How childhood trauma affects health across a lifetime | Nadine Burke Harris | TED

Translator: Inés San Luís Rodríguez Reviewer: Serv. de Norm. Lingüística U. de Santiago de Compostela

In the mid-'90s,

A mediados da década de 1990,

the CDC and Kaiser Permanente

o CDC (centro oficial para o control de enfermidades) e Kaiser Permanente

discovered an exposure that dramatically increased the risk

descubriron un tipo de exposición que aumentaba gravemente o risco

for seven out of 10 of the leading causes of death in the United States.

de sete das dez causas principais de morte nos Estados Unidos.

In high doses, it affects brain development,

En doses altas, afecta ao desenvolvemento cerebral,

the immune system, hormonal systems,

ao sistema inmunitario, ao sistema endócrino,

and even the way our DNA is read and transcribed.

e ata ao xeito no que o noso ADN é lido e replicado.

Folks who are exposed in very high doses

Os que están expostos a doses moi altas

teńen tres veces máis risco de ter doenzas cardíacas e cáncer de pulmón

have triple the lifetime risk of heart disease and lung cancer

and a 20-year difference in life expectancy.

e a súa esperanza de vida é 20 anos menor.

And yet, doctors today are not trained in routine screening or treatment.

Malia así, os nosos médicos non están preparados para detectala nin tratala.

A exposición da que estou a falar non é a un praguicida, nin a un produto químico.

Now, the exposure I'm talking about is not a pesticide or a packaging chemical.

It's childhood trauma.

É ao trauma infantil.

Okay. What kind of trauma am I talking about here?

Xa, de que trauma estou a falar?

I'm not talking about failing a test or losing a basketball game.

Non me refiro a suspender un exame ou perder un partido de baloncesto.

I am talking about threats that are so severe or pervasive

Refírome a ameazas tan graves e penetrantes

that they literally get under our skin and change our physiology:

que literalmente se meten baixo a nosa pel e cambian a nosa fisioloxía:

cousas como o abuso ou o abandono,

things like abuse or neglect,

or growing up with a parent who struggles with mental illness

ou crecer cun pai ou unha nai que sofre unha enfermidade mental

or substance dependence.

ou drogodependencia.

Now, for a long time,

Durante moito tempo,

I viewed these things in the way I was trained to view them,

eu vía estas cousas como me ensinaron a velas:

ou ben como un problema social --remitir aos servizos sociais--

either as a social problem -- refer to social services --

or as a mental health problem -- refer to mental health services.

ou como un problema de saúde mental --remitir aos servizos de saúde mental.

Pero logo aconteceu algo que me fixo reformular todo o meu enfoque.

And then something happened to make me rethink my entire approach.

When I finished my residency,

Cando rematei a mińa residencia,

I wanted to go someplace where I felt really needed,

quería ir a un sitio onde realmente me precisaran,

un sitio no que marcar a diferenza.

someplace where I could make a difference.

Así que fun a traballar para o California Pacific Medical Center,

So I came to work for California Pacific Medical Center,

one of the best private hospitals in Northern California,

un dos mellores hospitais privados do norte de California,

and together, we opened a clinic in Bayview-Hunters Point,

e xuntos abrimos unha clínica en Bayview-Hunters Point,

un dos barrios máis pobres e desfavorecidos de San Francisco.

one of the poorest, most underserved neighborhoods in San Francisco.

Now, prior to that point,

Ata aquel entón,

había unha única pediatra para todo Bayview

there had been only one pediatrician in all of Bayview

to serve more than 10,000 children,

que atendía a máis de 10 000 nenos.

so we hung a shingle, and we were able to provide top-quality care

Así que abrimos a clínica e ofrecemos atención sanitaria de alta calidade

regardless of ability to pay.

sen mirar a capacidade para pagar.

It was so cool. We targeted the typical health disparities:

Era impresionante. Centrámonos nas típicas desigualdades sanitarias:

access to care, immunization rates, asthma hospitalization rates,

acceso á atención sanitaria, taxas de inmunización,

taxas de hospitalización por asma, e tivemos moi bos resultados.

and we hit all of our numbers.

We felt very proud of ourselves.

Sentiámonos moi orgullosos.

But then I started noticing a disturbing trend.

Mais comecei a notar unha tendencia un tanto preocupante.

A lot of kids were being referred to me for ADHD,

Chegábanme moitos nenos con TDAH,

or Attention Deficit Hyperactivity Disorder,

trastorno por déficit de atención con hiperactividade,

but when I actually did a thorough history and physical,

pero en canto lles facía un exame clínico

what I found was that for most of my patients,

descubría que, á maioría deles, non os podía diagnosticar con TDAH.

I couldn't make a diagnosis of ADHD.

Most of the kids I was seeing had experienced such severe trauma

A maioría dos nenos que trataba

sufriran un trauma tan grave que sentía que había algo máis.

that it felt like something else was going on.

Dalgún xeito estaba pasando por alto algún detalle importante.

Somehow I was missing something important.

Now, before I did my residency, I did a master's degree in public health,

Antes de facer a mińa residencia, fixen un máster en saúde pública

and one of the things that they teach you in public health school

e unha das cousas que alí che ensinan é que se es doutor

is that if you're a doctor

e ves 100 nenos beber do mesmo pozo e 98 deles contraen diarrea

and you see 100 kids that all drink from the same well,

and 98 of them develop diarrhea,

you can go ahead and write that prescription

podes prescribir dose tras dose tras dose de antibióticos

for dose after dose after dose of antibiotics,

ou podes ir alí e preguntarte: Arre demo, pero que hai neste pozo?

or you can walk over and say, "What the hell is in this well?"

So I began reading everything that I could get my hands on

Así que lin todo o que atopei sobre como a exposición á adversidade

about how exposure to adversity

affects the developing brains and bodies of children.

afecta os cerebros e os corpos en desenvolvemento dos nenos.

And then one day, my colleague walked into my office,

Entón, un día, un compańeiro entrou no meu despacho

and he said, "Dr. Burke, have you seen this?"

e dixo: Dra. Burke, viches isto?

In his hand was a copy of a research study

Na súa man había unha copia dun estudo

called the Adverse Childhood Experiences Study.

chamado "Estudo sobre experiencias adversas na infancia"

That day changed my clinical practice and ultimately my career.

Aquel día cambiou a mińa práctica clínica e, en última instancia, a mińa carreira.

The Adverse Childhood Experiences Study

O “Estudo sobre experiencias adversas na infancia”

is something that everybody needs to know about.

é algo que todos deberiamos cońecer.

It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC,

Foi elaborado polo Dr. Vince Felitti de Kaiser e o Dr. Bob Anda do CDC.

Xuntos, preguntáronlles a 17 500 adultos

and together, they asked 17,500 adults about their history of exposure

sobre o seu historial de exposición a "experiencias infantís adversas" ou EIA.

to what they called "adverse childhood experiences," or ACEs.

Those include physical, emotional, or sexual abuse;

Estas inclúen o maltrato físico e psicolóxico e o abuso sexual,

physical or emotional neglect;

abandono físico ou emocional,

enfermidade mental dos pais, drogodependencia ou encarceramento,

parental mental illness, substance dependence, incarceration;

parental separation or divorce;

separación ou divorcio dos pais ou violencia doméstica.

or domestic violence.

Por cada "si", recibías un punto na túa puntuación EIA.

For every yes, you would get a point on your ACE score.

And then what they did

Logo, correlacionaron estas puntuacións cos problemas de saúde.

was they correlated these ACE scores against health outcomes.

What they found was striking.

O que atoparon foi sorprendente.

Two things:

Dúas cousas:

Number one, ACEs are incredibly common.

A primeira, as EIA son incriblemente comúns.

Sixty-seven percent of the population had at least one ACE,

O 67% da poboación tińa polo menos unha EIA.

and 12.6 percent, one in eight, had four or more ACEs.

E o 12.6%, 1 de cada 8, tińa catro ou máis.

The second thing that they found

A segunda cousa que descubriron

was that there was a dose-response relationship

foi que había unha relación dose-resposta entre as EIA e a saúde.

between ACEs and health outcomes:

Canto máis alta a puntuación EIA, peor a túa saúde.

the higher your ACE score, the worse your health outcomes.

For a person with an ACE score of four or more,

Para unha persoa cunha puntuación de 4 ou máis,

o risco relativo de ter unha doenza pulmonar obstrutiva crónica

their relative risk of chronic obstructive pulmonary disease

was two and a half times that of someone with an ACE score of zero.

era 2.5 veces maior que o de alguén cunha puntuación EIA de cero.

Tamén era 2.5 veces maior para hepatite.

For hepatitis, it was also two and a half times.

For depression, it was four and a half times.

Para depresión era 4.5 veces maior.

For suicidality, it was 12 times.

Para suicidio xa era 12 veces maior.

A person with an ACE score of seven or more

Unha persoa cunha puntuación de 7 ou máis

had triple the lifetime risk of lung cancer

ten 3 veces máis probabilidades de padecer cáncer de pulmón

and three and a half times the risk of ischemic heart disease,

e 3.5 veces máis risco de cardiopatía isquémica,

the number one killer in the United States of America.

a causa principal de morte nos Estados Unidos.

Ben, por suposto que isto ten sentido!

Well, of course this makes sense.

Some people looked at this data and they said, "Come on.

Algúns viron estes datos e dixeron

"Se tes unha infancia difícil, es máis propenso a fumar, beber

You have a rough childhood, you're more likely to drink and smoke

and do all these things that are going to ruin your health.

e facer todas esas cousas que arruinarán a túa saúde.

This isn't science. This is just bad behavior."

Isto non é ciencia. Tan so é mal comportamento."

It turns out this is exactly where the science comes in.

Pero resulta que é precisamente aí onde intervén a ciencia.

Agora entendemos máis que nunca como a exposición temperá á adversidade

We now understand better than we ever have before

how exposure to early adversity

affects the developing brains and bodies of children.

afecta o cerebro e o corpo en desenvolvemento dos nenos.

It affects areas like the nucleus accumbens,

Afecta a áreas como o núcleo accumbens, centro de pracer e recompensa do cerebro,

the pleasure and reward center of the brain

involucrado na drogodependencia.

that is implicated in substance dependence.

It inhibits the prefrontal cortex,

Inhibe o cortéx prefrontal necesario para o control dos impulsos

which is necessary for impulse control and executive function,

así como para a función executiva, unha área crucial para a aprendizaxe.

a critical area for learning.

And on MRI scans,

E, en resonancias magnéticas,

we see measurable differences in the amygdala,

vense cambios significativos na amígdala, o centro de resposta ao medo do cerebro.

the brain's fear response center.

Así que hai razóns neurolóxicas reais

So there are real neurologic reasons

why folks exposed to high doses of adversity

que explican por que a xente exposta a altas doses de adversidade

é máis propensa a adoptar comportamentos de alto risco.

are more likely to engage in high-risk behavior,

and that's important to know.

E é importante sabelo.

But it turns out that even if you don't engage in any high-risk behavior,

Pero resulta que incluso se non adoptas ningún comportamento de alto risco,

segues a ter máis probabilidades de ter enfermidades cardíacas ou cáncer.

you're still more likely to develop heart disease or cancer.

O motivo ten que ver co eixe hipotalámico-hipofisario-adrenal,

The reason for this has to do with the hypothalamic–pituitary–adrenal axis,

o sistema corporal e cerebral de resposta ao estrés

the brain's and body's stress response system

that governs our fight-or-flight response.

encargado de gobernar a nosa resposta de loita ou fuxida.

How does it work?

Como funciona?

Ben, imaxina que estás camińando polo bosque e ves un oso.

Well, imagine you're walking in the forest and you see a bear.

Inmediatamente, o hipotálamo envía un sinal á glándula pituitaria

Immediately, your hypothalamus sends a signal to your pituitary,

which sends a signal to your adrenal gland that says,

que envía outro sinal á glándula suprarrenal que di:

"Release stress hormones! Adrenaline! Cortisol!"

Liberade hormonas do estrés! Adrenalina! Cortisol!

And so your heart starts to pound,

O teu corazón comeza a latexar con forza, as túas pupilas dilátanse,

Your pupils dilate, your airways open up,

as túas vías respiratorias ábrense

and you are ready to either fight that bear or run from the bear.

e ti estás listo para loitar contra ese oso ou para escapar del.

And that is wonderful

E iso é estupendo! Se estás no bosque e hai un oso.

if you're in a forest and there's a bear.

(Risas)

(Laughter)

But the problem is what happens when the bear comes home every night,

Pero o problema é qué ocorre cando o oso vén á casa tódalas noites

e este sistema se activa unha vez tras doutra,

and this system is activated over and over and over again,

and it goes from being adaptive, or life-saving,

deixando de ser adaptable ou capaz de salvar unha vida,

to maladaptive, or health-damaging.

para ser pouco adaptable ou prexudicial para a saúde.

Os nenos son especialmente sensibles a esta activación repetitiva polo estrés,

Children are especially sensitive to this repeated stress activation,

porque os seus cerebros e corpos aínda se están desenvolvendo.

because their brains and bodies are just developing.

As doses altas de adversidade non afectan só á estrutura e ás funcións do cerebro,

High doses of adversity not only affect brain structure and function,

senón tamén ao sistema inmunolóxico, ao sistema endócrino,

they affect the developing immune system,

developing hormonal systems,

e incluso ao xeito no que se le e transcribe o noso ADN.

and even the way our DNA is read and transcribed.

A min, esta información fíxome tirar pola borda todo o que aprendera

So for me, this information threw my old training out the window,

because when we understand the mechanism of a disease,

porque cando entendemos o mecanismo dunha enfermidade,

when we know not only which pathways are disrupted, but how,

cando sabemos non só que vías están danadas senón tamén como,

then as doctors, it is our job to use this science

o noso traballo como médicos

é empregar a ciencia para previlo e tratalo.

for prevention and treatment.

That's what we do.

Iso é o que facemos.

So in San Francisco, we created the Center for Youth Wellness

Así que en San Francisco, creamos o Centro para o Benestar da Mocidade

to prevent, screen and heal the impacts of ACEs and toxic stress.

para previr, diagnosticar e curar o impacto das EIA e do estrés tóxico.

We started simply with routine screening of every one of our kids

Comezamos só con revisións rutineiras de tódolos nosos nenos

at their regular physical,

durante as súas visitas habituais,

because I know that if my patient has an ACE score of 4,

porque sei que se a mińa paciente ten unha puntuación EIA de 4,

ten 2.5 veces máis probabilidades de padecer hepatite ou DPOC,

she's two and a half times as likely to develop hepatitis or COPD,

she's four and half times as likely to become depressed,

é 4.5 veces máis propensa a ter depresión

and she's 12 times as likely to attempt to take her own life

e ten 12 veces máis probabilidades de intentar suicidarse

as my patient with zero ACEs.

que o meu paciente con EIA cero.

I know that when she's in my exam room.

Iso seino cando está no meu consultorio.

Para os pacientes que dan positivo, contamos cun equipo multidisciplinario

For our patients who do screen positive,

we have a multidisciplinary treatment team that works to reduce the dose of adversity

que traballa para reducir as doses de adversidade

and treat symptoms using best practices, including home visits, care coordination,

e tratar os síntomas coas mellores técnicas,

incluíndo visitas a domicilio, coordinación da atención,

mental health care, nutrition,

atención psiquiátrica, nutrición,

intervencións holísticas e, se é necesario, medicación.

holistic interventions, and yes, medication when necessary.

But we also educate parents about the impacts of ACEs and toxic stress

Pero tamén educamos aos pais sobre o impacto das EIA e o estrés tóxico

the same way you would for covering electrical outlets, or lead poisoning,

do mesmo xeito que o fariamos para falar de tapar os enchufes

ou sobre o envelenamento por chumbo,

and we tailor the care of our asthmatics and our diabetics

e adaptamos o coidado dos nosos asmáticos e diabéticos

in a way that recognizes that they may need more aggressive treatment,

para recońecer que quizais necesitan un tratamento máis agresivo

dados os cambios nos seus sistemas endócrinos e inmunolóxicos.

given the changes to their hormonal and immune systems.

So the other thing that happens when you understand this science

Outra cousa que sucede cando entendemos esta ciencia

is that you want to shout it from the rooftops,

é que o queremos gritar aos catro ventos

because this isn't just an issue for kids in Bayview.

porque isto non é un problema que afecte tan só aos nenos de Bayview.

I figured the minute that everybody else heard about this,

Eu pensaba que no momento en que todos souberan sobre isto

it would be routine screening, multi-disciplinary treatment teams,

habería rastrexos rutineiros, equipos multidisplinarios de tratamento

and it would be a race to the most effective clinical treatment protocols.

e habería unha carreira cara a protocolos máis eficaces de tratamento clínico.

Yeah. That did not happen.

Xa. Pois non pasou.

E foi unha gran lección para min.

And that was a huge learning for me.

O que pensara que ía ser a mellor práctica clínica

What I had thought of as simply best clinical practice

I now understand to be a movement.

hoxe entendo que é un movemento.

In the words of Dr. Robert Block,

En palabras do Dr. Robert Block,

the former President of the American Academy of Pediatrics,

ex presidente da Academia de Pediatría de EEUU:

"As EIA son a maior e a principal ameaza non resolta da saúde pública

"Adverse childhood experiences

are the single greatest unaddressed public health threat

á cal se enfronta hoxe en día a nosa nación."

facing our nation today."

And for a lot of people, that's a terrifying prospect.

E, para moita xente, esa é unha perspectiva aterradora.

A escala e o alcance do problema parecen tan grandes

The scope and scale of the problem seems so large that it feels overwhelming

que resulta desconsolador pensar como podemos abordalo.

to think about how we might approach it.

But for me, that's actually where the hopes lies,

Pero para min, en realidade, é aí onde radica a esperanza,

because when we have the right framework,

porque, se temos o marco axeitado,

when we recognize this to be a public health crisis,

se admitimos que isto é unha crise da saúde pública,

then we can begin to use the right tool kit to come up with solutions.

entón podemos empezar a usar as ferramentas axeitadas

para xerar solucións.

From tobacco to lead poisoning to HIV/AIDS,

Dende o tabaco ata o envelenamento por chumbo, pasando polo VIH,

the United States actually has quite a strong track record

os EEUU teńen, en realidade, unha traxectoria bastante sólida

with addressing public health problems,

á hora de abordar os problemas de saúde pública.

but replicating those successes with ACEs and toxic stress

Pero repetir eses éxitos coas EIA e o estrés tóxico

is going to take determination and commitment,

requirirá determinación e compromiso,

and when I look at what our nation's response has been so far,

e cando miro a reacción da nosa nación ata agora pregúntome:

I wonder,

why haven't we taken this more seriously?

Por que non tomamos isto máis en serio?

You know, at first I thought that we marginalized the issue

Ao comezo pensei que non lle damos importancia porque non nos afecta a nós,

because it doesn't apply to us.

That's an issue for those kids in those neighborhoods.

que era un problema dos deses barrios.

Which is weird, because the data doesn't bear that out.

O cal é estrańo porque os datos non mostran iso.

The original ACEs study was done in a population

O estudo orixinal de EIA realizouse cunha poboación

onde o 70% eran caucásicos e o 70% tińa educación superior.

that was 70 percent Caucasian,

70 percent college-educated.

But then, the more I talked to folks,

E canto máis falaba coa xente,

I'm beginning to think that maybe I had it completely backwards.

máis me daba conta de que, talvez, entendera todo ao revés.

If I were to ask how many people in this room

Se eu preguntara cantas persoas nesta sala foron criadas

nunha familia onde alguén tińa unha enfermidade mental,

grew up with a family member who suffered from mental illness,

I bet a few hands would go up.

aposto a que algún levantaría a man.

E se preguntara cantos tiveron un pai que bebía de máis

And then if I were to ask how many folks had a parent who maybe drank too much,

or who really believed that if you spare the rod, you spoil the child,

ou que cría que debía castigarte sempre que fixeras algo mal

apostaría que uns cantos máis levantarían a man.

I bet a few more hands would go up.

Even in this room, this is an issue that touches many of us,

Incluso nesta sala, este problema aféctanos a moitos de nós

e comezo a crer que non lle damos importancia porque si que nos afecta.

and I am beginning to believe that we marginalize the issue

because it does apply to us.

Maybe it's easier to see in other zip codes

Tal vez é máis fácil ver o problema noutros sitios,

because we don't want to look at it.

porque non queremos velo.

Antes preferiríamos estar enfermos.

We'd rather be sick.

Afortunadamente, os avances científicos e, francamente, a realidade económica

Fortunately, scientific advances and, frankly, economic realities

make that option less viable every day.

fan que esa opción sexa menos viable cada día.

The science is clear:

A ciencia é clara:

Early adversity dramatically affects health across a lifetime.

as adversidades da infancia afectan drasticamente a saúde de toda a vida.

Today, we are beginning to understand how to interrupt the progression

Hoxe en día, estamos comezando a entender como deter a progresión

from early adversity to disease and early death,

de adversidade temperá a enfermidade e morte prematura,

and 30 years from now,

e, en 30 anos, o neno cunha alta puntuación de EIA

the child who has a high ACE score

and whose behavioral symptoms go unrecognized,

cuxos síntomas no comportamento pasan desapercibidos,

whose asthma management is not connected,

cuxo control da asma non está correlacionado

and who goes on to develop high blood pressure

e que acaba desenvolvendo hipertensión,

and early heart disease or cancer

algunha enfermidade cardíaca ou cáncer a unha idade temperá

will be just as anomalous as a six-month mortality from HIV/AIDS.

será tan pouco usual como alguén cunha taxa de mortalidade para o VIH de 6 meses.

People will look at that situation and say, "What the heck happened there?"

A xente ao ver estes casos dirá: Arre demo, pero que pasou?

This is treatable.

Isto é tratable. Pódese superar.

This is beatable.

O máis importante que necesitamos hoxe

The single most important thing that we need today

is the courage to look this problem in the face

é o valor para enfrontar este problema e admitir que existe e nos afecta a todos.

and say, this is real and this is all of us.

Creo que nós mesmos somos o movemento.

I believe that we are the movement.

Thank you.

Grazas.

(Aplausos)

(Applause)