Generational Trauma: Breaking the Cycle of Adverse Childhood Experiences

How Our Understanding of ACEs Provides Better Healing Care for Adults

“The child is the father of the man.”

That’s a favorite quote of IU Health psychiatrist R. Andrew Chambers, MD. Like many physicians and researchers, Chambers would argue that the environment in which a child grows up matters just as much – and sometimes more – than genetics in determining the child’s future health.

“What you experience in childhood and how you grow up have huge implications for how you are as an adult,” said Chambers. “There’s been a growing movement away from that knowledge in healthcare because we often focus more on genetics and medication than environment.”

Providing healing and care for children and adults means addressing generational challenges. Adverse childhood experiences can be passed from generation to generation as if they were genetic. But breaking that generational trauma is complex. There aren't easy solutions. It involves an intricate web of understanding the issue, preventing and treating the root issues.

What is an Adverse Childhood Experience (ACE)?

An adverse childhood experience (ACE) describes the abuse, trauma or neglect that creates toxic stress in a child’s brain, which has been linked with physical illness and mental health conditions as an adult. A child who is abused or raised without proper care, connection and affection has higher risks for:

• Drug and alcohol use
• Severe obesity
• Depression
• Suicide
• Heart disease
• Cancer
• Stroke

“Adverse childhood experiences often come from various sources of violence,” said Mary Ciccarelli MD, an internist-pediatrician for Riley Children’s Health. “This could be witnessing or experiencing violence, neglect or abuse in your home or community, being close to someone who dies by suicide or being sexually assaulted in childhood.”

Typically, the parents of a child who experiences ACEs faced similar abuse or neglect when they were children, too. This effectively creates a vicious cycle that can last generations.

While living in poverty is considered an ACE, not all childhood trauma is related to socioeconomic groups. In fact, the groundbreaking study that first provided scientific evidence to link poor health outcomes with ACEs surveyed a population who was nearly 75% white and college educated.

“Perhaps your risk for ACEs is higher in neighborhoods where you may witness a drive-by shooting than if you lived in wealthier neighborhoods,” said Ciccarelli. “But witnessing problem drinking or intimate-partner violence in your home can happen in any culture and at any socioeconomic strata.”

ACEs by the numbers

One population who almost inevitably experiences childhood trauma is children in foster care. These children not only face absent parents but also disconnection, instability and trauma from whatever event caused their removal from their homes.

Consider: Nearly half of all children in the U.S. have at least one ACE. For kids at high risk for maltreatment – such as those in foster care – 91% have at least one ACE by the age of six. And likely a few more by age 16.

That’s according to Peggy Box, MA, behavioral health care specialist with the Foster Care Bridge Clinic at Riley Hospital for Children.

“They begin a cycle that accumulates more and more trauma,” Box said.

When compared to their peers, children with three or more ACEs are:

• Three times more likely to have academic failure
• Six times as likely to have behavioral issues
• Five times more likely to have attendance problems

Identifying ACEs: Getting to the Root of Generational Trauma

In order to break the cycle of adverse childhood trauma, experts say ACEs must be identified and the trauma treated as soon as possible. Ideally this would take place before young people begin to have children of their own.

“The comparison between ACEs and genetics is very interesting because ACEs tend to be passed down as if they were genetic, but it’s a culture that’s passed down from generation to generation within families,” said Chambers. “If you have adequate mental health and addiction care delivered to the adult population—especially those who are having children and raising them—that is the best possible way to disrupt it.”

In some ways, understanding one’s ACE score could be compared to passing along the gene for high blood pressure: if you know you’re at risk, you can start implementing habits and medications to reduce your likelihood for problems down the road. Parents who understand their risk for ACEs can get help to avoid passing them on to their children.

“Prevention starts before and during pregnancy by making sure mom doesn’t get pregnant until she’s ready to have another child. This means counseling mothers on contraceptive care at the infant well checks,” said Dorota Szczepaniak, MD, pediatrician for Riley Children’s Health. “If we can educate pregnant women on how leaving their diabetes untreated will reduce their child’s intelligence, they may consider changing behavior.”

“Prevention also involves encouraging a father’s engagement in his child’s life and supporting these dads in developing their roles,” added Ciccarelli. “Before they become so stressed that they cannot function, parents need to have support—either naturally in social circles or through programs like Healthy Families or Parent Cafés so they have help when they need it.”

While some parenting lessons may be new to all expectant mothers, Szczepaniak said there are many child-rearing habits that some parents simply didn’t experience themselves as children. This leaves them unable to provide them for their own infants.

One frequent area of concern is responsiveness. This builds attachment between parent and child. It also can be impeded by a mother's depression.

“When you’re depressed, you’re flat and unresponsive. You may not interact with your child or make responsive facial expressions that convey connection,” said Szczepaniak.

She said they use Parent-Child Interactive Therapy. This therapy guides parents in how to talk, play and form emotional responses appropriately with their children. They also teach parents how important reading to a child is for improving vocabulary and decreasing stress.

“Essentially, we are helping parents become better parents,” Szczepaniak said.

Although it’s not mandatory education, experts say sending a child to preschool can help those living in stressful environments. Preschool gives these kids a safe haven in which to learn and grow.

“It’s so important to identify trauma early so we can stop future ACEs and get these kids into early evidence-based interventions such as Fist Steps, Head Start programs, developmental preschool or more trauma-focused intervention such as parent-child psychotherapy or parent-child interaction therapy, which have been shown to counteract the adverse effects of early childhood trauma,” said Box.

“I send some of my most affected patients to preschool, and I see them grow tremendously,” added Dr. Szczepaniak.

A Challenging Solution: ‘The Problem isn’t the Child, but in the ACEs’

Probably the most complex aspect of adverse childhood experiences is resolving them. Although it sounds counterintuitive, this trauma cannot be treated entirely through pediatric care. Dr. Chambers describes an effective approach to settle down the chaos and reduce harm by:

• Limiting chaos or upheaval in a child’s life
• Introducing boundaries
• Achieving regularity in schedules
• Helping parents avoid the criminal justice system
• Encouraging parents to pursue their GED, college degree or technical occupation

“The conundrum pediatricians are always confronting is the category of ‘failure to thrive,’ or slowed growth, which happens to very young children and infants who experience abuse and neglect. There’s no real intervention because the problem isn’t the child, but in the ACEs that surround the child,” explained Chambers, who is the director of the Lab for Translational Neuroscience of Dual Diagnosis & Development at IU School of Medicine.

A family with a child experiencing bedwetting, stomach aches or delayed growth may need more help than anything a doctor can prescribe. In some situations, the family’s sole income earner may lose a job, or there’s no food in the refrigerator or a family who lost their home is pressured to live with a friend who abuses the children.

To begin detangling the trigger of a child’s trauma, a healthcare provider must use more resources than those available through traditional medicine.

“One of the advantages of caring for both children and adults is that I can shift from addressing a child’s need and into the mode of asking the parent about their mental health. If a parent confirms depression or discloses an intimate partner violence situation, physicians must know the resources and how to address that,” said Ciccarelli. “We’ve spent the last 20 years talking about domestic violence and post-partum depression in mothers, but as our understanding of ACEs advances, we are putting greater focus on the general mental health, cognitive ability and support system for the parent.”

Box works with foster caregivers to develop a “trauma-informed lens” through which they can help the child heal long term. While a young brain is vulnerable to damage from toxic stress, the organ is also equipped with a plasticity that allows children to build resiliency that aids in healing.

“One behavior we see a lot with traumatized children is tantrums. Whereas you might send a non-traumatized child to timeout for throwing a tantrum, we encourage foster parents to use a ‘time in’ procedure to avoid removing a child from relationships we are working so hard to heal,” said Box. “Caregivers can help children regulate their emotions and behaviors when they stay connected with them. The caregiver is the secure base that helps the child adventure out and explore their environment. The safe haven provides the child with security and regulation when things become overwhelming for them.”

In fact, resiliency is a crucial capability for children to develop, regardless of their circumstances.

“We need to build resilience in children, no matter how much toxic stress they experience,” added Dr. Szczepaniak. “If a young boy doesn’t have the stamina to play football, can he be the team photographer? If parents focus on the individual child, recognize his strengths and then empower, support and authentically praise him, parents can create connection and resilience in their children that will help them overcome adversity in adulthood.”

Addressing ACEs with Collaborative, Integrative Care

Adverse childhood experiences are created in a multi-generational web woven from culture, trauma and poor health outcomes. Thus, the healthcare response must be equally as complex. One way in which IU Health is addressing ACEs in patient populations is through integrative care.

This model uses a team approach to incorporate both mental healthcare and addiction care all under one roof for young adults who are reproductively active, said Chambers.

“When you do this, the psychotherapy helps correct the parenting experience, and the interaction between a patient and a psychotherapist can really repair relationship damage as these folks get to experience therapy through a positive, supportive relationship instead of a negative or exploitative one,” Chambers said.

A key to that network of support is an integrated team of healthcare providers moving together toward the same goal. At Riley Hospital for Children this includes social workers, child life specialists, a specialized child abuse prevention team and a full spectrum of clinical specialists—from child psychiatry to trauma coaches—working together to support families.

“All doctors and healthcare providers should communicate with each other and form a community around a patient and family,” said Szczepaniak. “Communication is crucial—whether that’s the obstetrician communicating with the pediatrician, family physician or specialists – to prevent errors and provide better care.”

Trained psychotherapists treat virtually the whole spectrum of mental illness and addiction. They also provide medication to treat the variety of anxiety and mood disorders linked to childhood trauma, including depression, PTSD, bipolar disorder and schizophrenia.

“Now you’ve given the parents a team of people who care for and support them and a base of people helping them with their parenting skills in a way that isn’t criminalizing them,” said Chambers.

Ultimately, getting parents to that starting line to receive the care they need is often one of the largest roadblocks. Some adults have a perceived stigma about getting treatment for mental health issues or simply don’t recognize how it can help.

The ability to start the conversation and the knowledge of what resources are available to help these parents are how healthcare providers like IU Health physicians can help end the cycle of adverse childhood trauma.

“There isn’t always a solution, that is the hard reality of the matter. It can’t be simplified by just finding children new families,” said Dr. Ciccarelli. “But by working within communities, with agencies like child protection, employing early childhood mother-baby preventive strategies, encouraging father support agencies and supporting stressed, young parents, perhaps we can prevent ACEs before the cycle begins again.”

Community & Hospital Resources

• WeCare Indiana for expectant mothers
• Fathers & Families Center
• Parent Cafés by Be Strong Families