Healthy, happy kids grow up to create a healthy, happy world.
Given the very high prevalence of adverse childhood experiences, and their long-lasting destructiveness, it is clear that primary prevention is the only serious approach to improving the current situation. No one knows how to do that right, but it is the right question for well-intentioned people to focus on.
A very warm welcome, Vincent, and thank you for joining the Primary Prevention discussion group. Over the past two months, while totally immersed in Burtt's recovery from complications following heart surgery, I've pondered questions such as you have posed: What might Primary Prevention look like?
An analogy to answering your question about what “Population Based Primary Prevention of ACES” would look like, is to think of this as a “very big jig-saw puzzle” whose pieces have been spread helter-skelter on the table with no photo on the front of the box to tell us what it will look like once completed. We know, however, that there will be many small pictures interconnected to make a whole tapestry. I’d be delighted to hear from anyone in the discussion group. To encourage discussion, here are three sub-sets of the big question:
1) What are you doing in your work, if it is with a discreet population, that would be applicable to a population based approach to ACES Primary Prevention? What possibilities do you see, what resources are needed, and what barriers do you forsee?
2) If you are currently working on a population based approach to the Primary Prevention of ACES, we’d like to hear what you are doing.
3) Who is mulling over ideas about Primary Prevention…. We’d like to hear what you have been thinking and doing.
Since this internet communications format is new to me, I’d welcome suggestions on how to make this discussion group “user friendly”. Regards, Gladys
Thank you Dr. Felitti and Gladys for opening the door to this discussion. Warning! My reply is lengthy.
Please understand that I am not a researcher, academic, or medical professional. As a CranioSacral Therapist my passion is working with pregnant moms, babies and children. Most often moms bring their babies/children to me (by referral) because the child is showing some sign of distress - fussiness, not sleeping, constipation, reflux, hyperactivity, difficulty nursing, "ADD", "ADHD", depression, anxiety, learning issues, repeated ear infections, social issues... and the list goes on. Through working with the children with this gentle, whole body therapy, at some point the majority of them tap into the stored memory of their birth. How do I know that? Because mom usually says something like "that's how he cried when he was a baby." Then I ask about the birth. Most often there have been interventions, and frequently those interventions led to Cesarean birth.
It is hard enough to be born in the first place, even though we are equipped with all the hormones and other juiciness that is timed perfectly in the dance between mother and baby. However, as birth has become medicalized, the natural hormones are suppressed, the dance is interrupted, and baby is taken from the mother's womb, one way or another. This experience is now part of the cellular memory of the child.
Given time, patience and support, every child can transform that cellular memory and reclaim his/her birthright of hormonal balance, gut health, brain health, etc. Watching a 5 year old re-enact the emotional trauma of being taken from the mother's womb by Cesarean birth, whisked away before there is skin to skin contact, put into a harsh isolette is disturbing. To me that is an unacceptable Adverse Childhood Experience... a PRIMAL one.
I do understand that there are, maybe not that often(?), situations in which an emergency Cesarean birth saves lives. And thank goodness early gentle treatment with CST can help mom and baby shift that trapped trauma - if they know about it - if there is someone trained to work with babies/moms/pregnancy - and if they can afford the cost (which is obviously not as expensive at this point as the birth was).
So rather than go on and on, I believe part of what Primary Prevention looks like is
1) excellent education and information for parents about what a healthy, natural birth gains for them and their baby
2) some kind of process (CST, EMDR) for the mother to discover and transform any held patterns of traumatic birth in her own body (generational, or specific to her birth).
3) CranioSacral Therapy becomes a mainstay of supporting mom and baby during gestation and in the first months after birth (and beyond).
The organization APPPAH (Assoc for Pre- and Peri-natal Psychology And Health) has published many studies, papers, opinions on these topics. In one such article I read (however, I cannot cite it and am not certain that my stats are right on).... the suggestion was that 66% of all Americans are suffering in some way from birth trauma, and of that 66%, at least one third are seriously handicapped in some way as a result of the birth trauma.
I will end by stating that clearly not all birth trauma is "caused" by medicalized births. Obviously a baby who has become entangled with the umbilical cord will experience a very real sense that she is being choked, that someone is attempting to harm her. However, I would very much like to work toward the day that the OB turns to someone and says, "ah - cord around the neck - please have the CranioSacral Therapist support this mom and baby to clear this trauma."
I feel very bold for having written this here. As you can see, I am passionate about birth and believe that how we are born has MUCH to do with how we perceive the world, how we proceed in life and how we then interact with others.
Thanks ever so much for reading/listening! Pam
This is an issue we have been discussing in Vermont, and there have been times when I have felt that my advocacy for screening of adults has been met with ...well, let's just say many are not enthusiastic. But my hope is that "in the intervention is the prevention." Not the only prevention, of course, but prevention, since I would think that a traumatized adult who receives treatment is far less likely to continue the cycle of abuse with his/her own children, or with children in a classroom, etc. Is there any way to know if this is true or even likely? I realize research can't prove a negative - in other words, it is impossible to say that because Woman A, who has an ACE score of 5, received treatment and showed great personal improvement that she therefore will not abuse any children she has in the future....But does treatment of adults with trauma histories interrupt the cycle? Is there any concrete method to know that?
Lack of professional enthusiasm for screening seems a pretty widespread human trait, Kathy. My best response would be a letter a patient wrote me, requesting publication over her name so that her message would not be diminished by anonymity. I'll see if I can upload the file. The point she makes is memorable.
Slowly, I have come to see that Asking, and Listening, and Accepting are a profound form of doing. In an unusual 125,000 patient sample, this turned out unexpectedly to be asociated with a significant reduction in doctor visits and ER visits over the next year. Moreover, the process was quite well-received by patients.
Here's the file.
Thank you very much! Do you mind if I use your comment about Asking, Listening and Accepting, as well as the letter, in my Trauma Network meetings, where we're talking about screening?
Dear Vincent and all,
Thank you for asking the question again. When we spoke in January in San Diego, I was beginning to put together a proposal for primary prevention. Since then I have met with the head of psychiatry in Sacramento Kaiser who immediately understood the ACE concept and said he would begin to use the questionnaire with his patients right away. His wife, a pediatrician, was interested in my ideas of offering parenting education from birth to one or three years, depending on the needs of the new family who have been identified through the ACE questionnaire, as needing support services as well as possible treatment of the own ACE traumas.
I will be meeting with them next week to follow up and reiterate my suggestion that this approach could be studied comparing various evidence- based parenting practices and on a long term basis evaluate possible cost savings for Kaiser. As you are well aware, these proposals may come to naught but it is a start.
Since I am a marriage family therapist who has taught early parenting classes through the Children's Health Council in Menlo Park and have been working in the Waldorf school system for the past twenty years, I have been talking with various school personnel, both public and private, about integrating birth to three (when 90% of brain development and attachment style take place) parenting programs into the school systems.
I am also involved with the Relationship Skills Center, that already offers similar classes for low income, at risk parents in federally funded programs.
We want to launch a private initiative this September and hope that you will come to Sacramento to speak to all of those professionals and parents that we are able to interest in such a proposal. I will keep everyone updated.
The time is right for all of this to take off.
Thanks, Barbara. I'm glad you found some people within KP who want to put the ACE findings to clinical use.
It looks like I didn't know how to upload the patient's letter I wanted everyone to read. I'll try again. The patient wanted her name used so that what she had to say would not be diminished by anonymity.
Separately, a good, free tool to keep in mind is "The California New Parent's Kit" that was created at Berkeley School of Public Health and was supposed to be delivered to every new parent in the State. A fine product, put out out on several DVDs by various famous people, it has a miserable distribution system even though First Five California has an agent in each county specifically for its dissemination. If you can't find your agent to get a free set, you can contact the Virginia Piper Trust in Phoenix (firstname.lastname@example.org) and ask for a copy of their Arizona New Parent's Kit, which is the identical item with an effective distribution system.
I will continue to pursue a project with Kaiser. I think that it is essential to inform the psychiatrists and other mental health practitioners. I will include copies of the two attached letters in my packet. Hearing from patients is essential as is your new DVD. Making "The California New Parent"s Kit" available will be a priority for me. Thanks so much.
In 1988 my husband and I started a Christian, residential boarding school for troubled kids, ages 7-18. In the last decade we became aware of the condition called Reactive Attachment Disorder (medical diagnosis) and in the last 2 years we have been on a major learning curve about the etiology, symptoms, and reversal of this disastrous response to chronic stress in the prenatal and first 3 years of the child's life. These children could be described as child sociopaths and are often dangerous to live with. The majority of our students are adopted from foreign orphanages or the US foster care system and are enrolled by parents whose loving home has been turned into a battlefield. We have been referring to these students as V-ACES (Very Early ACEs.) They do not like the term RAD) Thankfully, these students respond to our holistic learning program and we are passionate about constant improvement of all we do. Naturally, as a public health nurse, I am concerned about primary prevention. Here's some ideas that we implement or plan to:
1. Implement a comprehensive curriculum (both cognitive and emotional) empowering our own students in understanding and choosing practices that will prevent ACEs in their future lives and in their future children's.
2. Work with the local public schools for our students to go to health classes and share what they know about the negative impact on the brain and in the lives of babies/ kids/ adults and what prevents that. Their personal testimonies are also powerful. Other sites for them to go to will be explored.
3. Seek various opportunities for our team to share foundational concepts and practices with other professionals/community servants/ churches/parents,etc. Use the ACEs survey, the brain scan photos, and other resources to make an impact and facilitate motivation to address prevention and intervention on a broad scale. Especially target school personnel, since schools have the broadest access to children of school age.
4. Since our own students, if their past trauma/neglect/abuse is not resolved, have a high chance of contributing to ACEs in their future children, addressing successfully their ACES is important preventive strategies.
5. I personally have connections in health dept. clinics, postpartum hospital units, prenatal education centers, etc. and have a desire to get the word out to these agencies as quickly as possible.
We became aware of the ACEs Study about 6 weeks ago and are so thankful for all we are learning. Gayle Clark
Dr. Felitti and others,
In my work in the Untreated Trauma and Chronic Disease Network in Vermont, we talk about screening in primary care practice as one part of primary prevention. The thinking, of course, is that if an adult with trauma is identified in time and provided treatment, he or she will be far less likely to continue the cycle of abuse with his/her own children. Certainly it would be best if we could just stop all abuse from happening right now, but since we can't do that, we think screening in the doctor's office is one good piece of a prevention approach.
That, however, brings up the issue of how to screen. Several psychologists have said that episodic screens (such as the ACE questions, which ask about specific events or episodes) are "triggering" and can be very bad for the traumatized individual. For that reason, they recommend use of the Veteran's Administration's PTSD screen, which is symptom based.
Does anyone know if there is research about the issue of episodic vs. symptomatic screens? Or about "triggering" a traumatized person with screening?
Hi Kathy, Did you get an answer to your question about episodic vs symptomatic screens or 'triggering" a traumatized person with screening? I've heard Dr. Felitti speak about this on several occasions, as the questions have been raised in Maine during his visits. I'm sure we could find a quote, or ask him to respond again (his response that I've heard goes something like this: over 400,000 people have answered the ACES without a traumatic response that he's heard about). I'll wait for your reply. Gladys