Q&A: California’s first-ever surgeon general on her plans to tackle toxic stress in children

Phtoto courtesy of the California Surgeon General's office

Dr. Nadine Burke Harris, California's surgeon general, tends to a child in her office.

Phtoto courtesy of the California Surgeon General's office

Dr. Nadine Burke Harris, California's surgeon general, tends to a child in her office.

David Washburn

March 27, 2019

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Gov. Gavin Newsom made it clear throughout his campaign that improving the health and welfare of California’s children and young families would be among his signature issues.

To underscore his commitment in the days after he took office, Newsom named Dr. Nadine Burke Harris, a pediatrician who specializes in the impacts of trauma and toxic stress on the health of children, as the state’s first-ever surgeon general.

The 44-year-old Burke Harris was born in Canada and lived in Jamaica when she was a toddler, but spent most of her childhood in Palo Alto. In 2005, after earning her bachelor’s degree at Berkeley and her medical degree from UC Davis, she founded a clinic that serves children in the low-income neighborhoods of Bay View-Hunters Point in southeast San Francisco.

Through her medical practice and research, Burke Harris has become recognized as a pioneer in the study of how adverse childhood experiences affect the developing brain and can lead to lifelong health and mental health problems. EdSource recently caught up with Burke Harris, who is the mother of four boys, and talked with her about what she plans to do in her new job. Her answers to our questions were edited for length and clarity.

Gov. Newsom has made funding early education one of his highest priorities. How do you plan on incorporating trauma-informed teaching into the overall effort?

We’re understanding more than we ever had before the role of experience and environment in early childhood in shaping lifelong health outcomes. That is the data and research we are seeing across the board. So, when you look at something that is such a huge public health issue then we must recognize that to implement public health solutions we need to be engaging across sectors.

So, in our educational system, in our health system, in our justice system — across the board — we need to have broad-scale and coordinated efforts to address the impact of early adversity on health and development. Healthcare and early education go hand-in-hand.

When a child first walks into your office, what is it about him or her that indicates to you that they’ve had significant adverse childhood experiences?

Absolutely nothing — that’s why we have to screen. Many of the children who came to me in my practice were referred for ADHD. So, certainly we see greater behavioral and developmental issues in kids who have experienced high doses of adversity. But some kids don’t have behavioral symptoms, some kids you really can’t tell by looking. And that’s why it’s so important for California to move to routine screening for adverse childhood experiences.

That being said, in a study I published in 2011 looking at my patient population we found that if my patients had four or more adverse childhood experiences, they were 32 times more likely to have learning and behavioral issues. We often see learning and behavior as the canary in the coal mine, but it’s not always outwardly obvious. So, early detection and early intervention are critically important.

What are the various ways in which trauma can show up in a child’s performance and behavior in school?

When we think about the biology, what we can see are symptoms of poor impulse control, which indicates impairment of the prefrontal cortex. So, poor impulse control, quick to anger, inability to calm themselves down can indicate a high level of stress hormones that take longer to clear out of the body.

Oftentimes the symptoms look very much like ADHD, but it can also present as simply being withdrawn — the symptoms are really varied and it depends on the individual and their experiences. One of the challenges is that when some of these behavioral symptoms come up it’s really important for educators to ask the question: What could be at the root of this for this child? And how has what this child has experienced inform the best way for us to respond?

What role does school discipline play?

I think it’s absolutely critical for school systems to have trauma-informed and trauma-sensitive school discipline policies. We certainly want to support the safety of the school environment, but we are seeing that many of these exclusionary policies, including suspension and expulsion, are inequitably applied.

Many of the underlying behaviors that might call for that type of discipline may actually be symptoms of a child experiencing a toxic stress biology, in which case we want to respond to a health problem with a healthy and informed solution. Understanding what has happened to the child and providing the support that will address the root cause of the behavior.

You’ve spent your career working in low-income communities with high levels of trauma. What types of trauma are you seeing now that you didn’t 10 or 15 years ago?

Particularly right now I think there are many communities that are experiencing high levels of trauma in light of the current immigration and border enforcement debate and changes in regulations.

As a pediatrician, I’ve seen it in my own clinical practice, patients coming in to see me with complaints of chest pains, high levels of stress and anxiety and difficulty with behavior as both child and caregiver are experiencing high levels of stress and fear around ICE raids or fear about seeking services in public spaces like schools and healthcare systems. It is certainly different, and heightened from what it was in the past.

There has been a mountain of research into the effects of trauma and toxic stress on the growing brain. How much of the trauma ends up essentially hardwired into the child? And to what extent can the damage be reversed if proper interventions take place?

Significantly. I wouldn’t have taken the job if I didn’t believe deeply, and the evidence shows, that intervention can absolutely improve outcomes. Now, the earlier the identification and the earlier the intervention, the more we have the opportunity to take advantage of our developmental biology for the benefit of healing.

But it’s never too late to address a toxic stress physiology, it’s never too late. I think there is a lot of attention to the early childhood period because that is where we get the biggest bang for our buck — every dollar that we put into that now saves us dollars down the line.

But during adolescence, for example, all those hormones that make adolescence so horrifying — those hormones also enhance neuroplasticity. So, adolescence is another period of time where we have additional opportunity to take advantage of biology and make lasting changes.

When we look at rates of adverse childhood experiences experiences statewide, a number of rural counties are at the top of the list. What are your plans to address trauma in rural schools?

I think it is critically important. I am planning on visiting our rural counties that are most impacted. Our three highest counties in terms of [adverse childhood experiences] right now are Butte, Humboldt and Mendocino and those are all in rural Northern California. Those are places where I intend to visit and work with local organizations to be able to support efforts.

The one thing I wanted to also add to that is people do often think about low-income communities and communities of color. But what is really important to understand is that [adverse childhood experiences] happen in all communities.

Secondly, when you look at poor outcomes based on income, it’s actually a U-shaped distribution. The lowest income folks can have disproportionately poor outcomes, but then on the upper-income side, we also see some of the effect of the price of privilege. If there is lower social cohesion, if there is less support from parents and caregivers, especially in the very high-income group, kids also have poorer health and behavioral outcomes. This is something we have to look at across all of our educational systems in California.

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