Dispatches from the Field: Pioneers of Healing and Resilience

“You can’t go and undo ACEs, but you can treat the toxic stress response…We know from research that things like mental health interventions, mindfulness, experiencing nature, and establishing safe, stable, and nurturing relationships and environments help to regulate the biological stress response and improve physical and mental health outcomes.“ – Dr. Nadine Burke Harris

Interview with Dr. Nadine Burke Harris & Dave Ellis

It was a privilege to speak with Dr. Nadine Burke Harris and Dave Ellis about how to engage the medical profession and the community to address and reduce Adverse Childhood Experiences.

Read on for highlights from our enlightening conversation:

You both are in roles that are considered “firsts.” Dr. Burke Harris, you’re California’s first surgeon general and, Dave Ellis, you’re executive director of the new Office of Resilience in New Jersey’s Department of Children and Families. How did these positions come about?

Dr. Nadine Burke Harris: How my role came about is actually a very funny story. I had known Governor Newsom from when he was mayor of San Francisco. He had been really involved in community work, and he came and spoke at the opening of my clinic, the Bayview Child Health Center. From mayor, Newson went on to become lieutenant governor and when he was running for governor, I occasionally sent notes to his team, keeping them updated on what was happening on ACEs. I would explain about the excellent work on ACEs in other states and ask, “What is California doing about ACEs?” Sometimes we think we’re just shouting from the rooftops and we don’t know where it goes, but in this case it led to Governor Newsom issuing an executive order to create the role of state surgeon general. He specifically wanted someone to look at the upstream drivers of some of our biggest health challenges and was looking for a leader who would also take on ACEs and toxic stress. I was more than ready to take on those challenges and it’s been an amazing experience since I started in 2019.

Dave Ellis: Interestingly, New Jersey’s commitment to working on ACEs began with Dr. Burke Harris. After seeing Dr. Burke Harris’ TED talk about ACEs, the Burke Foundation partnered with The Nicholson Foundation and the Turrell Fund to host a dinner to discuss the need to do something here in the state. They felt they were pouring all this money into the community but were still not seeing the changes that they believed needed to happen.

They did some research and identified that 40% of all children in New Jersey have at least one adverse childhood experience. So, in thinking about addressing this, they started going into the communities of those most directly impacted and asking, “What do you think? What would work in the community?” And the community responded. In 2019, when these three funders released their report about ACEs, the community saw that all the things they had raised showed up in this plan. The funders knew they would need someone to oversee implementation of the report’s recommendations. They worked with the New Jersey Department of Children and Families and created this executive on loan position, which I occupy. I’m executive director of the Office of Resilience within the Department of Children and Families. I’m not a state employee, but part of the commissioner’s executive team.

Could both of you give a little bit of background on what ACEs are and why they matter?

NBH:  The term “ACEs” stands for Adverse Childhood Experiences and gets its origin from a landmark study by the Centers for Disease Control and Prevention and Kaiser Permanente in 1998. Over 17,000 adults who participated in the study were asked about their history in 10 categories of adverse childhood experiences: physical, emotional, or sexual abuse, physical or emotional neglect, growing up in a household where a parent is mentally ill, substance-dependent, or incarcerated, where there’s parental separation or divorce, or where there’s intimate partner violence. There were two outcomes that were really groundbreaking. First was that ACEs are incredibly common — two thirds of the population had experienced at least one ACE and one in eight had experienced four or more ACEs.

The second thing they found that was pretty surprising was that ACEs are not only associated with many of the things that we intuitively recognize, like depression or suicidality, substance dependence, or smoking, but that same dose-response relationship was seen for heart disease, stroke, cancer, Alzheimer’s, and autoimmune disease. We’ve learned that there’s a strong relationship between ACEs and nine out of 10 of the leading causes of death in the United States. Since that study was published, we now understand that adversity during that critical period of childhood can lead to something we call the toxic stress response. This is the prolonged activation of the body’s stress response — our fight-or-flight response — and that can cause changes in the way our brains and bodies develop, which can lead to lifelong health risks. We know that prolonged activation of the biological stress response is treatable, so early identification is critical.

DE: With ACEs, I look at it this way: Anything that happens to the body too fast, too often, or too intense for us to move through, we get stuck. That’s my simple definition for this. Then the question is, “how do we deal with the stuck-ness of that?” If you address the mother’s issues way upstream, I believe you can change her situation so she is not under as much stress. I say mothers, but I’m also talking about fathers because we have a tendency when we have these conversations to only talk about mothers and children, but the epigenetics and the conversation tells us that fathers are as deeply involved in this equation as anyone. So, we have to figure out how to lessen the stress load — that dose response that Dr. Burke Harris was talking about. How do we lower that?

Given that ACEs affect a large swath of the population and the strong connection between ACEs and poor health, why do you think ACEs have not become a larger part of the national discourse or figured more prominently in policy discussions?

NBH: Well, it is much more a part of the national discourse today than it was 10 years ago and certainly more than it was 20-plus years ago when the study came out. That’s largely been the result of the work of a lot of people around the country and around the world who have been percolating up models of solutions. That’s important because when the issue really comes to greater attention in government there are models that can be scaled. We see  a lot of work happening at the community level. Some pioneering states like New Jersey and California are really starting to do a deep dive on the statewide level. I think that, as we show proof of concept at the state level, then next in line will be a national initiative.

People wonder how I got California to invest $150 million in an ACEs initiative. We were able to show that the cost to the state of California [from negative health outcomes] annually exceeds $112 billion and we had a plan to reduce that cost. We realized the only way a state will invest that amount of money is when they can see that interventions will lead to improvements.

DE: I remember the first time I heard this information about ACEs at a conference. That was the first day I realized I wasn’t crazy because I finally had answers to some of the things I’d been struggling with my entire life. I believe the dialogue on ACEs starts with community. The solutions come from the people most directly impacted, who live with this every day. Community work is messy and it takes time and it takes intention. You can’t just go into a community with the, “Hi, I’m from the government, and I’m here to help you,” approach. We’ve tried that and it didn’t really work. There is this space and place that says the answers are with the people out there and how do we engage with them in a way that allows them to actually lead us. Then we can do the job we’re supposed to do, which is to put the resources behind their solutions to bring them to scale.

Dr. Burke Harris, you are one of the pioneers on ACEs screening, and are part of the team that designed the first-of-its-kind ACEs screening tool. Can you tell us more about this tool and its importance, and can you both address some of the criticisms that have come up related to screening people for ACEs?

NBH: Let me start by talking about where screening sits in the context of an ecological response to ACEs. With ACEs, there has to be an emphasis on prevention, early detection, and effective and evidence-based intervention. When I’m talking about screening — the early detection piece — I’m talking about using the Wilson and Jungner criteria of screening to detect asymptomatic individuals. That’s its purpose. So, if someone is interested in mental health symptomatology, they might say, “Okay, well, there are better screening tools for mental health symptomatology [than the ACEs screening tool].” But their screening tools don’t detect asymptomatic individuals because if you have mental health symptomatology, by definition you’re symptomatic.

But the research tells us there is this progression from exposure to adversity and development of the toxic stress response that unfurls into symptomatology. Identifying symptomatic individuals is not the goal. The goal is identifying those at risk. And all the research says the earlier you intervene you actually have the possibility of interrupting that process. I also want to point out that an ACEs screen consists of three things: An ACE score, the assessment of symptomatology of toxic stress, and also an assessment of protective factors, which leads to our understanding of how we can become more effective at delivering interventions.

Another question people ask about screening is, “what’s the point of screening when we can’t intervene? These ACEs already happened in the past, so it’s futile.” You can’t go and undo ACEs, but you can treat the toxic stress response. That’s very straightforward biology. We know from research that things like mental health interventions, mindfulness, experiencing nature, and establishing safe, stable, and nurturing relationships and environments help to regulate the biological stress response, improve physical and mental health outcomes, and even are associated with improved epigenetic regulation.

Whenever we hear criticisms of our screening process, I always ask, “what is your recommendation?”  The minute anyone gives me a better option, I’ll take it. But, in the meantime, I’m not willing to leave millions of Californians at risk when we have a safe and effective screening tool that’s undergone face validation in a randomized, controlled trial. This is an emerging field, and I’m going to apply the best of the science that we have right now because, frankly, waiting is not an option. Asking people to say, “I know that you are experiencing ACEs. I know that it is harming your brains and bodies, but you know what? We’re going to wait 15 more years until we have a tool that’s slightly better than the one now.” I’m not okay with that.

DE: I’m not a researcher, but I don’t think anyone can truly argue with what Dr. Burke Harris is talking about. But in the world that I work in I’m not a proponent of screening, for a very simple reason. I view those questions [typically used in a screening] as conversational. They’re not there to be part of a diagnostic piece because I don’t know what other positive factors may have intervened to offset them already. I think one of the other things to keep in mind is that there are only 10 factors being measured, when there are other issues that are worth considering. We know homelessness plays a role, people going hungry, or they may have a fear that they don’t have enough food. Then there are all the adverse community conditions that we have, from poverty to racism.

I look at what are the other positive factors that integrate into this. I go immediately to where we sit right now. We are in the middle of a pandemic. We didn’t test everyone, but we still want everybody to get a vaccination. So, I’m not opposed to the screening. But if ACEs are as prevalent as we say they are, if we treat everyone that comes to us as if they have had ACEs, then we can have that conversation and figure out how to do that work to come up with solutions.

The other part of this is an equity question for me. The question becomes, do the pediatricians on Rodeo Drive [in Beverly Hills, CA] do the exact same thing that everybody else does? Is this something that poor people and people of color get as a part of their service? The ACEs data tells us that those things happen regardless of what your socioeconomic status is. But we also know that people with means don’t play in the same field and that, to me, carries a whole different burden.

NBH: Yes, we clearly know that ACEs occur in all communities. If we asked doctors, “what’s the role of communities in preventing ACEs,” I think there are many who have a clear sense of being out there, engaging, talking to communities, advocating for creating the conditions to prevent ACEs from happening, and supporting families and caregiver resilience. Then if people ask, “well, what’s the role of doctors?” well, the role of doctors is to treat the illness when something comes up. Okay. But what if the role of doctors was the same as it is for cancer, tuberculosis, HIV, or any other public health crisis? What if we could get doctors to be part of prevention to bring the percentage of ACEs way down? That’s the point of developing a screening protocol and a screening tool.

In your work, you both focus on the power of responsive caregiving and how supportive relationships can serve as a buffer for children who experience ACES. Can you speak more about the role of parents and other caregivers and the kind of interventions that can be most useful in reducing the negative impact of ACEs?

DE: I start with three core protective systems. I know that when individuals feel they have value, that the things that they do are important, that they have agency, that matters. The second piece is about relationships. We talk about relationships with caring adults, but there’s another “C-word” we have to attach to that. That’s caring and competent adults. Then the last important system is community, culture, and spirituality.

Let’s remember that kids are typically with their parents more than they are with anyone else. So, we need to give parents the information they need to be a part of this process. That means literally training them on ACEs. We train professionals all the time, but the community itself really has never been in this conversation. So, from a preventive standpoint, I want to engage with communities. Let’s see if we can build around that. There are multiple angles we’re going to have to play. It’s not prevention versus intervention. I’m just a firm believer that part of this conversation has to be taken out into the community and paired with the professional conversations so it’s not just that one side is bringing the story. It’s what we’re trying to implement here in New Jersey. The first thing people in the community want to talk about is expanding leadership — figuring out who’s not at the table, who’s never been at the table, and why.

NBH: I agree 1000%. One of the key pieces is that we understand the biology of toxic stress and, as we’re caring for families, we are recognizing that parents have a prolonged activation of the stress response that is affecting their judgment, their impulse control, and the functioning of their prefrontal cortex. This is part of the reason why, in California, in our ACEs Aware program, we’re training providers to screen adults and kids because breaking an intergenerational cycle requires treating toxic stress in adults.

One of the things biology shows us is that if you look at the fetal HPA axis,¹ you can see markers of activation with mom’s own ACEs. We see that, even before the baby comes out, these biological changes are happening. So, my focus is also bringing as many people to the table as possible. Everything Dave is talking about — about community, about wisdom, about supporting parents, about listening to a diverse set of voices — all of that is true.

I also want to bring to the table the best primary care doctors out there. I want the cardiologists in there. I want the immunologists in there. I want the pulmonologists in there. I want every single one of our most powerful tools. When I say “powerful,” I mean the powerful wisdom of grandmothers and the powerful wisdom of gastroenterologists. All at the table, all being part of the solution. Maybe not even all at the same table, but doing the work in their space. Then when we add it all up, we have a whole that is greater than the sum of its parts.

1. The fetal hypothalamus-pituitary-adrenal (HPA) axis is at the center of mechanisms controlling fetal readiness for birth, survival after birth, and, in several species, determination of the timing of birth.