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This interview accompanies a feature from our July/August issue about the effects of the opioid epidemic on children. Read it here.

Working at a clinic in San Francisco’s poverty-stricken Bayview neighborhood a decade ago, pediatrician Dr. Nadine Burke Harris often saw patients who had experienced tough stuff, from incarcerated parents to violent homes to mentally ill caregivers. Many of these kids, she noticed, “failed to thrive”—they weren’t developing physically at a normal rate, despite parents’ best efforts to take care of them.

I had “a patient who is a six-year-old, who could literally walk me through every step of cooking up and shooting up heroin—who could sit there and pantomime it for me in front of my clinic.”

And then, in late 2008, Burke Harris read something that seemed to explain what she was seeing. In a study of more than 17,000 patients, researchers from the Centers for Disease Control and Prevention and Kaiser Permanente found that those who had experienced more so-called Adverse Childhood Experiences—things like physical or emotional abuse, exposure to domestic violence, neglect, and parental substance abuse—were far more likely to experience a host of physical and psychological ailments down the line, from liver disease to emphysema to depression. Burke couldn’t sleep for weeks after reading the study. “It was just the key to understanding what was happening biologically, and why I was seeing a lot of the things I was seeing in clinics,” she later told SFGate.

In 2011, Burke Harris founded Bayview’s Center for Youth Wellness, a pediatric clinic where clinicians also study the effects of childhood trauma and develop ways to reverse the damage. Burke Harris and the center have attracted big-name donors and publicity. She was the subject of a 2011 New Yorker profile and featured in Paul Tough’s book, How Children Succeed. Burke Harris’ TED talk on ACEs has been seen nearly than 3 million times. Google and San Francisco-based donor Tipping Point have donated millions. In the meantime, dozens of studies have corroborated the relationship between childhood trauma and poor health.

I reached out to Burke Harris to talk about the developmental and physiological effects one might expect to see among the children of the opioid epidemic—and what doctors can do about it.

Mother Jones: How does growing up with a parent who’s using drugs affect a child’s development?

Nadine Burke Harris: Let’s start in infancy. One of the very important foundations of brain development is a phenomenon of serve and return. Babies look at their parents’ faces, and they coo or they babble or they make facial expressions. When you have a healthy caregiver, the caregiver will return that. And that actually serves critical function for infant brain development, which is that when the baby serves it up and the parent returns that smile, that facial expression, that emotion, that helps to lay down neurological pathways for the infant. If it doesn’t happen, that really harms infant brain development. So you could imagine that a parent who is impaired or clouded or blunted by heroin is not going to be doing as much of that serve and return.

The other thing that’s really critically important that starts in infancy is attachment. Kids need safe, stable and nurturing relationships to understand that they are safe in the world. Babies learn the world based on whether they’re going to be cared for and protected or whether they’re not going to be cared for and protected. The attachment that’s established in infancy has an impact on all of our relationships for the rest of our life.

MJ: And what about as kids get older?

NBH: Every time a child gets into a scary or dangerous situation, it activates their stress response. The repeated activation of their stress response is what leads to the biological condition that we, in pediatrics, are now calling toxic stress. Toxic stress are the long-term changes to not only brain structure and function, but also to the hormonal system, immune system, and even all the way down to the way our DNA is read and transcribed. And these changes lead to increased risk for mental health and behavioral health consequences—increased risk of depression, increased risk of suicidality, increased risk of anxiety. But also increased risk of things like substance dependence.

Kids who have parents who are substance dependent get a double whammy. They may have a genetic predisposition to substance susceptibility, and they also have both a psychological and a neurological increased susceptibility to substance abuse.

Often times, as a society, we look at the parent who is addicted and we say, “Oh my goodness, how could you do this to your kid?” But if you go back far enough in time, you’re going to find that the parent, when they were a kid, experienced all the same things. And we know that an individual with four or more adverse childhood experiences is 10 times as likely to be an IV drug user as someone with zero adverse childhood experiences. When we look at the folks who are using, we have to understand that this is a cycle.

MJ: Is there an anecdote that comes to mind that helps illustrate the impact that the opioid crisis is having on kids?

NBH: When my team called me about this interview, the first thing that came to mind was the experience I had of having a patient who is a six-year-old, who could literally walk me through every step of cooking up and shooting up heroin—who could sit there and pantomime it for me in front of my clinic. It’s absolutely heartbreaking.

MJ: If you were to take a look at the brain of that six-year-old, or other kids who are growing up in similar situations, what sorts of differences would you expect to see, compared with a kid who is not going through that kind of trauma regularly?

NBH: The scientist in me will tell you that currently we don’t have reference research to measure this and say, “Ah, I see we have an enlarged amygdala.” But what we could expect to see is the activity and possibly the size of the amygdala would be increased. That’s the brain’s fear center. We would also expect to see decreased functioning of the nucleus accumbens, which is the brain’s pleasure and reward center. Many people think that people get addicted to substances because they just can’t get enough of it. And actually, interestingly, the brain’s pleasure center derives less pleasure in people who are substance dependent. They get less pleasure from the substance, and therefore they try to use more and more and more to get to that place.

We might see impaired executive functioning: difficulty with a lot of the things that kids need to be able to sit still in class and pay attention. Impulse control, judgment, the ability to weigh and balance a bunch of different inputs at a time—and then figure out which one you’re going to do and follow through on that. Those are all executive functioning tasks. And those reside in the prefrontal cortex, so we might see decreased prefrontal cortical activity.

If there was substance used while the child was in utero, then we might anticipate some other brain and body changes.

Rather than saying, “Automatically you lose your kid,” maybe it’s automatically you have to go to a mother-child rehab program that is focused on understanding what is the root cause.

MJ: In some states, if a baby is born in opioid withdrawal because Mom was using during pregnancy—also known as neonatal abstinence syndrome—then the child is automatically removed from the home. What are your thoughts on that?

NBH: This is where I would love to see much more of science informing policy. You certainly cannot leave that child to be at risk in a household. But would a better statewide policy be to ensure that we have programs where young mothers are with babies? Rather than saying, “Automatically you lose your kid,” maybe it’s automatically you have to go to a mother-child rehab program that is focused on understanding what is the root cause—the driver behind the mom’s substance use to begin with. Because whatever that is, that is probably the most dangerous thing in the household—whether that’s mom’s history of abuse or neglect or sexual assault or whatever it is. That thing will continue to come back and haunt that caregiver and the child-caregiver relationship for a very long time unless it’s addressed. They have a program like that here in San Francisco called Jelani House.

MJ: How does the response to this epidemic compare with responses to past drug epidemics?

NBH: The conversations that are happening in the policy world on Capitol Hill around this opioid epidemic feel very different than the conversations that have happened in the past. It feels like people are much more able to frame the issue as a health issue than as a moral failing—or not even moral failing, but depravity that other substance-use epidemics, like the crack epidemic that happened in the inner cities in the ’80’s. It seems like it’s a very different narrative and a very different response.

MJ: Do you think that’s because of race?

NBH: I think that there are multiple factors that play into it. This is America—undoubtedly race is one of those factors. But one really salient way in which that’s happening is that for many of the [politicians] who are responding, they see it as “us” as opposed to “them.” They see like “Oh my God, that’s my cousin.” For many people who are leading our national response in the United States, it’s something that feels close to them, so we see greater empathy in the response.

MJ: What public health responses to this epidemic would you like to see happen?

NBH: We’d like to see every pediatrician in America screening for adverse childhood experiences, and making sure that children who are exposed to ACES are getting the care that they need so that we can do prevention. It’s the old saying: “An ounce of prevention is worth a pound of cure.”