Moving From Adverse Childhood Experiences to Celebrating Supportive Nurturing Relationships

Driving through North Philadelphia on a cold winter morning, I see newspapers covering windows to keep in the warmth. A father with his children waiting for the school bus. A homeless encampment across the street from a community playground. Factories pumping dark smoke into the sky. Bodegas open 24/7 with “We accept EBT” signs. I pull into the hospital parking lot and see mothers with strollers and diaper bags being lugged across the street from the bus stop to their appointment. This daily drive gives me a glimpse into the lives and built environments of the families I serve.

You cannot read through a pediatric journal without encountering a study or commentary on adverse childhood experiences (ACEs); discussing how to screen for them or what they mean for our patient’s future health. It is clear we understand what ACEs are and how we can identify them. Now, the paradigm needs to shift to how we can combat ACEs and further support our patients.

As pediatricians, we are in a unique position because we confront our patients’ ACEs every day. We sit in “teen screens,” and if we are lucky, these amazing teens bear their traumas, as well as their hopes, fears, and insecurities. We see them when walking into our emergency department; social dynamics contributing to ACEs or mental health struggles caused by ACEs. These experiences allow us to reflect on our own upbringing and ACEs. Hopefully, our understanding of ACEs and their potential short- and long-term effects motivate us to help families heal from the trauma and buffer the long-term effects.

I often reflect on my personal ACE score of 7. What has helped me overcome the cycle of addiction, abuse, and dysfunction? The biggest factor was the safe, stable, and nurturing relationships and environments (SSNREs) outside of my home. SSNREs are relationships and environments children have with supportive adults, whether these are their parents, extended family members, or other adults in their life.¹  ACEs go hand-in-hand with toxic stress, which is the ongoing and excessive activation of the physiologic stress response without the counteracting protection of SSNREs.² 

To start, my day care provider, who was also my neighbor, was always there for me. She frequently reinforced to me how smart and kind I was. She understood and was empathetic toward the dysfunction that occurred in my household. When I was 6 years old, I was woken from sleep to loud thumps and my mother’s cries as she was being thrown around by my father. I snuck out of my room in only my nightgown, grabbed my younger brother from his bed, and walked barefoot down the block to her house: A place that I always felt safe. Having this safe haven helped lower the chronic stress my young body was so used to experiencing.

An added buffer was when my brother and I would often spend the summers with my aunts, uncles, and grandparents. Another set of adults in my life that helped balance the chaos. I had just started high school and came home from school on a Friday to find our power was out. This was not the first time we lacked enough money for basic necessities. By this point, my parents were separated, my father in jail again, and my mother succumbed to addiction. That afternoon, I overheard my mother’s sobs as she spoke on the phone with my aunt, asking for help. We spent that weekend packing our home, in the dark, eating nothing but $5 Little Caesars pizzas, and by Monday morning, we moved halfway across the country to stay with my aunt and uncle. As hard as it was to be uprooted at 14 years old, it was the only solution. That solution guided my path of helping children with similar stories, by becoming a pediatrician.

Tragically, my story is not unique. Many of my patients have heard, witnessed, and experienced many more traumatic experiences in their short lives. That is why it is important for pediatricians, general or specialized, to use their well-child checks, inpatient encounters, or emergency department visits to help identify a positive adult in their patient’s life. For instance, in my visits, I ask the question: “Who is the adult in your life you could go to if you were feeling sad, scared, or wanted to share good news?” This frequently opens the conversation about SSNREs. If they do not identify an SSNRE, then I help brainstorm an adult in their life that could be that positive relationship for them; is this their grandmother, teacher, or neighbor? For example, while sitting across from a quiet 13-year-old, who had just broken down about the dysfunction in her home, I shared with her the similarities of my story. I asked her if there was an adult in her life that she felt safe with or was a positive light; she thought about it, then answered her music teacher. We talked more about that relationship and how amazing it is that she has someone to go to if she ever needs anything. I told her that she could always come in to see me again if she ever needed to talk. These encounters remind me my ACEs do not define me nor my patients, and celebrating their SSNREs can make a positive impact.

As pediatricians, it is also important to understand that screening for ACEs is ineffective if you are not able to offer supportive interventions. Thus, understanding how a positive adult–child relationship can help develop resilience for children with ACEs is imperative. If you are a provider who sees newborns or young children of new parents, it is especially important to comment on the child–parent relationship you are seeing in front of you. Even expressing how well bonded their newborn is to them can help nurture a long-term supportive relationship between them. If you see adolescents, you can use the teen screen time in your appointment to identify and celebrate SSNREs. Even if you are seeing patients in a fast-paced emergency department or subspecialty clinic, taking a few seconds to ask the patient, “Who did you bring with you today? Are they important to you?” can help open the discussion of SSNREs. You can incorporate asking about SSNREs by simply adding the question into your note template within your “social history” section, right behind, “Who lives at home?” It is inevitable we are going to encounter our patient’s ACEs; thus, we should shift to identify and celebrate their SSNREs as buffers to their chronic stress.

Driving through North Philadelphia on the first warm afternoon of spring, I see children drawing on the sidewalks with chalk. Neighbors on their stoops having a barbeque. Every swing in the park occupied, every kid in the neighborhood getting to be just that: A kid. As pediatricians, rather than focus on if our patient has ACEs, we should work to expand community support and policies that provide our kids with safe, supportive, and nurturing environments. Our goal, our focus, must be to support, to identify, to celebrate those SSNREs. That made all the difference in my world. Likewise, with the patients I serve.