LEAVING THE HOSPITAL COUNCIL meeting that day, I was so distracted by my self-defeating questions that I didn’t even notice when she first called out.
The elevator yawned open.
“Excuse me, Doctor?” she repeated.
I turned and saw that it was the woman who had been pouring coffee for the CEOs in the conference room at the beginning of my presentation.
“Yes?”
She took a tentative step toward me. Up close, I could see that she had a rough-looking dye job and one tooth missing on the right side, but she was neatly tucked in and buttoned up in her hotel uniform. I paused for a moment and then let the elevator door close behind me, giving her my full attention.
“That’s me,” the woman said.
“Pardon?”
“That’s me that you were talking about up there. Those ACEs—the bad things that happen to people when they’re kids—all of that stuff you were talking about has happened to me. I’ve got every single one of those. I think I’m a ten out of ten.”
She paused and took a deep breath, shifting her gaze down to a small, dark gray tattoo on her left wrist.
“I’ve been working to stay sober and I’ve had lots of problems with my health. After hearing what you had to say just now, I feel like I finally understand what’s been going on with me.”
Her eyes met mine. “Anyways, I just wanted to say . . . thank you. Keep doing what you’re doing.”
“What’s your name?” I asked.
“Marjorie,” she said, smiling.
I smiled back.
“Thank you, Marjorie.”
Since that day with Marjorie and the hospital council, after every talk and every presentation, I make it a point to go up to the people clearing the tables or breaking down the PA system to ask them what they thought. No matter how well my presentations are received professionally, talking to these folks always gives me additional insight into how the story of ACEs is playing out in people’s day-to-day lives. I walk away understanding that no matter the geographies, ethnicities, and socioeconomic backgrounds, we are all affected by ACEs in similar ways. I was trained to believe in the power of clinical medicine and public health to improve lives, yet it is clear from these conversations that many people who have experienced ACEs and are grappling with their lifelong effects don’t know what they are dealing with. No doctor has ever told them that there might be a problem with their stress-response system, much less suggested what to do about it. Those few minutes in front of the elevator with Marjorie served as both a touchstone and a swift kick in the butt. If we didn’t have a clinical protocol to address ACEs and its many health impacts, then it was time to create one. Fortunately, I was too naive to understand how huge a task that would ultimately be.
On a small scale, we were already making progress at the clinic, so I knew we were on the right track. Along with screening all children for ACEs at their annual checkups, we were actively putting the toxic stress lens on our treatment plans and starting to look for evidence-based treatment models that focused on the underlying biology of children, parents, and communities dealing with the impacts of adversity. Outside of ours, there were no pediatric clinics I knew of that routinely screened for ACEs in 2008. Patients with toxic stress were most likely to come to the attention of their pediatrician with symptoms of behavioral problems or ADHD, which, as it turns out, was good news for them, because it meant that they were likely to be referred to a professional in the mental-health field, one of the few health-care specialties that had recognized the link between early adversity and poor health. Unfortunately, many physicians had no clear understanding that clinical illnesses like asthma and diabetes might also be manifestations of toxic stress. As we saw with Diego, psychotherapy was in fact one of the most well-supported therapeutic interventions for patients with symptoms of toxic stress whether those symptoms were behavioral or not.
When primary-care doctors have easy access to mental-health services for their patients, those patients have a better shot at getting the treatment they need. To that end, one of the best approaches for helping doctors who care for patients with ACEs and toxic stress (which, statistically speaking, is every single doctor in America) is integrated behavioral health services. That simply means having mental-health services available at the pediatrician’s (or primary-care clinician’s) office. Later I would find out that this was an emerging best practice, one now being endorsed by just about every national health-care oversight agency, including the U.S. Department of Health and Human Services. The Bayview community had asked for mental-health services before I’d read the ACE Study—that’s why I brought Dr. Clarke onboard. Having a mental-health clinician in our office was so successful and Dr. Clarke was in such high demand that I was soon looking for more mental-health resources to pour into our clinic.
For most pediatricians working in low-income, underserved areas, like I was, the available resources would typically be limited to a referral to a community agency, possibly a social worker if you were lucky, and then you’d cross your fingers and maybe say a few prayers. But in the months leading up to when I started treating Nia, we had begun working with Dr. Alicia Lieberman at the University of California, San Francisco, a renowned child psychologist who specialized in child-parent psychotherapy (CPP). This type of therapy focuses on children from from birth to five years old and is built on the notion that to help young kids experiencing adversity, you have to treat the parent and child like a team. The groundbreaking aspect of CPP, and what Dr. Lieberman believes makes it so effective, is the recognition that real conversations with kids about how trauma is affecting them and their families—even when kids are really little—are critical.
Alicia Lieberman recalls, as one of her earliest memories, the experience of waking up in the middle of the night to an odd feeling of movement. Growing up in Paraguay during a time of political revolution and unrest, she saw her father, a pediatrician who spoke out about the social injustices he witnessed, become a target of the government.He was periodically jailed for interrogation, but as a respected member of the community, he was returned each time. The growing civil unrest left the family constantly on edge. More and more community leaders were being jailed or simply “disappeared.”
When Alicia awoke that night, she saw that her mother and father were carrying the bed with her still in it. Her parents were transporting their sleeping daughter to the innermost room of the house to protect her from stray bullets that might come through the walls. Eventually, she and her family emigrated, taking a transatlantic ocean liner to Israel. On the ship, a fellow traveler asked the young girl what it was like to live under that kind of stress. At the mention of the events they were leaving behind, Dr. Lieberman remembers tensing up and having the realization that stress lives in the body.
Dr. Lieberman started her professional work from a place of deep personal familiarity and curiosity about trauma and stress. On top of the instability and fear of the family’s political circumstances, when Alicia was four years old the tragic death of a sibling threw her parents into a state of profound grief. The surviving children were never told what happened and young Alicia was left to create her own narrative, a story conjured up by her imagination out of confusion and sadness. As she got further into the study of child psychology, she saw that talking about the past openly and honestly with children wasn’t common practice. The thinking at the time was that little children didn’t understand things like death and violence and if you tried to talk to them about it, you would just retraumatize them. Dr. Lieberman doubted that the practice of telling Santa Claus stories to children when bad things happened was doing them any good.
Dr. Lieberman debunked the long-held myth that young children and babies don’t need treatment for trauma because they somehow don’t understand or remember the chaotic experiences they faced. Her work is built on research that shows that early adversity often has an outsize effect on infants and young children, just like it did on Dr. Hayes’s tadpoles. After years as a clinician, Dr. Lieberman came to understand that children’s need to create a story or narrative out of confusing events is actually very normal. Children are compelled to give meaning to what is happening to them. When there is no clear explanation, they make one up; the intersection of trauma and the developmentally appropriate egocentrism of childhood often leads a little kid to think, I made it happen.
Dr. Lieberman sought to explore ways in which both parents and children could talk openly and honestly about trauma. She also rightly recognized that parents’ own rough childhoods and the scars that they still carried might affect the way they responded to their child in stressful or traumatic circumstances, hindering their ability to act as a protective buffer. She learned from her mentor Selma Fraiberg that families can learn how to “speak the unspeakable” and that parents can discover tools to support and buffer their children, even in moments of crisis. Eventually, Dr. Lieberman would go on to codify the CPP protocol and demonstrate its efficacy in five separate randomized trials. Supported by the latest science, CPP is now one of the country’s leading trauma treatments for young children, and it is instrumental in helping the whole family begin to heal.
CPP takes into consideration all the other pressures and drama that both parent and child have to deal with—other family members, the community, work (or lack thereof)—everything that affects the parent-child bond. This allows patients to make connections between the traumas of the past and the stressors of the present, so they can better recognize their triggers and manage their symptoms.
Traditionally, if a mom is depressed, she finds her own therapist and they work one on one. CPP’s approach is based on the understanding that the quality of the relationship and the health of the attachment between the parent and child are absolutely fundamental to health and well-being. There was hardly a clearer case of this than Charlene and Nia. Fortunately, Dr. Todd Renschler, a postdoctoral fellow under Dr. Lieberman’s supervision, was just joining our team when Charlene and Nia first came into my waiting room. Charlene was understandably furious with me for months after I filed the report with Child Protective Services, but in their case it was exactly what needed to happen. In order to keep custody of Nia, Charlene was required to get help with her postpartum depression, which meant intensive psychotherapy.
When Charlene came to her first CPP session with Dr. Renschler, she had her iPod earbuds dug in deep with the volume turned up so loud he could have tapped along to the beat. She plopped Nia down on the couch beside her and stared blankly at Dr. Renschler. Needless to say, the first sessions were pretty challenging. Charlene felt betrayed by me and felt she was being forced to do something against her will. An experienced and patient clinician, Dr. Renschler took his time building rapport with Charlene, starting off by giving her some choice in how the sessions would proceed, offering her some power in a situation where she felt totally powerless. Instead of diving right into Nia’s health and Charlene’s depression, he started by addressing what Charlene said was her biggest problem, something that every parent of an infant can relate to: serious lack of sleep. Nia was waking up frequently in the night and Charlene was exhausted and frustrated.
It was no surprise that Charlene and Nia were struggling with sleep. Researchers have found that infants of depressed moms have a harder time regulating their sleep; they sleep an average of ninety-seven fewer minutes a night than infants of nondepressed moms and have more nighttime awakenings. Childhood adversity significantly increases the risk for just about every sleep disorder there is, including nightmares, insomnia, narcolepsy, sleepwalking, and psychiatric sleep disorders (sleep-eating, anyone?). Nighttime sleep plays a powerful role in influencing brain function, hormones, the immune system, and even the transcription of DNA.
Sleep helps properly regulate both the HPA and the SAM axes. During sleep, levels of cortisol, adrenaline, and noradrenaline drop. As a result, lack of sleep is associated with increased levels of stress hormones and increased stress reactivity. As you know from Chapters 5 and 6, these stress hormones kick off the party, triggering brain, hormone, immune, and epigenetic responses to stress. The downstream effects are impaired cognitive function, memory, and mood regulation.
Sleep deprivation doesn’t just make you groggy and cranky; it also makes you sick. Lack of sleep is associated with increased inflammation and reduced effectiveness of the immune system. While you’re catching z’s, your immune system does a systems upgrade, using the downtime to calibrate its defenses. Everyone knows it’s important to get sleep when you’re sick, but it’s just as important when you’re healthy. Lack of sleep leaves people more susceptible to illness because the immune system doesn’t appropriately fight off the viruses and bacteria that it is constantly exposed to.
Poor sleep is also associated with reductions in hormones such as growth hormone and with changes to DNA transcription, which for children can be especially problematic, opening the door to issues with growth and development.
Dr. Renschler worked with Charlene to create a routine that would help Nia sleep for longer stretches. He started by helping Charlene understand the importance of putting Nia to bed in a cool, dark, and quiet environment at the same time every night, avoiding stressful or stimulating activities just before sleep and instead giving her a soothing bath and reading a story before bedtime. Eventually both mom and baby started getting some much-needed shuteye. Feeling understood and ultimately supported in this problem helped Charlene believe Dr. Renschler knew what he was doing. More important, she saw that he was there to help her.
Soon, Charlene began to open up about the lack of support she had. Her ex-boyfriend (Nia’s dad) had been abusive during her pregnancy and was now out of the picture. She lived with her maternal aunt, who had raised Charlene and her little brother since their mother committed suicide, when Charlene was a young child. Ever since she had told her aunt she was pregnant, she’d received more criticism than support. Despite living with her aunt, she felt completely isolated, and it only got worse when Nia was born so prematurely. The further Dr. Renschler and Charlene got in their conversations about her relationship with her aunt, the more she expressed wanting to have a different kind of relationship with Nia. In a nuts-and-bolts way, meeting this goal came down to examining how she was interacting with Nia. In the CPP sessions, when Nia cried or smiled, Dr. Renschler encouraged Charlene to think about how that felt and what she thought it meant. Once, when Nia was in her lap, the baby reached up and pulled out Charlene’s earbuds. At first she was annoyed with her daughter’s “bad behavior,” but when Dr. Renschler wondered aloud about what else Nia could be communicating with that action, Charlene admitted that maybe her baby just wanted her attention. Charlene’s aunt was critical, distant, and unwilling to give her the kind of support she was craving, so when similar dynamics seemed to be playing out with Nia, Dr. Renschler helped Charlene recognize that and think about how she might respond differently.
Soon, the relationship started to shift. Charlene began taking one earbud out during sessions and, finally, both. As she became more tuned in to her daughter, Nia responded with fewer cries and more of the more coos and laughs that, as any parent knows, are the sweet rewards that make up for all the midnight feedings and cranky mornings. Charlene also began to take a more active role in solving her baby’s failure to gain weight. In her sessions with Dr. Renschler, she wanted him to help her fix the bottle at just the right temperature and asked a lot of questions about baby food and feeding. Our clinic team worked together to support Charlene with practical advice, nutrition information, and access to resources. We also regularly communicated as a team about Nia’s progress. Through these supportive conversations, Charlene’s resentment about the CPS report began to fade, and she became less angry with me.
While Charlene was doing great in her therapy sessions and her relationship with Nia, she continued to have issues with her aunt. One day, she made baby food for Nia (a big step for her!) and forgot to put away a bowl after she was done. Her aunt was so pissed off that she told Charlene she could no longer use the kitchen. Charlene felt frustrated and defeated. There she was, trying to do the right thing, and her aunt was punishing her for a small oversight. But the incident opened up space for Charlene to talk more with Dr. Renschler about her relationship to her aunt, the loss of her mother, and even her feelings of helplessness and depression following Nia’s birth. Her aunt had been angry when Charlene got pregnant, and without her aunt as a support system, Charlene had felt completely alone. Then the baby had stopped growing suddenly and had to be delivered via emergency C-section, and no one could tell Charlene why. After all, she wasn’t smoking or taking drugs, and as far as she knew, she had been doing everything right. At the time, we didn’t have any answers for her. It wasn’t until later that I learned just how closely ACEs and high doses of maternal stress were related to premature birth, low birth weight, and increased rates of miscarriage.
When Nia was in the NICU, Charlene was completely physically disconnected from her child. Nia didn’t look like any baby Charlene had ever seen before. She was small and frail with multiple tubes and monitors connected to her tiny body. Charlene was terrified that her daughter would die and she began to wall herself off emotionally. People leaving was something Charlene was accustomed to. She had never known her father, and her mother had left her and her brother when Charlene was just five years old. In a way, Charlene was preparing herself for the inevitable—the loss of her daughter.
Through her conversations with Dr. Renschler, Charlene realized that it was actually possible to talk through some of these difficult experiences. She wished that she could do this with her aunt. But her aunt, who had lost a child as a young mother, had her own wall up, making the intergenerational cycle of distance, disconnection, and stress seem impenetrable. As Dr. Renschler and Charlene worked together over time, Charlene began seeking a replacement for that maternal connection. Though her ex, Tony, was out of the picture, his older sister was welcoming of Charlene and wanted to have a relationship with Nia. Charlene started taking her daughter over to see her paternal aunt and began spending more and more time there. Dr. Renschler explained to Charlene that forming caring relationships, like the one she now had with Tony’s sister, was an important ingredient for health, both her child’s and her own.
Then, seemingly out of nowhere, Charlene stopped coming to therapy. Dr. Renschler didn’t see her for two weeks, and though he phoned and left several voicemails, his calls were never returned. When she finally came back, Charlene had the faint outline of a black eye, and her earbuds were firmly in place. A crying Nia sat beside her on the couch and Charlene was once again staring blankly at the wall. All those months of progress seemed to have evaporated. Only gradually did Dr. Renschler get the full story from Charlene. She had been visiting Tony’s sister with Nia when Tony showed up out of the blue, agitated and ranting. While she was holding Nia, he suddenly attacked her. Terrified, she ran away to call the police, leaving Nia with Tony’s sister. Following the attack, it was as if Charlene and her daughter had been transported back in time. Nia was up all night, screaming and inconsolable, and they were whisked back to the land of no sleep. Over the next several sessions, it became clear that what had happened with Tony had sent Charlene back into a depression and Nia into a state of distress. During one session when Nia was crying inconsolably, Charlene said to Dr. Renschler, “She just gets so mad at me.” They talked more about how Charlene felt when Nia screamed and cried, and Charlene admitted to worrying that Nia was going to be short-tempered like Tony. She got mad at Nia for crying because she didn’t want people to think her ten-month-old baby was crazy like her dad.
Charlene kept going to CPP and she and Dr. Renschler worked hard to find a path back to the success they’d had early on. During a particularly hard session, Charlene quietly put her hand on her stomach. When Dr. Renschler asked what she was experiencing, she explained this was what she did when she was really upset, something that helped her calm down when she felt she was going to lose it. Dr. Renschler told her it was actually a really good sign that she could recognize when she felt that way. Often when people’s stress response becomes activated, their biological systems are so overstimulated that they don’t know what to make of it. This lack of understanding means that people don’t take time to collect themselves; they just react in whatever ways their bodies tell them to—lashing out at others, acting impulsively, or self-medicating. For Charlene, this made intuitive sense.
The conversation about biology opened the door for Dr. Renschler to discuss mindfulness, the practice of being aware of internal thoughts and feelings in a sustained way. There were several calming techniques that Charlene could use when she was feeling stressed or overwhelmed, and she and Dr. Renschler worked on using breathing and awareness to focus and soothe her body’s response to stress. Charlene started employing mindfulness strategies at home when she and her aunt fought and found it to be a big help. While the trauma with Tony definitely set Charlene back, eventually, after filing charges against him for assault and working through the shame and anger she felt about it, things got better. Dr. Renschler, with the support of the clinic staff, continued to work with Charlene and Nia on feeding, sleep, and mindfulness, reinforcing techniques that could be used again and again when things happened to trigger them both, bringing trauma to the surface.
The good news was that the healthier Charlene got, the healthier Nia got. Over time, she put on weight and caught up on her developmental milestones, and the CPS case was successfully resolved. Charlene started looking for work and even described to Dr. Renschler how she used her mindfulness exercises to help calm herself during a stressful job interview. She got the job, moved into her own apartment, and eventually got into a healthy relationship. By then, Charlene had forgiven me for the CPS report. I had made a point of checking in on mother and baby when they arrived to see Dr. Renschler. Eventually, we resumed our relationship for Nia’s regular checkups. When Charlene came in and told me about getting the job, it felt like a victory. Instead of just treating the symptoms of Nia’s failure to thrive, we had been able to treat the root of it—the stress caused by depression and trauma and an unhealthy family dynamic. Despite setbacks along the way, the child-parent psychotherapy had been a real success, changing the dynamic that was affecting Nia’s health and strengthening Charlene’s ability to act as a buffer for her child when problems arose.
To this day I will never forget the image of a chunky sixteen-month-old Nia toddling through the clinic, giggling and being chased by her mother. As a doctor, there are moments when you realize that you have saved a life. It’s a tremendous feeling of satisfaction (mixed with exhaustion) that most often occurs in the chaos of the hospital after a successful resuscitation. As I saw Nia coming up the hall, I was struck with that same feeling: We did good.
As my colleagues and I made a conscious effort to look at our patients through the ACEs lens, the small victories started coming more and more steadily. While there were certainly challenges and stumbling blocks, we were having great success finding ways to help our patients with ACEs soothe their disrupted stress-response systems and manage their symptoms more effectively. We found that a focus on the underlying biology of toxic stress and the factors that helped balance the dysregulated pathways—sleep, integrated mental-health services, and healthy relationships—made a big difference for our patients. Soon, we were on the lookout for more tools to use in our toxic stress toolkit.
Pediatric obesity was one of the major health problems we targeted. With heartbreaking consistency, the 94124 zip code had the highest rate of obesity in all of San Francisco. Bayview is a food desert, which means there are way more fast-food outlets here than in other neighborhoods and almost nowhere to get fresh fruit and vegetables. I experienced this firsthand when I didn’t have time to go food shopping and couldn’t bring my lunch to work for a week. My options included all the greasy shades of fast food—taco truck, Taco Bell, McDonald’s, KFC, and the least of the evils, Subway. Despite what its marketing department says, there are only so many days in a row a girl can eat a Subway sandwich.
Thanks to a grant from a local foundation, we were able to implement a cool obesity-treatment program modeled on a successful program at Stanford. Every Tuesday evening, two nutritionists from CPMC and two trainers from the Bayview YMCA came to the clinic to lead a group of our overweight patients and their parents. The kids went with the trainers to do some fun physical activity in a former warehouse space at the back of the clinic. It was a pretty bare-bones setup, but the area was large enough for a group of twenty kids to play volleyball, dance to Zumba, hula-hoop, and do whatever else would get them to work up a sweat. At the same time, their parents received hands-on instruction about how to prepare nutritious meals, and everyone ended the evening with a delicious, healthy dinner. To top it off, we had received some donated bicycles from a local company, so each kid who met his or her treatment goal would get a bike. You would think that this shiny kid-bait would be enough to keep my patients on track, but the truth was that most of our kids really struggled.
Bayview parents couldn’t just let their kids run wild at the local park the way my parents did with my brothers and me. Parents in Bayview made sure their kids stayed safe by keeping them indoors—which meant that any stressful family dynamics were intensified. My colleagues and I knew that, as always, our kids with ACEs needed some extra help. To do that, we made sure that every patient in the program with a high ACE score (which was most of them) also received mental-health treatment with Dr. Clarke. Their therapy sessions focused on how their individual life experiences might be affecting their weight. The results were so good, it almost made me want to Zumba in celebration (almost). Pediatric obesity is a notoriously tough nut to crack, especially in communities like Bayview, but at the end of this program, every last bike was gone.
The program’s success showed us that addressing ACEs as part of a weight-reduction program was essential. But in an interesting twist, we found that if our goal had been simply to address ACEs instead of obesity, exercise and nutrition would still have been an important part of that. It wasn’t our initial intention to treat our patients’ toxic stress with dodgeball and cooking classes, but we were pleasantly surprised to see how much the kids improved when we added healthy diet and exercise incentives to therapy. I sat down to check in with the moms and grandmas each week, and they reported that when they changed their children’s diet and their levels of exercise went up, the kids slept better and felt healthier, and in many cases, their behavioral issues and sometimes their grades improved.
We found that there was plenty of science to support what we were seeing clinically. The data showed that regular exercise helped increase the release of a protein called BDNF (brain-derived neurotrophic factor), which basically acts like Miracle-Gro for brain and nerve cells. BDNF is active in parts of the brain important for learning and memory, like the hippocampus and the prefrontal cortex. We’ve long known that exercise improves cardiovascular health, but the research is piling up in exciting new directions, showing us that moving our bodies builds our brains as well as our muscles.
When it comes to combating toxic stress, addressing the dysregulated immune system is as important as supporting brain function. Regular exercise has also been shown to help regulate the stress response and reduce the presence of inflammatory cytokines. You might remember that cytokines are the chemical alarms that fire up your immune system and tell it to fight. For a person with toxic stress, moderate physical activity (like breaking a sweat for roughly an hour a day) can help the body better decide which fights to pick and which ones to walk away from. (While moderate exercise helps better regulate the stress response, there’s no need to sign up for that ultramarathon. If you get too crazy, intense wear and tear on your body can actually increase cortisol levels.)
We saw that exercising made a huge difference for our kids, but so did eating right. Making a few specific changes to what grade of fuel went in the tank (e.g., substituting lean proteins and complex carbohydrates for greasy fast food) improved the body’s ability to regulate itself. We explained that exercising and eating healthfully not only contributed to weight loss but also helped boost the immune system and improve brain function.
We’ve talked about how inflammation is one of the ways a well-regulated immune system fights infection, but as with everything else in the body, balance is critical. Too much inflammation causes all sorts of problems, from digestive issues to cardiovascular complications. Eating foods that are high in omega-3 fatty acids, antioxidants, and the fiber from fruits, vegetables, and whole grains helps fight inflammation and bring the immune system back into balance. By contrast, a diet high in refined sugar, starches, and saturated fats can promote further inflammation and imbalance. By choosing a healthier pattern of eating and adding moderate exercise to their routines, our patients had two great ways to bring their biological systems into better balance.
At that point, my staff and I had some strong strategies for specifically targeting and healing the dysregulated stress response: sleep, mental health, healthy relationships, exercise, and nutrition. Not surprisingly, these are the same things that, as Elizabeth Blackburn and Elissa Epel’s research showed, boost levels of telomerase (the enzyme that helps to rebuild shortened telomeres). Of course, I was excited to find more. So once again, I pored through the literature looking for treatments that could lower cortisol levels, regulate the HPA axis, balance the immune system, and improve cognitive functioning. Over and over again the research pointed to one treatment in particular—meditation. Though many of us have been led to believe that meditation requires brightly colored robes and a mountaintop, or at least lots of crystals and green juice, training the mind has, fortunately, become a lot more mainstream than that. While techniques based on meditation practices began with religious sects thousands of years ago, they are now being used by an unlikely successor—the medical community. From cardiologists to oncologists, doctors have begun incorporating mind training into their clinical treatments.
Dr. John Zamarra and his colleagues looked closely at a group of adult patients in New York with coronary artery disease to see what (if any) effect meditation might have on their cardiovascular condition. Half of the group was randomly assigned to participate in an eight-month meditation program while the other half was assigned to a wait list. Everyone underwent a treadmill test at the start and end of the study. Remarkably, the biometric results demonstrated that at the end of the study, the patients in the meditation group were able to exercise on the treadmill 12 percent harder and 15 percent longer before experiencing chest pain. Even more interesting, during the treadmill test, the meditation group experienced an 18 percent delay in the onset of EKG changes that indicated stress on the heart, whereas the control group saw no changes to any of the clinical parameters. Researchers doing a similar study on meditation and cardiovascular health found a difference in arterial-wall thickness. Meditation was shown to be associated with reversing the narrowing of arteries, which for patients suffering from ischemic heart disease can be nothing short of lifesaving. In another study involving breast and prostate cancer patients, researchers found that meditation was associated with decreased stress symptoms, increased quality of life, and improved functioning of the HPA axis. Other studies have shown that meditation decreases cortisol levels, enhances healthy sleep, improves immune function, and decreases inflammation—all critical parts of keeping our biological systems balanced and able to mitigate the effects of toxic stress.
The more I read, the more it made sense to me. If stress can negatively affect the way the body works at a basic chemical level, then I could see how taking on a calming practice could positively change those same chemical reactions. While stress activates the fight-or-flight system (also called the sympathetic nervous system), meditation activates the resting-and-digesting system (also called the parasympathetic nervous system). The parasympathetic nervous system is responsible for things like lowering heart rate and blood pressure, and it directly counters the effects of the stress response. Given the profound connection between the stress response and the neurological, hormonal, and immune systems, a calmer, healthier mind seemed like a good place to start reversing the effects of toxic stress.
It wasn’t long before I decided to take the science out of the journals and put it to work in the clinic. We quickly realized that reading the data on meditation was one thing but figuring out the right way to bring it to our patients was a whole different kettle of fish. I worried my patients would think meditation belonged in the hippie-dippie circles of the Haight-Ashbury district rather than in Bayview. What I really didn’t want was a lady named Moonbeam coming in to tell my kids that they just needed to “find their center.” I had to get my patients and their parents past the woo-woo factor and present meditation and mindfulness in a way that made them want to try it.
Being in the Bay Area, where cutting-edge science meets cultural sensitivity, I knew there had to be an in-between option; it was just a matter of time before I found it. And I did find it, in an impressive organization called the Mind Body Awareness (MBA) Project. MBA was doing mindfulness work (both meditation and yoga) with kids in juvenile hall and getting some solid results. I had seen the data on how many kids in juvie have their own fair share of ACEs (one study that came out later on looked at more than sixty thousand young people in the Florida juvenile justice system and found that 97 percent had experienced at least one ACE category and 52 percent four or more), so I figured it would be a good fit. After I met with MBA’s executive director, Gabriel Kram, and heard his story, I was even more sold on our proposed partnership.
Gabriel grew up in an upper-middle-class home and attended an elite private high school in St. Louis, Missouri, before heading to Yale to study neurobiology. A few years in, he began a daily meditation practice, discovered how disconnected he felt from his authentic self, and dropped out of school. He passed through a period of intense anger and got caught up with a seriously shady crew. Never having been around people who didn’t have his best interests at heart, Gabriel implicitly trusted them. One night, the leader of the group gave him a hit of LSD and then took him out with the intention of getting him to kill someone. He handed Gabriel a knife, identified the target, and shoved him toward the unsuspecting victim. Gabriel took a few steps and then paused. In that moment, a clear image of his father came to him. He realized that if he did this thing, he could never look at his father again without having to hide something. The image of his father literally stopped him in his tracks. That moment marked a turning point in Gabriel’s life, and though traumatic, it opened a door to deep healing. When he later reenrolled in school, his mindfulness practice became the center that helped him stay connected to his values and integrity.
What motivated Gabriel’s work with incarcerated youth was his realization that if it hadn’t been for his father, for his stable and loving relationship with him, he might not have stopped himself from doing the unthinkable. And that love, that connection—it wasn’t a given for every kid. Because of the possibility he had recognized in himself, he felt a strong desire to help those who didn’t have a person like that in their lives, someone who stops you cold in a moment of truth. That safe, stable connection, along with the essential tools of mindfulness, had helped him immeasurably and he wanted to share that.
If you’re ever lucky enough to meet Gabriel, the first thing you’ll notice is his intensity. Far from being intimidating, he’s totally magnetic, and as we sat down to plan our program I could already tell that my kids would love him.
To start out, we recruited fifteen girls with ACE scores of four or more for a ten-week program that involved a weekly two-hour session of mindfulness and yoga. I participated in the program with the girls and sprinkled in education about how the stress response works in the body, and how to recognize it and bring it back under control when it starts to go into overdrive. It was my favorite two hours of the week. The majority of my girls had experienced some type of sexual assault, and many of them had parents who were mentally ill or incarcerated, sometimes both. It was amazing to see the way the trainers from the MBA connected with our girls. By the end of the program, almost all of our girls reported feeling less stressed and, even better, as if they had new tools to manage stressful situations. Two of our girls stopped fighting in school, and most of them reported sleeping better as well as feeling more able to concentrate and connect in school.
With both our meditation program and our nutrition and exercise program, we saw the day-to-day evidence of progress, not by looking at numbers on a spreadsheet but by seeing individual kids literally dance into the waiting room, waving report cards that went from failing grades to honor roll. As their doctor, I got to see how, over time, they were hitting their clinical goals—better asthma management, weight loss, and so forth—but the special experiences for me were seeing Nia walk and Charlene smile and witnessing a kid with a sky-high ACE score lose ten pounds and take home a bike.
Slowly but surely, we were building our toolkit of clinical interventions to combat the effects of toxic stress. Sleep, mental health, healthy relationships, exercise, nutrition, and mindfulness—we saw in our patients that these six things were critical for healing. As important, the literature provided evidence of why these things were effective. Fundamentally, they all targeted the underlying biological mechanism—a dysregulated stress-response system and the neurologic, endocrine, and immune disruptions that ensued.
I got to see all the ways these interventions were making my patients’ lives better. I knew that was real, but as a scientist, I also knew it was anecdotal. We didn’t have the manpower or the money to do the kind of systematic data tracking that would translate all those good report cards and bike-giveaway parties into solid research that would stand up to scrutiny in scientific circles. At one point, I even thought to myself, We should be writing all of this up. But our team was stretched thinner than pantyhose. I realized that we could do or we could write, but we didn’t have the bandwidth for both. I decided that, for now, the doing was more important.