Are We, as Early Childhood Professionals, Asking the Right Questions?

The other day I was asked by a 4-year-old boy: “Have you ever been to prison? My daddy’s been to prison.”

Jay and his family live in my neighborhood in Brooklyn. Around the time Jay’s 2-year-old brother was born, his father was incarcerated. Jay’s father is absent during a critical time in the young boy’s life. But children are resilient and adaptable – capable of overcoming great adversity. What factors determine whether Jay’s path will be one of resiliency or not?

In other words: if you were caring for Jay in your medical practice, or in an early care and education setting, or visiting his family as a home visitor, what questions should you be asking about Jay and his family?

The Adverse Childhood Experiences (ACE) Study tells us we have to ask more, know more, and do more for families like Jay’s. The ACE Study focused on childhood abuse, neglect, and household dysfunction, and the impact of ACEs on health outcomes and social determinants later in life. Having an incarcerated parent is just one of the adverse experiences found to be associated with poor health and well-being in adulthood (see chart). With over 17,000 participants, the study found that exposure to multiple adverse experiences in childhood was proportionally linked to increased physical and mental health problems later in life, resulting in a shortened life expectancy. Further study by Dr. Felitti and Dr. Anda, the principal investigators of the ACE Study, confirmed “that individuals with an ACE score of 6 or higher had a life span almost two decades shorter than that of an ACE score of 0.”[1]

What does this mean for Jay? One ACE is extremely common –about two-thirds of the 17,000 participants had at least one ACE. However, the risk of early death increases with increasing ACE scores. That is why we need to know what else is happening in Jay’s life. The issues are additive: exposure to substance abuse, adult mental health disorders, parental separation, all forms of abuse, witnessing family violence add up to increased risk for the children exposed.

If Jay is exposed to multiple adverse childhood experiences, the very fabric of Jay’s being -his genetic makeup- is being changed due to socio-environmental factors beyond his control. The 2014 report about the epigenetics surrounding adverse experiences provided evidence that exposure to household dysfunction, abuse, and neglect in childhood may alter children’s biological makeup or DNA, making them less resistant to disease.[2]

Childhood abuse and household dysfunction don’t happen in one generation, but form patterns that are passed on from generation to generation. Nevertheless, that doesn’t mean nothing can be done to prevent and ameliorate these experiences. “Talking about the worst secret of one’s life with an experienced person, being understood, and coming away feeling still accepted as a human being, seems to be remarkably important and beneficial,” say the principal investigators of the ACE Study.[3]

If you were caring for Jay, the questions arise: what else is going on with Jay and his family, and what can be done to make sure Jay is understood and fully cared for?

A start can be screening parents and children for ACEs. This is one approach being implemented to address these issues at Montefiore Medical Group in the Bronx, NY. Leading the movement is Dr. Rahil Briggs a clinical psychologist and director of Montefiore’s Healthy Steps and Docs for Tots board member. Dr. Briggs’ work focuses on screening parents and their children for ACEs prenatally and during a child’s first well-child visit. Parents reporting an ACE of 4 or more are eligible to enroll in Healthy Steps, a national evidence-based primary care model focused on building relationships between health care professionals and parents in order to best address the physical emotional development of children from birth to age five.[4] The data strongly indicates that this type of program works.[5] Despite being raised by parents with a history of childhood trauma, children participating in Healthy Steps at Montefiore experience healthy social and emotional development that buffer the adverse experiences that they can’t control. This is great news for Bronx residents, and would be even better news for all New Yorkers if instituted at a statewide level.

Who is going to ask Jay’s family what is going on? Who is going to be there to make sure the path that Jay’s future takes builds on natural childhood resilience rather than multiple adverse experiences? A first step in New York State would be to collectively bring together those individuals that are actively working to address the issue of Adverse Childhood Experiences. Together we can work to ensure that every child, no matter what family he or she is born into, has an equal chance to succeed and live a healthy life.

References:

1. Vincent J. Felitti, and Robert F. Anda, “The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Health care,” in The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease, (New York: Cambridge University Press, 2010), 12  http://www.unnaturalcauses.org/assets/uploads/file/ACE%20Study-Lanius.pdf  

2. Colter Mitchell, John Hobcraft, Sara S McLanahan, Susan Rutherford Siegel, Arthur Berg, Jeanne Brooks-Gunn, Irwin Garfinkel, and Daniel Notterman, “Social Disadvantage, Genetic Sensitivity, and Children’s Telomere Length,” PNAS 111, no. 19 (2014):5947 http://www.pnas.org/content/111/16/5944.full.pdf

3. Felitti and Anda, The Relationship of Adverse (New York, Cambridge University Press, 2010), 13

4. “About Healthy Steps,” Healthy Steps, accessed February 1, 2016, http://healthysteps.org/about/

5. Rahill D. Briggs, Ellen J. Silver, Laura M. Krug, Zavhary S. Mason, Rebecca D. Schrag, Susan Chinitz, Andrew D. Racine, “Healthy Steps as a moderator: The Impact of Maternal Trauma on Social-Emotional Development,” Clinical Practice in Pediatric Psychology 2, no.2 (2014):166 http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2014-24042-003