Learning how to cope with adversity is an important part of growing up.
However, when adversities in childhood can exceed the child’s ability to manage them there can be negative consequences.
Stresses caused by exposure to poverty, neglect, abuse or community violence can alter the developing brain in ways which negatively impact physical and mental health well into adulthood.
Such experiences, when not buffered by caring, involved adult caregivers result in a type of neuro-developmental toxicity, changing neural pathways through epigenetic mechanisms.
Studies have shown that an alarming number of American children are exposed to or victims of violence involving a weapon.
According to one recent study published in the journal Pediatrics, nearly one-third of children in the United States are exposed to violence before the age of 18.
The study noted that about 1 in every 33 kids are assaulted with guns and knives during these incidents.
Denise Dowd, MD is here to discuss how the psychological and physical effects of these incidents are manifested in many ways and have long term implications on the child’s health.
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Adverse Childhood Events and Toxic Stress
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Learn more about Denise Dowd, MD
Denise Dowd, MD
Denise Dowd is a professor of pediatrics and emergency medicine at Children’s Mercy Hospital. She received her medical degree from St. Louis University School of Medicine. She completed her residency at Northwestern University/Lurie Children’s Hospital and a fellowship in Pediatric Emergency Medicine at Children’s Mercy Kansas City. She also has a Master’s in Public Health form the University of Washington. Dr. Dowd’s experience is in injury and violence prevention, pediatric emergency medicine and social determinants of health. Dr. Dowd has published over 120 articles in these areas.. She is the past chair of the American Academy of Pediatrics Resilience Project. In 2013 she received the Michael Shannon Humanitarian Award from the American Academy of Pediatrics Section on Emergency Medicine and in 2015 the Arnold Gold Foundation Humanism Award.Learn more about Denise Dowd, MD
Transcription:
Adverse Childhood Events and Toxic Stress
Dr. Michael Smith (Host): Welcome to Transformational Pediatrics. I’m Dr. Michael Smith and our topic is “Adverse Childhood Events and Toxic Stress.” My guest is Dr. Denise Dowd. Dr. Dowd is a Professor of Pediatrics and Emergency Medicine at Children’s Mercy Hospital. Dr. Dowd, welcome to the show.
Dr. Denise Dowd (Guest): Thank you.
Dr. Smith: So, a recent study published in the journal Pediatrics showed that nearly one third of children in the United States are exposed to violence before the age of 18. How much of an impact does early childhood adversity and stress contribute to disease and mental health issues later in life?
Dr. Dowd: It can have an enormous impact. Exposure to violence, both external to the family and especially within the family, has tremendous impact. I don’t know if you or your audience has heard about the ACE studies--Adverse Childhood Experiences Studies--that were done at Kaiser Permanente in San Diego in the late 1990’s, early 2000’s. Drs. Bob Anda and Vince Felitti looked at their database of Kaiser patients and saw health outcomes like diabetes, cancer, stroke, COPD, in addition to depression, suicidality, addiction and what they did with these adult patients is they actually did a survey and asked them, “Prior to age 18, were you exposed to violence in the form of sexual abuse, physical abuse, a parent who was dysregulated with a mental health problem, a parent who was addicted, a parent who went to prison?” and so forth There were about 9 or 10 of these and they called these ACES and you add them up and it gives you a score. They found out something extraordinary that really is influencing, I think, all of medicine right now, especially my field--pediatrics. What they found was, the more of those ACE’s you have, the more likely you are, as an adult, to have all of the mental health and depression consequences; and, in addition to that, more of your traditional bad health outcomes like cancer, ischemic heart disease. So, take a person with ACE scores of four or more and you compare them to a person with an ACE score of 0. They have 220% risk of ischemic heart disease, 240% the risk for stroke.
Dr. Smith: Wow.
Dr. Dowd: They have more than a 12 time’s risk of a suicide attempt and it goes on and on and on. It’s extraordinary.
Dr. Smith: Is this related to the terminology toxic stress that experts like you and Children’s Mercy uses? What exactly is toxic stress and what are the consequences of it?
Dr. Dowd: Yes. We hear the term toxic stress a lot. It actually came from Dr. Jack Shonkoff of Harvard Center for the Developing Child who kind of coined this term. You know, stress is unavoidable in life and tolerable stresses are things that happen. For a big test or soccer game, you get nervous and your body reacts with stress. You know that fight or flight kind of thing and you get nervous. Then, toxic stresses are those things that happen to a child that activate that stress response. That fight, flight or freeze mechanism that we all have it’s in our brain. We were back living in the woods fighting off animals. It was a very lifesaving reaction. What toxic stress is, and I’ll use a little analogy here, if you’re walking through the woods and a bear comes out, if this has ever happened or something a lot like this, you know your instant body reaction. You can just feel it. Your blood pressure goes up; your heart rate goes up; your eyes dilate. You’re going to take off; you’re going to fight or you’re going to freeze. That’s natural. Now, toxic stress happens when the bear is actually, let’s say, an intoxicated parent that comes home from the bar every night and you don’t know what’s going to happen as a little kid. You don’t know if you’re going to get smacked around. You don’t know if your parent who’s intoxicated is going to be really nice to you. It happens day after day after day where this stress response is activated. This lifesaving mechanism that we all have in us becomes life damaging because your brain, especially as little one who’s developing and growing, is basically stress hormones and if you don’t have any kind of what we call protective or buffering factors--an adult who can make you feel safe even in those circumstances—then his stress response actually changes the way the brain is shaped. It actually changes the way neurons fire and we say the “neurons which fire together wire together”. The neuropathways are actually changed through the science of what we now call “epigenetics”, which is not the DNA that is laid but the way that the DNA is expressed.
Dr. Smith: Are there certain red flags or signals that providers should look for to know if a child is experiencing toxic stress or having trouble coping with adversity?
Dr. Dowd: Yes, there are many things for which to look. I think, as a pediatrician or for your pediatrician listeners, the most important thing that you can pick up on, especially among the little kids, because you know what? It’s really in the first three years of life that the brain is going to be most shaped by these. So, they’re not going to tell you, “I’ve been exposed to a parent who’s neglecting me or a parent who’s abusive to me” or a violent neighborhood. But you are going to be able to see the other side of the coin which is the protective, social emotionally protective thing, and that’s the relationship with the parent. That’s a different kind of way of looking at things as a physician but you really have to become a student of the relationship that you see between the parent and the child. You can tell if it’s a safe, nurturing, protective relationship. Worry about actions that you see between a parent and a child which may look very neglectful, which may look very harsh. I think that’s one of the most telling things. Kids with symptoms, obviously, they can happen. We see this in school a lot. We have a ton of misdiagnosis of kids with ADHD that aren’t really ADHD. They can’t focus or they can’t pay attention; they can’t learn. It can be ADHD, but trauma, exposure to trauma and violence, presents the exact same way and it’s really prevalent across the United States. You’ve got to ask the right questions about what happened to that child in their life and what they’ve been exposed to. Kids can also take the other way and they can become very introverted; very withdrawn. Their accents can be very, very flat, non-interactive with no eye contact. Kids with asthma can present with more asthma exacerbation. They can wheeze a lot more. The medication’s just not working for them. Why? Something is raising their cortisol. Something is getting them stressed out. Certainly, exposure to violence within and external to the family can be that. So, there are a whole host of things to for which to look. I can mention to the listeners that the American Academy of Pediatrics has a wonderful kind of tool kit that primary care providers can use. They can just go on the aap.org website and look for the trauma toolkit. Search it out. There are some wonderful things in there to learn about just a little bit more.
Dr. Smith: For the last question, Dr. Dowd, explain to us the two generation model of early intervention.
Dr. Dowd: I was going to go back to that thing I said about the relationship. You know, most of the ACES, those childhood experiences, how are they coming? They are coming actually through a parent or somebody related to them. It’s dysfunction within the family. Community violence is important, too. Because the relationship between the parent and a child is going to be this thing that predicts the health of that child through adulthood and life course the most, through social, emotional connection, what we’re understanding now through this amazing convergence of neuroscience and behavioral science, is that we’re going to have to change how we do our business here in medicine. We’re going to have to address people across their life courses so we can’t make these silos, “Okay, there’s the kid and there’s the adult.” Two generation means we have to pay attention to both the child in the context of the relationship with the adult – that’s what matters; the interaction and the relationship. So, that’s going to create some opportunities and some challenges for us as pediatricians. We can’t just actually focus on the child. We’ve got to think about where that stress for the child--those ACE’s--are going to be coming from and that means paying attention to what’s around them: their families, their neighborhood, their communities.
Dr. Smith: Dr. Dowd, thank you so much for what you’re doing at Children’s Mercy and I want to thank you for coming on this show. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information you can go to childrensmercy.org. That’s childrensmercy.org. I’m Dr. Michael Smith. Have a great day.
Adverse Childhood Events and Toxic Stress
Dr. Michael Smith (Host): Welcome to Transformational Pediatrics. I’m Dr. Michael Smith and our topic is “Adverse Childhood Events and Toxic Stress.” My guest is Dr. Denise Dowd. Dr. Dowd is a Professor of Pediatrics and Emergency Medicine at Children’s Mercy Hospital. Dr. Dowd, welcome to the show.
Dr. Denise Dowd (Guest): Thank you.
Dr. Smith: So, a recent study published in the journal Pediatrics showed that nearly one third of children in the United States are exposed to violence before the age of 18. How much of an impact does early childhood adversity and stress contribute to disease and mental health issues later in life?
Dr. Dowd: It can have an enormous impact. Exposure to violence, both external to the family and especially within the family, has tremendous impact. I don’t know if you or your audience has heard about the ACE studies--Adverse Childhood Experiences Studies--that were done at Kaiser Permanente in San Diego in the late 1990’s, early 2000’s. Drs. Bob Anda and Vince Felitti looked at their database of Kaiser patients and saw health outcomes like diabetes, cancer, stroke, COPD, in addition to depression, suicidality, addiction and what they did with these adult patients is they actually did a survey and asked them, “Prior to age 18, were you exposed to violence in the form of sexual abuse, physical abuse, a parent who was dysregulated with a mental health problem, a parent who was addicted, a parent who went to prison?” and so forth There were about 9 or 10 of these and they called these ACES and you add them up and it gives you a score. They found out something extraordinary that really is influencing, I think, all of medicine right now, especially my field--pediatrics. What they found was, the more of those ACE’s you have, the more likely you are, as an adult, to have all of the mental health and depression consequences; and, in addition to that, more of your traditional bad health outcomes like cancer, ischemic heart disease. So, take a person with ACE scores of four or more and you compare them to a person with an ACE score of 0. They have 220% risk of ischemic heart disease, 240% the risk for stroke.
Dr. Smith: Wow.
Dr. Dowd: They have more than a 12 time’s risk of a suicide attempt and it goes on and on and on. It’s extraordinary.
Dr. Smith: Is this related to the terminology toxic stress that experts like you and Children’s Mercy uses? What exactly is toxic stress and what are the consequences of it?
Dr. Dowd: Yes. We hear the term toxic stress a lot. It actually came from Dr. Jack Shonkoff of Harvard Center for the Developing Child who kind of coined this term. You know, stress is unavoidable in life and tolerable stresses are things that happen. For a big test or soccer game, you get nervous and your body reacts with stress. You know that fight or flight kind of thing and you get nervous. Then, toxic stresses are those things that happen to a child that activate that stress response. That fight, flight or freeze mechanism that we all have it’s in our brain. We were back living in the woods fighting off animals. It was a very lifesaving reaction. What toxic stress is, and I’ll use a little analogy here, if you’re walking through the woods and a bear comes out, if this has ever happened or something a lot like this, you know your instant body reaction. You can just feel it. Your blood pressure goes up; your heart rate goes up; your eyes dilate. You’re going to take off; you’re going to fight or you’re going to freeze. That’s natural. Now, toxic stress happens when the bear is actually, let’s say, an intoxicated parent that comes home from the bar every night and you don’t know what’s going to happen as a little kid. You don’t know if you’re going to get smacked around. You don’t know if your parent who’s intoxicated is going to be really nice to you. It happens day after day after day where this stress response is activated. This lifesaving mechanism that we all have in us becomes life damaging because your brain, especially as little one who’s developing and growing, is basically stress hormones and if you don’t have any kind of what we call protective or buffering factors--an adult who can make you feel safe even in those circumstances—then his stress response actually changes the way the brain is shaped. It actually changes the way neurons fire and we say the “neurons which fire together wire together”. The neuropathways are actually changed through the science of what we now call “epigenetics”, which is not the DNA that is laid but the way that the DNA is expressed.
Dr. Smith: Are there certain red flags or signals that providers should look for to know if a child is experiencing toxic stress or having trouble coping with adversity?
Dr. Dowd: Yes, there are many things for which to look. I think, as a pediatrician or for your pediatrician listeners, the most important thing that you can pick up on, especially among the little kids, because you know what? It’s really in the first three years of life that the brain is going to be most shaped by these. So, they’re not going to tell you, “I’ve been exposed to a parent who’s neglecting me or a parent who’s abusive to me” or a violent neighborhood. But you are going to be able to see the other side of the coin which is the protective, social emotionally protective thing, and that’s the relationship with the parent. That’s a different kind of way of looking at things as a physician but you really have to become a student of the relationship that you see between the parent and the child. You can tell if it’s a safe, nurturing, protective relationship. Worry about actions that you see between a parent and a child which may look very neglectful, which may look very harsh. I think that’s one of the most telling things. Kids with symptoms, obviously, they can happen. We see this in school a lot. We have a ton of misdiagnosis of kids with ADHD that aren’t really ADHD. They can’t focus or they can’t pay attention; they can’t learn. It can be ADHD, but trauma, exposure to trauma and violence, presents the exact same way and it’s really prevalent across the United States. You’ve got to ask the right questions about what happened to that child in their life and what they’ve been exposed to. Kids can also take the other way and they can become very introverted; very withdrawn. Their accents can be very, very flat, non-interactive with no eye contact. Kids with asthma can present with more asthma exacerbation. They can wheeze a lot more. The medication’s just not working for them. Why? Something is raising their cortisol. Something is getting them stressed out. Certainly, exposure to violence within and external to the family can be that. So, there are a whole host of things to for which to look. I can mention to the listeners that the American Academy of Pediatrics has a wonderful kind of tool kit that primary care providers can use. They can just go on the aap.org website and look for the trauma toolkit. Search it out. There are some wonderful things in there to learn about just a little bit more.
Dr. Smith: For the last question, Dr. Dowd, explain to us the two generation model of early intervention.
Dr. Dowd: I was going to go back to that thing I said about the relationship. You know, most of the ACES, those childhood experiences, how are they coming? They are coming actually through a parent or somebody related to them. It’s dysfunction within the family. Community violence is important, too. Because the relationship between the parent and a child is going to be this thing that predicts the health of that child through adulthood and life course the most, through social, emotional connection, what we’re understanding now through this amazing convergence of neuroscience and behavioral science, is that we’re going to have to change how we do our business here in medicine. We’re going to have to address people across their life courses so we can’t make these silos, “Okay, there’s the kid and there’s the adult.” Two generation means we have to pay attention to both the child in the context of the relationship with the adult – that’s what matters; the interaction and the relationship. So, that’s going to create some opportunities and some challenges for us as pediatricians. We can’t just actually focus on the child. We’ve got to think about where that stress for the child--those ACE’s--are going to be coming from and that means paying attention to what’s around them: their families, their neighborhood, their communities.
Dr. Smith: Dr. Dowd, thank you so much for what you’re doing at Children’s Mercy and I want to thank you for coming on this show. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information you can go to childrensmercy.org. That’s childrensmercy.org. I’m Dr. Michael Smith. Have a great day.