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

Prevoditelj: Anja Kolobarić Recezent: Ivan Stamenković

In the mid-'90s,

Sredinom devedesetih

the CDC and Kaiser Permanente

CDC i Kaiser Permanente

discovered an exposure that dramatically increased the risk

otkrili su izloženost koja značajno povećava rizik

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

za sedam od deset vodećih uzroka smrti u SAD-u.

In high doses, it affects brain development,

Visoke razine utječu na razvoj mozga,

the immune system, hormonal systems,

imunološki i endokrini sustav,

and even the way our DNA is read and transcribed.

pa čak i način na koji se naš DNK čita i prepisuje.

Folks who are exposed in very high doses

Oni koji su izloženi visokim razinama

have triple the lifetime risk of heart disease and lung cancer

imaju triput veće šanse obolijevanja od bolesti srca i raka pluća

and a 20-year difference in life expectancy.

i dvadeset godina kraći životni vijek,

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

no suvremeni doktori nisu dovoljno obučeni za rutinske preglede i liječenja.

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

Izloženost o kojoj ovdje govorim nisu pesticidi ili kemikalije,

It's childhood trauma.

već se radi o traumama iz djetinjstva.

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

A o kakvim traumama govorim?

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

Ne mislim na jedinicu iz testa ili poraz na košarkaškoj utakmici.

I am talking about threats that are so severe or pervasive

Mislim na prijetnje koje su toliko ozbiljne ili sveobuhvatne

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

da nam se doslovno zavuku pod kožu i promijene nam psihu:

things like abuse or neglect,

stvari poput zlostavljanja, zanemarivanja,

or growing up with a parent who struggles with mental illness

odrastanja s roditeljem koji pati od duševne bolesti

or substance dependence.

ili koji je ovisnik.

Now, for a long time,

E sad, dugo sam

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

promatrala te stvari onako kako su me učili da ih promatram,

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

ili kao društveni problem koji se tiče socijalnih službi -

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

ili kao duševni problem koji se tiče službi za mentalno zdravlje.

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

No onda se dogodilo nešto zbog čega sam preispitala svoj pristup.

When I finished my residency,

Kada sam završila sa stažiranjem,

I wanted to go someplace where I felt really needed,

htjela sam otići negdje gdje sam mislila da sam zaista potrebna,

someplace where I could make a difference.

negdje gdje bih mogla nešto promijeniti,

So I came to work for California Pacific Medical Center,

pa sam otišla raditi za CPMC,

one of the best private hospitals in Northern California,

jednu od najboljih privatnih bolnica u Sjevernoj Kaliforniji

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

i zajedno smo otvorili kliniku u Bayview-Hunters Pontu,

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

jednom od najsiromašnijih, najzanemarenijih kvartova u San Francisku.

Now, prior to that point,

Prije toga

there had been only one pediatrician in all of Bayview

postojao je samo jedan pedijatar u cijelom Bayviewu

to serve more than 10,000 children,

koji je bio zadužen za više od 10 000 djece,

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

pa smo postavili pločicu i mogli smo pružiti kvalitetnu njegu

regardless of ability to pay.

bez obzira na sposobnost plaćanja.

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

Bilo je jako fora. Bavili smo se tipičnim zdravstvenim nejednakostima:

access to care, immunization rates, asthma hospitalization rates,

pristup brizi, razine imunizacije, razine hospitalizacije zbog astme

and we hit all of our numbers.

i postigli sve naše brojeve.

We felt very proud of ourselves.

Bili smo jako ponosni na sebe,

But then I started noticing a disturbing trend.

ali onda sam počela primjećivati jedan uznemirujući trend.

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

Mnogo mi je djece bilo poslano zbog sumnje na ADHD,

or Attention Deficit Hyperactivity Disorder,

odnosno poremećaja hiperaktivnosti i deficita pažnje,

but when I actually did a thorough history and physical,

ali nakon što sam obavila detaljan pregled povijesti bolesti i sistematski,

what I found was that for most of my patients,

otkrila sam da većini pacijenata

I couldn't make a diagnosis of ADHD.

ne mogu dijagosticirati ADHD.

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

Većina djece koja su mi dolazila doživjela su toliko teške traume

that it felt like something else was going on.

da se činilo kao da se nešto drugo događa.

Somehow I was missing something important.

Nekako mi je promaklo nešto bitno.

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

Prije nego što sam odstažirala, dobila sam diplomu za javno zdravstvo,

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

a jedna od stvari kojima te tamo nauče

is that if you're a doctor

jest da ukoliko ste doktor

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

i vidite 100 djece koja piju iz istog bunara,

and 98 of them develop diarrhea,

a 98 dobije proljev,

you can go ahead and write that prescription

slobodno možete napisati

for dose after dose after dose of antibiotics,

ispisati recepata i recepata za antibiotike

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

ili možete doći i zapitati: "Što nije u redu s ovim bunarom?"

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

Počela sam čitati sve što sam stigla

about how exposure to adversity

o tome kako izloženost nedaćama

affects the developing brains and bodies of children.

utječe na razvoj mozga i tijela u djece.

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

Jednog dana kolega mi je došao u ured

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

i rekao: "Dr. Burke, jeste li vidjeli ovo?"

In his hand was a copy of a research study

U ruci je držao kopiju istraživanja

called the Adverse Childhood Experiences Study.

pod nazivom: "Studija o nepovoljnim iskustvima u djetinjstvu."

That day changed my clinical practice and ultimately my career.

Taj mi je dan promijenio i kliničku praksu, a i karijeru.

The Adverse Childhood Experiences Study

To je istraživanje

is something that everybody needs to know about.

nešto s čime svatko treba biti upoznat.

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

Proveo ga je Dr. Vince Felitti na Kaiseru i Dr. Bob Anda na CDC-u.

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

Zajedno su ispitali 17 500 odraslih o njihovoj povijesti izloženosti

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

nečemu što su nazvali "nepovoljna iskustva u djetinjstvu", tj. ACE.

Those include physical, emotional, or sexual abuse;

Ta iskustva uključuju fizičko, emocionalno i seksualno zlostavljanje;

physical or emotional neglect;

fizičko ili emocionalno zanemarivanje;

parental mental illness, substance dependence, incarceration;

duševna bolest roditelja, ovisnost, zatvorski staž;

parental separation or divorce;

odvajanje roditelja ili razvod;

or domestic violence.

nasilje u obitelji.

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

Za svako "da", dobijete bod na ACE-testu.

And then what they did

Zatim su

was they correlated these ACE scores against health outcomes.

usporedili ACE-rezultate i zdravstvene ishode.

What they found was striking.

Saznanja su bila zapanjujuća.

Two things:

Dvije stvari.

Number one, ACEs are incredibly common.

Prvo, ACE-ovi su jako uobičajeni.

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

Čak 67% populacije imalo je barem jedan ACE,

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

a 12,6%, svaki osmi ispitanik, imao je 6 ili više ACE-ova.

The second thing that they found

Drugo -

was that there was a dose-response relationship

postoji odnos doza - odgovor

between ACEs and health outcomes:

između ACE-ova i ishoda zdravlja:

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

što je ACE-rezultat viši, to su gori ishodi zdravlja.

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

Osoba s ACE-rezultatom od četiri pa naviše

their relative risk of chronic obstructive pulmonary disease

ima veći relativni rizik od kroničnih respiratornih poremećaja

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

dva i pol puta veći od nekoga s ACE-rezultatom od nula.

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

Za hepatitis također dva i pol puta.

For depression, it was four and a half times.

Za depresiju četiri i pol puta.

For suicidality, it was 12 times.

Za sklonost samoubojstvu dvanaest puta.

A person with an ACE score of seven or more

Osoba s ACE-rezultatom od sedam pa naviše

had triple the lifetime risk of lung cancer

ima triput veće rizike za obolijevanje od raka pluća

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

i tri i pol puta za obolijevanje od ishemičke bolesti srca,

the number one killer in the United States of America.

vodećeg uzroka smrti u SAD-u.

Well, of course this makes sense.

Naravno, to ima smisla.

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

Neki su proučili te rezultate i rekli: "Ma daj!

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

Imao si teško djetinjstvo, pa si skloniji pušenju i opijanju,

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

a sve će ti te stvari uništiti zdravlje.

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

To nije znanost, to je samo loše ponašanje."

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

Ispada da znanost upravo tu uskače.

We now understand better than we ever have before

Sad bolje nego ikad razumijemo

how exposure to early adversity

kako izloženost ranim nedaćama

affects the developing brains and bodies of children.

utječe na razvoj mozga i tijela u djece.

It affects areas like the nucleus accumbens,

Utječe na područja poput nucleus accumbensa,

the pleasure and reward center of the brain

centra u mozgu zaduženog za užitak i nagradu

that is implicated in substance dependence.

koji je zahvaćen u ovisnostima.

It inhibits the prefrontal cortex,

On onemogućuje prednju koru mozga

which is necessary for impulse control and executive function,

koja je nužna za kontroliranje impulsa te izvršnu funkciju,

a critical area for learning.

ključno područje za učenje.

And on MRI scans,

Na MR-skeniranju

we see measurable differences in the amygdala,

vidljive su mjerljive razlike u amigdali,

the brain's fear response center.

centru u mozgu zaduženog za reakciju na strah.

So there are real neurologic reasons

Pravi neurološki razlozi objašnjavaju

why folks exposed to high doses of adversity

zašto su oni koji su izloženi visokim razinama nedaća

are more likely to engage in high-risk behavior,

skloniji visokorizičnim oblicima ponašanja,

and that's important to know.

a to je važno znati.

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

No, čak i ako se ne uključite u visokorizična ponašanja,

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

još ste uvijek skloniji obolijevanju od bolesti srca ili od raka.

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

Razlog za to ima veze s hipotalamusom, hipofizom i nadbubrežnom žlijezdom,

the brain's and body's stress response system

sustavom reakcije na stres mozga i tijela

that governs our fight-or-flight response.

što upravlja reakcijama za borbu ili bijeg.

How does it work?

Kako funkcionira?

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

Zamislite da šetate šumom i ugledate medvjeda.

Immediately, your hypothalamus sends a signal to your pituitary,

Hipotalamus odmah šalje signal hipofizi

which sends a signal to your adrenal gland that says,

koja šalje signal nadbubrežnoj žlijezdi:

"Release stress hormones! Adrenaline! Cortisol!"

"Pusti hormone stresa! Adrenalin! Kortizol!"

And so your heart starts to pound,

Srce vam počne lupati,

Your pupils dilate, your airways open up,

zjenice se prošire, zračni putevi otvore

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

i spremni ste ili na borbu s medom ili na bijeg od njega.

And that is wonderful

To je super

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

ako ste u šumi i naletite na medu.

(Laughter)

(Smijeh)

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

No problem nastaje kad medo dolazi kući svake noći,

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

a ovaj se sustav iznova i iznova aktivira

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

te od prilagodbenog sustava ili sustava za spašavanje života

to maladaptive, or health-damaging.

preraste u maladaptivni sustav ili sustav koji ugrožava zdravlje.

Children are especially sensitive to this repeated stress activation,

Djeca su posebno osjetljiva na ovakvu ponovljenu aktivaciju stresa

because their brains and bodies are just developing.

jer im se mozak i tijelo još uvijek razvijaju.

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

Visoke razine nedaća ne utječu samo na strukturu i funkcioniranje mozga

they affect the developing immune system,

već i na razvoj imunološkog

developing hormonal systems,

i endokrinog sustava,

and even the way our DNA is read and transcribed.

pa čak na način na koji se naš DNK čita i prepisuje.

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

Ovi podatci za mene potpuno su obezvrijedili moje dotadašnje znanje

because when we understand the mechanism of a disease,

jer kad razumijemo mehanizam bolesti,

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

kad znamo ne samo koji su putevi zapriječeni već i kako,

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

onda smo kao doktori dužni iskoristiti tu znanost

for prevention and treatment.

za prevenciju i liječenje.

That's what we do.

To je naš posao.

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

U San Francisku otvorili smo Centar za zdravlje mladih

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

kako bismo spriječili, uočili i zaliječili utjecaje ACE-a i toksičnog stresa.

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

Počeli smo s rutinskim pregledima svakog djeteta

at their regular physical,

na redovnim sistematskim

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

jer znam da ukoliko moja pacijentica ima ACE-rezultat od 4 i naviše,

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

dva i pol puta je sklonija obolijevanju od hepatitisa ili kroničnih bolesti,

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

četiri i pol puta je sklonija depresiji

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

i dvanaest puta sklonija pokušati oduzeti vlastiti život

as my patient with zero ACEs.

u usporedbi s pacijentima s rezultatom 0.

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

Znam to dok se nalazi u mojoj ordinaciji.

For our patients who do screen positive,

Za pacijente koji ostvare pozitivan rezultat

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

imamo tim multidisciplinarnog tretmana koji pokušava smanjiti razinu nedaća

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

i liječiti simptome koristeći se najboljim postupcima poput kućnih posjeta, njege,

mental health care, nutrition,

brige za duševno zdravlje, prehrane,

holistic interventions, and yes, medication when necessary.

holističkih zahvata, pa i lijekova kada je to potrebno.

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

Također educiramo roditelje o učincima ACE-a i toksičnog stresa

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

onako kako ih educiramo o prekrivanju utičnica ili trovanju živom,

and we tailor the care of our asthmatics and our diabetics

a brigu o astmatičarima i dijabetičarima oblikujemo

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

na način koji ukazuje na to da će im možda trebati agresivniji tretman

given the changes to their hormonal and immune systems.

imajući u vidu njihov endokrini i imunološki sustav.

So the other thing that happens when you understand this science

Kad shvatite tu znanost,

is that you want to shout it from the rooftops,

poželite o njoj vikati na sav glas

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

jer to nije problem samo djece u Bayviewu.

I figured the minute that everybody else heard about this,

Pretpostavila sam da će čim svi čuju za to,

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

uslijediti rutinski pregledi, multidisciplinarni timovi za tretiranje

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

te da će se utrkivati do najuspješnijih protokola kliničkih tretmana.

Yeah. That did not happen.

Aha, to se nije dogodilo.

And that was a huge learning for me.

Puno sam naučila iz toga.

What I had thought of as simply best clinical practice

Ono što sam smatrala najboljom kliničkom praksom

I now understand to be a movement.

sada smatram pokretom.

In the words of Dr. Robert Block,

Riječima dr. Roberta Blocka,

the former President of the American Academy of Pediatrics,

bivšeg predsjednika Američke pedijatrijske akademije,

"Adverse childhood experiences

"Nepovoljna iskustva u djetinjstvu

are the single greatest unaddressed public health threat

jedan su od najvećih zanemarenih prijetnji javnom zdravstvu

facing our nation today."

naše nacije."

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

Mnoge ljude to zaprepašćuje.

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

Domet i težina problema čine se toliko veliki da je previše

to think about how we might approach it.

čak i razmišljati o tome kako se s njim suočiti,

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

ali meni baš ta činjenica daje nadu

because when we have the right framework,

jer kad imamo pravi okvir,

when we recognize this to be a public health crisis,

kada ovo prepoznamo kao zdravstvenu krizu,

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

tek ćemo onda početi koristiti pravu opremu da dođemo do pravih rješenja.

From tobacco to lead poisoning to HIV/AIDS,

Od nikotina, trovanja živom, pa sve do HIV-a/AIDS-a

the United States actually has quite a strong track record

SAD ima dobar učinak

with addressing public health problems,

po pitanju bavljenja zdravstvenim pitanjima,

but replicating those successes with ACEs and toxic stress

ali ponavljanje tih uspjeha s ACE-ovima i toksičnim stresom

is going to take determination and commitment,

zahtijevat će odlučnost i predanost,

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

a kada pogledam kako se dosad prema tome odnosila naša nacija,

I wonder,

pitam se,

why haven't we taken this more seriously?

zašto to nismo ozbiljnije shvatili?

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

U početku sam mislila da smo marginalizirali problem

because it doesn't apply to us.

jer nas se ne tiče.

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

Tiče se one djece u onim kvartovima,

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

što je čudno jer podatci to ne pokazuju.

The original ACEs study was done in a population

Originalno ACE-istraživanje obavljeno je na populaciji

that was 70 percent Caucasian,

od 70% bijelaca,

70 percent college-educated.

70% fakultetski obrazovanih ljudi,

But then, the more I talked to folks,

ali što više razgovaram s ljudima,

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

to više počinjem misliti da sam sve krivo shvatila.

If I were to ask how many people in this room

Da pitam koliko je ljudi u ovoj prostoriji

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

odraslo uz člana obitelji koji je bolovao od duševne bolesti,

I bet a few hands would go up.

kladim se da bi nekoliko podiglo ruke.

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

A da vas pitam koliko vas je imalo roditelja koji je pio

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

ili koji su vjerovali da je "batina u raju izrasla",

I bet a few more hands would go up.

kladim se da bi još nekoliko podiglo ruke.

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

Čak i u ovoj prostoriji, to je problem koji se tiče mnogih od nas

and I am beginning to believe that we marginalize the issue

i počinjem vjerovati da marginaliziramo taj problem

because it does apply to us.

jer nas se tiče.

Maybe it's easier to see in other zip codes

Možda ga je lakše uočiti drugdje

because we don't want to look at it.

jer mi sami ne želimo gledati u njega.

We'd rather be sick.

Radije bismo bili bolesni.

Fortunately, scientific advances and, frankly, economic realities

Srećom, napredak znanosti i gospodarske realnosti

make that option less viable every day.

tu mogućnost čine sve manje održivom.

The science is clear:

Znanost je jasna;

Early adversity dramatically affects health across a lifetime.

rane nedaće znatno utječu na cjeloživotno zdravlje.

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

Tek sad počinjemo shvaćati kako omesti napredak

from early adversity to disease and early death,

od rane nedaće do bolesti i preuranjene smrti,

and 30 years from now,

a za trideset godina,

the child who has a high ACE score

to dijete s visokim ACE-rezultatom,

and whose behavioral symptoms go unrecognized,

čiji se bihevioralni simptomi ne primijete,

whose asthma management is not connected,

čije se liječenje astme ne povezuje

and who goes on to develop high blood pressure

i koji oboli od visokog tlaka,

and early heart disease or cancer

preuranjene bolesti srca ili raka

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

bit će jednako anomalan kao i šestomjesečna smrtnost od HIV-a/AIDS-a.

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

Ljudi promotre situaciju i zapitaju se: "Što se to ovdje događa?"

This is treatable.

To se može liječiti,

This is beatable.

može se pobijediti.

The single most important thing that we need today

Najvažnija stvar koja nam je u današnje vrijeme potrebna

is the courage to look this problem in the face

jest hrabrost da se suočimo s problemom

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

i kažemo da je stvaran i da se tiče svih nas.

I believe that we are the movement.

Vjerujem da smo mi taj pokret.

Thank you.

Hvala vam.

(Applause)

(Pljesak)