Pondering how best to care for the young patient sitting before her in clinic who was failing to thrive, pediatrician Nadine Burke Harris considered mounds of research linking health disparities with socioeconomic status and race:

If you are poor and African-American or Latino, the statistics show that you are more likely to have asthma or obesity as a child, and get a heart attack or die of cancer as an adult.

But the statistics alone can’t tell you why. My patients taught me the answer. It turns out that there’s a little-known factor damaging long-term health that plays out most profoundly in struggling communities like Bayview yet can affect Americans of any ethnicity, background or income level: toxic stress in childhood.


Dr. Harris says when researchers looked at childhood stress and other social determinants of health and disease, poverty and race were not big factors:

It was a survey of over 17,000 mostly white, college-educated Californians published by the Centers for Disease Control and Prevention and Kaiser Permanente in 1998. The researchers asked respondents about their childhoods and counted up how many “adverse” experiences they had. Did your parents divorce? Did a parent drink too much, take drugs or have a mental illness? Did a caretaker ever hit you or fail to take care of you? Was anyone in your household sent to jail?

The results were astonishing: Nearly two-thirds of the San Diego patients had at least one adverse experience, and 1 in 8 had four or more. More important, there was a strong and direct correlation between the number of adverse childhood experiences and poor health in adulthood — the higher the number of adverse childhood experiences, or ACEs, the higher the risk of disease. People who had four or more ACEs were twice as likely to have heart disease, twice as likely to have cancer, and almost four times as likely to suffer from emphysema or chronic bronchitis. Later research showed that people with six or more ACEs died nearly 20 years earlier than did those with none.

Importantly, research has shown that the number of ACEs has a much stronger association with long-term health outcomes than race or income.


Dr. Harris now screens children for adverse childhood experiences (ACEs) in her San Francisco clinic by using questionnaires for the child (completed by a parent) and teenager (completed by the parent or self-reported by the teen). She explains how chronic stress affects growing children and says that that same vulnerability makes them more responsive to treatment:

Children’s brains and bodies are particularly vulnerable to toxic stress. Because of the brain’s high level of plasticity in early childhood, negative experiences can deeply impact brain development. High levels of stress hormones can lead to changes including loss of brain cells, damage to cell connections, enlargement or shrinking of certain parts of the brain. For this reason, behavior is often the canary in the coal mine: Kids come to my attention with symptoms of poor impulse control or learning and developmental problems. (For kids without behavioral symptoms, the signs are less often recognized.) Chronic stress can also lead to changes in hormonal levels, inflammation in the body and premature cellular aging which can contribute to heart and pulmonary disease including asthma, as well as diabetes and cancer.


Dr. Harris adds up the costs of sweeping toxic stress in childhood under the rug:

This isn’t just a problem for the individuals affected; our nation is paying a profound economic cost for toxic stress. Having an ACE score of 4 or more is associated with elevated relative risk of developing 7 of the 10 leading causes of death in the U.S. And if we pursue policies that aggravate adversity in our communities, instead of investing in programs that support all children and families, we will continue to pay for it downstream. We’ll pay for it in health care costs. We’ll pay for it in lost productivity. We’ll pay for it in reduced competitiveness.


Read the rest of Dr. Nadine Burke Harris’s article “Toxic Childhoods” here.


(Google Images/Keith Negley)