Adverse Childhood Experiences (ACE) Study: Beyond Screening in Pediatrics

The evidence is clear. When bad things happen to us as young children, we are at significantly increased risk for not only mental health problems, but also a wide range of physical health problems including asthma, heart disease, and even early death. These "bad things" all involve disruptions in caregiving relationships. A national movement directed at screening for ACEs in pediatric practices has emerged from this work.

My suggestion that the implication of the Adverse Childhood Experiences (ACE) study is orders of magnitude greater than screening was met by spontaneous applause at two presentations I gave at the recent Zero to Three annual conference in San Diego.

If poor health outcome is directly proportional to experiences that adversely impact relationships, the natural conclusion is that promoting healthy parent-child relationships from birth must be the core of children's health care. 

An entire new field, termed infant-parent mental health, infant mental health or early childhood mental health, has emerged out of the wealth of scientific knowledge at the interface of genetics, neuroscience, and developmental psychology to inform a model of prevention, early intervention and treatment. My most recent book, The Developmental Science of Early Childhood synthesizes this work into a practical guide to its application from infancy through adolescence.  Efforts at "co-location" point in the right direction. However, it is the pediatric specialist who should be co-located.  The clinician whose primary task is to promote healthy relationships should be the primary care provider.    

What would such a restructuring look like?  Clinician training that places this body of knowledge at the center, rather than as elective, would be a start. Structure reimbursement so that the clinicians on the front lines, in essence saving lives by spending time listening to parents and children, would be financially rewarded. We would draw the most talented clinicians from the more lucrative subspecialties to the work of primary prevention. 

The original ACE research grew out of the observed high association between adult obesity and childhood sexual abuse. The original ACE questionnaires address experiences specific to relationships. Recent adaptations have expanded to include external stressors such as poverty and racism. Looking to the research of Ed Tronick (credit image below,) we can understand the parent-infant relationship as being either a buffer against or a transducer of these stressors. 

Healthcare clinicians cannot solve problems of poverty and racism. But we are ideally situated to use our relationship with families to build buffering relationships. 

Decades ago John Bowlby, influenced by Charles Darwin, observed that safe, secure caregiving relationships are central to our evolutionary success. Now abundant scientific research supports this observation. We need an army of clinicians whose primary objective, drawing on contemporary developmental science, is to promote healthy relationships from birth. I hope the powerful driving force of the ACE study, exemplified by advance praise of Nadine Burke Harris' forthcoming book on the subject, will move us beyond screening to deeper long-term solutions. 

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