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Subtitles and Transcript 0:11 In the mid-'90s, the CDC and Kaiser Permanente discovered an exposure that dramatically increased the risk for seven out of 10 of the leading causes of death in the United States. In high doses, it affects brain development, the immune system, hormonal systems, and even the way our DNA is read and transcribed. Folks who are exposed in very high doses have triple the lifetime risk of heart disease and lung cancer and a 20-year difference in life expectancy. And yet, doctors today are not trained in routine screening or treatment. Now, the exposure I'm talking about is not a pesticide or a packaging chemical. It's childhood trauma. What kind of trauma am I talking about here? I'm not talking about failing a test or losing a basketball game. I am talking about threats that are so severe or pervasive that they literally get under our skin and change our physiology: things like abuse or neglect, or growing up with a parent who struggles with mental illness or substance dependence. 1:30 Now, for a long time, I viewed these things in the way I was trained to view them, either as a social problem -- refer to social services -- or as a mental health problem -- refer to mental health services. And then something happened to make me rethink my entire approach. When I finished my residency, I wanted to go someplace where I felt really needed, someplace where I could make a difference. So I came to work for California Pacific Medical Center, one of the best private hospitals in Northern California, and together, we opened a clinic in Bayview-Hunters Point, one of the poorest, most underserved neighborhoods in San Francisco. Now, prior to that point, there had been only one pediatrician in all of Bayview to serve more than 10,000 children, so we hung a shingle, and we were able to provide top-quality care regardless of ability to pay. It was so cool. We targeted the typical health disparities: access to care, immunization rates, asthma hospitalization rates, and we hit all of our numbers. We felt very proud of ourselves. 2:44 But then I started noticing a disturbing trend. A lot of kids were being referred to me for ADHD, or Attention Deficit Hyperactivity Disorder, but when I actually did a thorough history and physical, what I found was that for most of my patients, I couldn't make a diagnosis of ADHD. Most of the kids I was seeing had experienced such severe trauma that it felt like something else was going on. Somehow I was missing something important. 3:20 Now, before I did my residency, I did a master's degree in public health, and one of the things that they teach you in public health school is that if you're a doctor and you see 100 kids that all drink from the same well, and 98 of them develop diarrhea, you can go ahead and write that prescription for dose after dose after dose of antibiotics, or you can walk over and say, "What the hell is in this well?" So I began reading everything that I could get my hands on about how exposure to adversity affects the developing brains and bodies of children. 3:58 And then one day, my colleague walked into my office, and he said, "Dr. Burke, have you seen this?" In his hand was a copy of a research study called the Adverse Childhood Experiences Study. That day changed my clinical practice and ultimately my career. 4:23 The Adverse Childhood Experiences Study is something that everybody needs to know about. It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC, and together, they asked 17,500 adults about their history of exposure to what they called "adverse childhood experiences," or ACEs. Those include physical, emotional, or sexual abuse; physical or emotional neglect; parental mental illness, substance dependence, incarceration; parental separation or divorce; or domestic violence. For every yes, you would get a point on your ACE score. And then what they did was they correlated these ACE scores against health outcomes. What they found was striking. Two things: Number one, ACEs are incredibly common. Sixty-seven percent of the population had at least one ACE, and 12.6 percent, one in eight, had four or more ACEs. The second thing that they found was that there was a dose-response relationship between ACEs and health outcomes: the higher your ACE score, the worse your health outcomes. For a person with an ACE score of four or more, their relative risk of chronic obstructive pulmonary disease was two and a half times that of someone with an ACE score of zero. For hepatitis, it was also two and a half times. For depression, it was four and a half times. For suicidality, it was 12 times. A person with an ACE score of seven or more had triple the lifetime risk of lung cancer and three and a half times the risk of ischemic heart disease, the number one killer in the United States of America. 6:30 Well, of course this makes sense. Some people looked at this data and they said, "Come on. You have a rough childhood, you're more likely to drink and smoke and do all these things that are going to ruin your health. This isn't science. This is just bad behavior." 6:49 It turns out this is exactly where the science comes in. We now understand better than we ever have before how exposure to early adversity affects the developing brains and bodies of children. It affects areas like the nucleus accumbens, the pleasure and reward center of the brain that is implicated in substance dependence. It inhibits the prefrontal cortex, which is necessary for impulse control and executive function, a critical area for learning. And on MRI scans, we see measurable differences in the amygdala, the brain's fear response center. So there are real neurologic reasons why folks exposed to high doses of adversity are more likely to engage in high-risk behavior, and that's important to know. 7:43 But it turns out that even if you don't engage in any high-risk behavior, you're still more likely to develop heart disease or cancer. The reason for this has to do with the hypothalamic–pituitary–adrenal axis, the brain's and body's stress response system that governs our fight-or-flight response. How does it work? Well, imagine you're walking in the forest and you see a bear. Immediately, your hypothalamus sends a signal to your pituitary, which sends a signal to your adrenal gland that says, "Release stress hormones! Adrenaline! Cortisol!" And so your heart starts to pound, Your pupils dilate, your airways open up, and you are ready to either fight that bear or run from the bear. And that is wonderful if you're in a forest and there's a bear. (Laughter) But the problem is what happens when the bear comes home every night, and this system is activated over and over and over again, and it goes from being adaptive, or life-saving, to maladaptive, or health-damaging. Children are especially sensitive to this repeated stress activation, because their brains and bodies are just developing. High doses of adversity not only affect brain structure and function, they affect the developing immune system, developing hormonal systems, and even the way our DNA is read and transcribed. 9:31 So for me, this information threw my old training out the window, because when we understand the mechanism of a disease, when we know not only which pathways are disrupted, but how, then as doctors, it is our job to use this science for prevention and treatment. That's what we do. 9:53 So in San Francisco, we created the Center for Youth Wellness to prevent, screen and heal the impacts of ACEs and toxic stress. We started simply with routine screening of every one of our kids at their regular physical, because I know that if my patient has an ACE score of 4, she's two and a half times as likely to develop hepatitis or COPD, she's four and half times as likely to become depressed, and she's 12 times as likely to attempt to take her own life as my patient with zero ACEs. I know that when she's in my exam room. For our patients who do screen positive, we have a multidisciplinary treatment team that works to reduce the dose of adversity and treat symptoms using best practices, including home visits, care coordination, mental health care, nutrition, holistic interventions, and yes, medication when necessary. But we also educate parents about the impacts of ACEs and toxic stress the same way you would for covering electrical outlets, or lead poisoning, and we tailor the care of our asthmatics and our diabetics in a way that recognizes that they may need more aggressive treatment, given the changes to their hormonal and immune systems. 11:16 So the other thing that happens when you understand this science is that you want to shout it from the rooftops, because this isn't just an issue for kids in Bayview. I figured the minute that everybody else heard about this, it would be routine screening, multi-disciplinary treatment teams, and it would be a race to the most effective clinical treatment protocols. Yeah. That did not happen. And that was a huge learning for me. What I had thought of as simply best clinical practice I now understand to be a movement. In the words of Dr. Robert Block, the former President of the American Academy of Pediatrics, "Adverse childhood experiences are the single greatest unaddressed public health threat facing our nation today." And for a lot of people, that's a terrifying prospect. The scope and scale of the problem seems so large that it feels overwhelming to think about how we might approach it. But for me, that's actually where the hopes lies, because when we have the right framework, when we recognize this to be a public health crisis, then we can begin to use the right tool kit to come up with solutions. From tobacco to lead poisoning to HIV/AIDS, the United States actually has quite a strong track record with addressing public health problems, but replicating those successes with ACEs and toxic stress is going to take determination and commitment, and when I look at what our nation's response has been so far, I wonder, why haven't we taken this more seriously? 13:14 You know, at first I thought that we marginalized the issue because it doesn't apply to us. That's an issue for those kids in those neighborhoods. Which is weird, because the data doesn't bear that out. The original ACEs study was done in a population that was 70 percent Caucasian, 70 percent college-educated. But then, the more I talked to folks, I'm beginning to think that maybe I had it completely backwards. If I were to ask how many people in this room grew up with a family member who suffered from mental illness, I bet a few hands would go up. And then if I were to ask how many folks had a parent who maybe drank too much, or who really believed that if you spare the rod, you spoil the child, I bet a few more hands would go up. Even in this room, this is an issue that touches many of us, and I am beginning to believe that we marginalize the issue because it does apply to us. Maybe it's easier to see in other zip codes because we don't want to look at it. We'd rather be sick. 14:33 Fortunately, scientific advances and, frankly, economic realities make that option less viable every day. The science is clear: Early adversity dramatically affects health across a lifetime. Today, we are beginning to understand how to interrupt the progression from early adversity to disease and early death, and 30 years from now, the child who has a high ACE score and whose behavioral symptoms go unrecognized, whose asthma management is not connected, and who goes on to develop high blood pressure and early heart disease or cancer will be just as anomalous as a six-month mortality from HIV/AIDS. People will look at that situation and say, "What the heck happened there?" This is treatable. This is beatable. The single most important thing that we need today is the courage to look this problem in the face and say, this is real and this is all of us. I believe that we are the movement. 15:51 Thank you. 15:53 (Applause)
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Subtitles and Transcript Translated by Anja Kolobarić Reviewed by Ivan Stamenkovic 0:11 Sredinom devedesetih CDC i Kaiser Permanente otkrili su izloženost koja značajno povećava rizik za sedam od deset vodećih uzroka smrti u SAD-u. Visoke razine utječu na razvoj mozga, imunološki i endokrini sustav, pa čak i način na koji se naš DNK čita i prepisuje. Oni koji su izloženi visokim razinama imaju triput veće šanse obolijevanja od bolesti srca i raka pluća i dvadeset godina kraći životni vijek, no suvremeni doktori nisu dovoljno obučeni za rutinske preglede i liječenja. Izloženost o kojoj ovdje govorim nisu pesticidi ili kemikalije, već se radi o traumama iz djetinjstva. 1:05 A o kakvim traumama govorim? Ne mislim na jedinicu iz testa ili poraz na košarkaškoj utakmici. Mislim na prijetnje koje su toliko ozbiljne ili sveobuhvatne da nam se doslovno zavuku pod kožu i promijene nam psihu: stvari poput zlostavljanja, zanemarivanja, odrastanja s roditeljem koji pati od duševne bolesti ili koji je ovisnik. 1:30 E sad, dugo sam promatrala te stvari onako kako su me učili da ih promatram, ili kao društveni problem koji se tiče socijalnih službi - ili kao duševni problem koji se tiče službi za mentalno zdravlje. No onda se dogodilo nešto zbog čega sam preispitala svoj pristup. Kada sam završila sa stažiranjem, htjela sam otići negdje gdje sam mislila da sam zaista potrebna, negdje gdje bih mogla nešto promijeniti, pa sam otišla raditi za CPMC, jednu od najboljih privatnih bolnica u Sjevernoj Kaliforniji i zajedno smo otvorili kliniku u Bayview-Hunters Pontu, jednom od najsiromašnijih, najzanemarenijih kvartova u San Francisku. Prije toga postojao je samo jedan pedijatar u cijelom Bayviewu koji je bio zadužen za više od 10 000 djece, pa smo postavili pločicu i mogli smo pružiti kvalitetnu njegu bez obzira na sposobnost plaćanja. Bilo je jako fora. Bavili smo se tipičnim zdravstvenim nejednakostima: pristup brizi, razine imunizacije, razine hospitalizacije zbog astme i postigli sve naše brojeve. Bili smo jako ponosni na sebe, 2:44 ali onda sam počela primjećivati jedan uznemirujući trend. Mnogo mi je djece bilo poslano zbog sumnje na ADHD, odnosno poremećaja hiperaktivnosti i deficita pažnje, ali nakon što sam obavila detaljan pregled povijesti bolesti i sistematski, otkrila sam da većini pacijenata ne mogu dijagosticirati ADHD. Većina djece koja su mi dolazila doživjela su toliko teške traume da se činilo kao da se nešto drugo događa. Nekako mi je promaklo nešto bitno. 3:20 Prije nego što sam odstažirala, dobila sam diplomu za javno zdravstvo, a jedna od stvari kojima te tamo nauče jest da ukoliko ste doktor i vidite 100 djece koja piju iz istog bunara, a 98 dobije proljev, slobodno možete napisati ispisati recepata i recepata za antibiotike ili možete doći i zapitati: "Što nije u redu s ovim bunarom?" Počela sam čitati sve što sam stigla o tome kako izloženost nedaćama utječe na razvoj mozga i tijela u djece. 3:58 Jednog dana kolega mi je došao u ured i rekao: "Dr. Burke, jeste li vidjeli ovo?" U ruci je držao kopiju istraživanja pod nazivom: "Studija o nepovoljnim iskustvima u djetinjstvu." Taj mi je dan promijenio i kliničku praksu, a i karijeru. 4:23 To je istraživanje nešto s čime svatko treba biti upoznat. Proveo ga je Dr. Vince Felitti na Kaiseru i Dr. Bob Anda na CDC-u. Zajedno su ispitali 17 500 odraslih o njihovoj povijesti izloženosti nečemu što su nazvali "nepovoljna iskustva u djetinjstvu", tj. ACE. Ta iskustva uključuju fizičko, emocionalno i seksualno zlostavljanje; fizičko ili emocionalno zanemarivanje; duševna bolest roditelja, ovisnost, zatvorski staž; odvajanje roditelja ili razvod; nasilje u obitelji. Za svako "da", dobijete bod na ACE-testu. Zatim su usporedili ACE-rezultate i zdravstvene ishode. Saznanja su bila zapanjujuća. Dvije stvari. Prvo, ACE-ovi su jako uobičajeni. Čak 67% populacije imalo je barem jedan ACE, a 12,6%, svaki osmi ispitanik, imao je 6 ili više ACE-ova. Drugo - postoji odnos doza - odgovor između ACE-ova i ishoda zdravlja: što je ACE-rezultat viši, to su gori ishodi zdravlja. Osoba s ACE-rezultatom od četiri pa naviše ima veći relativni rizik od kroničnih respiratornih poremećaja dva i pol puta veći od nekoga s ACE-rezultatom od nula. Za hepatitis također dva i pol puta. Za depresiju četiri i pol puta. Za sklonost samoubojstvu dvanaest puta. Osoba s ACE-rezultatom od sedam pa naviše ima triput veće rizike za obolijevanje od raka pluća i tri i pol puta za obolijevanje od ishemičke bolesti srca, vodećeg uzroka smrti u SAD-u. 6:30 Naravno, to ima smisla. Neki su proučili te rezultate i rekli: "Ma daj! Imao si teško djetinjstvo, pa si skloniji pušenju i opijanju, a sve će ti te stvari uništiti zdravlje. To nije znanost, to je samo loše ponašanje." 6:49 Ispada da znanost upravo tu uskače. Sad bolje nego ikad razumijemo kako izloženost ranim nedaćama utječe na razvoj mozga i tijela u djece. Utječe na područja poput nucleus accumbensa, centra u mozgu zaduženog za užitak i nagradu koji je zahvaćen u ovisnostima. On onemogućuje prednju koru mozga koja je nužna za kontroliranje impulsa te izvršnu funkciju, ključno područje za učenje. Na MR-skeniranju vidljive su mjerljive razlike u amigdali, centru u mozgu zaduženog za reakciju na strah. Pravi neurološki razlozi objašnjavaju zašto su oni koji su izloženi visokim razinama nedaća skloniji visokorizičnim oblicima ponašanja, a to je važno znati. 7:43 No, čak i ako se ne uključite u visokorizična ponašanja, još ste uvijek skloniji obolijevanju od bolesti srca ili od raka. Razlog za to ima veze s hipotalamusom, hipofizom i nadbubrežnom žlijezdom, sustavom reakcije na stres mozga i tijela što upravlja reakcijama za borbu ili bijeg. Kako funkcionira? Zamislite da šetate šumom i ugledate medvjeda. Hipotalamus odmah šalje signal hipofizi koja šalje signal nadbubrežnoj žlijezdi: "Pusti hormone stresa! Adrenalin! Kortizol!" Srce vam počne lupati, zjenice se prošire, zračni putevi otvore i spremni ste ili na borbu s medom ili na bijeg od njega. To je super ako ste u šumi i naletite na medu. (Smijeh) No problem nastaje kad medo dolazi kući svake noći, a ovaj se sustav iznova i iznova aktivira te od prilagodbenog sustava ili sustava za spašavanje života preraste u maladaptivni sustav ili sustav koji ugrožava zdravlje. Djeca su posebno osjetljiva na ovakvu ponovljenu aktivaciju stresa jer im se mozak i tijelo još uvijek razvijaju. Visoke razine nedaća ne utječu samo na strukturu i funkcioniranje mozga već i na razvoj imunološkog i endokrinog sustava, pa čak na način na koji se naš DNK čita i prepisuje. 9:31 Ovi podatci za mene potpuno su obezvrijedili moje dotadašnje znanje jer kad razumijemo mehanizam bolesti, kad znamo ne samo koji su putevi zapriječeni već i kako, onda smo kao doktori dužni iskoristiti tu znanost za prevenciju i liječenje. To je naš posao. 9:53 U San Francisku otvorili smo Centar za zdravlje mladih kako bismo spriječili, uočili i zaliječili utjecaje ACE-a i toksičnog stresa. Počeli smo s rutinskim pregledima svakog djeteta na redovnim sistematskim jer znam da ukoliko moja pacijentica ima ACE-rezultat od 4 i naviše, dva i pol puta je sklonija obolijevanju od hepatitisa ili kroničnih bolesti, četiri i pol puta je sklonija depresiji i dvanaest puta sklonija pokušati oduzeti vlastiti život u usporedbi s pacijentima s rezultatom 0. Znam to dok se nalazi u mojoj ordinaciji. Za pacijente koji ostvare pozitivan rezultat imamo tim multidisciplinarnog tretmana koji pokušava smanjiti razinu nedaća i liječiti simptome koristeći se najboljim postupcima poput kućnih posjeta, njege, brige za duševno zdravlje, prehrane, holističkih zahvata, pa i lijekova kada je to potrebno. Također educiramo roditelje o učincima ACE-a i toksičnog stresa onako kako ih educiramo o prekrivanju utičnica ili trovanju živom, a brigu o astmatičarima i dijabetičarima oblikujemo na način koji ukazuje na to da će im možda trebati agresivniji tretman imajući u vidu njihov endokrini i imunološki sustav. 11:16 Kad shvatite tu znanost, poželite o njoj vikati na sav glas jer to nije problem samo djece u Bayviewu. Pretpostavila sam da će čim svi čuju za to, uslijediti rutinski pregledi, multidisciplinarni timovi za tretiranje te da će se utrkivati do najuspješnijih protokola kliničkih tretmana. Aha, to se nije dogodilo. Puno sam naučila iz toga. Ono što sam smatrala najboljom kliničkom praksom sada smatram pokretom. Riječima dr. Roberta Blocka, bivšeg predsjednika Američke pedijatrijske akademije, "Nepovoljna iskustva u djetinjstvu jedan su od najvećih zanemarenih prijetnji javnom zdravstvu naše nacije." Mnoge ljude to zaprepašćuje. Domet i težina problema čine se toliko veliki da je previše čak i razmišljati o tome kako se s njim suočiti, ali meni baš ta činjenica daje nadu jer kad imamo pravi okvir, kada ovo prepoznamo kao zdravstvenu krizu, tek ćemo onda početi koristiti pravu opremu da dođemo do pravih rješenja. Od nikotina, trovanja živom, pa sve do HIV-a/AIDS-a SAD ima dobar učinak po pitanju bavljenja zdravstvenim pitanjima, ali ponavljanje tih uspjeha s ACE-ovima i toksičnim stresom zahtijevat će odlučnost i predanost, a kada pogledam kako se dosad prema tome odnosila naša nacija, pitam se, zašto to nismo ozbiljnije shvatili? 13:14 U početku sam mislila da smo marginalizirali problem jer nas se ne tiče. Tiče se one djece u onim kvartovima, što je čudno jer podatci to ne pokazuju. Originalno ACE-istraživanje obavljeno je na populaciji od 70% bijelaca, 70% fakultetski obrazovanih ljudi, ali što više razgovaram s ljudima, to više počinjem misliti da sam sve krivo shvatila. Da pitam koliko je ljudi u ovoj prostoriji odraslo uz člana obitelji koji je bolovao od duševne bolesti, kladim se da bi nekoliko podiglo ruke. A da vas pitam koliko vas je imalo roditelja koji je pio ili koji su vjerovali da je "batina u raju izrasla", kladim se da bi još nekoliko podiglo ruke. Čak i u ovoj prostoriji, to je problem koji se tiče mnogih od nas i počinjem vjerovati da marginaliziramo taj problem jer nas se tiče. Možda ga je lakše uočiti drugdje jer mi sami ne želimo gledati u njega. Radije bismo bili bolesni. 14:33 Srećom, napredak znanosti i gospodarske realnosti tu mogućnost čine sve manje održivom. Znanost je jasna; rane nedaće znatno utječu na cjeloživotno zdravlje. Tek sad počinjemo shvaćati kako omesti napredak od rane nedaće do bolesti i preuranjene smrti, a za trideset godina, to dijete s visokim ACE-rezultatom, čiji se bihevioralni simptomi ne primijete, čije se liječenje astme ne povezuje i koji oboli od visokog tlaka, preuranjene bolesti srca ili raka bit će jednako anomalan kao i šestomjesečna smrtnost od HIV-a/AIDS-a. Ljudi promotre situaciju i zapitaju se: "Što se to ovdje događa?" To se može liječiti, može se pobijediti. Najvažnija stvar koja nam je u današnje vrijeme potrebna jest hrabrost da se suočimo s problemom i kažemo da je stvaran i da se tiče svih nas. Vjerujem da smo mi taj pokret. 15:51 Hvala vam.