'Toxic stress' on children can harm their lifelong learning, mental and physical health

The 10-year-old girl suffered from persistent asthma, but the cause was unclear. Tests ruled out everything from pet hair to cockroaches.

Then the girl's mother thought of a possible trigger. 

“Her asthma does seem to get worse whenever her dad punches a hole in the wall," she told Dr. Nadine Burke Harris. "Do you think that could be related?”

Harris, a San Francisco pediatrician, includes the example in her new book, "The Deepest Well," to show the connection between what's known as "toxic stress" and physical health.

Medical professionals and researchers have long studied the effect of adverse childhood experiences (ACEs) and lifelong mental health and addiction. Now awareness is growing of the link between childhood trauma on long-term physical health.

The more ACEs a person suffers as a child – divorce, domestic violence, family members with addiction – the higher the risk of problems later in learning, mental and physical health, even early death.

That's because people with ACEs are more likely to experience “toxic stress” – repeated, extreme activation of their stress response.

Toxic stress affects the developing brain, the immune system, the cardiovascular system and the metabolic regulatory system, says Al Race, deputy director of the Center on the Developing Child at Harvard. It dramatically increases the risk of hypertension, heart disease and diabetes, among other costly health conditions. 

Children with four or more ACEs are four times more likely to suffer from depression in their lifetimes, eight times more likely to become alcoholics and 20 times more likely to use intravenous drugs, research shows. Those who are exposed to very high doses of adversity without caring adults to help can have more than double the lifetime risk of heart disease and cancer and a nearly 20-year difference in life expectancy.

"There's a huge body of science that shows the connection between the early years of life with a wide range of health problems later in life," Race says. "Toxic stress allows us to understand why that relationship exists and how it can get inside developing biological systems in the body."

Given the stakes, researchers are scrambling to figure out how best to diagnose ACEs.

Researchers at Harvard, the University of California-San Francisco and other institutions are working on screening tools to detect the biological markers of toxic stress in children so they can detect it earlier and help parents mitigate the effects.

"There's no one accepted way to measure the effect of excessive stress activation," Race says. As with adults, he says, "every child reacts to stress differently."  

The Center for Youth Wellness, founded by Harris, has launched a social media campaign and the new Stress Health website to share the science with parents. The National Pediatric Practice Community, a network of nearly 600 doctors organized by the center, is screening for ACEs and sharing ways to reduce their influence on mental and physical health.

Dr. Imelda Dacones is CEO of Northwest Permanente, the independent medical group that provides care to Kaiser Permanente members in the Northwest.

"More people are clamoring for government policy and health care organizations to provide trauma-informed care because the data is out there," she says. "The sad thing about ACEs is we've known about them since 1997, but there's been a lag in translating it to create a system to actually do something about it."

More than 20 million children have experienced three or more ACEs. Dr. Don Mordecai, the mental health leader for Kaiser Permanente, says children who experience multiple ACEs are at risk for toxic stress and the lifelong mental and physical health effects it can have.

Kaiser Permanente worked with the  federal Centers for Disease Control and Prevention to produce the original study on ACEs more than 20 years ago. 

About 25 percent of adults have experienced at least three or more ACEs.

In her book, Harris describes physical and emotional abuse as common for both the diverse patients at her low-cost clinic and the wealthy people in her area. 

"I see it every day in my practice," Harris says.

She sees children who experience frequent infections, failure to grow well and learning disabilities. 

The effect can start in infancy, Harris says, and is experienced by even sleeping babies who are in stressful environments.

One of the key ways parents can protect their children, she says, is by nurturing healthy relationships outside the home, especially if they experienced their own traumatic childhoods.

"All of the research is telling us that relationships are healing," Harris says. "Folks who have high levels of social support are more resistant to the flu and have better immune functioning."

Sleep, good nutrition, mindfulness and exercise also help. 

Former Surgeon General Vivek Murthy, a primary-care physician, has made human connection for adults’ health his post-government priority.

Harris and Murthy, who have been friends for more than two decades, agree that positive relationships help adults become better parents.

When parents' friends are part of children's lives, Harris says, they can boost the child's "cumulative dose of therapeutic interaction."

We can't "choose the homes in which we grew up," Murthy says, but relationships with family and others outside the home can help parents and others heal from early trauma.

Murthy is writing a book on social isolation.

"I worry we have come so far in terms of medicine, technology and economic advancement but seem to have a growing amount of emotional pain," he says. To help people heal from childhood or current trauma, he says, "one of the most powerful ways we can do that is by cultivating strong connections."

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The CDC is continuing the work it started with Kaiser Permanente by occasionally monitoring the health of the 17,000 people it began studying in 1995.

The Northwest Permanente Medical Group is developing a health complexity score, incorporating medical complexity and social complexity scores, for children and families.

The social complexity score will be based on information from the Oregon state health and human services agency, which will track ACEs as children and families move through services for food, housing, financial help, or correctional facilities. The scores will be used to help connect people with social organizations.

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Here are common signs of toxic stress in school-age children, according to the Center for Youth Wellness:

• Poor coping skills.

• Behavior and learning difficulties.

• Mood swings.

• Sleep problems.  

• Overeating and other compulsive behaviors.

• Fear and anxiety triggered by places or people that remind them of past trauma. 

Rahil Briggs is national director of HealthySteps, a pediatric program that works with parents and children to influence behavior to better prepare them for kindergarten, and founder of a pediatric psychology center at Montefiore Health System in New York. Montefiore is one of five medical sites working with Harvard on its biomarkers research.

When Briggs thinks of toxic stress, she thinks of two children, ages 7 months and 2 years, who were home in 2006 when their father killed a third sibling.

The infant couldn't sit up, and the toddler wouldn't speak at an age when kids should know 50 words and be able to string two together.

Worse yet, they both cried inconsolably. The older child would crawl under furniture when he wanted to soothe himself. 

"This child was finely tuned to understand it's better just to retreat rather than to ask for help," Briggs says. 

When children don't gain enough weight, or lose too much, they can be diagnosed with "failure to thrive." Briggs says the diagnosis is most often "related to the environment the child is growing up in."

Harris hopes her digital ad campaign will remind some parents of the danger their homes present for their children's long-term health.

In the video ads, a boy puts an ice pack on his sleeping mother's eye and cleans up liquor bottles around his father, who is sleeping on a couch.

He puts all the bottles into trash bags and stuffs them into an overflowing closet. He is shown opening the closet later in life.

Jabeen Yusuf heads public health education at the Center for Youth Wellness.

"For a lot of parents, they understand that if you’re hitting your child, it's harmful to their child," she says. "But they will say, 'I didn't realize the things they are witnessing could be harmful to their health.'"

Yusuf calls it the "myth of childhood amnesia."

"We have to create safe, stable relationships and sometimes leaving a dangerous environment is what’s going to be necessary," Harris says. "A lot of the times, moms in particular are willing to do for their children what they are not willing to do for themselves." 

If you are interested in connecting with people online who have overcome or are currently struggling with the health problems mentioned in this story, join USA TODAY’s ‘I Survived It’ Facebook support group.
Original Article

Should Childhood Trauma Be Treated As A Public Health Crisis?

Researchers followed a group of kids from childhood into adulthood to track the link between trauma in early life and adult mental health.

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When public health officials get wind of an outbreak of Hepatitis A or influenza, they spring into action with public awareness campaigns, monitoring and outreach. But should they be acting with equal urgency when it comes to childhood trauma?

A new study published in the Journal of the American Medical Association suggests the answer should be yes. It shows how the effects of childhood trauma persist and are linked to mental illness and addiction in adulthood. And, researchers say, it suggests that it might be more effective to approach trauma as a public health crisis than to limit treatment to individuals.

The study drew on the experiences of participants from the Great Smoky Mountains Study, which followed 1,420 children from mostly rural parts of western North Carolina, over a period of 22 years. They were interviewed annually during their childhood, then four additional times during adulthood.

This study has something other similar studies don't, says William Copeland, a professor of psychiatry at the University of Vermont who led the research. Instead of relying on recalled reports of childhood trauma, the researchers analyzed data collected while the participants were kids and their experiences were fresh. And the researchers applied rigorous statistical analysis to rule out confounding factors.

Even when the team accounted for other adversities aside from trauma, like low income and family hardships, and adult traumas, the associations between childhood trauma and adult hardships remained clear. The associations remained clear.

The study is "probably the most rigorous test we have to date of the hypothesis that early childhood trauma has these strong, independent effects on adult outcomes," he says.

For Copeland, the wide-ranging impacts of trauma call for broad-based policy solutions in addition to individual interventions. "It has to be a discussion we have on a public health policy level," he says.

Nearly 31 percent of the children told researchers they had experienced one traumatic event, like a life-threatening injury, sexual or physical abuse, or witnessing or hearing about a loved one's traumatic experience. And 22.5 percent of participants had experienced two traumas, while 14.8 percent experienced three or more.

SHOTS - HEALTH NEWS

To Head Off Trauma's Legacy, Start Young

The childhoods of participants who went through traumatic events and those who didn't were markedly different. Participants with trauma histories were 1.5 times as likely to have psychiatric problems and experience family instability and dysfunction than those without, and 1.4 times as likely to be bullied. They were also 1.3 times more likely to be poor than participants who didn't experience trauma.

When these children grew up, psychiatric problems and other issues persisted. Even after researchers adjusted for factors like recall bias, race and sex, the impact of those childhood psychiatric problems and hardships, the associations remained. Participants who experienced childhood trauma were 1.3 times more likely to develop psychiatric disorders than adults than those who did not experience trauma, and 1.2 times more likely to develop depression or substance abuse disorder.

Participants with histories of trauma were also more likely to experience health problems, participate in risky behavior, struggle financially, and have violent relationships or problems making friends. And the more childhood trauma a person experienced, the more likely they were to have those problems in adulthood.

Copeland acknowledges the study's limitations—it included mostly white participants in rural settings, and a disproportionately high number of Native American participants compared to the rest of the United States due to the area's high concentration of members of the Eastern Band of Cherokee Indians. But the study is nonetheless important, says Kathryn Magruder, an epidemiologist and professor of psychiatry at the Medical University of South Carolina.

"I think it should put to rest any kind of speculation about early childhood trauma and later life difficulties," she says.

Though the link has been shown in earlier research, Magruder says, this new study can help direct future research and policy. "Why are we revisiting it? Because it is time to think about prevention," she says. Trauma is a public health problem, she adds, and should be met with a public health approach.

Psychologist Marc Gelkopf agrees. In an editorial published along with the study, he writes: "If the ills of our societies, including trauma, are to be tackled seriously, then injustice must be held accountable."

SHOTS - HEALTH NEWS

Childhood Trauma And Its Lifelong Health Effects More Prevalent Among Minorities

The policy implications are clear, says Jonathan Purtle, a mental health policy researcher and assistant professor at Drexel University's Dornsife School of Public Health. "We need to prevent these things from happening to children and support family and community so that people can be more resilient," he says. Policymakers can create coalitions around issues like mental health and trauma-informed approaches in contexts like education and healthcare, he says.

One step in that direction comes with the SUPPORT for Patients and Communities Act, a bipartisan bill to address the opioid crisis that was signed into law October 24. The law recognizes links between early childhood trauma and substance abuse. It includes grants to improve trauma support services in schools, created a task force to provide recommendations on how the federal government can help families whose lives have been impacted by trauma and substance abuse, and requires the Department of Health and Human Services to help early childhood and education providers spot and address trauma.

Bills like the SUPPORT Act enjoy bipartisan and are a promising start, says Purtle — but they don't go far enough. To really reduce trauma and mitigate its effects, he says, policymakers must pursue community investment and policies like minimum wage laws that reduce economic pressure on people who are struggling.

"It's more than just 'toughen up and deal with it,' " he says. "A lot of it comes down to people not having to live their lives in a state of chronic and constant stress."

Erin Blakemore is a science writer based in Boulder, Colo.

UNICEF joins partners in emphasizing the benefits of breastfeeding

Welcome to World Breastfeeding Week!

To celebrate, UNICEF joins partners in emphasizing the benefits of breastfeeding, and renewing our longstanding commitment to promoting the practice to help ensure the healthy growth, development and survival of children around the world. 

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A community health volunteer advises a mother on breastfeeding, nutrition and infant care as part of a UNICEF-supported program in Jharkhand State, India. In recent years, India has seen a significant increase in the percentage of women who exclusively breastfeed their babies for the first six months of life, thanks to the implementation of new policies that effectively promote the practice. © UNICEF/UNI148848/Vishwanathan

UNICEF has long advocated for breastfeeding as the way to give babies the best start in life. In the developing world, it's the closest thing there is to a magic bullet against child malnutrition and infant mortality. 

Breastmilk is safe and reliable. It is always the right temperature, requires no preparation and is available even in environments with poor sanitation and unsafe drinking water — a steady and complete source of nutrition, even when resources are scarce and in times of crisis. Breastmilk contains all the water a baby needs, even in hot climates.

It also contains a mother's antibodies needed to combat disease. Children who are breastfed are less likely to contract diarrhea-related illnesses and respiratory infections, and are at lower risk of obesity, diabetes and other chronic conditions later in life. Breastfeeding is also known to boost cognitive development and lead to higher educational achievement.

Optimal breastfeeding would save more than 820,000 young lives every year

According to researchers, achieving near-universal breastfeeding would save more than 820,000 young lives every year in developing countries. Optimal breastfeeding, according to the World Health Organization (WHO), means starting breastfeeding within an hour of birth, exclusive breastfeeding (meaning no additional foods or liquids, not even water) for the first six months of life and continued breastfeeding until age 2 or beyond.

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A growing number of Chinese mothers are overcoming obstacles to breastfeeding their babies after maternity leave. As a working mother, Fiona, above, managed to breastfeed her baby for 28 months. “I made it because I learned correct knowledge of breastfeeding online, and also having a healthy baby makes me more confident," she told UNICEF. "But the biggest support is what I got from my family.” © UNICEF/UNI166592/Liu

And yet, an estimated 3 out of 5 babies are not breastfed within that first hour, putting them at higher risk of death and disease, and making them less likely to continue breastfeeding, according to a new report by UNICEF and WHO. Most of these babies are born in low- and middle-income countries.

Even a delay of a few hours can have life-threatening consequences. Studies show that newborns who began breastfeeding between two and 23 hours after birth had a 33% greater risk of dying compared with those who began breastfeeding within one hour of birth; and among newborns who started breastfeeding a day or more after birth, the risk was more than twice as high.

Skin-to-skin contact along with suckling stimulates the mother's production of breastmilk and — critically — colostrum, often called baby's first vaccine. "When it comes to the start of breastfeeding, timing is everything," UNICEF Executive Director Henrietta H. Fore said. The UNICEF/WHO report, entitled Capture the Moment, analyzes data from 76 countries and explores the reasons so many newborns are left waiting too long. "Each year, millions of newborns miss out on the benefits of early breastfeeding, and the reasons — all too often — are things we can change," Fore said. 

While overall breastfeeding rates have gone up in recent years, other persistent gaps are a strong indication that countries are not informing, empowering and supporting every mother to breastfeed. 

As part of its global campaign Every Child Alive, UNICEF urges governments, the private sector, civil society groups and communities to work together to increase breastfeeding rates by:

• increasing awareness of the health benefits of breastfeeding and other advantages 
• increasing funding for breastfeeding support programs 
• implementing measures to regulate the marketing of infant formula and other breastmilk substitutes 
• adopting workplace policies that support breastfeeding for working mothers 
• implementing 10 steps to successful breastfeeding in maternity facilities 
• ensuring mothers receive appropriate counseling and practical assistance in the first week after delivery, to increase their chances of success. 

"Breastfeeding is the best gift a mother, rich or poor, can give her child, as well as herself," said Shahida Azfar, UNICEF's Acting Deputy Executive Director. "We must give the world's mothers the support they need to breastfeed."

There has been progress in recent years. Countries like India and Vietnam, for example, have put into place strong policies to protect and promote breastfeeding. Others, like Turkmenistan, have very high rates of mothers giving birth in baby-friendly hospitals where breastfeeding is encouraged. Almost all mothers in New Zealand and Sri Lanka give birth at a baby-friendly facility. Cultural and political factors also play a role, as well as the level of support a new mother receives from her baby's father, her family, employer and community.

Breastfeeding and sustainable development go hand in hand. Improving the health and well-being of women and children provides a foundation for a more prosperous future for all. 

Learn more about how UNICEF is working to support breastfeeding mothers, to give all children the best start in life.

World Breastfeeding Week 2018 runs August 1 through August 7. Join the conversation! 

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Top photo: A mother breastfeeds her 6-month-old baby outside a health center in the village of Preak Krabao, Kang Meas District, Cambodia. © UNICEF/UN074025/Pirozzi