Beyond the ACE Score: “As the twig is bent…” 4/16/2021

Spoiler Alert:  Traumatic exposures, coupled with impaired parent-child relationships, experienced during early infancy and early childhood years are associated with great risk to children’s cognitive, emotional and social development.

The seminal Adverse Childhood Experiences study demonstrated the strong correlation between the number of adverse events experienced in childhood and the risks for negative health and social outcomes in adult life.  A recent paper in the Archives of Psychiatric Nursing (Hambrick, Brawner, Perry, et al)1 examines the timing of experienced adversity as a factor negatively impacting overall developmental outcomes. It demonstrates that disruptive and adverse experiences in the early years have significantly more troubling and pervasive consequences than the still harmful disruptions that occur later in childhood.   The study further identified that the presence of positive parent-child inter-relatedness is an important protective factor in the face of such early ACEs, and that the absence of positive relatedness is a damaging one, most particularly for infants and younger children.

This finding suggests that, while current efforts to identify all children and families with ACEs are important throughout childhood and adolescents, efforts to identify parents/families struggling with their own lives during the post-partum and their earliest years of their children’s lives can potentially mitigate some of the long-term risks to these children’s health and well-being.  This may be from current or future ACEs or from experiencing interpersonal and emotional neglect.

The context for the “Beyond the ACE Score” study referenced herein entailed awareness that social, emotional, cognitive, and physiological functioning of a child is impacted by a multiplicity of inputs, amongst which both overt trauma incidents (ACEs) and impairment in parent-child relatedness (relational poverty) are pivotal issues negatively impacting developmental outcomes.   The absence of a strong positive caregiver-child relationship in early childhood is in itself a challenge to healthy development, but its absence in the face of other stressors and adversity, magnifies the trauma load by removing from the equation the resiliency benefits that supportive caregiving, interpersonal engagement and responsive attention can provide to the traumatized child.

The importance of strong, and very importantly, early positive interactions between infants and their caregivers as a positive force in the child’s developing the core building blocks of social-emotional health (engagement, reciprocity, etc.) as well as in enhancing future cognitive and behavioral competency, is clearly supported by the study’s findings.

While adverse incidents and the lack of interpersonal support are problematic at any stage in childhood, the study clearly indicates that the earlier in time that exposure to these two negative factors (trauma and relational poverty) occurs, the higher the predictive risk for negative outcomes.   Conversely, but in no way surprising, the study indicated that greater levels of relational health were associated with better outcomes, even in the face of adverse events and challenges.

These findings provide strong support for providing screening and early intervention in support of parents and families (and their children) to mitigate the likelihood of harm and disruption in children’s overall development. Screening for maternal depression is one form of intervention that many primary care providers already do that are congruent with this goal.  Inquiries about the potential presence of other concerns such as food or housing insecurity, substance abuse in the home and community, and the presence of domestic conflict or domestic violence are other opportunities identify potential children and families at risk.

Making these inquiries can be awkward at times, but just as inquiries of youth and parents about ACEs and just as inquiries of teens about self-harm, substance use and sexuality can be challenging, framing the questions as a routine matter of health promotion can minimize discomfort on both sides of the interchange.    Asking about these risk factors in a calm and non-judgmental manner can open the door to discovery: “I hope this is not uncomfortable for you, but part of our work as healthcare providers is to ask all our patients’ parents about potential challenges that can have impact on health and well-being.  If you are OK with this, I’ve got a few personal questions.  Is this OK for you?  [If ‘No’, end of inquiry, but if ‘Yes’, proceed]   Is your family having challenges with: food insecurity; …..housing; …. substance use; ….interpersonal conflicts?”

If any replies are affirmative, an empathic and support comment (e.g., “That sounds tough” would be appropriate) followed by a recommendation about potential resources.  Responsive options could include the County’s 211 information line or referring to SmartCare’s Parent Line [868 956-5900] for further follow up and services.


Hambrick, Brawner, Perry, et al; “Beyond the ACE score:  Examining relationships between timing of developmental adversity, relational health and developmental outcomes in children; in Archives of Psychiatric Nursing 33 (2019) 238-247

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