How childhood stress can knock 20 years off your life
The Guardian, by Paula Cocozza
There is a scene in James Redford’s new film, Resilience, in which a paediatrician cites a parental misdeed so outmoded as to seem bizarre. “Parents used to smoke in the car with kids in the back and the windows rolled up,” she says, incredulous. How long ago those days now seem; how wise today’s parents are to the dangers of those toxins. Yet every week in her clinic in the Bayview-Hunters Point area of San Francisco, children present with symptoms of a new pollutant – one that is just as damaging. But unlike the smoke-filled car, this new pollutant is invisible, curling undetected around children’s lives and causing lasting damage to their lungs, their hearts, their immune systems.
“Stress,” Redford says. “It is a neurotoxin like lead or mercury poisoning.” He mentions the city of Flint in Michigan, where residents were exposed to lead in drinking water. “And that’s literally what’s going on” with children who are “coming from really stressful environments. We know what environmental toxins are. Well, this is an environmental toxin.” The proliferation of so-called “toxic stress” among children, Redford says, “is a public health crisis”.
He had just finished working on a film about dyslexia when he and his film partner, Karen Pritzker, were casting around for their next story. Pritzker came upon the 1998 research by Vincent Felitti and Robert Anda into adverse childhood experiences (ACEs). “She said, ‘Read this.’”
The ACE survey asks people to respond to questions about childhood: did they witness substance abuse? Did their parents divorce or separate? Did anyone in the home have a mental illness? Was a family member imprisoned? Those completing the questionnaire who rack up three or more (out of a possible 10) risk serious ill health. According to Redford’s film, three ACEs means you are twice as likely to develop heart disease as those who score zero. Four means you are three times as likely to have depression. Six reduces your life expectancy by 20 years. “I thought this is completely unknown,” Redford says. “This has to be told.”
The idea that exposure to difficult experiences in childhood might lead to health problems is a familiar idea. A child might self-soothe with drugs or food, become dependent or obese, and in turn have ill health. But the ACE research uncovers a different kind of connection – a response to stress that is biological rather than purely behavioural, which can cause serious illness, and is a stronger predictor of coronary heart disease than high blood pressure, high cholesterol, and even smoking.
The film is a little light on the science, so I’m hoping that Redford can explain.
“Think about a child who comes home and opens their front door and there’s a bear in the room,” he says. “And the bear roars.” The child’s adrenal glands begin to secrete cortisol. Blood pressure rises. Pupils dilate. Blood shoots from the stomach to the bigger muscles. “This is a biological response to fear. Now imagine that kid comes home every day.” But when she opens the door, what she finds in the living room is not a bear.
“It’s a mentally ill relative or a verbally abusive father or emotionally abusive parents or an unstable situation or no food or you don’t know where your parents are. Your body will continue to have that biological response if you are in stress. But day after day, those chemicals – the adrenaline, cortisol, the process of high sugar, that whole response, changes the way your brain processes information. It affects the development of the organs on a cellular level. This continual exposure to stress wears the body down, makes the immune system not work as well, makes you more prone to cardiovascular disease, cancers and other immune disorders later in life.”
This is not what childhood is meant to be like. “You are really not meant to be exposed to those hormones [at that level] on a daily basis,” he says.
Did Redford check his own ACE score when he began looking into the subject? There is a nervous laugh; he is talking on the phone from New York, though he lives in Fairfax, Marin County, with his wife, Kyle, an educator and writer. They have a son, 25, and a daughter who is in college. “Depending on how I analysed it, my score was between a two and a three.”
Some of the ACE questions are surprisingly broad. One asks, “Did your parents ever swear at you, insult you or put you down?” Another asks if “Your family didn’t look out for each other, feel close to each other or support each other?” The questionnaire makes the respondent interrogate their own experience, not only as a child but as a parent too.
“It does, doesn’t it? Because it’s more subtle than we’re used to. If you have zero ACEs in your life, you’re very … fortunate. You’re in the minority.”
ACEs are experienced across the social and economic spectrum. For one segment of Resilience, Redford filmed at a conference of social workers, researchers and educators, and 34% of the audience, which was mostly middle class and educated, reported four or more ACEs.
Of course, we do not yet know what activities in the home may constitute future ACEs. Maybe one day questionnaires will ask, “Did your caregivers work more than 50 hours a week? Did they repeatedly look at their smartphones while you were trying to talk to them?”
“That could easily be an ACE right there,” Redford shoots back. “Definitely. It changes the way we relate to others.”
In Resilience, words evoking adverse childhood experiences are summoned graphically on screen. “Substance abuse … Physical abuse … Divorce.” It is surprising to see divorce grouped into that same category of experience. So even well-handled, peaceful divorce is an adverse experience? “It is,” says Redford, whose parents – the actor Robert Redford and Lola Van Wagenen – divorced when he was 23.
It was Redford’s experiences as an adult, rather than as a child, he says, that made him connect with the research when Pritzker showed it to him. He had been born seven weeks prematurely, had ill health as a child, and was eventually diagnosed with ulcerative colitis. At the age of 30, he required a liver transplant; the first failed, and there was an anxious three-month wait for a second. His “brush with death”, he says.
“You have to be tested to make sure you can withstand the procedure, that you don’t have other problems that might get in the way. They [the doctors] spend a lot of time asking about your family, your relationships … I was newly married and very close and already had a son at the time.” He asked the surgeon, why all the questions? “And the surgeon said, ‘Well, we just find that transplant is such a difficult ordeal, if we transplant patients that don’t have any family support, they don’t survive nearly as well.’ That really stuck with me – that the psychological and emotional framework in your life can make you more likely or less likely to do well in surgery?” He frames his conclusion as a question and the way he lifts his voice makes me think he has been asking it for a very long time.
Somehow that conversation slipped from his memory – but when he began to read about ACE, there it was again. “Immediately it clicked with me.”
Maybe survival was Redford’s own proof of resilience. Certainly the word is important to him. And while it recalls the much-vaunted work on “grit” of the psychologist and author Angela Duckworth, the approaches couldn’t be more different.
“The message culturally is ‘get over it’,” Redford says. “If you have it rough, so did everyone else. There’s nothing special about you. Buck up and get on with it. If you’re struggling and you have problems with addiction, or you’re having depression or anxiety, you must be weak. That’s a very damaging message. The reason we called this film Resilience is to focus on what true resilience is. Which for most of us is something we need to develop.”
It sounds as if he is reclaiming the quality. “That’s what I’m hoping.”
So how can the ACE questionnaire be used as a tool to improve the life experiences of those people who experience sustained trauma in childhood? At one point in Resilience, Laura Porter, former director of the Washington State family policy council, suggests that the “general population will invent very wise actions” to confront the damage.
This sounds a rather noncommittal kind of optimism, but Redford says there are already signs of improvement. When he first read the ACE study, the phrase “toxic stress” had yet to be invented. (It was coined by Jack Shonkoff of Harvard University’s Center on the Developing Child, who also appears in the film.) “Now you have entire school districts focusing on being trauma-informed,” Redford says. The city of Tarpon Springs in Florida has declared itself a “trauma-informed” city. “So it’s starting to get out there.”
In the UK, “there is a growing momentum” to the exploration of the possible uses of ACEs, says Warren Larkin, clinical lead at the Department of Health’s adverse childhood experiences programme. He has recently worked with a school in Blackburn and Lancashire police and is starting to see attitudes change. Public Health Wales has published its own report. Others, such as a spokesperson for Early Intervention Foundation, point out that the evidence “is still at an early stage … We look forward to seeing the results from pilots that are running at the moment.”
“Just that,” Redford says. “Just that level of engagement had a positive effect on classroom performance. Paying attention. Showing a little curiosity about who they are.” In that moment, and then perhaps in life, “every one of those kids has the possibility of being really special.”