How Childhood Adversity Creates Toxic Stress

Pioneering pediatrician Nadine Burke Harris is transforming how public-health advocates respond to the toxic stress created by childhood adversity. Here, she shares her prescription for healing.

illustration of man looking into a well and seeing a childhood reflection

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

ACE Questionnaire

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

is an Experience Life staff writer.

Illustration by Jon Krause

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