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

翻译人员: FBC GLOBAL 校对人员: Gena Volz

In the mid-'90s,

90年代中期,

the CDC and Kaiser Permanente

CDC和Kaiser Permanente发现:

discovered an exposure that dramatically increased the risk

暴露于某种事物中 会极大增加死亡风险,

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

七成美国民众的首要死因皆由此引起。

In high doses, it affects brain development,

暴露剂量较高时,会影响大脑发育,

the immune system, hormonal systems,

免疫系统,内分泌系统,

and even the way our DNA is read and transcribed.

甚至影响到基因的读取及转录方式。

Folks who are exposed in very high doses

暴露在极高剂量下的人群,

have triple the lifetime risk of heart disease and lung cancer

有3倍的风险患上心脏病和肺癌,

and a 20-year difference in life expectancy.

预期寿命缩短20年。

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

然而,目前医生们还未被培训 以常规筛查和治疗的手段来应对这种风险。

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

我所说的暴露危害并不针对 某种农药或包装上的化学物质。

It's childhood trauma.

而是儿童期创伤。

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

那么,我要说的是哪种创伤呢？

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

我要说的可不是 考试不及格或输掉篮球比赛。

I am talking about threats that are so severe or pervasive

我要说的是那种 如此严重而又无处不在的威胁,

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

以致于它让我们毛骨悚然, 并从生理上改变了我们：

things like abuse or neglect,

比如,受虐待或被忽视,

or growing up with a parent who struggles with mental illness

又或者,抚养我们的父母, 本身就深受精神疾病之苦,

or substance dependence.

或是深陷于"物质依赖"疾病。

Now, for a long time,

一直以来,

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

我都按照所教导的方式 来看待这些事情。

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

要么把它当成一个社会问题-- 交给社会服务去处理,

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

要么把它当成一个心理健康问题-- 交给心理健康咨询来解决。

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

后来发生了一些事情, 使我反思我的整个思维方式。

When I finished my residency,

在医院实习结束后,

I wanted to go someplace where I felt really needed,

我想去个我觉得真正需要我的地方,

someplace where I could make a difference.

去个我可以有所作为的地方。

So I came to work for California Pacific Medical Center,

因此，我选择为加利利福尼亚 太平洋医疗中心(CPMC)工作,

one of the best private hospitals in Northern California,

这是加利福尼亚北部 最优秀的私立医院之一,

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

我与该医院合作,在旧金山最穷、 社区服务最差的居民区--

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

湾景区猎人角（Bayview-Hunters Point） 开了一家诊所。

Now, prior to that point,

在此之前,

there had been only one pediatrician in all of Bayview

整个湾景区（Bayview）社区 仅有一名儿科医生,

to serve more than 10,000 children,

为一万多名儿童服务,

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

因此,我们开始挂牌营业, 提供最优质的医疗服务,

regardless of ability to pay.

不论是否有能力支付医疗费用。

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

这种感觉很棒。 我们找出了在医疗服务上现状与标准的差距：

access to care, immunization rates, asthma hospitalization rates,

普及医疗保健, 免疫接种率、哮喘住院率等,

and we hit all of our numbers.

我们都完成了达标。

We felt very proud of ourselves.

我们为自己感到骄傲。

But then I started noticing a disturbing trend.

但就在那时,我开始注意到 一种令人忧心的趋势。

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

很多孩子因为多动症（简称ADHD),

or Attention Deficit Hyperactivity Disorder,

被送到我这里进行医治,

but when I actually did a thorough history and physical,

可是,当我对孩子们的病史和 身体状况进行彻查时,

what I found was that for most of my patients,

却发现大多数患儿的情况,

I couldn't make a diagnosis of ADHD.

我无法下"多动症"(ADHD)的诊断。

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

多数来就诊的孩子都经历过 如此严重的创伤,

that it felt like something else was going on.

让人觉得似乎事情并不简单。

Somehow I was missing something important.

不知怎的,我漏查了某个重要的因素。

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

在实习之前,我曾攻读公共健康硕士学位,

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

在公共健康学校里, 我们曾学过这样的一课,

is that if you're a doctor

如果你是一名医生,

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

当你知道有100个孩子从 同一口井中饮水,

and 98 of them develop diarrhea,

其中98人患了腹泻,

you can go ahead and write that prescription

你可以着手治疗,

for dose after dose after dose of antibiotics,

给每个病人都开抗生素, 一剂,一剂,又一剂的开。

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

可是你也可以走去井边， 问声,"井里到底有什么鬼东西?"

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

所以,我开始查阅手头所有的相关资料,

about how exposure to adversity

了解暴露在不幸中,

affects the developing brains and bodies of children.

是如何影响儿童的大脑和身体发育的。

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

然后有一天, 一个同事走进我的办公室,

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

他问我,"伯克医生,你看过这个吗?"

In his hand was a copy of a research study

在他手里的是 一份调查研究的复印件,

called the Adverse Childhood Experiences Study.

题目是"童年不良经历(ACE)研究"。

That day changed my clinical practice and ultimately my career.

那一天,改变了我的临床实践, 也最终改变了我的职业生涯。

The Adverse Childhood Experiences Study

童年不良经历(ACE)的研究

is something that everybody needs to know about.

是每一个人都应该要了解的。

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

Vince Felitti博士和Bob Anda博士 分别在 Kaiser 和 CDC 进行了这项研究,

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

他们两人一起询问了17,500成年人,

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

了解他们的"童年不良经历",又称ACE。

Those include physical, emotional, or sexual abuse;

这包括生理上、情感上 遭受的不幸或是性侵害；

physical or emotional neglect;

生理或情感上遭受的忽视；

parental mental illness, substance dependence, incarceration;

父母患有精神疾病、物质依赖、遭到监禁；

parental separation or divorce;

父母分居或离婚；

or domestic violence.

或家庭暴力。

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

每个问题只要回答"是", ACE分数就增加一分。

And then what they did

接下来,

was they correlated these ACE scores against health outcomes.

他们将ACE分数与健康状况关联起来,

What they found was striking.

得出的结果是令人震惊的。

Two things:

结论有两点：

Number one, ACEs are incredibly common.

第一点,ACE十分普遍, 简直令人不可思议。

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

67%的人曾至少有一个ACE得分,

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

有12.6%（八分之一）的人 有四或四以上的ACE得分。

The second thing that they found

研究发现的第二点,

was that there was a dose-response relationship

是ACE与健康状况之间

between ACEs and health outcomes:

存在着一种剂量反应关系：

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

ACE得分越高,健康状况越糟糕。

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

如果一个人的ACE分数大于等于4分,

their relative risk of chronic obstructive pulmonary disease

他患慢性阻塞性肺病的相对风险

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

是ACE分数为0时的2.5倍。

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

患上肝炎的风险是2.5倍。

For depression, it was four and a half times.

而患上抑郁症的风险是4.5倍。

For suicidality, it was 12 times.

自杀风险是12倍。

A person with an ACE score of seven or more

ACE分数大于等于7的人

had triple the lifetime risk of lung cancer

终身都有3倍的风险患上肺癌,

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

和3.5倍的风险患上冠心病--

the number one killer in the United States of America.

这种目前在美国 当属头号杀手的疾病。

Well, of course this makes sense.

当然,这其实挺有道理。

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

有些人看了这些数据之后会说,

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

"好啦,你有个糟糕的童年, 你更容易酗酒和抽烟,

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

还去做一切 会毁掉你健康的事情。

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

这又不是科学,这只是坏的行为而已."

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

然而,事实证明我们恰恰要用科学来分析它。

We now understand better than we ever have before

目前,我们前所未有的更加理解

how exposure to early adversity

早年遭受的不幸

affects the developing brains and bodies of children.

会怎样影响儿童大脑和身体的发育。

It affects areas like the nucleus accumbens,

早年遭受的不幸会影响大脑的伏隔核 (nucleus accumbens)--

the pleasure and reward center of the brain

人脑中与快乐和奖赏相关 的处理中心,

that is implicated in substance dependence.

它与"物质依赖"疾病相关。

It inhibits the prefrontal cortex,

早年遭受的不幸 还会抑制大脑的前额叶皮质(Prefrontal cortex),

which is necessary for impulse control and executive function,

而前额皮质对神经冲动控制 与执行功能是必不可少的,

a critical area for learning.

这个区域对于学习能力非常关键。

And on MRI scans,

在核磁共振成像扫描（MRI）上,

we see measurable differences in the amygdala,

我们观察到大脑的恐惧反应中枢 - 杏仁核(amygdala)中,

the brain's fear response center.

存在可以测量的差异。

So there are real neurologic reasons

因此,这便可以从神经学角度诠释：

why folks exposed to high doses of adversity

为什么人们一旦遭受大量不幸,

are more likely to engage in high-risk behavior,

则更容易出现高风险行为。

and that's important to know.

了解了这点十分重要。

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

但事实证明, 即使你不从事任何高风险的行为,

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

你仍然更容易患上 心脏疾病或癌症。

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

因为这与"下丘脑-垂体-肾上腺轴"有关--

the brain's and body's stress response system

它是大脑和身体的应激反应系统,

that governs our fight-or-flight response.

支配我们做出"或战或逃反应"。 (fight-or-flight response)。

How does it work?

这一系统是如何运行的呢？

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

想象你漫步在森林里, 突然看到一头熊。

Immediately, your hypothalamus sends a signal to your pituitary,

你的下丘脑会立即 向你的垂体发送信号,

which sends a signal to your adrenal gland that says,

垂体再向你的肾上腺发送信号：

"Release stress hormones! Adrenaline! Cortisol!"

"释放应激激素! 肾上腺素! 皮质醇!"

And so your heart starts to pound,

你的心脏因而开始快速跳动,

Your pupils dilate, your airways open up,

瞳孔扩张,呼吸道打开,

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

这时你已准备好： 要么就和熊战斗,要么就逃跑。

And that is wonderful

这个反应很棒--

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

如果你在森林里, 那还有一只熊。

(Laughter)

（笑声）

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

可问题是,假如每个晚上 熊都回家来该怎么办,

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

这套系统将一遍又一遍地被激活,

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

它就会从适应到不适应,

to maladaptive, or health-damaging.

从救你的命到损害你的健康。

Children are especially sensitive to this repeated stress activation,

儿童对这种反复的应激激活尤其敏感,

because their brains and bodies are just developing.

因为他们的大脑和身体 正处在发育阶段。

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

高剂量的不良经历不仅 会影响大脑结构和功能,

they affect the developing immune system,

还会影响正在发育的免疫系统,

developing hormonal systems,

以及正在发育的内分泌系统,

and even the way our DNA is read and transcribed.

甚至还会影响 我们的DNA读取和转录方式。

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

这些知识让我彻底抛弃了 以前所受训的那一套,

because when we understand the mechanism of a disease,

因为,当我们了解疾病机制时,

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

当我们 不仅知道哪些路径被干扰, 而且知道它们是怎样被干扰时,

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

作为医生,我们的职责, 就是使用这门科学

for prevention and treatment.

去做疾病的防治工作。

That's what we do.

那就是我们要做的。

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

因此，我们在旧金山创办了 青少年健康中心,

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

目的是预防、筛查和治愈 ACE和毒性应激的影响。

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

我们开始在孩子们的定期体检中,

at their regular physical,

对每个孩子进行例行检查,

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

因为我知道,如果我的病人ACE得分为4分,

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

她患上肝炎或慢性阻塞性肺病(COPD) 的概率是1.5倍,

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

患上抑郁症的概率是4.5倍,

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

她自杀的几率

as my patient with zero ACEs.

是ACE得分为0的病人的12倍。

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

她在我的检查室里, 我就已经知道这一切了。

For our patients who do screen positive,

对于检查结果为阳性的病人,

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

我们有一支多学科综合治疗团队, 致力于减少不良经历造成的影响,

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

并使用最佳疗法治疗病症, 包括家庭访视、护理协调、

mental health care, nutrition,

心理保健、营养、

holistic interventions, and yes, medication when necessary.

综合干预措施, 以及必要时结合药物治疗。

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

但我们也教家长们了解 ACE和毒性应激造成的影响,

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

这种影响与电源插座或铅中毒 的危险性可以相提并论,

and we tailor the care of our asthmatics and our diabetics

我们调整了哮喘及糖尿病患儿的护理服务,

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

意识到他们可能需要更积极主动的治疗,

given the changes to their hormonal and immune systems.

以作用于他们的内分泌和免疫系统。

So the other thing that happens when you understand this science

当你理解了这门科学时,

is that you want to shout it from the rooftops,

你会想要把它广而告之,

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

因为这不仅仅是 湾景区（Bayview)孩子的问题。

I figured the minute that everybody else heard about this,

我本来以为 其他人一旦了解到这一点,

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

就会着手例行检查、 组建多学科治疗团队,

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

甚至大家争先恐后 想找到最有效的治疗方案。

Yeah. That did not happen.

可这些都没有发生。

And that was a huge learning for me.

这可是给了我一个很大的教训。

What I had thought of as simply best clinical practice

我原以为简单的找到 最好的临床手段来治疗就行了,

I now understand to be a movement.

现在我明白了,这是一场运动。

In the words of Dr. Robert Block,

正如Robert Block博士,

the former President of the American Academy of Pediatrics,

这位前美国儿科学会会长所言,

"Adverse childhood experiences

"童年不良经历(ACE)是

are the single greatest unaddressed public health threat

今天我们国家所面临的,唯一,最大的,

facing our nation today."

未能解决的公共健康威胁."

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

对于很多人来说, 这个前景可不容乐观。

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

这个问题的范围之广,规模之大

to think about how we might approach it.

使我们不得不考虑应对之策。

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

但在我看来,危机即是转机，

because when we have the right framework,

当我们确立正确框架时,

when we recognize this to be a public health crisis,

当我们意识到 这是公共健康危机时,

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

我们才能开始使用 正确的方法来求得解决方案。

From tobacco to lead poisoning to HIV/AIDS,

从烟草到铅中毒,再到艾滋病,

the United States actually has quite a strong track record

在解决公共健康问题方面,

with addressing public health problems,

美国实际上保持着良好记录,

but replicating those successes with ACEs and toxic stress

但要,在ACE和毒性应激方面 取得同样成功,

is going to take determination and commitment,

则需要下定决心、履行承诺,

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

当我看到,我们国家 对这一问题至今的反应时,

I wonder,

我想知道,

why haven't we taken this more seriously?

为什么我们没有更认真的对待这个问题？

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

要知道,一开始我还想, 这是因为我们漠视了这个问题,

because it doesn't apply to us.

以为它跟我们无关。

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

以为只有别的小孩, 邻居家的小孩才有这问题。

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

但很奇怪,数据可不是这么说的。

The original ACEs study was done in a population

初始ACE的研究样本群体为：

that was 70 percent Caucasian,

白人占70%,

70 percent college-educated.

大学毕业占70%。

But then, the more I talked to folks,

后来,我和大家谈得多了,

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

我便开始想,也许 我把这个问题完全本末倒置了。

If I were to ask how many people in this room

如果我问现场这个房间内有多少人

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

在成长过程中 有家庭成员患有精神疾病,

I bet a few hands would go up.

我相信,会有几个人举手。

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

如果我再问,有多少人 父亲或母亲酗酒,

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

或者是坚信： 孩子要打,惯不得。

I bet a few more hands would go up.

我敢打赌会有更多的人举手。

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

即使只是在我们的会场, 这也是一个影响到了很多人的问题。

and I am beginning to believe that we marginalize the issue

我开始相信 我们漠视这个问题

because it does apply to us.

是因为,它与我们息息相关。

Maybe it's easier to see in other zip codes

也许把它说成别的地区的事, 我们才能更容易的看清楚,

because we don't want to look at it.

因为我们自己情愿生病,

We'd rather be sick.

也不愿意正视这个问题。

Fortunately, scientific advances and, frankly, economic realities

幸运的是,科学进步, 坦率地说,还有经济现实

make that option less viable every day.

逐渐使我们无法再继续漠视下去了。

The science is clear:

科学研究清楚显示：

Early adversity dramatically affects health across a lifetime.

早期不良经历对人的一生 的健康影响巨大。

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

今天,我们开始了解如何中断

from early adversity to disease and early death,

从早期不良经历发展至 疾病和过早死亡这一进程,

and 30 years from now,

从现在算起,30年后,

the child who has a high ACE score

高ACE分数的儿童,

and whose behavioral symptoms go unrecognized,

如果其行为症状未被识别,

whose asthma management is not connected,

哮喘诊疗未与ACE相关联,

and who goes on to develop high blood pressure

持续发展为高血压,

and early heart disease or cancer

并患上早期心脏病或癌症,

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

那么这就象6个月的婴儿患艾滋病一样, 都是异常的。

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

人们看到这种情况都会说： "这究竟发生的是什么鬼事?"

This is treatable.

这种病症是可以治疗的,

This is beatable.

也是可以战胜的。

The single most important thing that we need today

我们今天最需要的是

is the courage to look this problem in the face

直面这个问题的勇气,

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

并且承认,这个问题确实存在, 与我们息息相关。

I believe that we are the movement.

我相信我们将实现这一变革运动。

Thank you.

谢谢大家。

(Applause)

（掌声）