The Deepest Well: Healing the Long-Term Effects of Childhood Adversity

by Nadine Burke Harris

The body senses danger, and it sets off a firestorm of chemical reactions aimed to protect itself. But most important, the body remembers. The stress-response system is a miraculous result of evolution that enabled our species to survive and thrive into the present. We all have a stress-response system, and it is carefully calibrated and highly individualized by both genetics and early experiences.

What makes the stress response of a child with zero ACEs different from Diego’s stress response is a complicated question that we will begin to unravel, but it all starts with the same system. When it’s in good working order, it can help save your life, but when it’s out of balance, it can shorten it.

Living with the Bear (aka Dysregulated Stress Response) Over and over again in my practice I saw kids who had experienced terrifying situations. For one patient, the bear was his dad who verbally demeaned and physically abused his mom. For another, it was his mom when she didn’t take her psychiatric medications and left the kids uncared for, often in dangerous situations.

Despite the fact that these kids were no longer experiencing

trauma, the parts of their brains responsible for learning and memory were still shrinking, showing us that the effects of earlier stress were still

acting on the neurologic...

Apart from these revelations, the profound discovery was that our patients with four or more ACEs were twice as likely to be overweight or obese and 32.6 times as likely to have been diagnosed with learning and behavioral problems. When our statistician from Stanford first called to tell me how these numbers shook out, I was overwhelmed by a mix of emotions — elation at making an important discovery and a profound aching in my heart for all the kids who were struggling in school but being told that they had ADHD or a “behavior

problem” when these problems were directly correlated with toxic doses of adversity.

Currently, ADHD is a diagnosis based entirely on symptoms. If you remember, the criteria include inattention, impulsiveness, and hyperactivity, but the Diagnostic and Statistical Manual of Mental Disorders doesn’t say a word about the underlying biology. What it does say is that if these same symptoms are associated with a different mental disorder, like schizophrenia, then it’s no longer ADHD. Similarly, if we see impulsivity and hyperactivity but

Part of the problem has been that, unlike ADHD, the diagnosis of toxic

stress doesn’t yet exist in the medical literature.

When the amygdala is repeatedly triggered by chronic stressors, it becomes overactive, and what we see is an exaggerated response to a stimulus like the bear or, as I was beginning to notice in clinic, a nurse with a needle. MRI studies of severely maltreated kids from Romanian orphanages shows dramatic enlargement of their amygdalae. The other thing that happens when the amygdala is chronically or repeatedly activated is that it starts messing up its predictions

about what’s scary and what’s not. The amygdala begins sending false alarms to the other parts of your brain about things that shouldn’t actually be scary, just like the little boy who cried

w...

The dysregulated locus coeruleus releases too much noradrenaline (the brain’s version of adrenaline) and can result in increased anxiety, arousal, and aggression. It can also seriously mess with your sleep-wake cycles by overloading your system with hormones that tell it to remain vigilant because (hello!) a bear is in your cave.

What is so powerful about the follow-up ACE studies like the one Dube did is that they show a strong correlation between autoimmune diseases and exposure to something environmental and specific — childhood adversity.

But the ACE Study also showed that adversity in childhood could lead to health problems decades later. By that time, many

bubbling to the surface once again: How is it that ACEs are handed down so reliably from generation to generation? For many families, it seemed that toxic stress was more consistently transmitted from parent to child

When there is no clear explanation, they make one up; the intersection of trauma and the developmentally appropriate egocentrism of childhood often leads a little kid to think, I made it happen.

We explained that exercising and eating healthfully not only contributed to weight loss but also helped boost the immune system and improve brain function.

We’ve talked about how inflammation is one of the ways a well-regulated immune system fights infection, but as with everything else in the body, balance is critical. Too much inflammation causes all sorts of problems, from digestive issues to cardiovascular complications. Eating

that point, my staff and I had some strong strategies for specifically targeting and healing the dysregulated stress response: sleep, mental health, healthy relationships, exercise, and nutrition. Not surprisingly,

Over and over again the research pointed to one treatment in particular — meditation. Though

From cardiologists to oncologists, doctors have begun incorporating mind training into their clinical treatments.

The parasympathetic nervous system is responsible for things like lowering heart rate and blood pressure, and it directly counters the effects of the stress response.

Given the profound connection between the stress response and the neurological, hormonal, and immune systems, a calmer, healthier mind seemed like a good place to start reversing the effects of toxic stress.

Slowly but surely, we were building our toolkit of clinical interventions to combat the effects of toxic stress. Sleep, mental health, healthy relationships, exercise, nutrition, and

mindfulness — we saw in our patients that these six things were critical for healing.

started my usual spiel, figuring Molly would realize her mistake: “New research has shown that children’s exposure to stressful or traumatic events can lead to increased risk of health and developmental problems, like asthma and learning difficulties.

“Okay, so can we get real here for a minute? It’s obvious why screening every child is a must, but what do you do if you’re an adult and you had ACEs as a kid? Is there treatment for that? Honestly, I am thinking about my husband, Josh, right now.” “Absolutely,” I said. “It’s never too late to start rewiring your stress response.” “The impact of interventions for toxic stress may not be quite as dramatic in adults as it is in our kids, but it still can make a big difference. This might sound simple, but I cannot overstate this: The single most important thing is recognizing what the problem is in the first place.”

step toward healing. I went on to explain that for toxic stress, the six things that I recommend for my patients — sleep, exercise, nutrition, mindfulness, mental health, and healthy relationships — were just as important for adults. Checking in on how you are doing in those six areas and talking to your doctor is a good place to start. If necessary, you can request a referral to a sleep specialist, a nutritionist, or a mental-health provider. The other important piece I mentioned was that adults with high ACEs were at increased risk of health problems, which was why it was important for them to ask their doctors if they

had heard of the ACE Study. A doctor can help you understand how your ACE score and your family history affect your risk for certain illnesses, and then the two of you can work together to create a plan for prevention and early detection. The great news is that there is now a field, called integrative medicine, that is dedicated to looking at the whole person and using the latest science to improve health and well-being. The cool thing about integrative medicine is that it’s interdisciplinary, just like our team at CYW.

There are lots of different ways to combat toxic stress. If you hate yoga and rock climbing, you might be into running or swimming. That’s fine; as long as you’re doing some kind of regular exercise for about an hour a day, that’s what matters. Likewise, there are lots of types of mental-health interventions that work, but the most important thing is to make sure that they are trauma-focused. Ideally, you want to maximize all six...

the general idea is, the more of the six things you do, the more you’ll reduce stress hormones, reduce inflammation, enhance neuroplasticity, and delay cellular aging. “Of course, it’s also a good idea to cut out the stuff that accelerates inflammation and cellular aging, like cigarettes, and to minimize neurotoxins like alcohol,” I said, tapping on my wineglass. “All the fun stuff, is what Josh...

up the intimacy, he might not mind as much,” I said. “Does that fall under the exercise category?” asked Janet. I laughed. “There’s that, but it has more to do with the healthy-relationships piece of things. Sometimes I think folks out there are waiting for a fancy pill to show up and they’re missing the point that we, as humans, have a profound power to heal ourselves and one another....

absence of a buffering caregiver. So think about the flip side of that for us adults. We can damage each other’s health by repeatedly activating the stress response, but we also have the power to heal ourselves and others biologically. Let me give you an example — any of y’all get the drug Pitocin when you were having your babies?” Heads nod. “Well, that same drug, oxytocin, is actually n...

the uterus contract to push out the baby, it’s also this incredibly powerful bonding hormone, so that when your baby comes out, you’ve never seen anything so beautiful in your entire life and you would take a bullet for this little cutie. And oxytocin isn’t released only during childbirth; it’s also released during sex and with hugs and snuggles and healthy relationships. And it buffers the stress response by actually inhibiti...

effects. We literally have the capacity to change our own and one another’s biology. We don’t need to wait for a pill. I honestly believe that, right now, we have some very powerful tools to interrupt the intergenerational cycle of ACEs.” “Do you think your ex-husband had ACEs, Caroline?” asked Kathleen. “Absolutely.” She went on to tell us that Nick grew up in a well-to-do suburb in Conne...

like the Huxtables’ he grew up watching on TV and more like a scene from Whitney Houston and Bobby Brown’s short-lived reality show. Nick’s dad had a pretty significant problem with cocaine and marijuana. Then Nick’s parents divorced when he was ten and he endured a series of stepmoms, each with a progressively escalating coke habit. For the most part, Nick’s dad was able to fly under the radar, functioning as a physician...

stepmoms would get into heated, drug-fueled altercations. Nick always used the same word when he described his dad’s house — crazy. “Oh my goodness. That’s so sad,” I said. “The thing about it that breaks my heart is that we know that most ACEs are handed down from generation to generation. If Nick had figured out that what he experienced was ACEs and that he probably had a dysregulated stress response that ...

“It is ridiculous that everyone does not know this. How do we get people to pay attention to this as something that affects someone they love whether they know it or not?” asked Janet. “That’s what you’re supposed to tell me!” “Well, for starters I think Caroline should call up Time magazine and tell them they’ve got their next cover story,” said Kathleen. After that, ...

was in her own childhood to ideas about how to change the status quo by improving awareness and education around ACEs. The night was a total success, but not necessarily because I had gotten some practical “get the word out” strategies (though I definitely did). The evening showed me the power of the ACEs framework to open a dialogue about topics that feel largely taboo in our society. I knew statistically that ...

ACEs outside of the Bayview clinic until that night. I’ve often remarked, only half joking, that the biggest difference between Bayview and Pacific Heights is that in Bayview, people actually know who the molesting uncle is. And it’s not because the 94115 zip code has a magical force field that excludes anyone who might somehow harm a child or who is experiencing substance dependence or mental illness. Th...

upper-income circles, she responded that she believed it was because the risk to reputations was so high. “We are expected to be perfect. We are supposed to have it all together. The hiding is pervasive because exposure can cost people their careers...

After that dinner, it became clear to me that these hidden ACEs were hindering not only the people experiencing them but also the movement that CYW was trying to catalyze by perpetuating the myth that adversity was a problem for only certain communities.

Caroline’s bravery in sharing her story moved me to my core. ACEs and toxic stress thrive on secrecy and shame, both at the individual level and at the societal level. We can’t treat what we refuse to see. By screening for ACEs, doctors are acknowledging that they exist. By being open about ACEs with friends and family, people are normalizing adversity as a part of the human story and

toxic stress as a part of our biology that we can do something about. Toxic stress is a result of a disruption to the stress response. This is a fundamental biological mechanism, not a money problem or a neighborhood problem or a character problem. That means we can look at one another differently. We can see one another as humans with different experiences that have triggered the same physiological response. We can...

condition. We can see this problem for what it really is, a public-health crisis that is as indiscriminate as influenza or Zika. I closed the door after my last guest left and sat down at the table where we had all been gathered moments before. I realized that something important had just taken place. After years as an unwitting detective in Bayview and Pac Heights and a bunch of places in between, I had final...

inspected all the wells in all the towns and discovered that not only were they deeper than I had ever imagined but, more ...

demonstrating that Alberta was as affected by ACEs as anywhere else. People with high ACEs were (again) shown to be at much higher risk for depression and anxiety and also to have a greater risk of asthma, autoimmune disease, food allergies, cardiac disease, chronic obstructive pulmonary disease (COPD), migraines, fibromyalgia, reflux disease, chronic bronchitis, stomach ulcers — and the list goes on.