Dr. Claudia Gold: Empathy & Listening as ACE-Informed Practice

 

About Dr. Claudia M. Gold

Dr. Gold specializes in early childhood mental health and has practiced general and behavioral pediatrics for 25 years. She is on the faculty of the University of Massachusetts Boston Infant-Parent Mental Health Program, William James College, and the Austen Riggs Center.

a photo dr. gold

She has written several books. Her most recent title is Developmental Science of Early Childhood: Clinical Applications of Infant Mental Health: Concepts from Infancy Through Adolescence. She also writes for Psychology Today and her Child in Mind blog. a photo b

Below are excerpts from the Parenting with ACEs chat. The fuller transcript is available online and below (though edited) as a pdf.

ACN (ACEs Connection Network): You talk a lot about the powerful role listening has in your book. But when a family comes in and you have only 8 minutes...is it possible to listen and attend to health issues?

Dr. Gold: While a primary care clinician may be tremendously pressed for time, the relationship that develops over the course of multiple visits can be an invaluable asset. Five minutes of the full listening presence of a respected caregiver is potentially of much greater value than lists of behaviors parents are instructed to follow.

Dr. Gold: In my many years of clinical experience I have observed that dramatic shifts occur in families when we experience strong feelings during a visit. The predominantly right brain centers that control emotions change when they are actually firing. The powerful feelings associated with having a struggling child may make the higher left-brain thinking centers inaccessible. Moving through emotions in a safe caregiving environment helps us to feel calm and think clearly, making us more available for meaningful change.

“ACEs are intimately intertwined with stories of loss. When we can listen for loss and allow parents a safe space to grieve, we help them to move through mourning to healing.”

Dr Gold 1

ACN: What do you think works better for parents (than giving advice)?

Dr. Gold: “We need to help alleviate that stress rather than instruct parents in “what to do.” That stress takes many forms: the stress of a fussy baby, the everyday challenges of managing a family and work in today’s fast-paced culture, often without the support of extended family, are frequent causes. Stress may come from more complex relational issues between parents, between siblings, between generations. It is not that they don’t know how to parent, but that their natural abilities have been inhibited by stress, by negative models in the past, or both.

Parents who say, “I don’t want to raise Charlie the way I was raised” do not need “expert” advice. They need to develop confidence in their natural intuition. The goal is to support parents’ efforts to find a way of raising their children that is in keeping with themselves, with each other, and with their child.”

… I think finding our empathy for the parent is difficult but it's our way in. Having empathy for the parent will lead you to a place where the parent will be able to have empathy for the child.

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Dr. Gold: I think it's critically important to find self-regulating strategies for parents and children.

  • parent and child ( can) do martial arts together,
  • drumming is another really wonderful experience,
  • getting bodily self-regulation,
  • recognizing when you or a parent or child is provoked (and) is not at their best - and then employing basic breathing such as walking. When you walk your brain becomes more well-regulated - even walking around the house (can help).

 

Ginger Gentile: What recommendations do you give for a pediatrician or primary care physician to explain ACES and how it can impact health to teens and young adults? So they feel empowered and not "doomed" to be sick? There is a lot of talk with young people about being "traumatized" and "triggered", sometimes it seems to me it comes from a place of being "disempowering" (I can't deal with conflict, it triggers me.

Dr. Gold: I think it's such a brilliant question. I think it's rooted in the language of trauma and (that can make) people feel like victims rather than empowered. There's tremendous evidence that our brains change throughout our lives in the setting of attuned care relationships.



“You are absolutely not doomed from having ACEs! There's plenty of evidence (about that).”



Jane Stevens: And the ACE Study, and all the subsequent ACE surveys, shows that ACEs are NORMAL!!

Dr. Gold: Yes, ACEs are very common.

David Dooley: Would you comment on Dr. Felitti’s words: “If you were to ask me what my thoughts are on the most effective public health advance that I can think of in current times, I would say to figure out how to improve parenting skills across the nation.”  Vincent J. Felitti, MD ACE Study author

Dr. Gold: (Parents need) paid parental leave, quality child care and quality day care. It's not as much about parenting skills as supporting parents. I agree with what Dr. Felitti said in spirit, it's about (supporting) parents but not teaching parenting skills.

Jane Stevens: Can you add more to what you mean by "it's not parenting skills"?

Dr. Gold: This is the whole idea that the parent is the expert with regard to their own child. When they are stressed and overwhelmed they are not able to access their own expertise.  So the point of intervention is to relieve the stress on the parent not to teach the parent skills. You know, within reason.

Usually, parents who need help are stressed and overwhelmed. We have to address that first and listen to their stories and understand their unique situation.Dr. Gold 10

Linda Chamberlain: ....How we find language that is not "toxic" to families and highly traumatized communities (urban, indigenous, refuges etc.) and really convey what you are saying here--the capacity for all of our brains-bodies to heal...I hope this topic can be expanded in the future to learn more about "trigger" language and empowering language for both service providers/gatekeepers and clients. I believe the approach you describe of meeting the parent(s) where they are at relative to their level of stress, fear, etc. is so the first building block in the foundation!

Dr. Gold: I  think the stigmatizing nature of the language is important. For ex., when we use language like "high risk" groups…. (Instead) I think normalizing parenting struggles and (the) struggles (parents had) growing up. I think it's related to the use of the word trauma. ACEs is meant to be more normalizing but it's used often in a way (that's) equated with trauma. I use the word loss. Loss is universal experience. So when we think of universal experience of loss and (the) normalized challenges of raising children under multiple external stresses, I HOPE it decreases stigma and make people more open to ideas.

Jane Stevens: Loss is a great word!

Joan: I'm a pediatrician interested in incorporating the science of toxic stress into how we provide primary care. In addition to listening and empathy, anything else we can to do support families encountering toxic stress?

Dr. Gold: To recognize the extraordinary power you have with the family and not to underestimate the value of you spending time listening. Even the way the question is posed suggests that (listening) doesn't feel important, but it's very important. Doing that before you refer a family is of tremendous value.

If you refer a family within five minutes it's understandable they are not going to take that referral. But if you have a relationship with the family and can even take a couple of 30 minute visits where all you do is listen - that can really help shift things in a really different direction. It helps if you have some basic knowledge of contemporary development  science...

ACN: What does being ACE informed mean to you?

Dr. Gold: Respecting the importance of protecting time and a safe space for listening to the story. The idea that childhood experiences have long-term impact is not new. Our scientific understanding of how early experience gets into the body and brain is new and growing every day.

Dr Gold 9ACN: When did you learn about the ACE study? Did it change your views or work?

Dr. Gold: I first learned of it while practicing general pediatrics in 2000, but I did not fully appreciate its significance until I became immersed in early childhood mental health. I think the greatest power of the ACE study lies in the way it offers a common language that is based in evidence, and supports devoting resources to promoting healthy early parent-child relationships.

Jane Stevens: Is this a good example? This is what a pediatrician in Arizona once told me: “Asking all these questions can mean the difference between a healthy and an unhealthy child, says Bode. She tells the story of a woman and her young son, who was born with a heart condition. Over the last couple of years, when the mother brought him in for checkups, the physicians talked with her about the child’s medical complexities and urged her to make sure he was given a specialized formula. “I’ve seen him at least six times,” says Bode. “And he hasn’t been doing well. We finally did an ACEs and basic needs screening and found out that the mother was a victim of domestic violence, was intermittently homeless because she wanted to leave her partner but was unable to afford it, and couldn’t afford the child’s specialized formula. “I thought I had been doing a good job because I had been telling her about his medication needs, and how to promote his health. But because I didn’t ask the other questions, I didn’t find out about the things that were affecting his health even more than his heart condition. Yes, they’re social problems, but we know as pediatricians that they are just as important.”

Dr. Gold: It's the benefit of the ACE questions but (in that case) the benefit is more to the doctor than the patient because you open the doctor's eyes to the importance of talking to the person about their whole life circumstance. As long as the Dr. is available to talk about all these things that's exactly the benefit of the ACE questionnaire.

Ginger Gentile: ...to follow up, what advice could a MD give to seek treatment or things a teen could do? Often MDs have limited time, how would you quickly encourage them to see this as an opportunity to improve as opposed to just another risk factor? (assuming you see the teen alone with no parent).

Dr. Gold: I like to be very creative with teens.

  • Dance
  • Theater
  • Not necessarily go talk to a therapist.

“Developmentally,  talking to an adult about problems is not where teens are. (Find) creative ways to regulate. Once that’s done,(teens) may be able to access  insight-oriented therapy.”



ACN: How can ACE assessments be done in a pediatric practice? Any concerns, considerations?

Dr. Gold: Use of ACE assessments is of value when it occurs together with opportunity for listening. I think the questionnaire is helpful in calling attention to the importance of a person’s life story in understanding their behavior and current physical and emotional health.

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Dr. Gold: ...Self-care is critical for parents. I use the airline metaphor of needing to adjust your own oxygen mask first. Recognizing the way a child’s behavior provokes you, and taking steps to manage your reactions can be essential.

(The work of) Stephen Porges. I discuss his work (in my book) about how when people are feeling threatened, it literally distorts function of (the) middle ear and they can't take in information. It distorts facial muscles. It's (the) physiology of dissociation. They can't take in words, advice… First, make people feel safe. When they feel safe, even the most distressed parents, that many would judge to be (doing) bad parenting, on their own come up with their own really good decisions once they are given an opportunity talk about their own experience and relax enough to be curious about their child.

ACN: Do you use ACEs with families and if so, how? If not, how come? In what way/s?

Dr. Gold: My work is very much informed by Bruce Perry’s neurosequential model of therapeutics. When individuals have experienced early developmental/relational disruption (another term for ACES), in times of stress they may revert to more primitive levels of brain functioning. If significant disruption occurred early in infancy such as being raised in a neglectful home with substance abuse and mental illness, development may move forward but in a stressful situation the individual may regress to function at (a) developmental level more like an infant.

Dr. Gold: Gentle physical touch and speaking in a soft voice, as one would treat an infant may be needed to help that person return to a level of function more appropriate to their chronological age. Rational thought may not be possible.

“Both parent and child need to pay attention to basic things like breathing. Activities such as:

  • walking,
  • swimming
  • or others that consist of rapidly alternating movements can help regulate emotions.
  • Martial arts
  • dance
  • and drumming can also be useful.

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These activities occur in the context of relationships that can be healing. Only when the lower centers of the brain are functioning properly can the  higher centers of the brain come online.  Only at that time can talk therapy be useful, and developmental guidance, which can have a role to play, might be heard.”

ACN: Where do parents go for support when vulnerable, in crisis, having ACE-related issues come up while also balancing work, life and parenting?

Dr.Gold: Similar to the above answer:

  • Anything that helps you breathe and feel connected.
  • Recognizing your limits and what you need to do to take care of yourself. For example, you may need permission from an employer to come in 15 minutes late and leave 15 minutes late in order to attend an early morning yoga class.
  • Find relationships that give you emotional support, whether that be a family member, mental health professional, friend, colleague, or even a swing dance instructor.

Dana Brown: the ACEs Community Network Southern CA Regional Community Facilitator (who usually co-hosts chats ) wanted all to know about the Whole Child Assessment (WCA) of Dr. Ariane Marie-Mitchell in San Bernardino. Jane Stevens has written about her pioneering work on the ACEs Too High website.  Dr. Marie-Mitchell made the WCA available to other pediatrician writing  “If you are a California physician and would like to use the WCA, then you may make this request through your local managed care plan and, since the WCA has already been approved by the state, the process should be quite simple. If you are serving non-Medicaid patients or practicing outside of California, you have the option of using the WCA in its current form, or modifying it to fit your practice.”

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ACN: Do you feel like there are some misconceptions pediatricians have about parents?

Dr. Gold: When pediatricians are pressed for time and they do not have an opportunity to listen and make sense of the story, they may be judgmental and critical of parents.  For example, when a parent wants time to understand their child's behavior rather than diagnose them with ADHD, the parents may be labeled as "non-compliant" or "in denial."

ACN: Do you feel like there are some misconceptions parents have about pediatricians?

Dr. Gold: This issue has roots in the medical education system, health care system, and even the health insurance industry, where the role of listening may not be valued. Pediatricians need to feel valued and rewarded for taking time to listen, and educated in the science showing how listening changes the brain. The broad reach and compelling data of the ACEs study is certainly having an impact in this direction.

Dr. Gold: I'm happy to have found this community. I hope my thoughts have been helpful.

The original chat transcript can be found here. The slightly edited for sequence, clarity and readability version of the transcript is attached as a pdf below. To find Dr. Gold's work, books and blog online check out her website

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Christine Cissy White posted:
Dear Leslie: 

Thank you so much for your comment. If you have time, I'd love to know if/how you use your ACEs awareness and journey as a nurse and when working with parents and families with ACEs.

Also you are so on point about how often a child with ACEs is being parented by a parent or parents with ACEs and possibly an extended family and wider community. It's not always the case, as some adoptive parents with low scores have children with high scores, but it's often the case. 

Thank you for sharing about your own journey as well. Please share a link to your work, if you would like, where you interview others about their own stories.  

Cissy



Hi Cissy, thank you for your response. I use my ACE's experience to work with patients and friends and acquaintances almost every day. I share my experiences, my struggles, my successes and I let them know what did and didn't help me. I teach bits and pieces of my program all the time.

A  benefit of having a high ACE's score is that we often don't know how to set boundaries  I dont mind be vulnerable if it allows someone else to feel comfortable sharing. Also because of this I ask questions that many would not. You would be surprised how much people will share if you share first.  Almost every woman I have met (ACE's or not) wants to know

                 "Do you see me" Do you hear me? Do I matter?"

This is partly why I started filming Conversations that Matter with women. I saw them - I heard them - I wanted them to know they mattered. It was amazing to watch someone raise their awareness right in front of your eyes. There were so many Aha moments discovered by women. One day I would like to travel acoss the country having these conversations. For now what I discovered about resilience is this: 1) if a mother supported and stood by her daughter unconditionally then the daughter was more resilient   2) a child needs just one adult to really believe in them and encourage them - ideally their mothers.These conversations can be viewed on youtube WomenNotAlone Voices that Matter.

I have been working on getting my program out to decision makers for quite some time. I live in Philadelphia which is doing fabulous work with trauma informed care. The problem is that the programs they create aren't going to help professionals help the people who need it (many of the health care professionals I met have ACE's scores and are codependents themselves). Most of the programs in existence are too research oriented and based in education. ACE's deals with human thought processes and behaviors. It's so complex yet so damn simple! That's why I want to become a spokesperson of sorts for ACE's - I have the advantage of understanding both angles.

I did teach my program to Thomas Jefferson's Family Health Clinic last spring. I started with a group of 7 women (former heroin users clean for 5 years) and ended with around 12. The Director of the program commented that my program was "great content". So until I find support I do what I can as a team of 1.

If you are aware of any group/organization who may be interested in my message or my solution, please forward my name. If I can help you out at all please feel free to contact me at info@LesliePetersRN.com. Thank you!

In gratitude, Leslie

 

 

 

 

 

 

Dear Leslie: 

Thank you so much for your comment. If you have time, I'd love to know if/how you use your ACEs awareness and journey as a nurse and when working with parents and families with ACEs.

Also you are so on point about how often a child with ACEs is being parented by a parent or parents with ACEs and possibly an extended family and wider community. It's not always the case, as some adoptive parents with low scores have children with high scores, but it's often the case. 

Thank you for sharing about your own journey as well. Please share a link to your work, if you would like, where you interview others about their own stories.  

Cissy



I agree with Dr. Gold about empathy and listening. Also that teaching parents how to parent isn't usually effective and this is why...most often than not, a child with with ACE s  is being raised by a parent with ACE s.   The way the parent interacts with, speaks to and shows love to the child is usually the way they were treated as a child.  It's what they know and they don't know that it's not healthy. Breaking the cylce of Aces starts with the adults in the family. They need to become aware of how their childhood experiences play a role in who they are and where they are today. I believe it was Einstein that said tge same mind that creates the problem cannot be the one to solve it.

I Interview women about issues pertaining to love, trust, confidence,  ego, shame, guilt,  relationships, boundaries and so on. Without exception for those women who had negative childhood experiences,  as they tell their story they get an aha moment of how they are repeating the behavior of their parents. This is not a pleasant moment. I know because my ACEs score is 7.  The moment I became aware of how I was repeating my past by teaching my kids all of my unhealthy coping skills, it made me sick to my stomach.

Once I became aware of my unhealthy thoughts and beliefs, I spent 3 years of self-reflection and  retraining my brain, I turned my story from a curse to a gift. I created a 12 step guide on how to do this. I will tell you that the first step is  self-awareness. The parent must 1st undergo the painful process of self-reflection. Without that there is no turning around the story of your curse. Recent studies claim that 67% of our country has an ACEs score of at least one -that's a lot of perceived cursed stories that people are stuck in. 

I'm not stuck anymore. I am grateful to the research that has been done on this subject. However it cannot provide the human component of just how ACE's changes you at your core. How you become imprisoned in your mind while at the same time yearning for the "true" you, the one in your soul,  to be set free.

My passion, mission and purpose in life is to spread this message. In order to truly heal from ACE's and change lifelong behaviors and beliefs you absolutely must know your story. Never to use it as an excuse but to learn from it and break free of the cycle of ACEs. Then the children will be free to live the life that they were given.

In gratitide,

Leslie Peters RN

Info@lesliepetersRN

610-506-8298

 

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