A conversation with... Nadine Burke-Harris, M.D.
Co-founder, Center for Youth Wellness
Summer 2013
Children who suffer physical and emotional abuse are often scarred for life—a fact of which most educators are only too well aware. But the ways those adverse childhood experiences may manifest themselves, and their frequency, are just becoming known.
Researchers and physicians like Nadine Burke-Harris, M.D., a San Francisco-based pediatrician, are studying the link between trauma and disease, and seeing connections that have far-reaching implications for schools.
In 2011, Burke-Harris co-founded the Center for Youth Wellness, which provides a holistic approach to improving the health and well-being of children and youth in the Bayview-Hunters Point neighborhood where poverty and race present particular challenges.
She’s not fond of the expression “failing schools,” as it places the blame for low achievement on an institution that has little control over the stability of a child’s family or its economic condition, known to correlate to student performance. From her vantage point, however, Burke-Harris can see ways that schools can help children cope with stressors in their lives.
For one, look for partnerships with the medical community to support children and their families, she urges, among other strategies she shares in our conversation below. It’s an introduction to what she says is the “need to have a really systematic, systemwide approach for helping all kids.”
What are some common causes of trauma for California schoolchildren?
There are certainly lots of different types of trauma that are experienced by schoolchildren. These adverse childhood experiences include things like physical abuse, emotional abuse, sexual abuse, physical and emotional neglect, parental mental illness, parental substance dependence, parental incarceration, and parental separation or divorce. Those are the adverse childhood experiences criteria, or the ACEs criteria, that we have used and have been tracking in my clinical practice. They’re based on the Adverse Childhood Experiences study (www.cdc.gov/ace) that was done at Kaiser Permanente in San Diego.
How common is it for children to have these experiences? It is a growing issue?
The scope of the issue is huge—it’s massive. It’s a public health crisis. And it’s been a largely unrecognized public health crisis, the link between trauma and health.
Just to give you an example: In that Adverse Childhood Experiences study, they [Kaiser] found that about 67 percent of their population had at least one of these criteria, and 12.6 percent of their population had four or more of these criteria.
In my own research, we did an analysis of the number of kids in our clinical practice that were affected, and we found almost exactly the same numbers. We had about two-thirds who had at least one of these criteria, and we also had 12 percent who had four or more. So that’s a lot.
Now, mark you, my clinic is in a low-income community where we have a much higher proportion of families who are struggling in poverty, a higher proportion of families with a single parent, and usually that’s a single mom. And then there are other things that are not measured by the study, things like community violence, where we have many, many kids affected or touched by community violence, which also will compound the effect.
In our research, if a child had four or more of these adverse childhood experiences, their odds of having learning and behavior problems in school were 32 times as high as a child who had none of these.
Thirty-two times?
It’s 32.6 times, actually. But yes, 32 times as high. So for our kids who had no adverse childhood experiences, no exposure to any of these categories of trauma, very few of them had learning and behavior problems in school—only 3 percent.
That’s important for school leaders or teachers to know.
It’s very, very important for school leaders to know. And for our kids who had four or more of these adverse childhood experiences, 51.2 percent of them had learning and behavior problems in school.
Wow. So what is your strategy for addressing these issues?
I’m a pediatrician, and what we’re doing at the Center for Youth Wellness is we’re starting with universal screening. Then the second step is early and effective intervention. Those include mental health intervention, case management to help that family get the resources that they need to overcome their situation or to prevent that child from being exposed to even more categories of traumatic experiences.
And then the other thing that we have not started yet but we’re hoping to bring online early next year is evidence-based therapies like biofeedback and mindfulness. There’s good evidence that those therapies can help to counter the effects of trauma on the developing brain and body of a child.
You bring up a good point—why are children especially vulnerable to these experiences?
Children are particularly vulnerable because their brains are still developing. So exposure to trauma is particularly toxic for children. In the medical community, the way that trauma affects the brain and body of a child—we call that toxic stress. The reason we call it toxic stress is because it actually creates change. The analogy that I use is, imagine you’re walking in a forest and you see a bear. Your body has a reaction in that moment, and you release lots of hormones, like adrenalin and cortisol, that will help you either fight the bear or run from the bear. That’s called your fight or flight response. And when you have that response, it triggers the release of lots of different stress hormones in the body and other things that, if it happens only once in a while, is really protective. It can save your life. It activates you enough so that you’re able to respond appropriately to the bear.
But if that’s repeated, like in the case of children who are growing up in a household where there’s domestic violence, or children with a parent who has untreated mental illness, or if that bear is waiting for you when you’re getting off the bus every day—all of those chemicals are released, all those stress hormones, and the system becomes disregulated and it becomes health-damaging to the child.
Is that only damaging to a child’s physiology, or can this process cause mental illness as well?
That’s a really great question. What they found in the Adverse Childhood Experiences study is that adults who were exposed to trauma as kids were two-and-a-half times as likely to develop chronic obstructive pulmonary disease—chronic lung disease. About twice as likely to develop heart disease. And almost twice as likely to develop autoimmune disease. We see all these things as health problems.
They were also four-and-a-half times as likely to be depressed, and 12 times as likely to be suicidal. Ten times as likely to be intravenous drug users. And all of those numbers are for someone who has four or more of these adverse childhood experiences as compared to someone who has zero.
Now, the reason why that’s important—when you ask the question, is it just for these physical problems or is for mental health as well—is that stress is toxic to the developing brain of a child. It’s what we call a developmental insult. If a child is exposed to lead while their brain is developing, it affects the long-term development of their brain, right? It’s the same way when a child is exposed to high doses of stress and trauma while their brain is developing, it also affects the long-term development of their brain.
One of the most important parts of the brain that’s affected by stress is typically your prefrontal cortex, which is the part that’s very important for judgment, cognitive function, and learning. Think about it in this way: when you and I have to get up and give a speech in front of a huge audience, that’s a stressful experience. During the first couple minutes you’re stammering a little bit, it’s hard for you to find your words, you’re trying to think clearly but you’re really aware how stressed you are. The reason that happens is because those stress hormones are inhibiting your prefrontal cortex and your ability to think clearly. Literally, that’s what’s going on.
So when that stress is happening all the time with a child, then they can’t think properly in school or anywhere?
That’s right. And so it really has profound effects on learning.
That’s so significant for educators to recognize. But here’s the challenge for school leaders, since they can do little to reach inside the home or eradicate poverty: What can they do to help students who are affected by chronic stress?
There’s so much that schools can do. The first thing is to recognize the impact that exposure to chronic stress and trauma have on kids and their ability to learn. That’s No. 1, is recognition. How every school responds to that may be slightly different.
Some of the best practices can be to incorporate stress-reduction techniques into the school day, particularly if they are a school that is in a community where there’s a high degree of stress involved.
Some of the best practices include things like mindfulness-based stress reduction. There are a number of schools that are using mindfulness-based meditation in class, moments of quiet, helping kids regulate their behavior and kind of settle and land in the classroom so they’re able to focus and pay attention better. A lot of that requires teacher training.
There’s another thing that schools can do. The kids who are most affected tend to have really major behavioral issues, and they tend to be the kids that end up getting kicked out of school. So what that is doing is taking the kids already affected by trauma, and when they have the behavioral manifestation, they’re kicked out of school. So schools can figure out ways to have school discipline that does not involve kicking the kid out of school and is not punitive in a way that adds to the problem.
A number of schools use things like in-school suspensions where, when a child’s behavior is out of control, they’re suspended but they still have to come to school. Then, the school can take advantage of the time they’re in school on suspension to maybe do some work to help them to be able to regulate themselves a little better. Those are some of the best practices that schools can do.
Yes, CSBA has been interested in alternatives to suspension and expulsion as well. So let me ask you a related question: How can school board leaders help publicize the real underlying issues and how the rest of the community can help?
That is a great question. I think that when we look at some of the large studies—and there are now 19 states that are collecting statewide data on adverse childhood experiences—almost all of them have revealed that this is an exceedingly common issue. Among the states that are collecting statewide data, what we’re seeing is typically between 50 to 60 percent of the population have had at least one adverse childhood experience.
So this is all of our issue, whether we’re black or brown—it doesn’t divide along ethnic lines. In fact, the original adverse childhood experiences study was done in a population that was 70 percent Caucasian, 70 percent college educated. The impact is huge in terms of a kid’s ability to sit in class, learn, focus and pay attention. It’s also significant for us to be able to have sufficient use of our resources and for our competitiveness overall as a nation.
Clearly we have to help more children be successful.
Right. It’s such a common problem that we need to have a really systematic, systemwide approach for helping all kids.
We are partners with San Francisco Unified, and we do trainings for staff in what we call the Bayview School Zone in the Bayview-Hunters Point neighborhood, and with SFUSD district staff, about the impact of adverse childhood experiences on the development of kids and their learning. We help provide technical assistance and training for teachers, principals and district staff.
That sounds very helpful. How do you think those types of partnerships could be reproduced around the state?
In just about every county there are existing partnerships between the medical community and the education community. So I would really look for those partnerships.
A lot of schools have wellness centers, and I think they can really play a central role in leading the effort throughout the school or throughout the district. For example, school nurses and other personnel who already exist can take the lead. A lot of it is a matter of training, but we can use existing relationships, existing school personnel, to be able to support our children in a different way.
Thank you for informing us about the impact of adverse childhood experiences on young children.
Thank you for doing this article. I think it’s critically, critically important. And it’s a real emerging issue.
Kristi Garrett (kgarrett@csba.org) is a staff writer for California Schools.
Learn more about helping stressed-out children
“The Relationship of Adverse Childhood Experiences to Adult Health: Turning gold into lead”; Vincent J. Felitta, M.D., Kaiser Permanente Medical Care Program, 2002.
This summary of Adverse Childhood Experiences research establishes a clear link between health problems suffered by some middle-aged, middle-class Americans and the conditions and experiences of their childhood. It provides a good overview of the ACE study and the issues it raises for educators.
“The Adverse Childhood Experiences Study—the Largest Public Health Study You Never Heard Of”; Jane Ellen Stevens, Huffington Post, 2012.
This fascinating, comprehensive overview of the ACE study from the Huffington Post concludes with a summary of Dr. Nadine Burke-Harris’ work.
See also findings from the ACE Study at: