Treating toxic stress in kids a top priority for California’s first surgeon general

California Surgeon General Dr. Nadine Burke Harris at a healthcare symposium in Anaheim on March 1.
(Irfan Khan / Los Angeles Times)
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The little girl was not gaining weight.

The diagnosis: failure to thrive, a term used to describe a child who isn’t growing as expected. The remedy: nutritional shakes packed with protein.

That typically would be the end of the appointment, said the girl’s doctor, Nadine Burke Harris, a 43-year-old Jamaican American raised in Palo Alto who was named California’s first surgeon general last month. But, in her new role, Burke Harris said she will push to change a profession that too often settles for quick fixes over unearthing root causes of ailments.

The San Francisco pediatrician has been a leading advocate in pushing the state to expand screenings for abuse and extreme stress in children. Gov. Gavin Newsom included $45 million in his January budget proposal to start screening low-income Medi-Cal patients for what the medical community calls adverse childhood experiences, or ACES, beginning in 2020.


Burke Harris said that when children are exposed to high levels of stress or abuse often enough, hormones are triggered that can have lasting effects on brain development and the immune system. Burke Harris said that in such situations the body’s “stress thermostat,” which is high during traumatic events, breaks and stress hormones continue to pump into a child’s body.

Burke Harris said she wants universal stress screenings for all children as part of their regular physical exams, but that it was too early to say when she would make that push. Too often mental trauma is considered unrelated to medical care, she said, despite studies showing a clear link to physical ailments.

“The impact of early adversity gets under our skin in a way that can be invisible, but can have profound impacts on health and development over a lifetime,” Burke Harris said.

Burke Harris is based in San Francisco, where she lives with her four children, all boys, and husband Arno Harris, a clean power and transportation entrepreneur.

Burke Harris, who will make $200,000 in her new role, said that, while she is a political appointee, she doesn’t see herself wading into many of the contentious healthcare debates in the state Capitol. She said she will be “narrowly focused” on toxic stress, welcome words for her fellow advocates for universal trauma screening.

“She has a great deal of humility,” said Jeannette Pai-Espinosa, president of National Crittenton, an Oregon-based social justice group that supports girls and young women affected by trauma. “She does what she does for the right reasons — not for political reasons, not for expediency and not for notoriety.”


California is in the process of adopting screening tools to evaluate low-income children for toxic stress. Burke Harris raised funds and helped develop one of the tools being considered, which would be offered to the state free of cost.

Only three other states have a surgeon general. Newsom previously named Burke Harris to San Francisco’s Citizens Committee on Community Development when he was the city’s mayor. She has also worked with First Partner Jennifer Siebel Newsom, appearing in one of her documentaries and serving as an informal advisor to her while Newsom was mayor.

“Dr. Burke Harris is the right person for this state to take leadership across the country on this important issue,” the governor said in a statement.

Burke Harris said she wants to use her elevated platform to push fellow doctors to diagnose differently. Like with her pediatric patient who wasn’t gaining weight, she wants doctors to ask a series of questions about traumatic events to help properly diagnose physical symptoms now or prevent ailments later.

Burke Harris said that for her young patient, there were so many traumas that she didn’t know where to start. But she rattled off the statistics for what could happen if she didn’t address them — increased risks for stroke, heart disease, cancer, diabetes, Alzheimer’s and other ailments, and a higher rate of engaging in risky behavior like drug use.

Her diagnosis, knowing the girl’s troublesome home life?

“Toxic stress,” Burke Harris said.

Her revised remedy? Child-parent psychotherapy, follow-up doctors appointments, and yes, still the nutritional drinks.


Screening a child for toxic stress involves asking a parent to count how many of the following 10 issues a child has encountered: physical, sexual or emotional abuse, physical or emotional neglect, a parent’s mental illness, substance dependence, a parent’s incarceration, parental separation or divorce and domestic violence.

Each one results in a point, which doctors use to give a score. The higher that score, the higher the risk that the child has unhealthy stress levels. Burke Harris said that information can help doctors diagnose patients more accurately, offering mental health treatment, stress-reducing exercises or medication.

“You have to know what you are treating,” she said. “It’s like catching Stage 1 cancer versus Stage 4. If we can diagnose at Stage 1, you can treat far more people with the same resources.”

Early intervention has long been a priority for Burke Harris, even before she became a doctor.

When she was 17, her brother Louis, who was suffering from schizophrenia, opened the door of their parents’ car at a stop light and walked away. He has been missing ever since.

In the years that followed, Burke Harris said she has searched the faces of patients and strangers, hoping to find one that looks like her own.


“We literally do not know if he is still living,” she said. “This has been a big motivation for me in trying to serve vulnerable communities.”

When she opened a pediatric clinic in the Bayview Hunters Point neighborhood in southeastern San Francisco, a high-poverty, predominantly African American community, she said she saw kids repeatedly showing signs of poor health and wondered whether there was a biological link to trauma in their lives.

A 1998 study by Kaiser Permanente and the U.S. Centers for Disease Control and Prevention confirmed for her that there was.

“People told me, ‘How do you think you are ever going to solve this? It’s too big,’” Burke Harris said. “I don’t think I’ve ever met anyone who hasn’t experienced or knows someone who has experienced significant adverse childhood experiences. That means we are solving this for everyone.”

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