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ACE Testing During Pregnancy Is The Missing Link


About Mothers

Pregnancy is often welcomed with joy and hope however, many challenges and distress may still occur during a mother’s pregnancy. Any concerns simple or complex may impact the wellness of the mother, her baby and cause stress on her multiple relationships. Oftentimes, mothers have to face planned or unplanned life changing events.

Mothers to be can be confronted with life changes, identity shifts, relational conflicts, financial uncertainties, unplanned pregnancies, ambivalence about their bonding to their babies, body image difficulties and/or hormonal dysregulation.

For many mothers who were victims of childhood abuse, symptoms of depression, anxiety, or post-traumatic stress may return again, or surface for the first time during pregnancy.

Giving the ACE questionnaire to all the mothers at the beginning of their Pre-perinatal care is vital. If the score of a mother is high, Psychotherapy as well as, increased OB-medical attention will be advantageous.

During gestation mothers are particularly receptive to positively impacting both the life of their babies and their own. The ACE questionnaire can indicate the need for early intervention for mothers. This too can be a safeguard for the baby and prevent multigenerational trauma which we know can be passed down.

How do we protect and care for the baby “in utero” when the ACE scores are high?

  • Pre-perinatal psychotherapy can be most helpful, EMDR-attachment trauma informed therapy, even better.

-The management of life conflicts and situational distress is an effective intervention.

-Resourcing the mother and reducing common anticipatory anxiety will benefit her, the child and those around her.

- Conjoint sessions facilitated by the psychotherapist with the mother, the  father of the baby, family member(s) and other children, can be extremely helpful and informative for all involved.

-A Psychotherapist who reaches out to the medical team involved in the mother’s care such as, her OB doctor, Midwife, Ultrasound technician and others will prove invaluable.

-Psychoeducating the mother about the importance of a smooth adjustment between the children at home with the baby is an important conversation.

  • Nutritional support by a Registered Dietician is recommended as it will benefit the mother and child.
  • Integrating the OB-Medical care with the psychotherapy and the nutritional services is a best clinical practice.
  • Lastly, talking to the baby “in utero” is early stimulation and this positive communication will most likely promote a positive bonding experience and strong spontaneous mothering activities.


How a woman feels about being pregnant and how much perceived support she feels that she is getting from her partner will contribute to a successful pregnancy.


Growing a Healthy Baby

Early interaction between parents and their child is critical.  The real question is what do babies want and need.

This is what babies might say:

As a baby in my mother’s womb if I could talk I would want my parents to acknowledge me now.  I would want my mother, my father, my caregivers and all those around me to –

  • LOVE me. Tell me out loud so I can hear it. I need to hear my parents. I need to hear my mom, my caregiver. I need to hear that I am BEING loved.
  • I need to be told that I am WELCOME, constantly and of course after birthing, but I need to hear it now, while I am in my mom’s womb.
  • You will tell me to TAKE MY TIME that I do not need to hurry.
  • My NEEDS are welcome by you.
  • I have the lovely RIGHT to be here, to be fed and taken care of.
  • You are GLAD and PLEASED I am a girl/boy.
  • You LIKE ME being near you and you enjoy touching me.
  • TALK to me, I need to be talked to every day, I exist. If twins, “we” exist individually, even though we are stronger together, we each matter. Talk to both of us together and separately.
  • DANCE with me and let me know about the song. If dad is around, or I have siblings, let’s all dance together. Allow them to love me, to bond with me, to enjoy who I am. Movement and rhythm matters.
  • READ to me, babies love stories.
  • ROCK me in a swing or a rocking chair, bilateral movements are calming.
  • If you argue in my presence please let me know it is not my fault. Release me of any wrong doing or responsibility. We need to have emotional boundaries starting now, while I am “in utero”. You can always APOLOGIZE if you argue in my presence, I know you are human.
  • Let’s PLAY. We could do soapy bubbles in the air and breathe, or find some big Legos. We could build a house together and you could tell me all about it.
  • We could PAINT. You could even paint your belly, I will feel you.
  • Let’s take PICTURES together.


All these lovely interactive activities and experiences will allow the baby to experience being loved and protected.

Remember that once in the womb the baby is already here and that life has already begun, the time to talk to the baby is now!


About the Author

Rosita Cortizo, Psy.D, MFT, MA, is originally from Panama, Republic of Panama and works as an OB-GYN, EMDR Pre-perinatal High Risk Psychologist in San Diego, CA. She has worked with pregnant woman, babies and their families for the past 26 years.

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Comments (17)

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After reading Kate White's article on Prenatal and Perinatal Care, in the Winter 2015 issue of Somatic Psychotherapy journal, I'm inclined to believe that some of her points would compliment this post....

All of this is correct, true and welcome as ACEs are such a wonderful tool to work with. But ACEs is about Education too, and in this regard, we could say (must say) that it has to begin way before conception takes place. AM told us over twenty years ago - coincidence? - that 'ideally, every woman should have processed her own history before concieving as, on top of everything else during the nine months of pregnancy, birth itself can be the biggest triggering moment, and that is not the best time  to 'get triggered'.

In an effort to find the write words to express the above, it didn't take me long to find the following link, which I invite you all to read and listen too. 

To all happy mamas and their babies   

And supporting dads of course!

Last edited by Raymond Lambert
Hello, Raffaat, Thank you for your comments. I was head of a large women’s health program for 6 years and the challenge of aligning and providing comprehensive –wrap around services to our pregnant and parenting moms and dads is always a challenge. I try to think expansively as to what may provide support for our mothers. In a rural community we have sparse resources and certainly lack psychotherapists, particularly those with specific training in trauma interventions and modalities. A couple of ideas we tried: first and foremost was to ask the mom what she needs to support her in dealing with her ACEs and her ability to parent? She may not know and having a list of options from frequent phone visits - “peer support” – relief nursery – more time with existing home visitors focused on ACEs and Resiliency skills/tools etc. is helpful.

It is not always possible to provide psychotherapy but an alternative is to enhance those individuals who already have a relationship with the moms to provide skills and interventions as well. I do however believe that all communities need to be actively discussing how to develop robust trauma informed mental health resources as few communities have MH resources adequate to meet the demand. In the interim, I think we use a continuum of support including focused efforts to augment – ‘build up’ existing resources to strengthen our mom’s and the communities that surround them. We also are working to establish community health workers (CHW) as people in neighborhoods who can be trained up around ACEs and Resiliency to build community capacity to support both individual and the larger community health.

Specifically related to strengthening the Home Visitors response/role, I am attaching a fabulous guide that was developed collaboratively between Oregon and Washington State for Home Visitors called NEAR@Home – (Neurobiology – Epigenetics – ACEs and Resiliency) – it really provides a comprehensive look at what is needed to provide an evidence based approach to home visiting which addresses ACEs and building resiliency.

I hope this is helpful.



Thanks for this insight.  In Ontario, Canada, we screen every newborn and their primary care giver (usually the birth mother) for a number of physical and psycho-social risk factors that could compromise child development.  We use what is called the "HBHC Screen" which is composed of 36 questions. The resulting screen score is used to determine which families would benefit most from a home visiting intervention. 

Recently, through data analysis, we have confirmed that a cluster of these 36 questions occurs strongly together like the ACE factors.  As the HBHC Screen can also be used prenatally, we are hoping to improve our targeted screening in order to achieve the objectives you've outlined in this blog post.  We also use NCAST's Promoting Maternal Mental Health in Pregnancy when providing home visiting service prenatally and the content is very aligned to the interactive activities you've described.

We are currently trying to understand more about aligning psychotherapy services with the home visiting interventions.  Any insight on supporting this type of service integration/system development would be greatly appreciated.

Great posting.  We are working on a Maternal - Child Health Program "Safer Futures" that has actively been training healthcare providers/staff  and cross sector community agencies in  supporting mom's facing IPV and high ACEs.  As a rural community resources are very thin to non-existent for those mothers, and mothers to be who are at/in highest risk.  I believe it is very important to provide access to a continuum of information, peer to peer, lay support, and professional support if and when available and desired.  If we are truly are interested in shifting the inter- generational impact of ACEs through both 'nature' = epigenetics, and 'nurture' parental love, attachment and support, we must move upstream and take a Public Health approach addressing ACEs across the lifespan with a particular and prioritized focus on reproductive health -as you post states so clearly.  ACES integrated into our schools, then focused efforts that begin addressing ACEs  in reproductive health first in our teen populations, then pre-peri-natal, post delivery, pediatrics and beyond.  We have been trying to build a coordinated approach that prioritizes Women's Health and Pediatrics to 'make the link' and move upstream to support mothers as a critical/essential point in the lifespan to  leverage change.  As another article  today change, particularly in the realm of healthcare at this point in history can be slow and daunting.   After decades of involvement in this field of work, i know we don't always see the immediate impact of our efforts but know that each can contribute to change - for individuals and the systems and communities that we are a part of.



I love "What Babies's Might Say." I can see that as a poster in many nurseries or as the cover of a journal. I shared this post in the Parenting with ACEs group as well. It's excellent. 

Patricia: I hear you. I think there are legit reasons many with high ACEs don't trust the support systems available which have sometimes-often-always been unsupportive depending on one's experiences. That's why I'm so glad this community is here so we can all keep educating each other across sectors and experiences.

Barbara: Can you share some links/URL's and/or post in Parenting with ACEs? You mentioned great stuff of interest to lots of us. I'd love to learn more. 

I know for me, an adoptive parent with a high ACE score, I did benefit from the lengthy home study process while applying to be an adoptive parent. It included an autobiography, job info and references and gave me a lot of time to think about the past. It also gave me a good amount about attachment and ways to think about what my child-to-be might need long before I was even parenting. That was excellent.  

Not all experiences are positive though. I know people who had over a decade of sobriety who weren't allowed to adopt because they had shared that they were alcoholics while those who said they didn't have a drinking issue (even if they did, in present tense) were able to adopt. Sharing and screening and transparency are not always beneficial to the parent or the child/child-to-be and who is gathering info. and what is being done with it.  Bias certainly factors in.

I wish there were more peer-led or parent mentoring programs from those who have been there and are likely to get it in a lived experience way. 

What helped me and still helps me is learning about attachment, parenting and also trauma and trauma recovery from other adoptive parents. And also, talking with older parents who have good relationships with their children and learning from and watching them. 


This sounds like a wonderful program.  I will also recommend the work of Phyllis Klaus LMFT, who wrote the book, "When Survivors Give Birth" and works with many traumatized pregnant women with a brief, targeted therapy.  She will be offering a training at the Birth Psychology (Association of Prenatal and Perinatal Psychology and Health, (APPPAH.) in San Diego on Nov 30-Dec 3.  She and her pediatrician husband, Marshall Klaus wrote "Maternal Infant Bonding" and created the first Doula programs in the US.  See DONA.  

See also the work of Jennie Joseph, British midwife in Florida.

This is some of the most important primary prevention work that we can do and is extremely cost effective.

Jane, this work was initiated prior to their focus on ACEs. 

As seen with the original ACEs research, their data also indicates that ACEs (parents had a problem with substances) were strongly associated with substance use, mood disorder, and IPV during the perinatal period. 

With WHO and CDC technical support, they developed a bundled screening tool using a trio of evidence based screening forms.  Research demonstrated substance use, mood disorders and IPV were interconnected and often presented together.  By combining these three forms into one document, it reduced the risk for missed screenings. 

During this time MCAH become more aware of ACEs and found it interesting that the data collected appeared to support the original ACEs hypothesis. 

Here is a link to the report:

Last edited by Karen Clemmer (ACEs Connection Staff)

Sonoma County Maternal Child Adolescent Health Department was one of six sites nationally selected to work on preventing substance exposed pregnancies.  During this process a screening  tool was developed that bundled substance use, mood disorder, and intimate partner violence.  The rationale being that these three issues often intersect.  Through this process over 5000 pregnant women were screened.  One of the unexpected findings identified by their epidemiologist was that women who marked "yes" to the question "did your parents have a problem with substance use" were significantly more like to have a history of substance use, IPV, and mood disorder.  In essence, this screening tool reaffirmed the importance of screening for ACEs during pregnancy.  

Through the Comprehensive Perinatal Services Program, resources including behavioral health, nutrition, psycho social support, health education, and substance use treatment were made available to these women. 

Last edited by Karen Clemmer (ACEs Connection Staff)

Thanks for all the comments and valuable information.

I am a part of an OB-GYN department. When pregnant mothers are (on a voluntary basis) referred to me by their OB-MDs, or pre-perinatal coordinators they are already "somewhat curious" about treatment.  The ACE questionnaire is given by me (an ACE and trauma trained licensed psychologist) with dignity and compassion. I provide information, resources and a plan, all of this is voluntary and psychoeducationally based. I have found our ACE screening meeting  to be a brilliant opportunity to honor the mother's strengths and to open a discussion about what may she-baby want.

As I mentioned in my blog, "Giving the ACE questionnaire to all the mothers at the beginning of their Pre-perinatal care is vital. If the score of a mother is high, Psychotherapy as well as, increased OB-medical attention will be advantageous.

During gestation mothers are particularly receptive to positively impacting both the life of their babies and their own. The ACE questionnaire can indicate the need for early intervention for mothers. This too can be a safeguard for the baby and prevent multigenerational trauma which we know can be passed down."

Robert, my EMDR informed treatment starts as I say "hello" to a client. I am thinking EMDR-attachment-resourcing from the beginning, however, is all about what the mother-baby want and need. Treatment follows a very collaborative healing path where the mom is the champion. So the short answer is, it depends (i.e., gestational stage, environment, social-familial supports, type of trauma and multigenerational patters, both adaptive/maladaptive). The phases of EMDR treatment and how we advance will depend on the many variables of the specific mother-baby being in therapy. I consider treatment to be very individual. I hope I answered your question.

Lastly, I have not been in a position to call CPS on the contrary, I have been at the other end of the continuum making sure that CPS involved mothers have the most positive outcomes for themselves, their children and their families.

Last edited by rosita cortizo

Thank You Rosita, Carey, and Patricia, for this essential dialogue.

Rosita, I concur with your point about 'Resilience Assessment' (while I had an ACE score of 6-using the WHO ACE International Questionaire, I also had a Resilience Score of 10...). Would it enhance this discussion to note the purpose/function of the 'O'Hare [or O'Shay]/Paulsen' EMDR protocols... ? ? ? Thank You.

Thank you for making it clear. Unfortunately, I have seen programs use assessment tools for diagnosis and for reporting.  My organization has been working to make sure the our community is aware of the use of the ACE tool.  We also, however, also always assess resilience as well to see what strengths can be increased to off set the ACEs

Patricia I absolutely agree with you. The services suggested are voluntary. In addition to, the ACE questionnaire is not diagnostic and the questions are meant to validate some of the moms' experiences and to provide support needed and "wanted". Thanks for your comments. Rosita

I like your idea, but I would caution that pregnant women, especially those of color or who are poor, do not find themselves referred to the child welfare system if they refuse to participate in services based on their ACEs Score only.

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