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TED:童年创伤如何影响你的一生? [复制链接]

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In the mid-'90s, the CDC and Kaiser Permanente discovered an exposure that dramatically increased the risk for seven out of 10 of the leading causes of death in the United States. In high doses, it affects brain development, the immune system, hormonal systems, and even the way our DNA is read and transcribed.
在上世纪90年代中期,美国疾病控制与预防中心(CDC)和凯萨医疗机构(Kaiser Permanente)发现,在美国10种主要死亡原因中,有7种是由于暴露在空气中而导致的,这大大增加了患病风险。在高剂量下,它会影响大脑发育、免疫系统、荷尔蒙系统,甚至我们的DNA的读取和转录方式。
Folks who are exposed in very high doses have triple the lifetime risk of heart disease and lung cancer and a 20-year difference in life expectancy. And yet, doctors today are not trained in routine screening or treatment. Now, the exposure I'm talking about is not a pesticide or a packaging chemical. It's childhood trauma.
暴露在高剂量辐射下的人罹患心脏病和肺癌的风险是常人的三倍,预期寿命相差20年。然而,今天的医生并没有接受常规筛查或治疗的培训。我说的接触不是农药或包装化学品。它的童年创伤。
Okay. What kind of trauma am I talking about here? I'm not talking about failing a test or losing a basketball game. I am talking about threats that are so severe or pervasive that they literally get under our skin and change our physiology: things like abuse or neglect, or growing up with a parent who struggles with mental illness or substance dependence.
好吧。我说的是什么创伤?我说的不是考试不及格或输掉一场篮球赛。我指的是那些非常严重或非常普遍的威胁,它们真的会进入我们的皮肤,改变我们的生理机能:比如虐待或忽视,或者在父母与精神疾病或物质依赖作斗争的环境中长大。
Now, for a long time, I viewed these things in the way I was trained to view them, either as a social problem -- refer to social services -- or as a mental health problem -- refer to mental health services. And then something happened to make me rethink my entire approach. When I finished my residency, I wanted to go someplace where I felt really needed, someplace where I could make a difference.
在很长一段时间里,我都是按照我所接受的训练来看待这些事情,要么是社会问题——指的是社会服务——要么是心理健康问题——指的是心理健康服务。后来发生了一件事,让我重新思考我的整个方法。当我完成实习工作后,我想去一个我觉得真正需要的地方,一个我可以发挥作用的地方。
So I came to work for California Pacific Medical Center, one of the best private hospitals in Northern California, and together, we opened a clinic in Bayview-Hunters Point, one of the poorest, most underserved neighborhoods in San Francisco.
于是我来到加利福尼亚太平洋医疗中心工作,这是北加州最好的私立医院之一,我们一起在Bayview-Hunters Point开了一家诊所,这是旧金山最贫穷、服务最不完善的社区之一。
Now, prior to that point, there had been only one pediatrician in all of Bayview to serve more than 10,000 children, so we hung a shingle, and we were able to provide top-quality care regardless of ability to pay. It was so cool. We targeted the typical health disparities: access to care, immunization rates, asthma hospitalization rates, and we hit all of our numbers. We felt very proud of ourselves.
在那之前,Bayview只有一名儿科医生为超过1万名儿童提供服务,所以我们挂了一个小木瓦,我们能够提供高质量的医疗服务,无论支付能力如何。太酷了。我们针对的是典型的健康差异:获得治疗的机会、免疫接种率、哮喘住院率,我们达到了所有的数字。我们为自己感到骄傲。
But then I started noticing a disturbing trend. A lot of kids were being referred to me for ADHD, or Attention Deficit Hyperactivity Disorder, but when I actually did a thorough history and physical, what I found was that for most of my patients, I couldn't make a diagnosis of ADHD. Most of the kids I was seeing had experienced such severe trauma that it felt like something else was going on. Somehow I was missing something important.
但后来我开始注意到一个令人不安的趋势。很多孩子被推荐给我治疗注意力缺陷多动障碍,或者是注意力缺陷多动障碍,但当我做了详细的病史和身体检查后,我发现对于我的大多数病人,我不能诊断出ADHD。我看到的大多数孩子都经历过严重的创伤,感觉好像有什么别的事情在发生。不知怎的,我错过了一些重要的事情。
Now, before I did my residency, I did a master's degree in public health, and one of the things that they teach you in public health school is that if you're a doctor 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 preion for dose after dose after dose of antibiotics, 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 about how exposure to adversity affects the developing brains and bodies of children.
现在,在我居住,我做了一个公共卫生硕士学位的一件事,他们教你在公共卫生学校,如果你是一个医生,你可以看到100个孩子,所有喝同样的好,和98个开发腹泻,你可以继续写处方剂量的抗生素剂量后剂量后,或者你可以走过去,说,“到底是这个吗?”所以我开始阅读所有我能接触到的关于逆境如何影响儿童大脑和身体发育的书籍。
And then one day, my colleague walked into my office, and he said, "Dr. Burke, have you seen this?" In his hand was a copy of a research study called the Adverse Childhood Experiences Study. That day changed my clinical practice and ultimately my career.
然后有一天,我的同事走进我的办公室,他说,“伯克博士,你见过这个吗?”他手里拿着一份研究报告的副本,这份报告被称为“不良童年经历研究”。那一天改变了我的临床实践,最终也改变了我的职业。
The Adverse Childhood Experiences Study is something that everybody needs to know about. It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC, and together, they asked 17,500 adults about their history of exposure to what they called "adverse childhood experiences," or ACEs. Those include physical, emotional, or sexual abuse; physical or emotional neglect; parental mental illness, substance dependence, incarceration; parental separation or divorce; or domestic violence.
不良童年经历研究是每个人都需要知道的事情。这项研究是由Kaiser的Vince Felitti博士和CDC的Bob Anda博士共同完成的,他们询问了17500名成年人关于他们接触过他们称之为“不良童年经历”(ace)的历史。包括身体虐待、情感虐待或性虐待;身体或情感上的忽视;父母精神疾病,药物依赖,监禁;父母分居或离婚;或家庭暴力。
For every yes, you would get a point on your ACE score. And then what they did was they correlated these ACE scores against health outcomes. What they found was striking. Two things:Number one, ACEs are incredibly common. Sixty-seven percent of the population had at least one ACE, and 12.6 percent, one in eight, had four or more ACEs. The second thing that they found was that there was a dose-response relationship between ACEs and health outcomes: the higher your ACE score, the worse your health outcomes.
每一个“是”,你就会在你的ACE得分上得一分。然后他们做的是把这些ACE分数和健康结果联系起来。他们的发现是惊人的。有两件事:第一,ace非常普遍。67%的人至少有一个ACE, 12.6%的人(八分之一)有四个或更多ACE。他们发现的第二件事是ACE和健康结果之间存在剂量反应关系ACE得分越高,健康结果越差。
For a person with an ACE score of four or more, their relative risk of chronic obstructive pulmonary disease was two and a half times that of someone with an ACE score of zero. For hepatitis, it was also two and a half times. For depression, it was four and a half times. For suicidality, it was 12 times. A person with an ACE score of seven or more had triple the lifetime risk of lung cancer and three and a half times the risk of ischemic heart disease, the number one killer in the United States of America.
对于ACE分数在4分以上的人来说,他们患慢性阻塞性肺疾病的相对风险是ACE分数为0的人的2.5倍。对于肝炎来说,也是2.5倍。对于抑郁症,是4。5倍。自杀率是12倍。得分在7分以上的人一生中患肺癌的风险是美国头号杀手缺血性心脏病的三倍,三倍半。
Well, of course this makes sense. Some people looked at this data and they said, "Come on. 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. This isn't science. This is just bad behavior."
当然这是有道理的。一些人看着这些数据说,“来吧。你有一个艰难的童年,你更可能喝酒,抽烟,做所有这些会损害你的健康的事情。这不是科学。这只是坏行为。
It turns out this is exactly where the science comes in. We now understand better than we ever have before how exposure to early adversity affects the developing brains and bodies of children. It affects areas like the nucleus accumbens, the pleasure and reward center of the brain that is implicated in substance dependence.
事实证明,这正是科学的作用所在。我们现在比以往任何时候都更清楚地认识到暴露于早期逆境如何影响儿童发育中的大脑和身体。它影响伏隔核等区域,伏隔核是大脑中与物质依赖有关的快乐和奖赏中枢。
It inhibits the prefrontal cortex, which is necessary for impulse control and executive function, a critical area for learning. And on MRI scans, we see measurable differences in the amygdala, the brain's fear response center. So there are real neurologic reasons why folks exposed to high doses of adversity are more likely to engage in high-risk behavior, and that's important to know.
它抑制前额皮质,这是冲动控制和执行功能所必需的,是学习的关键区域。在核磁共振扫描中,我们看到杏仁核,大脑的恐惧反应中心,有明显的不同。所以有真正的神经学原因为什么人们暴露在高剂量的逆境中更有可能从事高风险的行为,这是很重要的知道。
But it turns out that even if you don't engage in any high-risk behavior, you're still more likely to develop heart disease or cancer. The reason for this has to do with the hypothalamic–pituitary–adrenal axis, the brain's and body's stress response system that governs our fight-or-flight response.
但事实证明,即使你没有从事任何高风险的行为,你仍然更有可能患心脏病或癌症。原因与下丘脑-垂体-肾上腺轴有关,下丘脑-垂体-肾上腺轴是大脑和身体的应激反应系统,它控制着我们的战斗或逃跑反应。
How does it work? Well, imagine you're walking in the forest and you see a bear. Immediately, your hypothalamus sends a signal to your pituitary, which sends a signal to your adrenal gland that says, "Release stress hormones! Adrenaline! Cortisol!" And so your heart starts to pound, Your pupils dilate, your airways open up, and you are ready to either fight that bear or run from the bear. And that is wonderful if you're in a forest and there's a bear.
它是如何工作的?假设你在森林里散步,看到一只熊。你的下丘脑立即向你的脑下垂体发出信号,脑下垂体又向你的肾上腺发出信号:“释放压力荷尔蒙!”肾上腺素!皮质醇!”于是你的心脏开始跳动,瞳孔扩大,气道打开,你准备要么与熊搏斗,要么逃离熊。如果你在森林里,有一只熊,那就太棒了。
(Laughter) But the problem is what happens when the bear comes home every night, and this system is activated over and over and over again, and it goes from being adaptive, or life-saving, to maladaptive, or health-damaging. Children are especially sensitive to this repeated stress activation,because their brains and bodies are just developing. High doses of adversity not only affect brain structure and function, they affect the developing immune system, developing hormonal systems, and even the way our DNA is read and transcribed.
但问题是,当熊每天晚上回家时,这个系统会被一遍又一遍地激活,它会从适应,或者拯救生命,变成适应不良,或者损害健康。儿童对这种反复的压力激活特别敏感,因为他们的大脑和身体正在发育。高剂量的逆境不仅会影响大脑的结构和功能,还会影响发育中的免疫系统、荷尔蒙系统,甚至我们的DNA的读取和转录方式。
So for me, this information threw my old training out the window, because when we understand the mechanism of a disease, when we know not only which pathways are disrupted, but how, then as doctors, it is our job to use this science for prevention and treatment. That's what we do.
所以对我来说,这些信息把我以前的训练抛到了一边,因为当我们了解了疾病的机制,当我们不仅知道哪些途径被破坏了,而且知道作为医生,我们的工作就是利用这些科学来预防和治疗。我们就是这么做的。
So in San Francisco, we created the Center for Youth Wellness to prevent, screen and heal the impacts of ACEs and toxic stress. We started simply with routine screening of every one of our kids at their regular physical, because I know that if my patient has an ACE score of 4, 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, and she's 12 times as likely to attempt to take her own life as my patient with zero ACEs.
所以在旧金山,我们建立了青少年健康中心来预防,筛选和治疗不良童年经历和有毒压力的影响。我们开始简单的常规筛查定期身体的每一个我们的孩子,因为我知道,如果我的病人有一个王牌的4分,她是两个半倍可能患肝炎或慢性阻塞性肺病,她是四倍半变得抑郁,她12倍试图以自己的生命为我的病人与ACE为零。
I know that when she's in my exam room. For our patients who do screen positive, we have a multidisciplinary treatment team that works to reduce the dose of adversity and treat symptoms using best practices, including home visits, care coordination, mental health care, nutrition, holistic interventions, and yes, medication when necessary.
我知道当她在我的检查室时。对于筛查呈阳性的患者,我们有一个多学科的治疗团队,通过最佳实践,包括家访、护理协调、心理健康护理、营养、整体干预,以及必要时的药物治疗,努力减少逆境和治疗症状。
But we also educate parents about the impacts of ACEs and toxic stress the same way you would for covering electrical outlets, or lead poisoning, and we tailor the care of our asthmatics and our diabetics in a way that recognizes that they may need more aggressive treatment, given the changes to their hormonal and immune systems.
但我们也让父母了解ace和有毒的影响压力相同的方式覆盖插座,或者铅中毒,我们调整我们的哮喘患者和糖尿病患者的护理,认识到他们可能需要更积极的治疗,激素和免疫系统的变化。
So the other thing that happens when you understand this science is that you want to shout it from the rooftops,because this isn't just an issue for kids in Bayview. I figured the minute that everybody else heard about this, it would be routine screening, multi-disciplinary treatment teams, and it would be a race to the most effective clinical treatment protocols. Yeah. That did not happen. And that was a huge learning for me. What I had thought of as simply best clinical practice I now understand to be a movement.

所以当你理解这门科学的时候,另一件发生的事情是你想从屋顶上大声喊出来,因为这不仅仅是Bayview的孩子们的问题。我想当其他人听到这个的那一刻,那将是例行的筛查,多学科的治疗团队,这将是一个最有效的临床治疗方案的竞赛。是的。但这并没有发生。这对我来说是一个巨大的学习。我曾经认为是最好的临床实践,现在我明白这是一个运动。
In the words of Dr. Robert Block, the former President of the American Academy of Pediatrics, "Adverse childhood experiences are the single greatest unaddressed public health threat facing our nation today." And for a lot of people, that's a terrifying prospect. The scope and scale of the problem seems so large that it feels overwhelming to think about how we might approach it.
用美国儿科学会(American Academy of Pediatrics)前院长罗伯特•布洛克(Robert Block)博士的话说,“不良童年经历是当今美国面临的最大公共健康威胁。”对很多人来说,这是一个可怕的前景。问题的范围和规模似乎如此之大,以致于一想到我们可能如何处理它,就会觉得难以应付。
But for me, that's actually where the hopes lies, because when we have the right framework, when we recognize this to be a public health crisis, then we can begin to use the right tool kit to come up with solutions. From tobacco to lead poisoning to HIV/AIDS, the United States actually has quite a strong track record with addressing public health problems, but replicating those successes with ACEs and toxic stress is going to take determination and commitment, and when I look at what our nation's response has been so far, I wonder, why haven't we taken this more seriously?
但对我来说,这就是希望所在,因为当我们有了正确的框架,当我们意识到这是一场公共卫生危机,我们就可以开始使用正确的工具箱来提出解决方案。从烟草铅中毒艾滋病毒/艾滋病,美国确实有相当强大的记录与解决公共健康问题,但这些成功复制与ace和有毒的压力是需要决心和承诺,当我看看我们国家的回应是到目前为止,我想知道,为什么我们没有采取更严重的吗?
You know, at first I thought that we marginalized the issue because it doesn't apply to us. That's an issue for those kids in those neighborhoods. Which is weird, because the data doesn't bear that out. The original ACEs study was done in a population that was 70 percent Caucasian, 70 percent college-educated. But then, the more I talked to folks, I'm beginning to think that maybe I had it completely backwards. If I were to ask how many people in this room grew up with a family member who suffered from mental illness, I bet a few hands would go up.
一开始我认为我们忽视了这个问题因为它不适用于我们。这对那些邻居的孩子来说是个问题。这很奇怪,因为数据不能证明这一点。最初的ACEs研究是在一个70%白人,70%受过大学教育的人群中进行的。但后来,我和人们交谈得越多,我就开始想,也许我完全把事情搞反了。如果我问在座的有多少人是和一个患有精神疾病的家庭成员一起长大的,我敢打赌肯定会有人举手。
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, I bet a few more hands would go up. Even in this room, this is an issue that touches many of us, 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 because we don't want to look at it. We'd rather be sick.
然后,如果我问有多少人的父母可能喝得太多,或者他们真的相信如果你不打孩子,你就会宠坏孩子,我敢打赌会有更多的人举手。甚至在这个房间里,这是一个涉及我们许多人的问题,我开始相信我们忽视了这个问题,因为它确实适用于我们。也许在其他邮政编码中更容易看到,因为我们不想看它。我们宁愿生病。
Fortunately, scientific advances and, frankly, economic realities make that option less viable every day. The science is clear: Early adversity dramatically affects health across a lifetime.
幸运的是,科学的进步,坦率地说,经济现实使这种选择越来越不可行。科学很清楚:早期的逆境会极大地影响一生的健康。
Today, we are beginning to understand how to interrupt the progression from early adversity to disease and early death, and 30 years from now, the child who has a high ACE score and whose behavioral symptoms go unrecognized, whose asthma management is not connected, and who goes on to develop high blood pressure and early heart disease or cancer will be just as anomalous as a six-month mortality from HIV/AIDS.
今天,我们开始了解如何从早期逆境中断进展疾病和过早死亡,30年后,ACE得分高的孩子,其行为症状得不到承认,他的哮喘管理没有关系,继续发展早期高血压和心脏病或癌症将一样异常为期6个月的艾滋病死亡率。
People will look at that situation and say, "What the heck happened there?" This is treatable. This is beatable. The single most important thing that we need today is the courage to look this problem in the face and say, this is real and this is all of us. I believe that we are the movement.
人们看到这种情况会说,“到底发生了什么?”这是可以治愈的。这是可打的。我们今天需要的最重要的一件事是面对这个问题的勇气,说,这是真实的,这是我们所有人。我相信我们是运动。
Thank you.
谢谢
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