The Not Mini Adults Podcast - “Pioneers for Children’s Healthcare and Wellbeing”
The Not Mini Adults Podcast - “Pioneers for Children’s Healthcare and Wellbeing”
Episode 33: 'ACEs' with Sarah Marikos
On this weeks Podcast we are delighted to welcome Sarah Marikos who is the Executive Director of the ACE Resource Network.
ACE standing for 'Adverse Childhood Experiences'.
Sarah’s professional career has focused on the science of things that can hurt us and heal us. As an undergraduate at the University of California Berkeley, Sarah studied and conducted research on the US national opioid epidemic, the emergence of 2009’s H1N1 in-fluenza, and other major public health problems.
But witnessing Hurricane Katrina’s devastating and inequitable impact on communities influenced her to pivot from the pre-med track to public health, deciding to pursue a master’s in public health (MPH) in epidemiology to better understand the confluence of factors that influence the health and well-being of people and communities.
Today Sarah says that she enjoys connecting people and data to improve systems in order to prevent harm and help people recover and heal.
In this episode we talk to Sarah about her journey and most importantly the impact that discovering the research around Adverse Childhood Experiences has on families and the impact that it could have on society if it was better understood by all.
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Follow Dr Burke Harris on Twitter here. Discover her book The Deepest Well/Toxic Childhood Stress here.
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Theme Music - ‘Mountain’
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copyright Lisa Fitzgibbon 2000
Written & performed by Lisa Fitzgibbon,
Violin Jane Griffiths
Podcast editing - Right Royal Audio
Podcast artwork thanks to The Podcast Design Experts
ACEs are strongly associated in a dose response fashion, with some of the most common and serious health conditions that our societies face. At least seven of the 10 leading causes of death. So essentially, they found that the more ACEs you experience, the more likely you are to experience heart disease or stroke, depression, anxiety, COPD, asthma, I could go on. They found that it affects all of us. It crossed racial and ethnic, socio economic, gender and geographic lines.
David:Hello, and welcome back to the Not Mini Adults Podcast, Pioneers for Children's Health Care and Well Being. This is season three and this is episode 33. My name is David Cole and once again I am joined by my wife Hannah and we are the founders of UK children's charity, Thinking of Oscar. Last year I came across a book that had a big impact on me, written by the now Surgeon General of California, Dr. Nadine Burke Harris, the book, Toxic Childhood Stress, The Legacy of Early Trauma and How to Heal, forms part of our conversation today. We are delighted to welcome Sarah Marikos, who is the Executive Director of the ACE Research Network, a standard for adverse childhood experiences. Sarah's professional career has focused on the science of things that can hurt and heal us. As an undergraduate at the University of California, Berkeley. Sarah studied and conducted research on the US National opioid epidemic, the emergence of 2009's H1N1 influenza and other major public health problems. But witnessing hurricane Katrina's devastating and inequitable impact on communities influenced her to pivot from the pre med track to public health. Deciding to pursue a master's in public health in epidemiology, to better understand the confluence of factors that influence the health and well being of people and communities. Today Sarah says that she enjoys connecting people and data to improve systems in order to prevent harm, and help people recover and heal. In this episode, we talk to Sarah about her journey and most importantly, the impact that discovering the work around adverse childhood experiences has on families and the impact that it could have on society. If it was better understood by all. We really hope you enjoy today's episode. Sarah, Hello, thank you so much for joining us on the Not Mini Adults Podcast.
Sarah:Thank you. It's a pleasure to be here.
David:So the subject that we're going to be talking about today has been so important to us to try and get on and to share. Ever since I read Dr. Nadine Burke Harris's book, I bought it, I've shared it with people. So we're so excited to be able to share the work that she's done, but just as importantly, your story as well and how you've got to be doing the work that you're doing. So maybe if we could start there and tell us a little bit about yourself, for our listeners, please.
Sarah:Yes, thank you. Well, I've always been interested in trauma in adversity and how it impacts us as individuals and how it impacts us as communities. This was really informed by some of my early life experiences. So I really always sought to understand and that informed my university experiences. I was interested in larger scale events like natural disasters. I was involved in the response to a different pandemic, the 2009 H1N1 pandemic and the impact of that on our communities and individuals. I always wanted to better understand why were some people more impacted than others? How do we prevent trauma and adversity? Then how do we heal from it. This led me to pursue a graduate degree in epidemiology to better understand the impacts of trauma and it was through my graduate work that. I'd taken classes on communicable disease epidemiology on chronic disease epidemiology, learned the epidemiology of 100's of conditions. It wasn't till the very end of my schooling that I had a lecture on the Adverse Childhood Experiences study or the ACEs study as we refer to it. It was the at the end of this chronic disease epidemiology course. It was just like a lightbulb for me. We had just spent the whole semester talking about heart disease and strokes, diabetes and all these conditions. Then we learned about Adverse Childhood Experiences and how the impact of them. How widespread they are and how they are associated with over 40 health conditions that the medical field, the scientific field, the public health field, puts all our energy and resources into. It was like why aren't we talking about ACEs when we're talking about the prevention and mitigation of disease? That is how I came upon the study and learned about Dr. Nadine Burke Harris's work. I've just had the immense privilege to be able to do this work at a national scale in the United States and being led really by Dr. Nadine Burke Harris, who is the California Surgeon General and a paediatrician.
David:So before we get into ACEs in the study, and I'm thinking a bit more about that, and I have to say, I know you've taken it to obviously a far greater level to me, but I felt exactly the same way when I read about ACEs in terms of why aren't these known more? Why is this not shared more? Obviously, that's why we're here today to try and talk about that.But in terms of the work that you're doing now, you're now working for a nonprofit, which is promoting and trying to share these ideas. Talk to us a little bit about the nonprofit work that you're doing, please.
Sarah:Yeah, I will and I'll just share that. You know, after I learned about the the ACEs study, I gave Dr. Burke Harris's book, The Deepest Well, to my aunt, who ran the NICU at a large hospital in California for 30 years. I shared it with my mom who ran infant toddler programme's for 30 years and they both had that response. So many people that I talked to have that response, like it's the light bulb, why haven't I heard of this? So our group, The ACE Resource Network, we recognise that only about 20% of US adults know about ACEs and their impact. Then we wanted to look deeper, we looked into different professions. What does the medical field know about ACEs? What do educators know about ACEs? What do mental health or behavioural health professionals know? We were surprised to learn that not even half of medical professionals in the United States know about ACEs. About 50% of educators do a little bit more than 50%, of behavioural health professionals. Seeing that data and understanding the deep and sometimes long lasting impact of early adversity and trauma. We said what can we do to make more people aware. That's what led to the launch of the first ever national public awareness campaign on ACEs in the United States, we launched earlier this year, we are working with a variety of partners from celebrities and other influencers, we believe that everyone should know about ACEs, and it needs to be assessable. We're working with educators, we're working with health care providers, and we hope to be working with 1000s of more partners in many different fields, any field that works with children, or works with adults who've experienced trauma or adversity. So you can learn more about the campaign at numberstory.org If you're interested in learning more about our activities this year,
David:We will make sure that there's a link to your website in the show notes for this podcast. I think it's it's funny that obviously we both kind of came across this in in a similar way. The book now, it was called The Deepest Well, I think it's been republished and the copy I certainly haven't, that I've shared is now called Toxics Childhood Stress, but you just touched upon it. But one of the kind of headlines within the book is that actually, two thirds of us have experienced at least one adverse childhood experience or one Ace Which is an incredible amount of people in the world, if you think of it from that perspective. So maybe if you could tell us a little bit more about the initial study and actually, you know, what are ACEs?
Sarah:So the Adverse Childhood Sxperiences Study or ACEs study was conducted by the centres for disease control and prevention in the United States and Kaiser Permanente at large health system. They essentially surveyed about 17,000 adults who had health insurance and enrolled in this health system in Southern California and they ask them about their adverse experiences. The 10 types of adversities that they queried this group about, we're about three types of abuse, physical, emotional, and sexual abuse before the age of 18. Neglect, two types of neglect, physical and emotional neglect. Five types of what we call household challenges. So these include having a parent or caregiver with substance use issues, mental health challenges, witnessing domestic violence, having a parent or caregiver incarcerated, and then divorce or separation of one's parents or caregivers. What they found and you shared, what was so powerful for many is that two out of three of these adults had experienced at least one and one in eight, reported four or more ACEs. So it showed the field how prevalent childhood adversity is. Again, this is only defining childhood adversity with these 10 categories. Then what they found is that ACEs are strongly associated in a dose response fashion, with some of the most common and serious health conditions that our societies face. Atleast 7 of the 10 leading causes of death. So essentially, they found that the more ACEs you experience, the more likely you are to experience heart disease, or stroke, depression, anxiety, COPD, asthma, I could go on, and they found that it affects all of us at cross racial and ethnic, socio economic, gender, and geographic lines.
David:That for me is why this is so phenomenally important to share that, the experiences just don't do cause all of these multitude of problems. We've talked quite a bit on on this podcast and, you know, in day to day, just in terms of preventative care. We have a sick care system, basically, wherever you look, whether it be the US, the UK, or any other country. We treat people that come in that are unwell, we don't think about it necessarily, completely from a preventative perspective. I guess actually, when I listened to what you're talking about, and trying to get people to understand more about ACEs that really is preventative care. It's trying to get that preventative measure up.
Sarah:Absolutely, because there are things that we can do in our communities, in our families that can prevent ACEs from occurring. One of the things that I think is really important for our healthcare systems and Dr. Burke Harris talks a lot about this. Is that, identification or screening of ACEs or early childhood trauma by paediatricians and other health professionals can actually be a form of prevention. So we talked about primary prevention where you know, the harm never happens. But secondary prevention involves that you've been exposed to some some trauma, but we're going to identify it early. So we're going to be able to intervene and get the diagnosis correct, to inform whatever that child and that family needs to prevent what the field calls the toxic stress response. So that I think is really critical to understand that many of us experience ACEs. Parents are going to have mental illness, there are going to be adversities that our children face and ACEs aren't deterministic. Just because you experience a lot of childhood adversity doesn't mean you're going to have these negative health outcomes. What leads to these negative health outcomes are when you develop a toxic stress response. What we mean by that is when you know, kids are growing and developing and these sensitive periods of development when they experience adversity that is overwhelming and they don't have sufficient buffering protections from healthy relationships or healthy and safe environments. That's what can lead to the disruptions of brain development, immune and metabolic systems. This leads to the toxic stress response that can lead to these negative health outcomes. So from a prevention standpoint, in healthcare settings, there's a great and broader. There's a great opportunity to identify and intervene early to really give that child that dose of buffering that antidote to the adversity.
Hannah:Well, you've made me think about then is that, you have the group of ACEs and the factors that can lead to the toxic stress. What you're explaining is, so by identifying it early, the early intervention is going to have a very positive impact. But also mulling over is is it also as much about being a barometer as a kind of menu of interventions that a caregiver or whichever as you say, whichever party it is that's involved in the child, or indeed adults life that can see the traumas that have occurred. So you can see that there say three or four given traumas that may have occurred and then there are associated interventions of those. But I think what I'm hearing you say, as well I might be able to cope with one of the traumas and my body may have the buffering for that. But if I'm experiencing four or six, then that is what I mean by the barometer does it also as a caregiver, or a stakeholder who can help get that kind of give you a sense of the pressure that this human being has been enduring so far?
Sarah:Yeah, if I understand your question. The science shows and we say over and over and over, a caring adult can absolutely make a difference in a child's life. No matter the cumulative adversity, the number of experiences, whether they were chronic or acute. This is where I think there's so, I think the field has been so focused on these adverse childhood experiences. I think what's so important and what's coming up for me is that we also talk and stress and influence the positive experiences in a child's life. The positive experiences matter more than the adverse ones. So it's really critical that as much as we can, we want to mitigate and prevent the adverse ones, that we have those supportive, positive experiences for children. Even if a person experiences six, or seven, or eight, and we haven't even talked about other types of childhood adversity, that can lead to that toxic stress response, like living in poverty, like discrimination, like racism, like losing a parent or caregiver. If we have those buffering supports for children, we can prevent or mitigate that longer term impact.
David:So you just mentioned kind of two elements actually, that we wanted to discuss. One was I think you actually call it the PACEs? So the positive...
Sarah:And adverse childhood experiences.
David:Yeah. Okay. The other one is that actually, there was an original 10, which you went through in terms of the ACEs study. But there's now a longer list that has been looked at and identified that actually can cause ACEs.
Sarah:Yeah, so I'll first talk about PACEs and so there's a there's a great global group called the PACEs Connection, that I highly encourage people to look into, if they're interested in learning more about what's happening in this world, in their community or in their profession. So PACES Connection works across the globe, geographic base communities, education base, medical based, legal based initiatives. They support communities on the ground to really bring in the science of both positive and adverse childhood experiences. They change their name. They were called the ACEs Connection for many years and recently changed their name to PACEs connection to reflect what we're learning about the importance of positive childhood experiences and mitigating the adverse ones. But yes, and I want to clarify around language a little bit. So when we talk about the ACES study, it will always refer to those original 10 ACEs, identified in that study. That's where there's been a tremendous amount of research since their original study 25 years ago and continues to be regularly conducted in the US and in other countries. But what we've seen and many have known for a long time is that we now have, just in the last 15 - 20 -25 years with new medical technologies are really seeing the impact on our bodies and brains as a result of living in poverty as a child and know that that can lead to disruptions in our development that can affect us long term. So that's critically important. Witnessing community violence. So the original ACEs, talked about witnessing domestic violence, but living in a community where there's violence and witnessing that violence. That makes sense, right? When we think about ACEs, well, that's not a traditional, at the core of aces is adversity and not living in that safe or stable or predictable environment. So witnessing community violence can also disrupt the healthy development of a child and discrimination, whether that's because of our sexual orientation, or gender identity, our racial ethnic group, our country of origin, our levels of ability, can also have a really critical impact on us as we develop as children.
David:Knowing this and being able to identify the ACEs. Is it that you can actually reverse some of the impact on the individual to help them you know, move through life? How is that kind of being addressed?
Hannah:Another part of the same question is, and who can do that, because I'm listening to you thinking, you know, school units run by us. Schools or foster parents or other folks that are involved as well. How qualified do you need to be to take advantage of the research?
Sarah:Yeah, no. Great, great questions. So the science now shows, it's not just a fancy, fun phrase that people throw around. But that our bodies and brains can heal and recover. That can be done in a variety of ways. At an individual level, what that can look like if you've experienced ACEs or other childhood adversities, and experienced toxic stress, or have a dysregulated toxic stress system. That can look like, they're sort of seven different strategies that are good for all of us. But particularly important for people who've experienced a lot of early adversity. Those seven are things like healthy relationships, being in connection with people that you trust and feel safe. We know that isolation is really bad for our health. But particularly for those of us who've experienced early adversity, it's really important to be in healthy relationships. Mindfulness can help us heal, feel better and recover. Movement, physical activity is really important. A lot of our trauma is stored in our body, physical movement is really healthy and good for us. Good nutrition, whatever that means for us. That's defined differently for people, particularly people who've experienced ACEs. Good sleep can help mitigate the impact of toxic stress on our bodies. Then mental health care can be critically important for some of us who've experienced early adversity. Then lastly, is access to nature and being in nature. We know that being in nature can lower blood pressure. There's lots of things that it can do. Now, not all of us have the same level of access to nature, but nature can be very healing places. It doesn't have to be, I think a lot of times what people think is like, I have to be in like a national park or on a Island. It can really be trying to find some green space where you can let your body you know, rest and regulate.
David:It strikes me that all of those measures that you just described seem all the things that we would love to be able to provide to our children and to you know, ourselves. But many of the individuals, many of the children that will have experienced ACEs won't necessarily have the opportunity to get a lot of that support. I guess that's potentially where the work that you're doing comes in and also the education for caregivers and care providers, clinicians, and everything else. It's so important to do it, but not wanting to be negative, but I guess there's always going to be, you know, some challenges trying to give a lot of those things to individuals.
Sarah:Absolutely. I love to comment on that. That's, you know, our campaign is a public health awareness campaign. This is not, the solutions are not just individualised. The solutions are in our communities and in our systems. That's why for example, Dr. Burke Harris and her role as California Surgeon General is training healthcare providers and understanding ACEs and how to respond to them. That's why educators, I spoke to a group of 1000 educators and a large Los Angeles school district yesterday. Why educators are learning about ACEs? How it can show up in the classroom of the child is experiencing adversity? What may that look like in the classroom? A lot of times what I think happens is, people notice behaviours, right. They oftentimes kids may be punished for behaviours be viewed as, you know, a bad kid or a bad behaviour. But when you bring an ACEs lens, to working with children and with adults, it helps you, you know, get to the root of what an understanding. Like I mentioned before, you know, diagnosis equals treatment, if we don't diagnose what's happening correctly, the things we're doing to try to help may not help. So it's bringing that ACEs lens to all our systems and our communities so that we can really tackle this as a true public health problem. Oprah Winfrey recently published a book called What happened to you? That's part of the question, right? It's not what's wrong with you, but what happened to you. When you can bring that to your work, it really shifts things. With that, it's what happened to you and then it's what can we do to help and support you. It's not just up to that individual who may be experiencing negative health outcomes associated with it. Negative, you know, workplace outcomes, negative relationships associated with it. It's really about what can we do to, how can we help individuals and communities who have particularly have disproportionately experienced early adversity? How can we one, what can we do to prevent that? Then two what can we do to ensure that there are the resources which include funding infrastructure that can mitigate the impact of the early adversity in some communities throughout the United States and the globe?
David:You mentioned Oprah and I know that you don't know when this is necessarily going to be but two things, I guess, people for whom to look out for one is that Dr. Nadine, Burke Harris has actually got a TED talk. So you can go and listen to that. That is, you know, out in the community, YouTube, whatever it might be. But she's also recently spoken to Oprah to and can you give us a little bit of insight as to hopefully that'll be available, but but some of the things that they discussed that, you know, the importance of that discussion and some of the things that they discussed during that conversation?
Sarah:Yeah, I'd be happy to. It was such a wonderful experience to be able to listen to two powerful voices, who have been dedicated to this work for decades. They've done it in different ways. But both use their voices to raise this issue. So Oprah has worked in many different places. But she spoke a lot about her work in South Africa, and her learnings about the impact of early, the long term impact of early adversity. That experience Miss Winfrey talks about led her to working with Dr. Bruce Perry, who is a co author on the book with Oprah to have a trauma responsive trauma informed school in South Africa. After they recognise that the young girls in their school, we're coming from backgrounds with lots of adversity and trauma and it was disrupting their ability to learn in school. So she spoke a lot about that, where Dr. Burke Harris spoke about her efforts in California to train healthcare providers. I've mentioned this, but just right before the pandemic started. California began an initiative to train healthcare providers in recognising ACEs and toxic stress. Over 20,000 healthcare providers have been trained, there is state reimbursement for screening. There's a big, about a $4 billion investment as part of the governor's budget to improve the behavioural health system for young people 0 to 25. So what was really exciting to see through their conversation as they're both applying it in spaces where it's so critical. I talked about sort of that ACES lens, and Miss Winfrey's question, what happened to you is, I believe really the same. It's trying to understand the root of many of the challenges that lots of us face.
David:One thing I do need to point out to listeners that are not in the US, I guess is that Dr. Nadine Burke Harris is title of Surgeon General, is basically the chief medical officer for California, right? It's not necessarily a title that kind of translates that particularly well, but she is a head clinician in California. So that's a pretty, that's a pretty, pretty big role. Very conscious of time and, you know, very grateful for everything that you've been sharing. One question I need to ask is, if there's people listening to this podcast, and they want to start to learn more about ACEs, or they know, clinicians who have patients, and they think that actually, you know, this could help them. What could they do? What would you advise from that point of view?
Sarah:Great question. So for health care providers, I'd encourage them and medical professionals to go to acesaware.org, that is the California site where they've collected the latest research, screening algorithms, guidance, there's webinars on a monthly basis. I think there's a great opportunity for healthcare providers to get resources and information there. For the general public, for those of us still learning about ACEs. I encourage people to go to numberstory.org, we've essentially taken all the research and the science and work to make it more accessible for all of us. So we don't all have to read white papers and peer reviewed articles. There are videos, there are infographics, lots of ways to assess this information and make sense of what it may mean for you and your family or for the children in your life. So those are the two places, I would encourage people to look as well as Dr. Burke Harris's TED Talk is a great starting point as well.
David:Thank you and we will share all of those links in the notes for this podcast ofcourse. Before we we wrap up, one of the things I just wanted to mention was I think there's a lot of examples in Dr. Burke Harris's book around actually not just children, but adults. That when they start to hear about ACEs, there's a light bulb that goes off and they realise that actually, they too, were subjected to a lot of these things and it can account for, you know, some of the things that have happened in their life. So I guess just thinking about that from all perspectives, not just from from children, and, you know, everyone kind of thinking about. How powerful the work is that you are doing and Dr. Nadine Burke Harris has done and you know, this discussion, I guess.
Sarah:Particularly for people who have children, it's critically important for us to do that self examination and sort of do our, take our own ACEs history. Because we know that trauma, we can pass trauma down to the next generation, you know. When we know better, we can do better. I think we can leave different legacies for our children. So I think it's definitely, we don't want people to think of this purely as a an issue among children, right? It's the theimprint, as Oprah said, can stay with us forever. So I think one of the most powerful things we can do is take an inventory for ourselves, for our loved ones for our children. What I find when people do that, that it can bring up a lot of grief. It can be really painful. It can also, I've seen be very freeing for some people to learn that they are not alone. That other people experienced similar things. That there are, you know, people who are not damaged and that there are things we can do to take care of ourselves and feel better. So I think it's critically important for adults to have a better understanding how early adversity may have affected us.
David:So thank you, I promise. Last two questions. The first one is what next? Where is your work and where do you think that the work of you and your colleagues is going?
Sarah:Well, I'll be brief, but I'll just say we just started.Only 20% of US adults know about ACES. We want 70%, 80%, 90% of us to know about ACEs. So we're just getting started with our partnerships. In 2022, we will be continuing broad awareness and be working in some of the sectors that we named to increase awareness among professionals who work with children and adults.
Hannah:Last question today. So if you had a magic wand, and we asked this at the end of most of our conversations and you could wave a magic wand to achieve one thing, one change in child health. What would that be, for you?
Sarah:Within our healthcare systems It would be what's happening piecemeal in different systems already. It would be that early identification and screening of everything that impacts children and their health. Not just ACEs and the resources to actually respond to them. So we know multidisciplinary teams work. We know that children who are experiencing food insecurity or housing insecurity or poverty, that there is resources that we can bring to them that will improve their health. If those systems are working, if the data and information systems are working. So within healthcare systems, it's really building that early identification and true response to support children. I would love to see that and then outside of the health care system, you know, if we could make everything perfect and the health care system. We would not see the games we'd want to see in child health, it also has to happen outside the healthcare system, because the science makes clear how powerfully our experiences and our environments affect our biology. So that would be if we want to improve child health, it's working on things like reducing poverty, it's so that every child has clean air safe water, safe food. We're fortunate in the United States that most kids do enjoy those things. But not everyone does. So I think we'd have to make some real improvements in the the communities, where our children live and grow to see major gains in child health, as well.
David:Sarah thank you so much, we've had a theme on this season of the podcast, which is about impact. I think the work that you are doing, the ACEs work and sharing this conversation will hopefully have and we can see is having, you know a big impact. The other thing and I know we said this at the beginning, but we talk a lot about preventative care. There's been almost a little bit of an epiphany moment for me during this conversation around the opportunity for preventative care by sharing the ACEs story and all the work you're doing and everything else. So thank you so much for giving us your time. It's been, you know, it's been a wonderful conversation and good luck with everything that you're doing.
Sarah:Thank you both very much. It was a pleasure.
David:Thank you so much to Sarah for joining us on this week's Not Mini Adults Podcast. Impact is a word that is probably overused. But as I said on the podcast for me, people being able to understand ACEs and the consequences around them and then being able to prevent that really could have a massive impact on children's lives. Next week, we continue the theme of inequalities and we are delighted to welcome Professor Ian Sinner from Alderhey Children's Hospital to discuss that very topic. Thank you so much for listening to the podcast. If you're enjoying it then please do leave us a review and we really hope that you can join us next time.