To what extent did the lecture by Nadine Burke Harris address each
of the following levels of social environments in terms of their implications for development among children facing maltreatment: micro-social, meso-social, and macro-social? give an example of how the presentation could have addressed one of the levels even more forcefully. Within this discussion, make sure to demonstrate your clear understanding of each level of the social environment, citing core course materials (with in-text citations) as part of your demonstration of understanding.
In the mid-'90s, the CDC and Kaiser Permanente discovered an exposure that dramatically increased the risk for seven out of 10 of the leading causes of death in the United States. In high doses, it affects brain development, the immune system, hormonal systems, and even the way our DNA is read and transcribed. Folks who are exposed in very high doses have triple the lifetime risk of heart disease and lung cancer and a 20-year difference in life expectancy. And yet, doctors today are not trained in routine screening or treatment. Now, the exposure I'm talking about is not a pesticide or a packaging chemical. It's childhood trauma.
Okay. What kind of trauma am I talking about here? I'm not talking about failing a test or losing a basketball game. I am talking about threats that are so severe or pervasive that they literally get under our skin and change our physiology: things like abuse or neglect, or growing up with a parent who struggles with mental illness or substance dependence.
Now, for a long time, I viewed these things in the way I was trained to view them, either as a social problem -- refer to social services -- or as a mental health problem -- refer to mental health services. And then something happened to make me rethink my entire approach. When I finished my residency, I wanted to go someplace where I felt really needed, someplace where I could make a difference. So I came to work for California Pacific Medical Center, one of the best private hospitals in Northern California, and together, we opened a clinic in Bayview-Hunters Point, one of the poorest, most underserved neighborhoods in San Francisco. Now, prior to that point, there had been only one pediatrician in all of Bayview to serve more than 10,000 children, so we hung a shingle, and we were able to provide top-quality care regardless of ability to pay. It was so cool. We targeted the typical health disparities: access to care, immunization rates, asthma hospitalization rates, and we hit all of our numbers. We felt very proud of ourselves.
But then I started noticing a disturbing trend. A lot of kids were being referred to me for ADHD, or Attention Deficit Hyperactivity Disorder, but when I actually did a thorough history and physical, what I found was that for most of my patients, I couldn't make a diagnosis of ADHD. Most of the kids I was seeing had experienced such severe trauma that it felt like something else was going on. Somehow I was missing something important.
Now, before I did my residency, I did a master's degree in public health, and one of the things that they teach you in public health school is that if you're a doctor and you see 100 kids that all drink from the same well, and 98 of them develop diarrhea, you can go ahead and write that prescription for dose after dose after dose of antibiotics, or you can walk over and say, "What the hell is in this well?" So I began reading everything that I could get my hands on about how exposure to adversity affects the developing brains and bodies of children.
And then one day, my colleague walked into my office, and he said, "Dr. Burke, have you seen this?" In his hand was a copy of a research study called the Adverse Childhood Experiences Study. That day changed my clinical practice and ultimately my career.
The Adverse Childhood Experiences Study is something that everybody needs to know about. It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC, and together, they asked 17,500 adults about their history of exposure to what they called "adverse childhood experiences," or ACEs. Those include physical, emotional, or sexual abuse; physical or emotional neglect; parental mental illness, substance dependence, incarceration; parental separation or divorce; or domestic violence. For every yes, you would get a point on your ACE score. And then what they did was they correlated these ACE scores against health outcomes. What they found was striking. Two things: Number one, ACEs are incredibly common. Sixty-seven percent of the population had at least one ACE, and 12.6 percent, one in eight, had four or more ACEs. The second thing that they found was that there was a dose-response relationship between ACEs and health outcomes: the higher your ACE score, the worse your health outcomes. For a person with an ACE score of four or more, their relative risk of chronic obstructive pulmonary disease was two and a half times that of someone with an ACE score of zero. For hepatitis, it was also two and a half times. For depression, it was four and a half times. For suicidality, it was 12 times. A person with an ACE score of seven or more had triple the lifetime risk of lung cancer and three and a half times the risk of ischemic heart disease, the number one killer in the United States of America.
Well, of course this makes sense. Some people looked at this data and they said, "Come on. You have a rough childhood, you're more likely to drink and smoke and do all these things that are going to ruin your health. This isn't science. This is just bad behavior."
It turns out this is exactly where the science comes in. We now understand better than we ever have before how exposure to early adversity affects the developing brains and bodies of children. It affects areas like the nucleus accumbens, the pleasure and reward center of the brain that is implicated in substance dependence. It inhibits the prefrontal cortex, which is necessary for impulse control and executive function, a critical area for learning. And on MRI scans, we see measurable differences in the amygdala, the brain's fear response center. So there are real neurologic reasons why folks exposed to high doses of adversity are more likely to engage in high-risk behavior, and that's important to know.
But it turns out that even if you don't engage in any high-risk behavior, you're still more likely to develop heart disease or cancer. The reason for this has to do with the hypothalamic-pituitary-adrenal axis, the brain's and body's stress response system that governs our fight-or-flight response. How does it work? Well, imagine you're walking in the forest and you see a bear. Immediately, your hypothalamus sends a signal to your pituitary, which sends a signal to your adrenal gland that says, "Release stress hormones! Adrenaline! Cortisol!" And so your heart starts to pound, Your pupils dilate, your airways open up, and you are ready to either fight that bear or run from the bear. And that is wonderful if you're in a forest and there's a bear. (Laughter) But the problem is what happens when the bear comes home every night, and this system is activated over and over and over again, and it goes from being adaptive, or life-saving, to maladaptive, or health-damaging. Children are especially sensitive to this repeated stress activation, because their brains and bodies are just developing. High doses of adversity not only affect brain structure and function, they affect the developing immune system, developing hormonal systems, and even the way our DNA is read and transcribed.
So for me, this information threw my old training out the window, because when we understand the mechanism of a disease, when we know not only which pathways are disrupted, but how, then as doctors, it is our job to use this science for prevention and treatment. That's what we do.
So in San Francisco, we created the Center for Youth Wellness to prevent, screen and heal the impacts of ACEs and toxic stress. We started simply with routine screening of every one of our kids at their regular physical, because I know that if my patient has an ACE score of 4, she's two and a half times as likely to develop hepatitis or COPD, she's four and half times as likely to become depressed, and she's 12 times as likely to attempt to take her own life as my patient with zero ACEs. I know that when she's in my exam room. For our patients who do screen positive, we have a multidisciplinary treatment team that works to reduce the dose of adversity and treat symptoms using best practices, including home visits, care coordination, mental health care, nutrition, holistic interventions, and yes, medication when necessary. But we also educate parents about the impacts of ACEs and toxic stress the same way you would for covering electrical outlets, or lead poisoning, and we tailor the care of our asthmatics and our diabetics in a way that recognizes that they may need more aggressive treatment, given the changes to their hormonal and immune systems.
So the other thing that happens when you understand this science is that you want to shout it from the rooftops, because this isn't just an issue for kids in Bayview. I figured the minute that everybody else heard about this, it would be routine screening, multi-disciplinary treatment teams, and it would be a race to the most effective clinical treatment protocols. Yeah. That did not happen. And that was a huge learning for me. What I had thought of as simply best clinical practice I now understand to be a movement. In the words of Dr. Robert Block, the former President of the American Academy of Pediatrics, "Adverse childhood experiences are the single greatest unaddressed public health threat facing our nation today." And for a lot of people, that's a terrifying prospect. The scope and scale of the problem seems so large that it feels overwhelming to think about how we might approach it. But for me, that's actually where the hopes lies, because when we have the right framework, when we recognize this to be a public health crisis, then we can begin to use the right tool kit to come up with solutions. From tobacco to lead poisoning to HIV/AIDS, the United States actually has quite a strong track record with addressing public health problems, but replicating those successes with ACEs and toxic stress is going to take determination and commitment, and when I look at what our nation's response has been so far, I wonder, why haven't we taken this more seriously?
You know, at first I thought that we marginalized the issue because it doesn't apply to us. That's an issue for those kids in those neighborhoods. Which is weird, because the data doesn't bear that out. The original ACEs study was done in a population that was 70 percent Caucasian, 70 percent college-educated. But then, the more I talked to folks, I'm beginning to think that maybe I had it completely backwards. If I were to ask how many people in this room grew up with a family member who suffered from mental illness, I bet a few hands would go up. And then if I were to ask how many folks had a parent who maybe drank too much, or who really believed that if you spare the rod, you spoil the child, I bet a few more hands would go up. Even in this room, this is an issue that touches many of us, and I am beginning to believe that we marginalize the issue because it does apply to us. Maybe it's easier to see in other zip codes because we don't want to look at it. We'd rather be sick.
Fortunately, scientific advances and, frankly, economic realities make that option less viable every day. The science is clear: Early adversity dramatically affects health across a lifetime. Today, we are beginning to understand how to interrupt the progression from early adversity to disease and early death, and 30 years from now, the child who has a high ACE score and whose behavioral symptoms go unrecognized, whose asthma management is not connected, and who goes on to develop high blood pressure and early heart disease or cancer will be just as anomalous as a six-month mortality from HIV/AIDS. People will look at that situation and say, "What the heck happened there?" This is treatable. This is beatable. The single most important thing that we need today is the courage to look this problem in the face and say, this is real and this is all of us. I believe that we are the movement.
Relative to the physical environment, the social environment has received a lot more attention within social work. In fact, this dimension can be tricky to understand because so many people have tried to define and describe this dimension in somewhat different ways. For example, some have articulated that there are five important subdimensions of people's social environments, including (a) families, (b) groups, (c) organizations, (d) communities, and (e) society as a whole. For the purposes of this class, we will consider the social environment in terms of three different levels.
Levels refer to how close in space the social relationships are relative to the focal individual. Another way to think of this is how proximal versus distal elements of the social environment are. We will return to this idea in an example. Listed below are three levels of social environments, beginning with the most proximal.
-The micro-social level consists of people with whom individuals have face-to-face contact. It could be one other person, which would make the interaction dyadic (that is, when there are two people interacting with each other). Or it could be with a bunch of other people, such as a family eating a meal together or a group of students interacting by conference call.
-The second level of the social environment is more distal relative to micro-social environments. It includes social relationships that involve some face-to-face contact, but that can never be interfaced with in its entirety. Think of a neighborhood as a meso-social environment. People can experience their neighborhood in bits and pieces at a time, right? Such as by talking with this business owner or attending that church. However, people cannot ever experience the whole entirety of their neighborhood at one single point in time. There are always elements of a neighborhood that are more distal to the individual.
-The third level of the social environment is the macro-social. This includes institutions and structures that pattern ways of organizing social relationships across large geographic areas. Examples of the macro-social environment include widely held social norms regarding the meaning of particular groups and organizations. Consider, for example, the social institution of family. Although people's individuals experiences of families differ, most societies have some expectations for what families mean and do. These are social forces that operate on a very large-scale way.Looking at examples from the life of the author Wes Moore can help clarify the distinction across these three levels of the social environments..
First, consider the most proximal level—the micro-social. Remember that this is the level that includes people with whom a person has face-to-face contact. For the author Wes Moore, this includes his close friends, his grandparents, his sisters, his teachers, etc.
What about the next level—the meso-social? This might be a little trickier. Remember—these are social environments that people can interact with to some degree, but never in their entirety. In the author Wes Moore's life as a boy, this might include his neighborhood in New York or his school at Riverdale. For example, the school contains people with whom he has face-to-face contact, including his teachers, classmates, and the principal. However, he is not very likely to interact with the entire school at any point in time. This would also apply to you at your university. You have some face-to-face contact with people at the university, such as specific classmates and your instructors, but this setting is too large and diffuse to interact with all instructors and students at the same time.
Finally, consider the third major level—the macro-social. This is the most distal level of the environment. An example of this in the author Wes Moore's life are larger economic forces that made the production of crack cocaine in the Caribbean quite cheap, with large shipments coming into the United States, driving down the price, and increasing demand.
Beyond identifying these levels of the social environment, an important proposition of the person-environment perspective is that like all dimensions of a person, all levels of the social environment influence each other. What happens at the macro-social level influences the meso-social, which influences the micro-social, and vice-versa.
Look at this again in the example of Wes Moore. Here is a quote that demonstrates richly how these different levels of environment influence each other.
"I had thought my mother's rules were strict but soon realized that my grandparents' were many times worse. They made it very clear that Paulding Avenue was their home and their rules would apply. All chores had to be done before we even thought about going outside to play. If we heard any gunfire or, as my grandmother called it, 'foolishness,' outside, we were to immediately return home, no matter when it was. These were not Bronx rules, these were West Indian rules." (Moore, 2011, p. 42)
Here we can see the interplay of the three levels of environment. Most obviously, we have a micro-social environment—Wes's grandparents and how they provide structure in Wes's life through their face-to-face interactions. These interactions are shaped, in part, by responding to meso-level circumstances—"foolishness," including community violence and other community-level threats to the children's safety and well-being. We see that how the grandparents respond to such threats is shaped by something quite distal to the author Wes Moore—West Indian culture, which dictates large-scale macro-social norms around family and child-rearing.
Before we conclude the content for this week, it is important to highlight one final and central aspect of the person-environment perspective. First, let's step back and take stock of the main ideas already covered in the video lecture. Recall that the person-environment perspective is like a map. It identifies the major points of interest when observing a person in their physical and social environments. The perspective not only delineates relevant dimensions of persons in their own right, as well as environments in their own right, but also demonstrates:
How persons and environments mutually constitute and influence each other.
This is the key idea of a transactionalapproach.
A person-environment perspective views individuals and environments as a unity, an inseparable whole—with environments influencing individuals and individuals influencing environments, forever and always.
A very simple example can help illustrate this idea. As you watch this video, consider how it demonstrates people and environments inseparable parts of a larger whole and how both parts always influencing each other.
Watch: (begin at 2:43:30)
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A person-environment perspective suggests how Mr. Quiet is both influenced as well as influences his environment. Here is additional explanation below:
Propositions around person-environment transactionsExample
Environments influence people.
Mr. Quiet's emotional reaction to his varying environments is clear. Any sounds from the environment (e.g., physical, such as the sound of the falling leaf, or social, such as Mr. Mischief's laughter) are "painful" to Mr. Quiet.
People influence these very environments in terms of which environments they select into and how they respond to their environments.
Mr. Quiet relocates himself throughout the film—such as to the country, and then taking the row boat, which leads him to the island. He also seems to be able to somewhat manage the noise in his environments, such as when Mr. Noisy comes through on the train.
Environments and people cannot be understood without always looking at them in relationship to each other.
What makes the environment meaningful in this story is Mr. Quiet's experiences of it, and what makes Mr. Quiet so intriguing in this story is the environment around him. We cannot understand one without considering the other. Mr. Quiet and his environment are part of the same person-environment whole.
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