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

譯者: Marssi Draw 審譯者: Regina Chu

In the mid-'90s,

90 年代中期，

the CDC and Kaiser Permanente

疾病防治中心和凱薩醫療機構

discovered an exposure that dramatically increased the risk

發現暴露於某種物質， 會使死亡風險劇增。

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

在美國，它占主要死亡原因的 70%。

In high doses, it affects brain development,

暴露於高劑量時，會影響大腦發育、

the immune system, hormonal systems,

免疫系統、激素系統、

and even the way our DNA is read and transcribed.

甚至影響 DNA 讀取和轉錄方式。

Folks who are exposed in very high doses

暴露在高劑量下的人們，

have triple the lifetime risk of heart disease and lung cancer

有 3 倍風險患上心臟病和肺癌。

and a 20-year difference in life expectancy.

預期壽命減少 20 年。

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

但現時醫生未接受相關培訓， 對其進行常規檢查或治療。

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

這種病因指的不是農藥 或包裝上的化學物質，

It's childhood trauma.

而是童年創傷。

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

到底是哪種創傷呢？

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

不是考試不合格或輸掉籃球賽。

I am talking about threats that are so severe or pervasive

那種危害極其嚴重、無孔不入，

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

以致深入骨髓，改變了我們的生理：

things like abuse or neglect,

例如虐待、忽視，

or growing up with a parent who struggles with mental illness

或童年受到患有精神病的父母影響，

or substance dependence.

或父母患物質依賴症。

Now, for a long time,

很長一段時間裡，

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

我看待這些事的方式受教育影響，

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

將其視為社會問題， 交由社會服務解決，

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

或視為心理健康問題， 運用心理健康服務。

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

但有一件事， 重塑了我整個思維方式。

When I finished my residency,

醫院實習結束後，

I wanted to go someplace where I felt really needed,

我想去一個真正需要我的地方，

someplace where I could make a difference.

一個我能有所作為的地方。

So I came to work for California Pacific Medical Center,

所以我去了 加利福尼亞太平洋醫療中心，

one of the best private hospitals in Northern California,

北加最好的私立醫院之一，

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

我們合作 在舊金山灣景區開了家診所，

那是舊金山最窮、 社區服務最差的區。

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

Now, prior to that point,

在這之前，

整個灣景區只有一位兒科醫生，

there had been only one pediatrician in all of Bayview

to serve more than 10,000 children,

負責一萬多名兒童的醫療，

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

於是我們開始掛牌營業， 提供最優質的服務，

regardless of ability to pay.

不論病人能否支付費用。

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

這很有意義， 我們旨在減少常見醫療服務的差距：

access to care, immunization rates, asthma hospitalization rates,

如：看護服務、 疫苗接種率、哮喘住院率，

and we hit all of our numbers.

每項我們都達標了，

We felt very proud of ourselves.

我們感到很自豪。

But then I started noticing a disturbing trend.

但我注意到一個讓人憂心的趨勢。

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

很多孩子被診斷患有 「過動症」交給我，

or Attention Deficit Hyperactivity Disorder,

或稱：「注意力不足過動症」。

but when I actually did a thorough history and physical,

但我給他們做 全面病史和身體檢查後，

what I found was that for most of my patients,

發現大部分病人，

I couldn't make a diagnosis of ADHD.

我難以斷定是過動症。

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

這些孩子多數受過嚴重的創傷，

that it felt like something else was going on.

讓我覺得另有起因。

Somehow I was missing something important.

我莫名地感覺遺漏了一個重要因素。

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

實習之前， 我取得過公共衛生碩士學位，

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

在學校裡，我學到的一點是：

is that if you're a doctor

如果你是個醫生

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

看到 100 個孩子喝了同一口井的水，

and 98 of them develop diarrhea,

其中 98 個得了腹瀉，

you can go ahead and write that prescription

你可以直接開張處方，

for dose after dose after dose of antibiotics,

一劑又一劑的抗生素，

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

或問：「這井裡到底有什麼鬼東西？」

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

於是，我開始查閱 手上所有相關文獻，

about how exposure to adversity

研究長期暴露在逆境下

affects the developing brains and bodies of children.

對成長期間的小孩 有何身心健康影響。

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

有一天，我同事走進辦公室，說：

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

「柏醫生，妳看過這個嗎？」

In his hand was a copy of a research study

他手裡是一份研究報告，

called the Adverse Childhood Experiences Study.

名字是《童年不良經驗研究》。

That day changed my clinical practice and ultimately my career.

那一天，改變了我的醫療方法， 最終改變了我的職業生涯。

The Adverse Childhood Experiences Study

童年不良經歷研究

is something that everybody needs to know about.

是大家都需要了解的東西。

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

它由凱薩醫療機構的文醫生 (Vince Felitti) 和 疾控中心的安達醫生 (Bob Anda) 聯手完成。

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

他們詢問了 17500 名成年人，

了解他們的「童年不良經驗」， 簡稱 ACE。

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

Those include physical, emotional, or sexual abuse;

包括身心上的不良經歷及性虐待；

physical or emotional neglect;

生理或情感忽略；

parental mental illness, substance dependence, incarceration;

父母患精神疾病、物質依賴或入獄；

parental separation or divorce;

父母分居或離婚；

or domestic violence.

或家庭暴力。

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

每經歷一種，ACE 指數就加 1。

And then what they did

接著，

was they correlated these ACE scores against health outcomes.

他們把 ACE 指數 與健康現狀聯系起來。

What they found was striking.

他們得出驚人的結果。

Two things:

其中有兩點：

Number one, ACEs are incredibly common.

一是 ACE 非常普遍。

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

67% 的人有至少一個 ACE，

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

12.6%，即八分之一的人 有 4 個以上的 ACE。

The second thing that they found

二是：

was that there was a dose-response relationship

ACE 經歷的多少與 健康狀況有關係：

between ACEs and health outcomes:

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

ACE 指數越高， 健康現狀越差。

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

ACE 指數為 4 或更高的人，

their relative risk of chronic obstructive pulmonary disease

患慢性阻塞性肺疾病的相對機率，

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

是指數爲 0 的人的 2.5 倍。

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

患肝炎的機率也是 2.5 倍。

For depression, it was four and a half times.

患憂鬱症的機率是 4.5 倍。

For suicidality, it was 12 times.

自殺傾向則是 12 倍。

A person with an ACE score of seven or more

ACE 指數為 7 或以上的人

had triple the lifetime risk of lung cancer

患肺癌的終身風險為 3 倍，

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

患冠心病的終身風險為 3.5 倍，

the number one killer in the United States of America.

這疾病是美國頭號殺手。

Well, of course this makes sense.

這當然說得通，

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

有些人看了這些數據會說：

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

「如果你有個痛苦的童年， 你抽煙喝酒的機率更高，

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

會做些毀掉健康的行為。

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

這不是科學，只是不健康行爲。」

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

但這正是其科學性的所在。

We now understand better than we ever have before

現在我們比以前更清楚地知道，

how exposure to early adversity

童年遭遇不良經歷，

affects the developing brains and bodies of children.

會影響兒童的身體及大腦發育，

It affects areas like the nucleus accumbens,

它對腦部伏核産生影響，

the pleasure and reward center of the brain

這是大腦對快樂和獎勵的處理中心，

that is implicated in substance dependence.

它與物質依賴有關。

It inhibits the prefrontal cortex,

不良經歷會抑制前額皮質，

which is necessary for impulse control and executive function,

這個部位對衝動控制 和行動力有影響，

a critical area for learning.

對學習能力有決定性影響。

And on MRI scans,

在核磁共振掃描上，

we see measurable differences in the amygdala,

會發現杏仁核有明顯的差異，

the brain's fear response center.

它是大腦的恐懼反應中心。

So there are real neurologic reasons

因此，從神經學而言

why folks exposed to high doses of adversity

遭遇較多不良經歷的人，

are more likely to engage in high-risk behavior,

做出高風險行為的機率更大，

and that's important to know.

了解這一點很重要。

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

但事實上，即使你不做高風險行爲，

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

你依然容易患上心臟病或者癌症。

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

這點跟 下丘腦—垂體—腎上腺軸有關，

它是大腦和身體的應激反應系統。

the brain's and body's stress response system

that governs our fight-or-flight response.

影響著我們「戰還是逃」的決定。

How does it work?

這是怎麼運作的呢?

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

想像一下， 你在森林中看見一隻熊。

你的下丘腦會瞬間發送信號到腦垂體，

Immediately, your hypothalamus sends a signal to your pituitary,

which sends a signal to your adrenal gland that says,

腦垂體向腎上腺發信號，

"Release stress hormones! Adrenaline! Cortisol!"

「釋放應激激素！腎上腺素！皮質醇！」

And so your heart starts to pound,

然後你開始心跳加快，

瞳孔放大，呼吸道大開，

Your pupils dilate, your airways open up,

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

你已經做好準備， 跟這只熊抗擊或逃跑。

And that is wonderful

這非常重要，

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

如果你在森林中，而那裡有隻熊。

(Laughter)

（笑）

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

但問題是， 如果這只熊每天都來騷擾你，

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

這個應激系統 一而再再而三地啓動，

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

它從一種適應性或救命的系統,，

to maladaptive, or health-damaging.

變成適應不良或有損健康的系統。

Children are especially sensitive to this repeated stress activation,

兒童對這種反復的應激激活很敏感，

because their brains and bodies are just developing.

因爲他們的大腦和身體 都還在發育階段，

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

大量的逆境 不單損傷他們的大腦結構和功能，

they affect the developing immune system,

還會影響發育中的免疫系統、

developing hormonal systems,

激素系統，

and even the way our DNA is read and transcribed.

甚至影響 DNA 的讀取和轉錄方式。

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

對我而言， 這個發現顛覆了我以前的認知，

because when we understand the mechanism of a disease,

因爲當我們明白了一種疾病的機制，

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

知道了被干擾的路徑及方式，

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

作爲醫生，我們理應運用科學

for prevention and treatment.

去預防和治療這種疾病。

That's what we do.

是職責所在。

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

於是，我們在舊金山 創立了青少年健康中心，

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

用以預防、檢查並治癒 因 ACE 及有害壓力所造成的影響。

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

我們開始對每個孩子做檢查， 作為常規體檢的一部分，

at their regular physical,

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

因爲我知道 如果病人有 4 分的 ACE 值，

她患肝炎或慢性阻塞性肺病 機率是 2.5 倍，

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,

4.5 倍的機率患憂鬱，

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

12 倍的機率選擇自殺，

as my patient with zero ACEs.

比那些 ACE 為 0 的人而言。

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

當她在檢查室裡，我就知道了。

For our patients who do screen positive,

檢查結果呈陽性的患者，

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

我們有支多學科的團隊， 致力於降低逆境的影響。

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

運用最好的療法， 包括家訪、協調護理、

mental health care, nutrition,

心理保健及營養均衡、

全面干預措施， 以及藥物治療，有必要的話。

holistic interventions, and yes, medication when necessary.

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

同時我們也向家長普及 ACE 和有害壓力的危害。

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

這危害可與觸電或鉛中毒相提並論。

and we tailor the care of our asthmatics and our diabetics

同時我們調整對哮喘患者 和糖尿病患者的護理，

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

意識到他們可能需要更積極的治療，

given the changes to their hormonal and immune systems.

因為他們的荷爾蒙 和免疫系統受到了影響。

So the other thing that happens when you understand this science

知道這個科學道理後，

is that you want to shout it from the rooftops,

你會想要廣而告之，

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

因爲這不僅是灣景區孩子們的問題。

I figured the minute that everybody else heard about this,

我以為每個人明白這道理後，

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

相關檢查會變為常規， 多學科團隊會組成，

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

大家爭先尋找有效治療方案。

Yeah. That did not happen.

但這些都沒有發生。

And that was a huge learning for me.

對我而言，這是個大教訓。

What I had thought of as simply best clinical practice

我簡單地認為 找到最好的治療方法就能解決。

I now understand to be a movement.

現在我明白了，這是一場運動。

In the words of Dr. Robert Block,

如美國兒科學會的前會長 羅伯特博士所說：

the former President of the American Academy of Pediatrics,

「不良的童年經歷

"Adverse childhood experiences

are the single greatest unaddressed public health threat

是現時我國唯一一個最大的 未解決的公共健康威脅。」

facing our nation today."

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

對於大多數人而言， 這個前景並不樂觀。

這個問題的範圍和規模似乎太大了，

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

以至讓人感覺這難以解決。

to think about how we might approach it.

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

但於我而言，那正是希望之所在，

because when we have the right framework,

因爲當我們有正確的框架，

when we recognize this to be a public health crisis,

並意識到這是個公眾健康危機，

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

我們就可以開始運用合適的工具 去找出解決辦法。

From tobacco to lead poisoning to HIV/AIDS,

例如煙草、鉛中毒、愛滋病，

the United States actually has quite a strong track record

美國在解決公共健康問題方面，

實際上保持了良好的記錄，

with addressing public health problems,

but replicating those successes with ACEs and toxic stress

若要在 ACE 和有害壓力方面也成功，

is going to take determination and commitment,

將需要決心和承諾，

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

基於現時我看到民眾對此的反響，

I wonder,

我想知道，

why haven't we taken this more seriously?

爲什麽我們沒有 更嚴肅地看待這個問題?

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

起初我以為我們忽略了這個問題，

because it doesn't apply to us.

以為它和我們無關，

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

那只是鄰居家孩子的問題。

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

這很奇怪， 因爲數據不支持這個說法。

The original ACEs study was done in a population

在最早的 ACE 研究中，

that was 70 percent Caucasian,

白種人占 70%，

70 percent college-educated.

受過大學教育的占 70%。

But then, the more I talked to folks,

但我愈向人們談論此問題，

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

我愈認為我可能本末倒置了。

If I were to ask how many people in this room

若我問在座各位有多少人

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

與患有心理疾病的家人一起長大，

I bet a few hands would go up.

我打賭有幾個人會舉起手。

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

若我問有多少人的父母經常喝醉酒，

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

或認為你不打孩子就是溺愛他們，

I bet a few more hands would go up.

我打賭會有更多人舉起手。

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

即使是在這個會場， 這個問題也影響了很多人，

and I am beginning to believe that we marginalize the issue

我開始認為，我們忽視這個問題

because it does apply to us.

正因爲它影響著我們。

Maybe it's easier to see in other zip codes

或許作為旁觀者更易看清，

因爲我們寧願生病， 也不想面對這個問題。

because we don't want to look at it.

We'd rather be sick.

Fortunately, scientific advances and, frankly, economic realities

幸運的是，科學的進步以及 坦率地說，經濟現實

make that option less viable every day.

逐漸使我們變得難以忽視它。

The science is clear:

科學道理很明確：

Early adversity dramatically affects health across a lifetime.

童年逆境對健康 有著終身性的巨大影響。

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

現在我們開始了解如何阻止其發展，

from early adversity to disease and early death,

從童年逆境發展到疾病和過早死亡，

and 30 years from now,

現在開始未來 30 年裡，

the child who has a high ACE score

ACE 指數過高的小孩，

and whose behavioral symptoms go unrecognized,

若其行為症狀無法確認，

whose asthma management is not connected,

哮喘治療未與 ACE 關聯，

and who goes on to develop high blood pressure

逐漸發展成爲高血壓，

and early heart disease or cancer

或是早期心臟病或癌症，

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

這將和患愛滋病六個月 就死亡一樣異常。

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

對此，人們會問： 「到底發生了什麼?」

This is treatable.

這是可以治癒的。

This is beatable.

可以戰勝的。

The single most important thing that we need today

現在我們需要做最重要的一件事是

is the courage to look this problem in the face

勇於直接面對這個問題，

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

接受這就是現實， 它和我們息息相關。

I believe that we are the movement.

我認為我們就是這項運動的關鍵。

Thank you.

謝謝。

(Applause)

（掌聲）