The Deepest Well: Healing the Long-Term Effects of Childhood Adversity

Nonfiction | Book | Adult | Published in 2018

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Summary

Chapter Summaries & Analyses

Introduction and Part 1

Part 2

Part 3

Part 4 and Epilogue

Key Figures

Themes

Index of Terms

Important Quotes

Essay Topics

Part 4 and EpilogueChapter Summaries & Analyses

Part 4: “Revolution”

Part 4, Chapter 11 Summary: “The Rising Tide”

After the encounter with Caroline, Burke Harris found that her work gained more visibility and connected her to more collaborators. Burke Harris gave a widely viewed TED talk on ACEs and toxic stress—and even participated in several high-profile conferences. At these conferences, she learned of some pushback against her focus on ACEs.

At one conference, community activists passionately argued that Burke Harris’s toxic stress framework was turning a societal and cultural problem into a medical one (a phenomenon called “medicalization”). What people needed was work on inequities, they argued, and labeling the problem as ACEs and toxic stress responses simply added more stigma to people of color and poor communities already dealing with great challenges. One person even argued that Burke Harris was labeling the children of poor people of color as “brain-damaged” (178). Burke Harris (by then a mom) missed this blowback because she was out pumping milk, but Jeanette Pai-Espinosa, the president of a foundation that centered work on addressing ACEs in the lives of young women, and Nancy Mannix, the chair of a Canadian foundation that used an ACE lens to create the Alberta Family Wellness Initiative, filled her in. The trio began working together because of that encounter.

Another important peer for Burke Harris was Pamela Cantor, who spearheaded work on the effect of ACEs in education under the umbrella of Turnaround for Children. Cantor used what she knew about ACEs to run programs in schools to do research and create intervention for children and communities traumatized by the attacks on New York on September 11, 2001. Although she expected trauma symptoms to be most prevalent in the middle-class neighborhood closest to the attack sites, children in under-resourced, poorer neighborhoods farther from the site had higher ACE scores.

A field visit to an elementary school in Washington Heights, a predominantly Afro-Latin neighborhood near Harlem, revealed that while 9-11 was on everyone’s mind, these children were dealing with chronic, toxic stress due to a lack of safety in both their community and their school. Turnaround’s partnership to help manage toxic stress responses yielded a decrease in suspensions and an improvement in the classroom climate and morale, but test scores didn’t reflect the improvements.

To improve the academic outcomes, the foundation created programs to enhance the basis for learning—a “healthy attachment” to caregivers, “stress management, and self-regulation” (187), things that most children in the school lacked due to persistent adversity in their lives and those of their caretakers. In other words, the children needed both enrichment and intervention to thrive. Cantor’s group established family programs and used ACE scores to determine where children were in terms of developing these readiness skills. The programs paid off with gains in test scores. These three people and their organizations helped Burke Harris realize that the effect of ACEs could be felt in many domains and only collaborative working could address the issue.

At another conference, Burke Harris listened as one community-embedded speaker argued that the people experiencing ACEs and resultant stress were never in the room with people at these conferences. A perceived tension existed, in other words, between the lived experience of people surviving ACEs and the people studying them as statistics. Personal experience, including watching her white husband deal with stress responses as the father to Black children confronting a racist world, had taught Burke Harris that everyone—not just poor people or people of color—is subject to the tides of ACEs and stress responses. Burke Harris stood, and this insight moved her so powerfully that she reverted to the patois of her childhood to explain the universality of the effects of ACEs.

Burke Harris concludes her chapter by arguing forcefully that the sense that resources for one community preclude help for other communities leads even well-meaning people to engage in us-versus-them thinking. Burke Harris believes that getting help for everyone might unite people, thus allowing for all people to benefit from the help.

Part 4, Chapter 12 Summary: “Listerine”

Burke Harris opens the chapter by returning to the story of Diego, the patient who first got her thinking in a more systematic way about the biological mechanisms by which ACEs lead to poor health outcomes. In 2017, Diego was 16. His mother had developed skills that allowed her to be a more effective buffer for Diego and to know when he was getting off track from the success that better management of his stress responses had brought him. With the exceptions of some setbacks at ages 8 and 12 due to more traumas, Diego was thinking ahead to college, dating, and even working as an intern at a law office.

Diego’s setbacks almost always related to new traumas in his orbit, like a girlfriend whose house exposed him to violence in her family or when he had to deal with the death of a friend because of a random shooting. This last event sent Diego into a tailspin that made his mother fear he was on the verge of dying by suicide. The intervention measures were always the same: The multidisciplinary team at Bayview (now housed in CYW) would support Diego in “the six critical areas of sleep, exercise, nutrition, mindfulness, mental health, and healthy relationships” (202) to help him more effectively regulate his sensitive stress response. Burke Harris acknowledges that a person like Diego always carries around a past that makes him more vulnerable to dysregulation of the stress response. The goal of her work is to reduce the harm these responses cause.

For widespread and effective intervention, treating people with ACEs and toxic stress responses requires protocols like those developed in the decades since the 1950s to treat childhood cancers. These protocols took a long time to develop and implement, and both medical responses and information from a public health approach were essential to making changes in and outside of hospitals.

Burke Harris re-emphasizes how a paradigm shift (i.e., a change in the basic assumption) from miasma theory to germ theory allowed John Snow to crack the code to controlling cholera. She also describes how Joseph Lister, a contemporary of Snow’s, instituted effective infection control measures because he’d read Louis Pasteur’s work on microbes. The benefits of these shifts took time, but Burke Harris is confident that shifts in how we understand the relationship between adversity in the past and health in the present and future will eventually lead to a revolution in healthcare.

Part 4, Chapter 13 Summary: “In the Rearview”

In this deeply personal chapter, Burke Harris reveals the power of an ACEs lens in her own life. Her brother Evan (the Evan from the introduction) had a stroke that could have killed him or left him with a severe brain injury, despite his having none of the usual risk factors. Burke Harris used her ACEs lens to recognize that Evan did have one. Their mother had severe, untreated paranoid schizophrenia. Evan responded to this stressor by becoming a charmer, Burke Harris by becoming attuned to nonverbal cues and dead calm during crises (a good skill for a doctor to have); Louis, their brother, failed to thrive. Like their mother, he had paranoid schizophrenia and simply disappeared when he was 17.

Burke Harris lost a baby when she was six months pregnant. The depression in the aftermath of the loss left her so undone that she found herself uncontrollably weeping in her car one morning. She’d left her home that morning after reaching the end of her ability to cope and feared that she’d become an incapacitated parent like her mother. Serendipity—in the form of her brother Evan, who happened to be running in the neighborhood where she was parked—saved her. Her knowledge of the importance of a buffering caretaker for children during adversity helped her find a path forward during this crisis. She secured able and supportive childcare for her growing family and engaged in self-care that allowed her children to be secure and her to recover.

Epilogue Summary

In her epilogue, Burke Harris imagines a world in 2040 in which childhood screening for ACEs is just as common as immunization. She is a grandmother who’s proud of her teacher son and of a grandchild who’s following her to become a doctor. Stigma around ACEs lessened after the important medical organizations and celebrities got together to educate the public about the reality of the link between ACEs and health. Massive government investment in addressing toxic stress responses have reduced the usual poor health outcomes to such an extent that the US government has tapped Burke Harris to advise on a project to take the intervention global. Burke Harris closes with a vision of herself as a woman satisfied with the difference that she made.

Part 4 and Epilogue Analysis

Burke Harris leans in fully to her personal stake in using the toxic stress lens to navigate life and job challenges. This turn to the personal allows her to more fully develop her theme of the connection between the past and present—and to make the case that everyone needs access to this important information.

The Burke Harris who emerges over the course of the previous chapters is highly competent, a seeming superwoman who’s capable of being the mother to four children, running a center, doing scientific research on ACEs, and engaging in the kind of high-powered networking and fundraising needed to get a center off the ground. In these chapters, however, Burke Harris reveals that behind that persona is a child who suffered adversity: She grew up with a mother who had untreated paranoid schizophrenia. Her description of learning to figure out which mother—the functioning one or the one who made her feel unsafe—she was likely to encounter each day is poignant and drives home her point that everyone, no matter how successful, may deal with the effect of ACEs on the present. Her inclusion of details about her depression after pregnancy loss and her discussion of her brother Evan’s silent risk factor for a stroke serve the same function.

Burke Harris increasingly mentions aspects of her family life, including how her husband dealt with racial profiling of their kids and how she dealt with pumping breast milk at a conference, and pregnancy loss. These details present a realistic portrait of the balancing act of being both a scientist/doctor and a mother; still, she experienced great success in creating the center and the momentum around collaborative work on ACEs. The take-home point of these personal details is that being a scientist, doctor, and mother aren’t mutually exclusive roles.

Burke Harris includes details about important aspects of her identity, and her representation of these parts of her identity, shaped long ago in childhood, shows that they can be sources of authenticity and authority. Burke Harris, “trembling with emotion” and speaking in her “childhood dialect” (194) recounts her reversion to patois to address a critique of the focus on ACEs by Jenee Johnson, who believed that people with ACEs are poorly represented in the conversation. Burke Harris’s emotion (anger, even, based on the tone in the remainder of that chapter) seems to be about Johnson’s erasure of Burke Harris’s own ACEs but also a belief that Johnson’s focus on the inequities that affect Black people is too narrow a lens to result in change. Burke Harris uses her childhood voice, marked by her immigrant roots, to insist on ACEs and toxic stress as universal experiences. Her insistence on universality runs counter to more contemporary ideas about intersectionality (the way that identities of people of color, especially women, is particular and shaped by multiple and overlapping oppressions), but here Burke Harris’s pragmatic approach to securing resources is apparent.

In the epilogue, Burke Harris imagines what her work over the years could lead to. Her final self-representation is of a proud grandmother and working scientist who has made a difference. The epilogue strikes a balance between those personal and professional identities, almost as if to reveal that Burke Harris—and by extension, anyone—can be all those things.