The Deepest Well: Healing the Long-Term Effects of Childhood Trauma and Adversity—A Transformative Guide to Understanding Childhood Trauma and Health

by Nadine Burke Harris

The worst part for me was thinking of the men, women, and children struggling with the effects of ACEs and toxic stress, walking around every day without knowing what the problem was and, harder still, not knowing that there were effective treatments. Their doctors don’t tell them because chances are, their doctors don’t know. To anyone looking at the day-to-day practice in the average doctor’s office—or looking anywhere else in society—it was as if the research didn’t exist. The more I knew, the more intolerable it felt to me that almost no one seemed to have this information.

Center for Youth Wellness (CYW) into the world. The Bayview clinic, supported in part by the hospital, would keep doing what it did—regular checkups for kids in the community and ACE screening. Once a patient screened positive for ACEs, the CYW clinical team would provide the multidisciplinary services focused on treating toxic stress—mental health, mindfulness, home visits, nutritional counseling, all the stuff our research told us could make a difference. The research team would track the data, and the advocacy team would get the word out. It was going to be a top-to-tail health-care home for kids and what we hoped would be a model for future organizations.

Guthrie’s true legacy was that he set the precedent for universal screening. It’s something I think about every time I see an ACE score in a patient’s chart. In the same way that babies with PKU aren’t born with any outward signs that they have the genetic disorder, kids don’t come into my office with signs around their necks saying I HAVE TOXIC STRESS. That’s why the universal is just as important as the screening. Time and again, I am reminded of what Guthrie showed the world—that we shouldn’t wait for our kids to come to us with symptoms of neurologic damage when there’s something simple that can be done to prevent it.

We weren’t aware of this at the time, but our approach would later become a best practice known as team-based care. Our patients’ lives didn’t get less complicated, but we found that this new model helped patients get better faster, and it had the added bonus of improving staff morale

I wanted to throw my arms around Lila, hold her tight to my chest, and tell her it would be okay. I wanted to make those seven ACEs disappear like kissing away one of Kingston’s boo-boos. But I couldn’t. And it wasn’t my role. What I could do was make sure that Lila’s ACEs weren’t written into her biology for the rest of her life. In fact, that was my job.

In babies, exposure to ACEs is associated with growth delay, cognitive delay, and sleep disruption. School-age children show higher rates of asthma and poorer response to asthma rescue medication (such as albuterol), greater rates of infection (such as viral infections, ear infections, and pneumonia), and more learning difficulties and behavioral problems, and adolescents exhibit higher rates of obesity, bullying, violence, smoking, teen pregnancy, teen paternity, and other risky behaviors such as early sexual activity.

If it wasn’t for the ACE scores, no one would have suspected that Lila and her brother were at such high risk for so many health and developmental problems. Possibly they might have gotten some attention if they’d started to show behavioral problems in preschool, but even in that case, it’s likely they would have been diagnosed with ADHD and been funneled down the medication path. If they had never manifested any behavioral symptoms, chances are—even if they developed asthma, or an autoimmune disease, or any of the other significant immunological consequences of toxic stress—the underlying problem would likely have gone undetected and untreated. Guthrie had shown that the only way to radically move the needle on patient outcomes is to screen universally, because otherwise you are relying on chance: The chance that Lila’s symptoms would get bad enough that her doctor asked more questions. The chance that this particular doctor had heard about ACEs and knew to ask those questions in the first place. How much damage could be done while you were waiting for the right questions to be asked, the right tests to be run? Guthrie knew. His sister-in-law knew. They saw what happened when PKU was not tested across the board, when the opportunity for early intervention was lost. That is why an ounce of screening is better than a pound of cure.

The prenatal and early childhood periods offer special windows of opportunity because they represent “critical and sensitive periods” of development. A critical period is a time in development when the presence or absence of an experience results in irreversible changes.

A sensitive period is a time when the brain is particularly responsive to a stimulus in the environment, but unlike critical periods, the window doesn’t totally close at the end of the sensitive period; it just gets a lot smaller.

Critical and sensitive periods are times of maximal neuroplasticity (the brain’s ability to rewire or reorganize itself in response to a stimulus). This growing and changing of neurons and synapses can happen in response to injury, exercise, hormones, emotion, learning, and even thinking. Our brains are always changing in response to our experiences, and overall, that’s a good thing.

There are two types of neuroplasticity, cellular and synaptic. Synaptic plasticity is a change in the strength of the connection across the junction from one brain cell to the next (the synapse). It’s kind of like changing your voice from a whisper to a shout. Cellular plasticity, however, is a change in the number of brain cells that are talking to each other, the difference between one person shouting and a whole stadium shouting. While synaptic plasticity is lifelong (it’s how an old dog learns new tricks), cellular plasticity happens most rapidly in the first years of life. About 90 percent occurs by the time a child turns six, but the rest of it stretches out until about age twenty-five.

Babies are born with an oversupply of brain cells and the brain also goes through a pruning process. The brain cells on the circuits you don’t use get pruned, and the ones on the circuits that you do use grow and strengthen. Our experiences, both positive and harmful, determine which brain pathways are activated and continue to strengthen over time. In that sense, early experiences literally shape the brain. We know that early adversity activates the brain pathways that are associated with vigilance, poor impulse control, increased fear, and inhibition of executive functioning. But if we can identify kids who are at high risk for toxic stress early enough, we can intervene in time to take advantage of high levels of both synaptic and cellular plasticity. The most effective way to rewire the brain is to implement early interventions that help to prevent the stress response from becoming dysregulated and that support practices that buffer the stress response (as with child-parent psychotherapy). By doing this, you give the brain the greatest opportunity to grow in new and healthy ways.

hormonal changes occurring in adolescence, pregnancy, and new parenthood open up windows of neuroplasticity that are believed to be additional sensitive periods.

All of these hormones stimulate synaptic plasticity, biochemically enhancing the ability to learn and adapt to one’s environment. These times represent special opportunities for healing, moments when enriching experiences have an even better shot at being “wired in.”

things that you can actually do yourself to boost your synaptic plasticity; sleep, exercise, nutrition, and meditation all enhance the process.

We know that the earlier we start, the more tools we have—young children are the most vulnerable to adversity, but they also have the greatest capacity for healing when the interventions are begun early. And we also know that it’s never too late to use biology to our advantage for healing.

First, the new one was on paper (or a tablet), something that a parent was able to fill out before I came into the exam room. Second (and this was the real innovation), on the new one, we listed the ten ACEs and specifically asked the patient’s parents not to tell us which of them their child had experienced, only how many. At the bottom of the page, the caregiver wrote the total number, and that’s the ACE score. We call this our “de-identified” screen because it doesn’t identify the individual ACEs, and it goes a long way to solving two of the biggest challenges—time (previously, a positive screen took a very long time to unpack) and the sensitive information we’re asking for.

The other important thing that the CYW ACE questionnaire did was go beyond the traditional criteria developed by Felitti and Anda and ask about additional risk factors for toxic stress. We don’t call them ACEs because they are not from the ACE Study and we don’t have the large body of population data to tell us odds of disease, but our experience in Bayview told us that our patients faced other adversities that repeatedly activated their stress-response systems.

Our research team worked actively with the community (youth and adults) to learn what the greatest stressors were in their day-to-day lives. Informed by these insights, we reworked our screening tool to include other factors that we believe may also increase the risk for toxic stress. Community violence Homelessness Discrimination Foster care Bullying Repeated medical procedures or life-threatening illness Death of caregiver Loss of caregiver due to deportation or migration In our teen screener, we also include the following: Verbal or physical violence from a romantic partner Youth incarceration

Researchers are just beginning to look at the supplemental categories on a large scale, but the preliminary data indicates that stressors at the household level (the traditional ACEs) seem to have a greater effect on health than stressors at the community level. This was a surprise to many in the field (myself included), but the data suggests that if a child grows up in a stressful community environment but has a well-supported and healthy caregiver, he or she is much more likely to stay in the tolerable stress zone as opposed to the toxic stress zone.

“Honestly, it sounds like Karl was experiencing toxic stress,” I said. “It makes perfect sense that he did so much better because exactly what you did is the treatment for toxic stress. Number one, reduce the dose of adversity; number two, strengthen the ability of the caregiver to be a healthy buffer. Your getting healthy was actually an incredibly important part of the equation. It’s like when a flight attendant tells you to put your own oxygen mask on before putting it on your child. That’s no joke. Your stress response was dysregulated, which made it impossible to help him regulate his. That’s the mechanism that is so critical to understand. You getting out and taking care of yourself wasn’t selfish—it was the exact right thing to do for Karl.” Caroline nodded. “I’ve noticed that the more I do for myself, the better he copes with things.” “It’s crazy how resilient kids can be when they have a strong buffer,” I said.