The Deepest Well: Healing the Long-Term Effect of Childhood Adversity
By Nadine Burke Harris
Houghton Mifflin Harcourt, New York, 2018
“Imagine you’re walking in the forest and you see a bear.”
Dr. Nadine Burke Harris asks us to think about this scenario early in her book The Deepest Well: Healing the Long-Term Effect of Childhood Adversity.
“Immediately your body sends a bunch of signals to your adrenal glands … saying, “Release stress hormones! Adrenaline! Cortisol!” So your heart starts to pound, your pupils dilate, your airways open up and you are ready to either fight the bear or run from the bear. That’s the response commonly known as fight or flight. It has evolved over millions of years to save your life.” [pp. 48-49]
We’ve all had experiences like this, maybe not meeting a bear in the woods exactly, but experiences that make your heart pound and time seem to slow down. It’s a normal, healthy yet primal response to a stressful or threatening situation. You probably know from experience that it can take a while to calm down, for your heart and your breathing to go back to normal. Those stress hormones, adrenaline and cortisol, are powerful and their effects can be lasting.
But then Dr. Burke Harris asks, what if you don’t just encounter a bear in the forest? What if the bear lives with you? What if “the bear” is really physical or sexual abuse in your home, neglect or violence or other conditions that make your life hell?
You’re going to have that stress reaction, hormones flooding your body, often, perhaps dozens of times a day. The stress will go from tolerable to toxic.
As an adult you might be able to cope for a while. But how do children cope under such adverse conditions? How does toxic stress affect our kids?
The main point of The Deepest Well is that adverse childhood experiences (ACEs) can dramatically impact health over an entire lifetime. The book is about those impacts, how to recognize them and how to treat them.
The term adverse childhood experience comes from a 1998 study by Dr. Vincent Felitti, Dr. Robert Anda and their colleagues which looked at the relationship between traumatic childhood experiences and health outcomes for about 17,500 men and women in the San Diego area.
Felitti and Anda identified ten ACEs:
- Emotional abuse
- Physical abuse
- Sexual abuse or contact
- Physical neglect
- Emotional neglect
- Alcohol or substance abuse in the household
- Mental illness in the household including depression or attempted suicide
- Mother treated violently
- Parental divorce or separation
- Incarceration of a household member
Your ACE score is simply the number of ACEs you experienced before the age of eighteen.
ACEs touch people in all levels of society and from all backgrounds. 67% of the US population has at least one ACE and about 12.5% have four or more. Dr. Burke Harris stresses this point because the American culture of individualism can sometimes lead to people being blamed for their health problems. In other words, health problems are sometimes attributed to a person’s own behavioral choices, or neglect, or carelessness, without recognizing that environmental or developmental factors beyond their control can also have significant influence.
High doses of toxic stress during childhood development have a range of impacts:
Neurological: Affecting brain function including cognition, executive function and impulse control leading to learning difficulties and high risk behaviors like smoking, and alcohol and substance abuse.
Hormonal: Hormone imbalances contributing to obesity or occasionally stunted growth.
Immunological: Unbalanced immune system responses making people more susceptible to colds, flu and other infections, and even to autoimmune disorders such as arthritis, diabetes and celiac disease.
Epigenetic: Influencing how your DNA is read and transcribed. (I’ll come back to this one.)
According to the study, when compared to adults with zero ACEs, people with four or more ACEs are:
- 2.2 times as likely suffer from heart disease
- 4.6 times as likely to suffer from depression
- 10.8 times as likely to inject drugs
- 12.2 times as likely to attempt suicide
One of the most interesting, and maybe controversial, ideas in the book is that ACEs can affect how your DNA is read and transcribed. Exposure to toxic stress doesn’t directly change your DNA, but Dr. Burke Harris says it can impact which parts of your DNA are switched on or off, and therefore impact which proteins are expressed when cells reproduce, and even how cells might function. These impacts are known as epigenetic.
Epigenetics, particularly in humans, is a hotly debated topic among scientists, as this article suggests. I can see that it would be advantageous for organisms to have a way to adapt to changes in their environment more quickly that random genetic mutation which takes many generations. Wouldn’t it be great if coral or whales could adapt more quickly to warming oceans, or if trees could adapt to hotter, drier climates? Still, the exact mechanisms by which such impacts are transmitted from parent to child don’t seem to be fully understood yet.
Dr. Burke Harris advocates combining both medical and public health approaches to treating childhood adversity.
She outlines the medical approach throughout the book when she describes her work at the Bayview Child Health Center, and the Center for Youth Wellness, both in San Francisco. It’s a holistic, multi-disciplinary approach that addresses sleep, exercise, nutrition, mindfulness, mental health and healthy relationships.
On the public health front, we’re still in the very earliest stages. Dr. Burke Harris urges early and regular screening for ACEs, for example at a child’s annual check-up. We need more research on ways to reliably detect the biological signs of toxic stress, perhaps through blood tests. And there probably needs to be greater coordination between doctors, schools and caregivers to ensure that children with ACEs are quickly identified and given the proper comprehensive care.
She concludes by urging everyone to recognize that how we’re affected by adversity is not a “referendum on our character.”
“… I know that the long-term impacts of childhood adversity are not all suffering. In some people, adversity can foster perseverance, deepen empathy, strengthen the resolve to protect, and spark mini-superpowers, but in all people, it gets under our skin and into our DNA, and it becomes an important part of who we are.” [p. 218]
The important thing isn’t “overcoming” whatever childhood adversity you may have experienced, but rather understanding the impacts it has had on you, and developing mechanisms to support yourself and the people you love.
Most of us understand that our experiences growing up have profound impacts on who we become as adults. Did our parents read to us as kids? Did they encourage us to participate in sports, or get involved in drama club at school, or robotics club? Were they religious or secular, conservative or liberal? The Deepest Well opened my eyes to the profound ways that childhood experiences can influence not just personality or career choices, but also physical and mental health.
The idea of ACEs and their impact is really important, and not just for medical practitioners and caregivers. I think it’s an important tool for self-understanding too. My parents divorced when I was a kid and I probably experienced some emotional neglect growing up, so I’d give myself 2 ACEs. Over the years I’ve come to understand how profoundly those experiences have shaped my life. But I never realized how much they could also be affecting my health.
Dr. Burke Harris does a great job throughout The Deepest Well putting a human face on the impacts and the suffering caused by childhood adversity. She presents detailed case studies of several of her patients to illustrate their symptoms and their responses to treatment. The stories are sometimes tragic and hard to read.
She also explains technical details well. She takes us on a fascinating tour deep inside the brain, tracing how stress responses are handled by the brain’s various sub-systems. She gives a good introduction to the field of epigenetics, something I’d never heard of before reading this book.
My one caveat is about the structure of the book. It’s semi-autobiographical, organized around the story of Dr. Burke Harris’s career. She takes us through her journey learning about ACEs and their impact, about how to care for her patients who have them, and about her work advocating for ACE screening. I was less interested in those parts of the book (sorry, Doctor!). There’s plenty of worthwhile scientific and medical detail throughout The Deepest Well, but if that’s your main interest, as it was mine, then you’ll have to untangle that information from her biography.
Nadine Burke Harris’s TED Talk: How childhood trauma affects health across a lifetime
Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study
New Yorker profile: The Poverty Clinic
New York Times article, Can We Really Inherit Trauma?