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Stories about people overcoming hardships are embedded in American culture, but there’s more to these tales. “At best, they paint an incomplete picture of what childhood adversity means for the hundreds of millions of people in the United States (and billions around the world) who have experienced early-life stress,” notes pediatrician Nadine Burke Harris, MD, MPH. “More often, they take on moral overtones, provoking feelings of shame and hopelessness in those who struggle with the lifelong impacts of childhood adversity.”

Medical research shows that unmitigated toxic stress from adverse childhood experiences affects child­ren’s physiology, triggers chronic inflammation and hormonal changes, alters the way the body reads its DNA, and affects how cells replicate. It dramatically increases the risk of heart disease, stroke, cancer, diabetes, and Alzheimer’s.

In 2007 the award-winning physician began witnessing the untold story while practicing at the pediatric clinic (now known as the Center for Youth Wellness) she founded in San Francisco’s low-income Bayview–Hunters Point community.

Employing standardized clinical protocols led to improved health outcomes, including fewer asthma hospitalizations. But Harris was still puzzled. “If we were doing everything right, why didn’t we see any indication that we could make a dent in this community’s dramatically reduced life expectancy?”

One day a 7-year-old boy named Diego, who’d stopped growing after a sexual assault, arrived in her clinic. “Maybe it was the extreme presentation. Maybe I had finally seen enough cases to start putting the pieces together,” she explains in The Deepest Well: Healing the Long-Term Effects of Childhood Adversity. “Whatever the reason, I couldn’t get away from the nagging feeling that Diego’s terrible trauma and his health problems weren’t just a coincidence.”

Harris dug into public-health research and discovered a landmark 1998 report: Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. Conducted in partnership between Kaiser Permanente and the Centers for Disease Control and Prevention, the study explains how chronic stress caused by early adversity affects long-term health. It was the missing piece of the puzzle for Harris.

Researchers examined exposure to 10 types of adversity commonly experienced by the mostly white, middle-class, health-insured study participants. The data showed that adverse childhood events are incredibly common: Thirteen percent of participants reported four or more incidents, while 67 percent recalled at least one. It also revealed that the more adverse events a child experiences, the higher his or her risk of experiencing chronic disease, suicide, depression, and violent assault as an adult.

For example, having an ACE score of 4 or higher makes it twice as likely you’ll develop heart disease and four-and-a-half times as likely you’ll become depressed. “A person with an ACE score of 7 or more has triple the lifetime odds of getting lung cancer and three-and-a-half times the odds of having ischemic heart disease, the No. 1 killer in the United States,” Harris explains.

Harris was one of the first pediatri­cians to use the ACE screen­ing ques­tionnaire in clinical practice. Along with providing her a multidisciplinary approach to care, the research has substantially improved her patients’ health and well-being. Today, she’s leading the charge to tackle this public-health crisis by encouraging all U.S. pediatricians to use the ACE screening tool by 2028.

ACE Screening Questionnaire 

Knowing your ACE score can help you better understand the toxic stress you were exposed to during childhood and provide a starting point for healing. “A doctor can help you understand how your ACE score and your family history affect your risk for certain illnesses, and then the two of you can work together to create a plan for prevention and early detection,” says Harris. (For more information about what your ACE score means, visit

Prior to your 18th birthday: 

1. Did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you or act in a way that made you afraid that you might be physically hurt?







2. Did a parent or other adult in the household often or very often push, grab, slap, or throw something at you or ever hit you so hard that you had marks or were injured? No Yes
3. Did an adult or person at least five years older than you ever touch or fondle you or have you touch his or her body in a sexual way or attempt or actually have oral, anal, or vaginal intercourse with you? No Yes
4. Did you often or very often feel that no one in your family loved you or thought you were important or special, or did your family not look out for each other, feel close to each other, or support each other? No Yes
5. Did you often or very often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you, or were your parents too drunk or high to take care of you or take you to the doctor if you needed it? No Yes
6. Were your parents ever separated or divorced? No Yes
7. Was your mother or stepmother often or very often pushed, grabbed, or slapped, or did she have something thrown at her; was she sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard or ever repeatedly hit over at least a few minutes or threatened with a gun or knife? No Yes
8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? No Yes
9. Was a household member depressed or mentally ill, or did a household member attempt suicide? No Yes
10. Did a household member go to prison?

To get your ACE score, add up your “yes” answers.

No Yes

Download a copy of the ACE Screening Questionnaire.

6 Strategies to Lower the Effects of Toxic Stress 

Each of these interventions targets the body’s dysregulated stress-response system. Regardless of your age, Harris recommends maximizing all six to reduce stress hormones, lower inflammation, and enhance neuroplasticity. 

  1. Eat a well-balanced diet to help reduce cortisol levels. (See “How Trauma Affects Our Eating Habits” for more.)
  2. Prioritize sleep to regulate your mood, stress-hormone levels, and metabolism, and to maintain your immunity.
  3. Exercise for about one hour daily. (Why? See “How Exercise Heals“.)
  4. Practice mindfulness or meditation to help you find calm when you get triggered.
  5. Seek help from a mental-health provider with experience helping those recovering from trauma.
  6. Build healthy relationships. Having just one safe, sustaining relationship with an adult can buffer the effects of stressful childhood events. 

This originally appeared as “The Deepest Well” in the January-February 2019 print issue of Experience Life.

Illustration by: Jon Krause

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  1. consider adding parental or sibling suicide

    consider adding shunning or abandonment or ridicule by a much older sibling (10+ years older)

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