photo by John Morgan
More than 40 years ago, a classic experiment established that we can learn a lot about the adults children will grow into using only a soft, sugary treat.
The Stanford marshmallow experiment, first conducted in 1972, showed that a child’s ability to resist the aforementioned marshmallow in pursuit of a future reward predicted that child’s future academic and social success with surprising accuracy. But in the decades since the test, that simple marshmallow has grown remarkably complicated in the context of what we know about a child’s brain and an adult’s health.
The close link between the health of the mind and of the body is one that scientists and medical professionals both increasingly recognize and closely observe. In one simplified example, I may hit the chocolate chip cookies a little too hard not because I’m hungry, but because I’m anxious. If that is the case, addressing my anxieties might be more effective than simply padlocking the cookie jar. Conversely, poor nutrition may amplify my anxieties, causing a mind-body feedback loop that makes it harder to resist the cookies.
The original marshmallow test measured whether children could resist instant gratification. But new research suggests our health care strategies may improve if we ask why some children can resist and why others can’t.
An updated marshmallow experiment, published in 2012, suggested that children are better at resisting temptation when they had a “reliable environment” - that is, when they had evidence for trusting that their patience would indeed yield a reward. Nurture, as well as nature, was implicated in the formation of self-control and determination.
Other research, though, demonstrated the consequences of undermining a child’s trust in his or her surroundings on a larger and more saddening scale. In the mid-1990s, the Kaiser Permanente Institute conducted a study measuring Adverse Childhood Experiences (ACEs) and their link to later-life health outcomes. The study, conducted in partnership with the Centers for Disease Control and Prevention, formed the foundation for ongoing investigation of the connection between childhood experience and adult health and well-being.
The study identified 10 prevalent ACE categories, sorted broadly into abuse, neglect and household dysfunction. The study found that as the numbers of ACEs a person reported increased, so too did the probability that the person would develop health problems, which could range from physical (liver disease) to mental (clinical depression) to behaviorally induced (smoking or illegal drug use).
Now, even more than at the time the study took place, neurology is able to explain the lifelong impact of childhood trauma on the brain. Dr. Nadine Burke-Harris, a pediatrician who has incorporated the ACE findings into clinical practice, is one example of a doctor who has made a point of reframing social issues as neurochemical ones in her practice. In a 2013 interview with the California School Boards Association, Burke-Harris explained why ACEs and the associated stress are particularly harmful: “Children are particularly vulnerable because their brains are still developing.” She went on to say that repeated stress responses - often called “fight or flight” - deregulate a child’s ability to cope with physical and emotional stressors in the future and adversely affect the child’s health in a variety of ways.
Such extended stress exposure seems self-evident in cases of prolonged abuse. But neglect and deprivation are turning out to be neurologically hazardous too. The Wall Street Journal recently described a study that found brain scans of young children already show reflections, positive or negative, of their socioeconomic status. In communities that are both poor and violent, some psychologists have reported that children exposed to street violence risk developing post-traumatic stress disorder, with symptoms similar to those found in combat veterans.
Health care organizations are increasingly recognizing the value of incorporating mental health expertise in an individual’s overall medical team. But when it comes to the long-term effects of childhood deprivation or trauma, the question becomes what, exactly, can we do about it?
Dr. Jeffrey Brenner argued recently that ACE scores should become a vital sign in clinical practice - used not as destiny, but as a risk factor family physicians and other clinicians should keep in mind when treating their patients.
While recognizing and identifying trauma may be helpful, it is not the same as undoing trauma’s effects. The evidence is mounting that a child’s environment can profoundly shape that child’s risks not only for adverse mental health outcomes as an adult, but for physical health problems too. Yet it is difficult enough to try to protect children from danger and neglect while they are still children. If we can’t solve the problems that lead to constrained brain development or ongoing toxic stress at the outset, it is hard to be optimistic about our ability to undo this damage once those children become adults. We may find ourselves managing the symptoms and ongoing effects, rather than repairing them.
That said, I am not an expert in neurology or psychology. I hope those who have credentials in those areas possess or can develop restorative treatments.
From a broader perspective, we need to spend our health care dollars far more efficiently than we currently do. Inexpensive measures that change children’s behavior, and the behavior of those closest to them, may perform as well or better than costly treatments to address adult symptoms down the line.
Inexpensive, though, won’t necessarily mean easy. Behavior can be very difficult to change for many of us. I say this as someone who has been known to eat one or two chocolate chip cookies too many.