ACEs-informed Interventions that work in early childhood

A Report from the 2016 California Adverse Childhood Experiences Conference

At the 2016 California ACEs Conference, First 5 Executive Director Moira Kenney moderated a panel October 20 on Early Identification and Promising Interventions in Early Childhood (focus on ages 0-5). The conference was hosted by the Center for Youth Wellness in San Francisco and sponsored by the California Endowment, Kaiser-Permanente, and Genentech.
 
Public Health Professor Christina Bethell, who also directs the Child and Adolescent Health Measurement Initiative at Johns Hopkins University, said the Through Any Door Family Center she oversees takes a family-centered approach with a focus on pre-natal prevention of ACEs.
 
“If the mom is not doing well physically or mentally,” she said, “often ACEs are high in the child as well.”
 
The center first engages parents, then identifies ACEs and assesses what needs to be done. Nearly half of all young children, ages 0 to 5, with emotional and behavioral problems have high ACEs.
 
She said the center is using an ACEs screening tool developed by Head Start, and following up with parents to help their child express feelings so they can learn to control behaviors. She recommends a developmental screen for ACEs beginning when a child is 10 months old.
 
She hopes this work deactivates the shame surrounding ACEs and activates conversation. Her vision is psychiatric classification using ACEs as a developmental trauma disorder.
 
Kadija Johnson, associate chief social worker and director of  the Infant-Parent Program at the UCSF Department of Psychiatry, said, “What’s unique and most challenging is identifying trauma in very young children.”
 
For infants and young children, trauma is different than for older children because because their brain circuitry is still developing. “The psychiatric risk is greater because they are less able to interpret adversity and more likely to blame themselves or their parents,” she explained.
 
“Why are efforts to address early adversity so limited?” she asked and then answered her own question. First, it’s difficult to acknowledge suffering in anyone, especially with infants and young children, who have a natural tendency to ignore these experiences.
 
Secondly, to assuage our own fears, we assume that kids will outgrow trauma or that they will not remember such experiences. That’s because we think memory doesn’t exist without cognitive development; but Johnson says visual and emotional memories developed in infants and children under five years of age can and do persist.
 
Another reason we ignore ACEs in very young children is that symptoms can be hard to decipher. For example, is a panic attack triggered by trauma or is it something else, like an ordinary temper tantrum?
 
Successful interventions at the Infant-Parent Program at UCSF are aimed at identifying the relationship that might have caused the trauma. Johnson said social workers “listen to ghosts in the nursery,” addressing the contribution of caregivers to the history of trauma. This process legitimizes the child’s response to trauma.
 
Resilience is then developed by resurrecting and creating benign relationships that provide containment, consistency and coherence in the child’s life.
 
At UCSF Benioff Children’s Hospital in Oakland, California, Dr. Dayna Long, a pediatrician and researcher, said 90 percent of the patients in her clinic live below the poverty level and most are patients of color. With 90 medical residents but only one social worker, this hospital is one of the nation’s largest clinics serving the underserved.
 
Although the mission of the clinic is to achieve health equity for all, Long said most physicians there say they have no capacity to address the unmet social needs like poverty and violence that lead to poor health of their patients.
 
In 2012, when she first brought up ACEs, she was told it was not her job to ask patients the screening questions. So she conducted a survey and found that 60 percent of the families she sees were food insecure; 50 percent witnessed violence regularly at home or in their community; and 40 percent had mental health issues.
 
As a result of the survey, a recent health pilot was funded by a $5 million grant. The clinic selected some of the most relevant ACEs questions and added others that deal with cultural issues such as discrimination and violence. She said the ACEs in the patients she sees in her clinic are much higher than in the original CDC-Kaiser Permanente ACE Study because of poverty and race factors.
 
The families in the clinic say that their doctors should be talking to them about their ACEs and should also be doing something to help them heal. “But the providers don’t want to talk about it,” said Long.
 
But she isn’t giving up. By the 2018 ACEs conference, she hopes to find and present ways to screen in prevent ACEs in low-income areas.

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