never enough training. And you talk about that frustration and you say that the problem, before there was the questionnaire, doctors had to just rely on asking patients about their history. And the problem with this approach, you say, is that it took a long time. And sometimes that meant that the doctor asking questions had to navigate a serious emotional obstacle course that most primary care clinicians neither have the time or training to navigate thoughtfully. In addition to universal screenings of ACEs, where can we also talk about training of not only primary care doctors, but also teachers, to be learning how to listen to kids? Perhaps similarly to the way that you listened to Sister J with empathy.

I think this is one of the most important things that I want to talk about this evening. Which is that especially given the fact that two thirds of us have experienced adverse childhood experiences, and oftentimes what that does is – so when folks first talked to me about this, when I first started talking about this issue, it was like, “Oh, it’s two thirds of Americans. It’s too big. You can’t solve it, you can’t solve it.” And I was just like, “Hmm. That means two thirds of people know what this feels like. And probably 100% of people have a loved one who this has affected. So actually that’s the cavalry. This is the bench.” But the challenge with that, oftentimes, especially for folks who do know what this experience feels like, we want to rush into the burning building. We want to run in and save folks. And oftentimes if we are not thoughtful about how we do that, it’s really easy for us to get burned out. It’s really easy for us to experience vicarious trauma.

So one of the most important things that I think that we can do? When I talk to doctors, they say, “This is too overwhelming. How are we supposed to respond to this in clinic? We can’t screen everyone. We don’t have the resources. It’s too much to do.” I talked to teachers, “Oh, well, how are we supposed to respond to this? We don’t have the resources. Too much to do.” You know, social workers. “We have–” You know? And for me, it’s just getting clearer and clearer that we don’t each all have to do everything. Doctors have to screen universally because all the science shows that the earlier we identify, the earlier we intervene, the better the outcomes are. The more efficient this work is. The more effective this work is. Educators have a really important role to implement trauma-informed and trauma-sensitive educational environments. And that means training everyone in the child’s educational environment, from the bus driver to the lunch person to the teacher to the principal about what symptoms of toxic stress look like, and being able to create educational environments that are responsive. But often, teachers ask me, “Should we be screening for ACEs in our school?” No, you don’t have to screen. You let us, but let’s divide and conquer. Let’s decide who’s going to screen, okay? Doctors. We want to get kids from the time they’re 0. So we’re going to say, every child-serving medical professional is doing the screening. And we’ll figure out all the protocols, because that’s work. We’re going to have to figure that out. Educators, you figure out what a trauma-informed educational environment, trauma-sensitive and responsive educational environment looks like. Social workers, you figured out your piece. Mental health practitioners, you make sure you guys are the furthest down the field. You’re the ones who’ve been knowing about this and responding to it the longest. And as we each take our piece, whether you’re an employer, and you’re thinking about how to have a family-friendly and family-supportive work environments and policies, whether you’re a policy maker, whether you are a funder and you are part of creating this infrastructure. What’s important right now, as people are waking up to this issue, is making sure that we are creating the right linkages, the right infrastructure, the right systems, for us to be able to work together so that we can create an ecosystem of support for children that changes outcomes. (Audience applause)

KL: (29:20) The screening is so simple.

NBH: (29:32) Yes.

KL: (29:32) And it seems so easy to implement. And part of what makes it so simple and so actionable is that it’s a de-identified screen.

NBH: (29:43) Mhm.

KL: (29:43) And that seems so simple, but it actually blew my mind, coming from an education background, to think that we need to know if this trauma is present in the child’s life in order to move forward. But that doesn’t mean at that moment, we also need to know all of the details and unpack that trauma at that time. And that the first step is knowing the number. Can you talk more about how important it was to realize that the screen had to be de-identified? In other words, we just want the number and that patients didn’t have to explain the specific trauma or which ones that they had a number one next to?

NBH: (30:22) So when people think about innovation in the science of ACEs and toxic stress, oftentimes people are thinking, “Are you going to develop a pill? What are you going to develop?” And people underestimate the importance of process innovation as opposed to product innovation. It’s not necessarily creating a new thing, it’s doing things differently. So when you talked about the doctors who had to go through this really difficult experience in the screening, you know I’m talking about myself, right? It was years when I first read the ACE study. For me, it was critical to be able to do this early identification, but it started out I just asking. And then we, in our center, we were trying to make the process easier and faster. And then we had a paper checklist, and then the next piece was figuring out how we improve on this. And there was actually, I talked to a guy at Hopkins who was a researcher who mentioned that for one of the screens that they did, they actually had a de-identified screen. And I was like, “Oh my goodness” – we’re in the house of the Lord. And so the reason that this de-identified screen is so important is, we don’t ask our patients which ones of the ACEs that they experienced. Only how many. And this is because in order to make sure that every child is screened, the screening has to happen in primary care. If you’re waiting for a child to get to the mental health practitioner, it means that that child is already symptomatic. Which means that the biological process has been going on for long enough that it has changed the child’s biology. So rather than waiting for them to be symptomatic and then reacting to that, how do we get upstream to identify kids who are at high risk to put in the supports and the two-generation work for families to prevent kids from developing toxic stress in the first place?

But in order to be able to do that, you have to have a fast and easy screen. Because my appointments are 15 minutes long. 20, if I’m lucky. And I may have 10 of them in an afternoon. So in order to be able to do, consistently, for every patient, day in day out, at scale, we had to figure out a way that I did not have to unpack this entire history of adversity for each of my patients. And the de-identified screen allows a pediatrician to be able to assess a child’s risk – high, low, moderate, or high risk for toxic stress in three minutes or less – and then connect them to someone who has the expertise, who has the time, who has the capacity, not only to be able to contain that process both for the family, but also for themselves. We’re trying to think about how we thoughtfully design these systems that allow us to be able to do this work at scale in a way that is sustainable. And that is what our team at the Center for Youth Wellness is thinking about day in and day out, every single day, is that our goal is that every pediatrician in America will be screening for adverse childhood experiences. And right now we’re only at 4%. So we have a long way to go, but I believe that we will get there. (Audience applause)

KL: (34:34) Your hope for that comes through loud and clear in the book. But you wait to bring that on, which is like such – you go on a journey in this book. And before you arrive at the hope, it’s so clear that this is such a crisis in the medical world. It’s a crisis in our education world. It’s a crisis, not only for all of our children, but for many of us as well. And it really is so beautiful at the end to feel that hope from you, not only as a doctor, but as a mother, and then ultimately also as a daughter. And then you not only infuse this with optimism, you give us an action plan, which is excellent. And in fact, you outlined six things. So if you’re learning about these phases and you agree that this is a crisis and that we do need universal screenings and that it’s tragic, and yet somehow comforting, perhaps, to find out how common this is, how linked we all are to this, know that there is an action plan. And you lay out six things that we can do. And here are the six things. You say sleep, exercise, nutrition, mindfulness, mental health, and healthy relationships. Which all sounds great, I’m in for that action plan. But for those of us who are busy, perhaps working, or going to school or parenting, or all of the above, is there a priority? Are there a couple of things that we can focus on?

NBH: (36:22) Yeah. The action plan happens in the context of the framing. The action plan and the framing go together. And then I would say the most important thing that we can do is understand that the fundamental problem is an overactive stress response. That’s the biology. And when we list out the six things, those are the six things that we have some of the strongest evidence for that actually mitigate the impacts of toxic stress. So they reduce stress hormones, they reduce inflammation, they enhance neuroplasticity. But one of the most important things about that is doing it in the context of – we know that this is a combination between nature and nurture. There’s individual variability in how our adversity affects us. But recognizing like, “Oh, Hey, wait a minute. Do I have, is it possible that I might have a little bit of an overactive stress response? Let me just take a little pulse check here.” And then, understand what seems to work the most for me. Like for some folks, and I see this with my patients. For some of my kids, the pieces that are really critical are making sure that they get regular exercise, making sure that they’re getting the mental health care, and for kids in particularly, that two generation approach. But for us as adults, I think we kind of know. “When I go for that run and I do it five times a week, I just feel right. I feel better. Or when things are really difficult with my spouse or I’m dealing with all kinds of pressure and I can feel like the stress hormones building up in my body, I know I have that one girlfriend that if I can reach out to her and we got to get together for a cup of tea, that that relationship is healing to me.” It’s those pieces of putting the two together. And when we understand what the problem is, we can begin to individually calibrate what works best for us.

KL: (38:45) Excellent. For our last question, I’d actually like to circle back to the introduction of your book. And you said that as a human being – you’re talking about learning about the prevalence of ACEs in all of our lives. And you said, “As a human being, I was brought to my knees by it. As a scientist and doctor, I got up off those knees and began asking questions.” Your questions have led to such a powerful tool that I agree should be universally implemented. But what would you like to leave us with? If we’re not a pediatrician, if we’re not in a place to implement this questionnaire, what can we do?

NBH: (39:24) Every single one of us is a very important part of the solution. And if there’s one thing that I want to leave folks with, one of the biggest things that we need right now, is we need the public will. Because in order to implement all these things, to put into place all of this infrastructure, the right support for educational environments, the actual funding for, the reimbursement for doctors to be able to screen universally. Right now, all the work that our team is doing, we got to raise money for it. We don’t even get any reimbursement at the Center for doing all this. That’s not going to work. If every doctor in America has to raise the money to do an ACE screen. We need the public will to demand investment in the infrastructure, in the policies and the practices, in the supports for parents, for educators, for judges, for lawyers, for police officers, for doctors, to be able to be part of the solution without having to be wearing themselves out. Throwing themselves up against the same wall over and over again. Because this is long work. And we have to make sure that we can do this in a way that is sustainable for long enough to achieve public health scale change. (Audience applause)

Patron 1: (41:14) Hello. Hello. Hi. Hello. I have a two-part question. My name is Jody Ann. And it’s both around disproportionate uptake of the interventions that you’re talking about. And so the first part is, when you’re talking about really marginalized communities, be it by class, race, et cetera, how do you get this public will and targeting those resources to the communities that actually need them? I mean, everyone needs them. But I’ve worked in some schools in New York where they were really wealthy, have the money, they have the strong PTA to advocate for themselves. They have the mindfulness and the breathing classes and whatever. And I’ve worked in really low-income schools and they don’t have the resources. They don’t have the ability to uptake the things that you’re talking about. And then the second part is, the disproportionate uptake of the action plan, of the interventions. Because often these people in these communities don’t have a really strong ability to access help, exercise, taking time to go for a run or have the right foods or have those healthy relationships. And so I understand what you’re saying, but it’s going to land in different communities differently. And I’m just curious about your thoughts on that.

NBH: (42:49) I think that’s a great question. And I think the crux of the question is, how do we ensure that the science helps to narrow the gap instead of widening it as the communities that have the greatest resources are able to avail themselves of those resources while other communities are left behind. And I think that a big part of that, ultimately, is around how do we ensure that all communities have access to the healing interventions that make a difference for kids? And I think it’s a big challenge that we have to face as we’re moving forward in this question. And one of the big pieces of it is – just one the ways that that I’ve approached it is I believe that with some of our investments in research, in investments in – so let me give an example. HIV AIDS. Initially, folks thought it was a gay men’s disease. And then Ryan White. I don’t know if folks remember, there was a little Caucasian kid by the name of Ryan White who got HIV, and when Ryan White got it, all of a sudden it was very important for all of us to make sure that we had a cure for AIDS. And then folks unified, and the federal government invested huge amounts of dollars in advancing the research into early detection, developing the HIV AIDS test, investing in anti-retrovirals, and HIV AIDS went from a mean mortality of six months, right? 50% of people were dead six months from diagnosis. To now on standard anti-retroviral therapy, the life expectancy is more than 50 years. When folks got that self-interest, when they looked at Ryan White and said, “Oh man, that could be my kid.” Then we poured the money into the resources that lifted everybody up. And now, even though we still still see disparities in outcomes, what we see is that for everyone, the outcomes are far and away just unbelievably better than they were six months ago. And that is what I’m hoping will happen with the science of toxic stress.

Patron 2: (46:06) Hi. I wrote it down. So you’ve talked a bit about the importance of pediatricians and other doctors who work with kids doing universal screening, starting at birth. And I wonder if you could share your thoughts a little bit on including and expanding preventative services to include folks like obstetricians to screen new mothers and talk about their lived experiences and really addressing this intergenerational transmission of trauma.

NBH: (46:32) Amen, my sister. So there are actually in California at Kaiser – Richmond, they actually did a pilot of ACE screening in pregnant moms. And that is, ideally, something that I would absolutely love to see. Because I’m not an OB, our team has been focused on the protocols of doing this in pediatrics. But frankly, to be honest, if we wanted to do better medical care, we’d be doing it in OB. We would be doing it in pediatrics. We would be doing it in adult medicine. We would be doing it across a life course. Because the impacts of ACEs are across the life course.

Patron 3: (47:24) Hi, thank you so much for talking with us. I just want to ask. Where and how do we thoughtfully community design systems that permit ecotherapy and practices that you mentioned such as mindfulness to be accessed by underserved and underrepresented populations that increasingly live in the urban environment? And as a result of things like segregation and redlining, have often lived fragmented from healthy green space and habitats?

NBH: (47:48) Ooh, that’s a great question. So I think that increasingly. So this is why raising national awareness is such a critical part of the solution to this work, because as one of the things that I say in the book is when you understand the fundamental mechanism, when you understand that what folks are exposed to changes their biology in ways that affect our entire society, then you don’t have to be a doctor to be part of the solution. You can be somebody building community housing. You can be part of a housing and urban development. Ben Carson, can you hear me? (laughs) You can be a community-based organization. You can be someone designing green space. And that is the point. Is that when we put this knowledge into every aspect of our society, then it will change the way that we do things in ways that you or I, or the folks in this room, might not ever even imagine. Right? There’s someone out there who is so deep in this work, who are now, everything that they do, is being filtered through this lens. And hopefully those folks are thinking about, “How can I be part of the solution?

Patron 3: (49:37) Thank you.

NBH: (49:37) Sure.

Patron 4: (49:40) Hi, Nadine.

NBH: (49:40) Hi.

Patron 4: (49:40) So unfortunately, I feel like many of us here interact with kiddos in an emergency situation. It’s pretty reflective of our Western culture of medicine where it’s in that crisis management moment. I wanted to ask you for any pointers and like a, “who, what, when, where, how,” like the best ways that we should be implementing ACE questionnaires and obtaining those ACE scores in a crisis management situation, for example, an inpatient adolescent psych unit, where we work.

NBH: (50:14) You know, it’s interesting. I have to say, I’m not totally sure if – well, I do think that it’s important. But I feel like in an inpatient adolescent psych unit, I kind of feel like – don’t you guys have so many more sophisticated tools for assessing and responding to childhood – am I wrong? I’m not a mental health professional. But I–

Patron 4: (50:50) Unfortunately right now, I feel like we’re utilizing ACE scores by throwing darts in the dark. We don’t have that. We don’t have adequate training. In my personal opinion, we’re not asking these questions anonymously. We’re asking these kids straight-out. And so they’re unpacking, on top of coming in in this crisis situation, whether it’s that tried to kill themselves, or they ended up in police custody, whatever. On top of that, we’re sitting down and asking them these questions and they’re unpacking it. I just want to get your perspective on the place of utilizing ACE questionnaires in that setting.

NBH: (51:34) So I’m going to turn it around and throw it right back at you. And this is what I’m going to ask you to do. I’m going to ask you, first of all, to make sure that in your organization, everybody’s got a copy of my book. (laughs)

Patron 4: (51:58) Are you donating any books?

NBH: (51:58) Oh, there’s funders in the room. Funders, did you hear this? They need donated books over here. Right? So what I want to make sure is that everyone in your organization has a copy of my book. And then I want you guys to sit down together and start doing some planned study act. These tests of intervention about what you guys can do differently. Because you know better than I do all of the ins and outs, the details and the intricacies, of what the challenges are in your day to day. And what I would ask you to do is work together with your team to start generating, thinking about solutions, and working together to evaluate them. Maybe there are some funders in the – what’s the name of your organization?

Patron 4: (52:53) I work at Unity Behavioral Health in Portland, Oregon.

NBH: (52:56) Alright. So maybe there are some folks in the room who want to reach out to Unity Behavioral Health to help them go through that process and develop the resources to be able to do this work, so that you guys can feel like you have good systems for solving this problem.

Patron 5: (53:14) Hi, thanks so much for all of your insights so far this evening. I only just got the book and have not read it yet. So I apologize if this is something you’ve addressed already. But I’m curious what your thoughts are on community-driven solutions to toxic stress. I know you mentioned like Sister J earlier, and she may have been beyond convincing. But how do you take leaders like her and bringing this knowledge back to their communities where accessing these professional institutions may be a little bit out of reach? If that makes sense.

NBH: (53:55) Yeah. So at the Center for Youth Wellness, in addition to doing the clinical work and the research, one of the biggest and actually, one of the most important things that we do is this movement building work. And we just started something called the Stress Health Campaign. The Stress Health Public Education Initiative. For anyone who wants information, or who wants to direct parents who can get more information or even to do their own ACE tests, it’s And our initiative – so this is my like secret plan – the book and the TED Talk and all of this stuff is part of what we call the air game. And we’re working on doing a social media campaign to educate folks. But the other piece of it is the ground game. And one of the things that we are in process in working on is pulling together a toolkit for communities. Because we know the power of community, the power of connection, the power of the people leading. And to give folks resources. So what’s going to be included in that toolkit is, “What are the resources for doctors to be able to screen? What are the resources for educators? What are the resources for parents? And a community tool kit to be able to deploy this work. Hopefully at scale at a community level. So coming soon, we’re in process. If we get the funding, so we’ll see. I hope we will. We hope we will.

Patron 6: (55:46) So a child who experiences a traumatic loss or a traumatic event, do you think that if they had such severe toxic stress, that it could actually cause an acute medical event that couldn’t be explained medically? Like not just chronic illness or down the road, but an acute medical event, like a brain bleed or something like that, that can’t be explained by other means?

NBH: (56:17) I think that what we are learning more and more, in the research about toxic stress, is that we’re now beginning to make the connection between early adversity, the toxic stress response, and some of these health outcomes. And, in fact, in the beginning of my book, I talk about an adult in this case who had a stroke. And this acute medical event, this crisis, that he was at dramatically increased risk for, because of his history of adverse childhood experiences. But nobody knew it. He didn’t know it, his doctors didn’t know it. And so they didn’t know to look out for it. And I think that’s a big part of the reason why we need more investment in research.

KL: (57:24) Thank you very much. Thank you to all of you for being here.

NBH: (57:26) Thank you.

JP: (57:37) Thank you for listening to our Town Hall Seattle Science Series. I’m Jini Palmer. Check out our new curated podcast, In The Moment. Steve Scherr will be interviewing an upcoming presenter that you won’t want to miss, and I’ll give you highlights from the past two weeks at Town Hall. Find it on iTunes or your favorite podcast app. A special thanks to our audio engineer Moe Provencher. This song was recorded live and performed by JACK Quartet from our Town Music Series. If you like our Science Series, look for our Civics and Arts & Culture Series as well. For more information, visit our website at

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