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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Community Trauma Prevention Starts with Parent-Infant Relationships

I recently had the privilege of listening to Bessel van der Kolk, trauma researcher and author of The Body Keeps Score. He began his talk with a video clip of a mom and her baby, who looked to be about 3 months old, having a conversation. It started with an exchange of soft sounds, moving on to more complex communication, including shared facial expressions. Palpable delight characterized the moment of meeting.

As the conversation between mother and baby increased in complexity, a slight lapse appeared between the baby's signal and the mother's response. Herein lies the development of resilience. World-renowned child development researcher Ed Tronick, who van der Kolk referenced at the start of his talk, has demonstrated, with second-to-second videotape analyses, that in typical relationships parent and infant are mismatched in 70 percent of interactions. What he terms "quotidian resilience" develops in the repair of these countless moments.

Ways of being together are laid down in our minds and bodies the early weeks, months, and years of life. They become part of us; part of our DNA. Our earliest relationships sculpt our nervous system and the way our body responds to stress. The moment-to-moment mismatch and repair of early infancy is the material of which our self, with our own skin—our own border—is made. Survival of disruption, together with the joy of repair, creates trust, an essential ingredient of intimacy. We develop a confidence that when we feel bad, we won’t always feel bad. This early experience builds a foundation of hope. 

The talk was sponsored by Berkshire United Way, which is taking a lead in making our community "trauma-informed." Driving the movement to create "trauma-informed communities" is the powerful longitudinal Adverse Childhood Experiences Study showing the poor long-term outcomes of a range of experiences including not only abuse and neglect, but the more ubiquitous experiences of parental mental illness, marital conflict, and divorce. The greater the number of ACEs, the greater the likelihood of a wide range of negative physical, emotional, and social consequences.  

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. Again 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. 

 An extensive body of research shows us how these early experiences get into the body and the brain.  But perhaps we need look no further than van der Kolk's opening video. My colleague in Scotland, Suzanne Zeedyk, who is taking extraordinary strides to make an entire country "trauma-informed" in large part through showings of the film Resilience  about the ACEs study, began her work in the arena of public policy with a beautiful film, the connected baby. Both she and van der Kolk recognize that babies have an extraordinary capacity for connection and communication from the moment of birth. "ACEs" are experiences that violate that connection. 

Adverse Childhood Experiences can be understood as developmental derailment of the healthy process of mismatch and repair. Prolonged lapse between mismatch and repair occurs when a parent is preoccupied with depression, substance use, marital conflict, or domestic violence. Absent mismatch occurs with an anxious intrusive parent. Unrepaired mismatch occurs in the setting of abuse and neglect. 

Van der Kolk went on to demonstrate, using research evidence and clinical examples, how when bad things happen to us early in our lives, the experiences live in the body. Offering a message of hope, he encouraged his audience—a broad range of individuals from our local community—to recognize that healing begins with the body. Theater, martial arts, drawing, drumming, yoga, and dance are among the many ways in which, in the setting of relationships, parts of the brain damaged by the experience of trauma can begin to heal. 

In conclusion, van der Kolk returned to babies. He advised us to look to paid parental leave, high-quality daycare for all, and other measures to support new parents as the path to a trauma-informed community. In keeping with his recommendations, our local Berkshire United Way chapter is supporting a project designed to give every newborn baby and parent a voice.

Using the Newborn Behavioral Observations (NBO) system, founded in the work of pediatrician T. Berry Brazelton, as a model of care for all new families, we aim to offer opportunities for nonjudgmental listening to parent and baby together. One mother had an unexpected emergency cesarean section and feared that the disruption in her birth plan would damage her connection with her baby. When we used the NBO to take time to demonstrate how well she did, in fact, understand her baby, she was flooded with relief and joy. 

A recent Time magazine article, The Goddess Myth, identifies the unrealistic expectations of the transition to motherhood as potentially damaging to mothers. The article cites the statistic that close to 50 percent of mothers have deliveries that do not go according to plan. Sometimes referred to as "birth trauma,"  the lack of ability to repair the disruption in a holding environment characterized by connected relationships can enhance the traumatic nature of the experience. 

The word "trauma" can itself be traumatizing. As we move forward with this work, I wonder if we might aim to build not "trauma-informed" communities, but, taking the lead from van der Kolk's presentation of mother and baby, simply "connected communities."  Parents and babies are an excellent place to start.

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When Parents Fear "It's All My Fault"

Many of my colleagues in the field of early childhood mental health work with what are termed "high risk" populations. Children of drug addicted parents, victims of child abuse, and families in abject poverty. While the challenges these families face are daunting, I find myself feeling some envy for my colleagues whose clients are in such obvious distress that the need for intensive treatment of parent and infant is not in question.

In my rural, small-town population things are not so clear. Many families struggle under the radar for years. Recently in my behavioral pediatrics practice (details are changed to protect privacy) I saw a 3-year-old boy, who, in taking a detailed history, I could see barreling 100 miles an hour towards trouble from the moment he was born, or even before.  But the story unfolded before our eyes without intervention. Did the parents resist help? Did the many professionals in with contact with the family not recognize the problems? Probably some combination of both.

 We know from the CDC sponsored Adverse Childhood Experiences (ACEs) study that neglect and abuse, as well as more ubiquitous experiences of such things as marital conflict, parental mental illness, domestic violence, and substance abuse lead to a wide range of negative health outcomes both physical and mental. Yet babies come and go to pediatric practices and we don't discover or address until years later that in the early weeks and months, when their brains were most rapidly growing, parents-many themselves with a history of ACEs-struggled significantly. 

We need to find a way to engage these families with intensive support from the very beginning without making parents feel that they are somehow not "good-enough." Engagement means not only behavior management for children and/or medication for parents. It means listening to parents and infants together from the start. We need to listen to the vulnerabilities the child brings into the world as well as the often-complex relational issues between partners, among siblings, and with extended family.

The mother of my 3-year-old patient struggled with severe postpartum anxiety and profound social isolation. She described her son as "inconsolable" from birth. The marriage faltered. He developed severe separation anxiety, frequent explosive tantrums, and sleep disturbance among a range of other behavioral and developmental disturbances.

We know from infant research that a core sense of self develops in the moment-to-moment interactions between infants and their caregivers. Babies arrive in state of complete helplessness, relying 100% on their caregivers to make sense of the world and of themselves. This does not mean parents need to be perfect. In fact, perfection as well as absence can inhibit self-development and lead to fearful and rigid states. It is the very imperfections in relationships that help infants to develop resilience and a positive sense of themselves in the world.

But when parents are fighting constantly, when a mother or father is preoccupied with anxiety and/or depression, when a parent is in an altered mental state intermittently from substance abuse, this core sense of self may be distorted as infants struggles to make meaning of their experience. The "symptoms" of my 3-year-old patient can be understood as difficulties managing both his body and developing mind in a complex social world.

The transition to parenthood is challenging under the best of circumstances. Alicia Lieberman, one of the giants of the field of infant mental health, speaks in a kind of paradoxical way of how "trauma" is "normal." ACEs are extremely common. I recently heard a leader in the trauma field say in a presentation, "ACEs are normal."

If we engage families at or even before birth, presenting the challenges of the transition to parenthood as normal, when a parent struggles we will be right there to work more intensively to support these early relationships when bigger disruptions arise, rather than waiting until families are in crisis. Universal home visiting, relationship-based Early Intervention services and community support groups for parents and infants offer opportunities for a population based, non-stigmatizing approach to supporting new families.

Pediatricians present an ideal opportunity to engage families in this way. Currently Jack Shonkoff at the Center on theDeveloping Child is partnering with pediatric practices to develop a preventive model on the front lines where parents and babies regularly go. My colleague Ed Tronick has said on multiple occasions that parent-infant mental health should be the core of pediatrics, not a subspecialty. The abundant evidence from the ACE study certainly supports this claim.

At the tender of of 3 there is plenty of opportunity to help my patient and his family, who are invested in doing the work to set relationships and development on a better path. But I hope for shifts in culture, health care, and public health that will allow all families to set out on a healthy path from the start.

When Birth Plans Go Awry: Wisdom from Dr. Spock

Self- efficacy, or the belief in one's ability to be a good parent, plays a central role in healthy child development.  Many things can come along and derail that sense of confidence. Often the first of these is a delivery that does not go as planned.

In a recent conversation a colleague wondered if the abundance of books about the importance of the first months of life might serve to heighten parents' anxiety. I slept on her wise words and woke thinking of the famous opening line of Dr. Spock's Baby and Child Care, "Trust yourself: You know more than you think you do."

I went straight to my bookshelf that morning, and was surprised and pleased to find that he addresses what is today referred to as "birth trauma" in the opening pages:

If your labor and delivery experience is not what you expected, its normal to feel bad, even guilty. If you go in hoping for a natural birth and end up with a cesarean, its natural that you might feel that you were somehow to blame (you weren't) or that your baby will be somehow permanently harmed by the experience (almost never the case.) Many parents fear that if they are away from their baby in the first hours or days bonding will be permanently undermined. This is also not true. Bonding-the process of parent and baby falling in love with each other- develops over months, not hours.

The equating of bonding, a word that itself creates anxiety in parents, with falling in love, along with acknowledgment that this process is different for every family, holds great value. He brilliantly goes on, in words that echo pediatrician turned psychoanalyst D.W. Winnicott and anticipate research of psychologist Ed Tronick on the value of mismatch and repair, to dispel anxiety around a birth plan that goes awry:

Parenthood is an ideal guilt-generating business, and labor often delivers the first volley. I think this situation has come about in part because of the fantasy that everything has to be perfect in order for the child to do well. Of course nothing could be further from the truth. First off, the "perfect" parent has yet to see the light of day. Secondly there is no need to be perfect or to follow any one script. The process of human development is powerful. There is plenty of room for variation and even for making mistakes. Infants are incredibly resilient. As long as the infant is healthy, the type of childbirth is unlikely to have long-term consequences, unless there is so much guilt attached to the memory that it has a negative impact on parental self-confidence or starts the process with a strong but misguided sense of guilt. So my advice is to have your baby however seems right for you and your family. Then don't worry if what happens doesn't follow the script. Being a parent is tough enough without creating problems where there really aren't any.

Parents today are more likely to think of Spock as a Vulcan than a pediatrician.  With anxiety, stress, and uncertainty on the rise in our day-to-day lives, a healthy dose of Dr. Spock may be just what the doctor ordered.

The Decline of Empathy: A Hopeful Solution

Pediatrician T. Berry Brazelton was among the first to recognize the tremendous capacity of the newborn for complex connection and communication. Developmental psychologist Ed Tronick, drawing on this observation, designed the famous Still-Face Experiment to show the devastation, for both parent and baby, when they struggle to connect. Extensive research at the interface of developmental psychology, neuroscience, and genetics, as I document in my first book, shows the long-term benefit of investing in early parent-child relationships.

"Once you know it, you can't un-know it." My wise colleague Kyle Pruett, MD child psychiatrist, said this of the power of working with parents together with very young children to a move a family in a healthy direction.

After having recently written The Silenced Child, an admittedly dark account of how our society fails to listen to parents and children, and the potentially disastrous effects of this course of action, I am overjoyed to now be writing about a hopeful solution to this problem.  The following piece, published in our local paper on Sunday, offers a view into the work unfolding in this small rural town in Western Massachusetts. My hope is to bring this model to other communities. The aim is to offer this listening stance to all babies and families without potentially stigmatizing parents by identifying them as "at-risk."

Giving Every Newborn Baby A Voice

On a stormy November evening in 2016, I led a meeting in the small patient lounge of the maternity unit of Fairview, our local community hospital in rural Western Massachusetts. As the meeting was scheduled at change of shift, all 10 nurses who attend to the approximately 150 deliveries per year squeezed into the warm room. They eagerly shared their troubling feelings of helplessness when they see families who are clearly struggling, and have no choice but to send them home “on a wing and a prayer.”   They listened in rapt attention, and seemed empowered by the idea of learning new ways to support parents and newborns.

As a pediatrician specializing in parent-infant mental health, I attended the meeting under the auspices of the new Human Development Strategic Initiative at the Austen Riggs Center, led by Donna Elmendorf, PhD. a child clinical psychologist and director of the Center's Therapeutic Community Program.  The initiative seeks to bring Riggs’ relational view of early development to a community-based preventive model of care.

About six months later, on a spring weekend when from Friday to Sunday the weather shifted dramatically from snow to warm sunshine, half of these nurses, together with pediatricians, family and nurse practitioners, early intervention specialists, home visitors, and lactation consultants, many of whom are participants in the Berkshire United Way sponsored South County Community Coalition, gathered at Austen Riggs for a training in the Newborn Behavioral Observations system (NBO) to focus on giving babies in our community a healthy start.. The nurses who covered the maternity unit that April weekend traveled to Harvard Medical School in June for the same training.

We now have the opportunity to offer this intervention to every new baby and family, and an extended network of caregivers throughout our community who can support families in a similar way beyond the newborn period.

Early in his work as a general pediatrician in the 1950s, T. Berry Brazelton, recipient of Obama’s Presidential Citizen’s medal in 2012, observed the tremendous capacity of the newborn infant for complex communication. Research based on these observations led to development of the Neonatal Behavioral Assessment Scale (NBAS.) The scale changed the way both child development experts and pediatricians understood babies. The NBO, a clinical application of the NBAS developed by psychologist J. Kevin Nugent and colleagues, is a relationship-building tool that is as its core an opportunity for listening to parents and babies without judgment. Ongoing research around the world demonstrates the role of the NBO in supporting parent-infant relationships.

While the medical model of care often puts the professional in the role of expert, this intervention seeks to shift that mindset, mobilizing parents’ unique capacity to tune into and respond to their newborn. The 18 neurobehavioral observations of the NBO are not an assessment or evaluation. Rather, they offer a frame in which to support parents’ earliest efforts to get to know their baby.Participants in the training learn together about how to engage parents’ natural expertise and ability to listen to their baby’s earliest communications as they navigate this dramatic transition in their lives.

The Discovering Your Baby Project, the first community project of the Human Development Initiative, grew from a wish to have every family on our community feel heard and valued. We feel so fortunate to

have received local and national grant support for this burgeoning effort. . Research at the interface of developmental psychology, neuroscience, and genetics offers evidence for  investing resources in these earliest relationships.

Families who deliver at Fairview Hospital may have relocated from the Upper West Side of Manhattan, lived for generations as local workers, or recently emigrated from Ecuador. Families from the full range of socioeconomic backgrounds may have struggled with generations of mental illness, substance abuse, or other adverse childhood experiences.

At the NBO training one of the nurses who has worked for decades on the same unit shared how she sees troubled family relationships passed from one generation to the next. “Now,” she said, “I feel hopeful that the next generation may have a different path.” 

Our population-based intervention for all families who deliver at Fairview aims to instill confidence and de-stigmatize the struggles of the transition to parenthood, with the larger community of caregivers available to engage families in this way as development progresses. We hope the Discovering your Baby Project can serve as a model for communities large and small, urban and rural, throughout our country.

We learn to listen by being listened to. We see our work as a “baby step” toward giving every person a voice from the moment of birth.  Perhaps it will also be a first step toward restoring empathy in our society.