Nadine Burke Harris is a pediatrician and founder of the Center for Youth Wellness in San Francisco. In 2007, she founded a clinic in one of the poorest neighborhoods in San Francisco, where her work with families helped her identify adverse childhood experiences as a major risk factor affecting long-term health. She is author of The Deepest Well: Healing the Long-Term Effects of Childhood Adversity (Houghton Mifflin/Harcourt Brace, 2018). In 2019, she was named California's first surgeon general.
In The Deepest Well, you describe how working with families at your clinic in San Francisco showed you how deeply childhood trauma affects a person's life outcomes. What have we learned about how early trauma affects life outcomes?
When any of us are exposed to stress or trauma, it activates our biological stress response. When that response is activated once in a while, it's normal. But when that stress response is activated too often, such as when a child lives with frequent trauma, what happens is, during the response, we see release of the hormones adrenaline and cortisol. Those hormones have an effect on the brain, and on our hormonal systems, immune systems, even how our DNA is read and transcribed. If that response is activated too often, it can go from being life-saving to being health-damaging. We see changes to the structure and function of the developing brain, changes to the developing immune and hormonal systems—long-term changes that lead to increased risk of health problems throughout life. There's a tremendous amount of science behind this.
What's important for teachers to understand about working with kids with trauma?
One thing that's really important is how to recognize when a student may be experiencing a toxic stress response. Being an educator is about imparting knowledge and information, but it's also about guidance and mentorship. One challenge of an educator is managing behavior. One thing I saw many times in my medical practice was that kids who were having difficulty with impulse control or self-regulation—some of them truly did have ADHD, but many of the kids I worked with were actually showing symptoms of impaired executive functioning as a result of trauma. Now, an educator might not know that just looking at a child sitting in the classroom. But it's important for teachers to keep that in mind when they're seeing kids having trouble with their behavior and impulse control.
Two things I would say are important: (1) Recognize that behavior may be symptoms of a toxic stress response, and (2) realize that behavior isn't the only symptom of a toxic stress response. Kids who have frequent headaches or tummy aches—especially around certain activities or situations—those may also be signs that a child is dealing with significant adversity that's overwhelming their system.
One role educators can play is helping to create that stable relationship and environment that really is the antidote to the effects of stress on executive functioning and health. Just as the science shows us it's the cumulative adversity that puts kids at greatest risk of negative health and behavior outcomes, similarly, cumulative doses of "buffering"—nurturing, buffering care—literally do the opposite. This buffering helps to release healthy hormones, to calm down the biological stress response and, in fact, interrupt the stress response.
Educators can provide those stable nurturing relationships and environments that we know are healing. That involves moving away from punitive consequences for certain behaviors and more toward interventions that are healing. To be able to do that, it's important that educators are well-supported. They need resources and tools and training to provide those environments for kids who are in their care.
We all have an important role to play in a societal response to ACEs and toxic stress. We don't expect educators to be screening for ACEs. But, as a doctor, I might be the one to screen, but there's no way I am going to be able to deliver the daily doses of nurturing care that will make the difference to a child facing trauma. The educational environment is a place where kids can get that nurturing care on a daily basis.
It's also really important to avoid blaming and shaming. When we engage with students, that's fairly intuitive, but it can be less natural to extend that same avoidance of blaming to parents and caregivers. When we see kids who've experienced ACEs, it's easy to feel angry at the parents. But in my clinical practice, one thing I see is that whatever a child's ACE score is, often their parents' score is higher—almost uniformly. When you recognize that intergenerational cycle, it's easier to see the solution is not to blame and shame parents but to understand how we together can bring the right supports for the family to interrupt that intergenerational cycle. As a pediatrician, I'd say to families, "Listen, we know these things are handed down generation to generation. I'm here to partner with you to break that cycle."
You've said that, as California's first surgeon general, you want to make addressing early toxic stress a priority.
In California, we've started a program called ACEs Aware—a first-in-the-nation effort to train clinicians to screen children and adults for ACEs and respond with trauma-informed care. We've already trained more than 12,000 primary care clinicians in screening for ACEs. We're also creating a program called Network of Care. We know educators are doing so much when it comes to helping kids with trauma—but often what's happening in education isn't coordinated with what's happening in other sectors. That connection is what we're developing now.
Can the COVID-19 pandemic be a traumatic experience for children?
The pandemic is a huge stressor. On top of that, we're seeing increased reports of intimate partner violence, mental health concerns, substance abuse, and similar things among adults. That is increasing the rates of ACEs for kids. The other huge concern is, as we're all staying home, access to that buffering care for kids facing ACEs may be decreasing. That's very concerning. I encourage anyone who's in a child's life—coach, educator, grandparent—to reach out and check in. That's really important as we're back in another uncertain school year—maintaining that connection.
—Naomi Thiers
Editors' note: This interview has been edited for space.
