Illustration: Nathalie Lees
US researchers have found early intervention can help prevent negative experiences in infancy turning into long-term health risks
by Lauren Zanolli in New Orleans- The Guardian
When Sabrina Bugget-Kellum walked into a neighbourhood clinic in New York for a routine appointment in in 2016, she was desperate. Her son was in prison. She was trying to look after his two young children, who were aged one and two. Their mother was emotionally unstable. Bugget-Kellum did not want the chaos of the adults’ lives passed down to another generation.
“We didn’t know if they would be safe with their mother,” she recalled recently. “I began to pray, please God, I need some help. There were so many things going on.”
While at the clinic, Bugget-Kellum learned about a new parenting programme designed for carers of young children who have faced early adversity such as domestic abuse, homelessness or the loss of a parent to incarceration. “It was like I had my ammunition and I knew how to fight,” said Bugget-Kellum of the programme.
The scheme, called Attachment and Biobehavioural Catch-up (ABC), pairs parents with a coach trained in the needs of infants and toddlers who have experienced trauma.
Bugget-Kellum’s coach reinforced simple techniques to form a healthy bond between adult and child, and helped her work through her own emotional wounds to create a less stressful environment at home. The results were so transformative, she said, that she started working as a parent coach for the same programme.
“I have a son who is 26 and in prison, so I’m thinking maybe had I had an opportunity to get some of this, I don’t know, maybe I could have been more nurturing,” she said. “ABC gave me the confidence to say, you can do this. I don’t have to be angry with myself any more.”
Traumatic or highly stressful childhood experiences are known to have lifelong emotional, behavioural and physiological impacts. Children who are abused, neglected, or exposed to conflict, violence and horror, are far more likely to have drink and drug problems, criminal records and perhaps resort to violence and abuse themselves. But researchers have also found that interventions such as the ABC programme can significantly buffer the damaging effects of stress and trauma, even at a biological level.
A growing number of advocacy and public health organisations are working to bring “trauma-informed” approaches into the mainstream for doctors, carers and first responders.
The crucial role of caring and calming adults
Scientists are continuing to untangle the complex biological effects of childhood trauma on the brain and body. Research in the past decade points to “toxic stress” as the root of the connection between adverse childhood experiences (Aces) and health problems in adult life.
The theory is that continuous or repetitive exposure to stressful situations through, say, domestic abuse, or growing up in poverty, causes the body’s natural fight-or-flight stress response to stay switched on. Researchers say that without the influence of a caring and calming adult the stress becomes “toxic”, and elevated cortisol levels change the functioning of the child’s brain, weakening the immune system and even altering the way a child’s DNA is “read and transcribed”.
“This is the source that a lot of the problems in our society can be traced to,” said Leena Singh, programme director for the National Paediatric Practice Community on Adverse Childhood Experiences (NPCC), which has an office in San Francisco. “There is a saying in public health – we need to move upstream. This is the work that is the root of the root.”
Singh’s organisation is working to integrate screening for adverse childhood experiences into standard paediatric primary care. The programme hopes to recruit 1,000 clinicians to screen 300,000 children for Aces over three years and is running pilot sites at six clinics across the US, with plans to add more.
Singh says paediatricians have a vital role to play. They could refer patients for behavioural therapy or social support, but in medical schools they are rarely trained in the impacts of toxic stress. There are logistical hurdles to overcome too, such as how to add another process on to providers that are already overburdened, and how to bill insurers for time spent screening.
NPCC says it is working through its pilot sites and member network to resolve those problems. It is also involved, through its parent organisation, the Center for Youth Wellness, with a clinical study on the effects of Ace interventions on certain biomarkers.
Ultimately, Singh believes, their work could contribute to long-term shifts in the paediatric field. “If we can address and intervene early when some of these things happen in very young children we can actually prevent some of the risky behaviours and health impacts later in life.”
A two-generation approach can short-circuit the cycle of abuse
One of the main challenges in pushing the model further, say proponents of trauma-informed care, is the lack of long-term data on the effectiveness of the approach. Researchers, including the CYW group and Mary Dozier, creator of the ABC intervention, say they are working to fill that gap.
“In some regards [Aces are] a universal experience,” said Leslie Lieberman, director of special initiatives at Mobilising Action for Resilient Communities (Marc), a collaboration between 14 American cities and communities focused on trauma-informed programmes.
Many programmes take a two-generation approach to try to short-circuit the cycle of physical, emotional or substance abuse. Tennessee, for instance, is in the third year of its Building Strong Brains initiative, a $1.25m scheme to fund innovative Aces-focused programmes across the state.
One programme funded under the initiative, called Thrive by 5, will conduct Aces screening on all pregnant women at the Baptist Memorial Hospital for Women in Shelbyville. Women who report four or more of the different types of childhood adversities (physical, sexual or emotional abuse, neglect, domestic violence, household substance abuse or mental illness, parental separation, divorce or incarceration) will receive programme interventions and parenting education.
Another programme called Handle With Care, which started in West Virginia and since expanded, allows police officers to notify a child’s school if they are called to their home for potentially traumatic event like domestic abuse or a shooting. School officials don’t receive any incident details but the notice allows them to better respond to behavior changes or offer necessary support to the student.
The “infant courts” are also expanding. Zero to Three, an advocacy group for early child development resources, started piloting “safe babies court teams” in 2005, and now has more than 20 sites across the US. The teams work with young children separated by the court from their parents, often because of abuse or neglect, providing developmental medical screening, mental health services and community advocates to ease the trauma of entering the foster care system.
Parents can receive psychological services too to deal with traumas of their own – a study by such a team found that more than two-thirds of parents in the programme had an Ace score of four or higher.
For families who are reunified, the teams’ work appears to have an impact. Zero to Three reported that maltreatment recurrence rates over 12 months among children in the scheme was 1.2%, compared with more than 9% nationwide. As part of its statewide initiative one Tennessee court is building a new programme based on the scheme, with an emphasis on preventing Aces in children stuck in the court system, and on addressing parents’ own childhood traumas.
The opioid drug epidemic, which kills more than 100 people every day in the US, has also brought into focus Ace interventions tailored to families facing substance abuse. Vermont experienced a 40% increase in the number of children taken into care between 2013 and 2016; more than half of children under five in 2016 were there due to parental opioid abuse. The state’s Opioid Coordination Council has recommended an “intergenerational approach”, calling for expanded maternal health and infant care programmes for high-risk families to mitigate the trauma of children born to opioid-addicted parents, and drug education programmes in schools to help prevent addiction in the next generation.
Tucked inside a bipartisan opioid epidemic bill just signed by Donald Trump, called the Support for Patients and Communities Act, are several federal provisions encouraging wider recognition of Aces and trauma-informed care. The bill calls for an “interagency task force” to identify best practices within three years for mitigating the impact of trauma on infants and children and to create a national strategy to improve coordination of trauma-informed care at a federal level. The bill also authorises the Department of Education to provide grants to schools for mental health programmes to help mitigate the impacts of childhood trauma.
Experts say greater cross-sector collaboration and more funding is needed for trauma-informed care to really make a difference. “The lifelong manifestations of that childhood trauma are cross-sector – it effects educational outcomes, employment opportunities, it affects your health,” said Marc’s Lieberman. “You’re not going to make a population-level impact without a cross-sector approach.”
That makes the execution of trauma-informed care inherently complicated. But at bottom there is a simple and revolutionary idea, says Lieberman: “It’s about moving from ‘what’s wrong with you?’ to ‘what happened to you?’”
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