童年创伤影响一生的健康

Inthemid-’90s,90年代中期,theCDCandKaiserPermanenteCDC和KaiserPermanente发现:discoveredanexposurethatdramaticallyincreasedtherisk暴露于某种事物中会极大增加死亡风险,forsevenoutof10oftheleadingcausesofdeathintheUnitedStates.七成美国民众的首要死因皆由此引起。Inhighdoses,itaffectsbraindevelopment,暴露剂量较高时,会影响大脑发育,theimmunesystem,hormonalsystems,免疫系统,内分泌系统,andeventhewayourDNAisreadandtranscribed.甚至影响到基因的读取及转录方式。Folkswhoareexposedinveryhighdoses暴露在极高剂量下的人群,havetriplethelifetimeriskofheartdiseaseandlungcancer有3倍的风险患上心脏病和肺癌,anda20-yeardifferenceinlifeexpectancy.预期寿命缩短20年。Andyet,doctorstodayarenottrainedinroutinescreeningortreatment.然而,目前医生们还未被培训以常规筛查和治疗的手段来应对这种风险。Now,theexposureI’mtalkingaboutisnotapesticideorapackagingchemical.我所说的暴露危害并不针对某种农药或包装上的化学物质。It’schildhoodtrauma.而是儿童期创伤。Okay.WhatkindoftraumaamItalkingabouthere?那么,我要说的是哪种创伤呢？I’mnottalkingaboutfailingatestorlosingabasketballgame.我要说的可不是考试不及格或输掉篮球比赛。Iamtalkingaboutthreatsthataresosevereorpervasive我要说的是那种如此严重而又无处不在的威胁,thattheyliterallygetunderourskinandchangeourphysiology:以致于它让我们毛骨悚然,并从生理上改变了我们：thingslikeabuseorneglect,比如,受虐待或被忽视,orgrowingupwithaparentwhostruggleswithmentalillness又或者,抚养我们的父母,本身就深受精神疾病之苦,orsubstancedependence.或是深陷于物质依赖疾病。Now,foralongtime,一直以来,IviewedthesethingsinthewayIwastrainedtoviewthem,我都按照所教导的方式来看待这些事情。eitherasasocialproblem--refertosocialservices--要么把它当成一个社会问题--交给社会服务去处理,orasamentalhealthproblem--refertomentalhealthservices.要么把它当成一个心理健康问题--交给心理健康咨询来解决。Andthensomethinghappenedtomakemerethinkmyentireapproach.后来发生了一些事情,使我反思我的整个思维方式。WhenIfinishedmyresidency,在医院实习结束后,IwantedtogosomeplacewhereIfeltreallyneeded,我想去个我觉得真正需要我的地方,someplacewhereIcouldmakeadifference.去个我可以有所作为的地方。SoIcametoworkforCaliforniaPacificMedicalCenter,因此，我选择为加利利福尼亚太平洋医疗中心(CPMC)工作,oneofthebestprivatehospitalsinNorthernCalifornia,这是加利福尼亚北部最优秀的私立医院之一,andtogether,weopenedaclinicinBayview-HuntersPoint,我与该医院合作,在旧金山最穷、社区服务最差的居民区--oneofthepoorest,mostunderservedneighborhoodsinSanFrancisco.湾景区猎人角（Bayview-HuntersPoint）开了一家诊所。Now,priortothatpoint,在此之前,therehadbeenonlyonepediatricianinallofBayview整个湾景区（Bayview）社区仅有一名儿科医生,toservemorethan10,000children,为一万多名儿童服务,sowehungashingle,andwewereabletoprovidetop-qualitycare因此,我们开始挂牌营业,提供最优质的医疗服务,regardlessofabilitytopay.不论是否有能力支付医疗费用。Itwassocool.Wetargetedthetypicalhealthdisparities:这种感觉很棒。我们找出了在医疗服务上现状与标准的差距：accesstocare,immunizationrates,asthmahospitalizationrates,普及医疗保健,免疫接种率、哮喘住院率等,andwehitallofournumbers.我们都完成了达标。Wefeltveryproudofourselves.我们为自己感到骄傲。ButthenIstartednoticingadisturbingtrend.但就在那时,我开始注意到一种令人忧心的趋势。AlotofkidswerebeingreferredtomeforADHD,很多孩子因为多动症（简称ADHD),orAttentionDeficitHyperactivityDisorder,被送到我这里进行医治,butwhenIactuallydidathoroughhistoryandphysical,可是,当我对孩子们的病史和身体状况进行彻查时,whatIfoundwasthatformostofmypatients,却发现大多数患儿的情况,Icouldn’tmakeadiagnosisofADHD.我无法下多动症(ADHD)的诊断。MostofthekidsIwasseeinghadexperiencedsuchseveretrauma多数来就诊的孩子都经历过如此严重的创伤,thatitfeltlikesomethingelsewasgoingon.让人觉得似乎事情并不简单。SomehowIwasmissingsomethingimportant.不知怎的,我漏查了某个重要的因素。Now,beforeIdidmyresidency,Ididamaster’sdegreeinpublichealth,在实习之前,我曾攻读公共健康硕士学位,andoneofthethingsthattheyteachyouinpublichealthschool在公共健康学校里,我们曾学过这样的一课,isthatifyou’readoctor如果你是一名医生,andyousee100kidsthatalldrinkfromthesamewell,当你知道有100个孩子从同一口井中饮水,and98ofthemdevelopdiarrhea,其中98人患了腹泻,youcangoaheadandwritethatprescription你可以着手治疗,fordoseafterdoseafterdoseofantibiotics,给每个病人都开抗生素,一剂,一剂,又一剂的开。oryoucanwalkoverandsay,Whatthehellisinthiswell?可是你也可以走去井边，问声,井里到底有什么鬼东西?SoIbeganreadingeverythingthatIcouldgetmyhandson所以,我开始查阅手头所有的相关资料,abouthowexposuretoadversity了解暴露在不幸中,affectsthedevelopingbrainsandbodiesofchildren.是如何影响儿童的大脑和身体发育的。Andthenoneday,mycolleaguewalkedintomyoffice,然后有一天,一个同事走进我的办公室,andhesaid,Dr.Burke,haveyouseenthis?他问我,伯克医生,你看过这个吗?Inhishandwasacopyofaresearchstudy在他手里的是一份调查研究的复印件,calledtheAdverseChildhoodExperiencesStudy.题目是童年不良经历(ACE)研究。Thatdaychangedmyclinicalpracticeandultimatelymycareer.那一天,改变了我的临床实践,也最终改变了我的职业生涯。TheAdverseChildhoodExperiencesStudy童年不良经历(ACE)的研究issomethingthateverybodyneedstoknowabout.是每一个人都应该要了解的。ItwasdonebyDr.VinceFelittiatKaiserandDr.BobAndaattheCDC,VinceFelitti博士和BobAnda博士分别在Kaiser和CDC进行了这项研究,andtogether,theyasked17,500adultsabouttheirhistoryofexposure他们两人一起询问了17,500成年人,towhattheycalledadversechildhoodexperiences,orACEs.了解他们的童年不良经历,又称ACE。Thoseincludephysical,emotional,orsexualabuse;这包括生理上、情感上遭受的不幸或是性侵害；physicaloremotionalneglect;生理或情感上遭受的忽视；parentalmentalillness,substancedependence,incarceration;父母患有精神疾病、物质依赖、遭到监禁；parentalseparationordivorce;父母分居或离婚；ordomesticviolence.或家庭暴力。Foreveryyes,youwouldgetapointonyourACEscore.每个问题只要回答是,ACE分数就增加一分。Andthenwhattheydid接下来,wastheycorrelatedtheseACEscoresagainsthealthoutcomes.他们将ACE分数与健康状况关联起来,Whattheyfoundwasstriking.得出的结果是令人震惊的。Twothings:结论有两点：Numberone,ACEsareincrediblycommon.第一点,ACE十分普遍,简直令人不可思议。Sixty-sevenpercentofthepopulationhadatleastoneACE,67%的人曾至少有一个ACE得分,and12.6percent,oneineight,hadfourormoreACEs.有12.6%（八分之一）的人有四或四以上的ACE得分。Thesecondthingthattheyfound研究发现的第二点,wasthattherewasadose-responserelationship是ACE与健康状况之间betweenACEsandhealthoutcomes:存在着一种剂量反应关系：thehigheryourA