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Taking an ACEs History -- Who's Doing It and How?

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Pioneering Research Study on Child-Parent Psychotherapy Incorporates ACEs

Una Majmudar, program manager The Child Parent Project, a five-year, $3 million federally funded project in Philadelphia, is the first research study in the U.S. partnering with public health agencies and family courts to gauge the impact of child-parent psychotherapy (CPP) plus ACEs screening on reuniting parents with substance abuse whose very young children have been removed from the home.


Although the results aren’t in yet – the five-year study is just in year two with 15 families (out of an anticipated 85) engaged – there’s no doubt that the ACEs screen has already had an impact on parents and treatment.



“Although the ACEs screen isn’t the only tool we use, because it doesn’t ask everything, it really helps us and informs our work because it’s simple for people to use and it’s backed by strong research,” says Una Majmudar, the program manager and a licensed clinical social worker.


“ACEs” refers to the CDC-Kaiser Adverse Childhood Experiences Study, a groundbreaking public health study that discovered that childhood trauma leads to the adult onset of chronic diseases, depression and other mental illness, violence and being a victim of violence. The 10 ACEs the researchers measured include physical, sexual and verbal abuse, physical and emotional neglect; a family member who is depressed or diagnosed with other mental illness, addicted to alcohol or another substance, in prison, witnessing a mother being abused, losing a parent to separation, divorce or other reason.


At the first of weekly sessions, which last nine months to a year or longer if needed, parents of children between newborn to five years old are required to complete an ACE survey. They do so by themselves or in response to the clinician’s questions, whatever seems more appropriate. Although their children’s ACE scores are not determined, the parents are asked and educated about the impact of their own traumas on their child as well as on their own lives. Later sessions include parents and their children.


“Often traumas are intergenerational, so whatever we can identify with the parent can help them change their behavior so not as to repeat the same cycle,” explains Majmudar.



In addition, she adds, “It’s a tool that has significant research behind it and we wanted the opportunity to be in a major research project with the ACEs a part of it because it makes our research more meaningful.”


As one example, Majmudar cited a parent who had witnessed her mother being physically abused by her father when she was about two, the same age as her own child. By discussing her ACEs, she was able to reflect on her mother’s experience and express anger at her mother. With her own child removed from her because of her substance abuse, the parent gained an understanding of the impact of her own ACEs on her relationship with her daughter.


“This is an opportunity to change things for the next generation,” said the orihect clinician, “by establishing or restoring a trusting relationship between a biological parent and her or his child with both of them present during therapy sessions.”


Majmudar says that ACEs scores for parents are usually very high, and they use a different tool for testing the children called the Traumatic Events Screening Inventory-Parent Report Revised.


The initial visits are with the parent to discuss their ACEs, their overall trauma history, and their child’s history. Then they agree on a course of treatment and plan how to explain the treatment to the child. Weekly joint child-parent sessions follow. And often the parent may be encouraged to continue with individual treatment. But the project does not require the parent to go into substance abuse treatment before starting the child-parent therapy.



“Participating in child-parent psychotherapy, however,” says Majmudar, “may motivate the parent to get treatment because it helps them understand and sometimes change behaviors so that they can reunify with their child.”


The weekly sessions help parents and children learn how to interact with each other in healthy ways. Parents learn how their children should be developing at different ages, and receive guidance in how to talk to the child in an age-appropriate way, In this way, the child will see the parent as a protector and someone they can trust. Parents and child are also encouraged to talk about what it’s like to be separated from one another.


“One of the best things we do for parents is that we become an advocate for them. We go to meetings with other public health agencies; we go to court. Sometimes we are the first ones to hear the level of trauma the parent has experienced, so we might be the ones to recommend they get therapy.”


How do Majmudar and her staff deal with the impact of these sessions with parents and children on their personal lives?


“You have to be vigilant about your own care and set boundaries,” says the program manager. “We provide constant availability for peer consultation and ongoing individual and group supervision, which allows us to reflect on the work that we do.”



The Child Parent Project took a year of planning and 18 months of intensive training for its three therapists, including Majmudar. The therapists bring a trauma-informed approach to all aspects of the work.


The project works with the city’s Department of Human Services, Department of Behavioral Health and Intellectual Disability Services, and the family courts. It’s based at the Achieving Reunification Center, where parents can take advantage of other services, such as parenting classes, housing and financial workshops, and an onsite mental health clinic.


Since this five-year project is a research study, there is a control group and participation is voluntary. This means that half of the 85 participant families are randomly designated to receive the CPP plus ACEs treatment while the other half receive information about public health agencies but no CPP or ACEs screen. The selection process is completely random, and participants understand this when they sign on for the study. An independent company, Wilder Research, will be issuing research results when more participants have completed the program. With lessthan a full year of operation, two families have reunified so far in the CPP group, but it’s still to early for an evaluation.


For more information about the project, which is funded by a Regional Partnership Grant administered by The Children’s Bureau, part of the Administration on Children and Families.


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I wonder if the greater detail in the World Health Organization's modified 18 question ACE screening questionaire would give these various agencies more substantive detail to work more effectively ... ? ? ? 

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