To Head Off Trauma's Legacy, Start Young
At the Cobbs Creek Clinic in West Philadelphia, Dr. Roy Wade relies on some of the same tools every pediatrician uses for exams — blood pressure cuffs, a stethoscope, and, of course, tongue depressors.
He also uses particular questions to get at something that few doctors try to measure: childhood adversity.
Wade is working on his own screening tool, a short list of questions that would give every young patient at the clinic an "adversity score." The list will include indicators of abuse and neglect (which pediatricians already are on the lookout for) and also check for signs of poverty, racial discrimination or bullying.
Dr. Roy Wade, a pediatrician at Children's Hospital of Philadelphia, says asking about tough experiences his patients have faced gives him a way in — a way to be a doctor to the whole family.
Wade wants to take action because research suggests that the stress of a tough childhood can raise the risk for later disease, mental illness and addiction. The American Academy of Pediatrics put out a call in 2011 to doctors to address what the Academy characterizes as "toxic stress" among young patients.
Of course, not every kid with a rough childhood will suffer long-term effects. But asking every patient (or their parents) about adversity in their lives, Wade says, could help identify the kids who are at higher risk.
If a patient has a high adversity score, Wade says, he's likely to track the child's development more closely. "That'll be the kid where I'll say, 'Come back to me in three months, or two months,' " he says. " 'Let's see how you're doing. Let's check in.' "
Take 11-year-old Tavestsiar Fullard. When I met Tavestsiar at the Cobbs Creek Clinic last summer, he smiled with shy excitement about starting middle school, and told stories about his new puppy, Midnight. But just a few years ago, he was a very different kid.
"He wouldn't talk," says Tavestsiar's dad, Silvester Fullard. "He didn't want to be around other kids. If you'd just say something, he'd go into a little shell."
Tavestsiar started living with his dad in 2010. Before that, things were tough.
He'd been living with his mom in a shelter. One morning on a Philadelphia city bus, she grabbed the little boy's face, and left scratch marks with her nails. Child protective services intervened, and Silvester Fullard got a call that same day to come pick up his son, Tavestsiar.
Back then, Silvester says, Tavestsiar seemed so closed off and unhappy. The father wanted to help — and often, he says, food became a way to do that.
Honor roll certificates and achievement awards now line the bedroom walls of 11-year-old Tavestsiar Fullard.
Silvester says he partially blames himself for Tavestsiar's struggles with severe obesity, which he links to the trauma in the boy's childhood.
"I started just giving him whatever he wanted, to make him feel better after all the things he'd been through," Silvester explains.
But after a while, Tavestsiar gained so much weight that he and his father nearly wore the same size clothes.
"So I was like, 'OK, it's time,' " Silvester says – time to get Tavestsiar signed up for a weight loss program for kids at Children's Hospital of Philadelphia.
Becoming a father to Tavestsiar has led Silvester to start taking care of his own health, too. When he got the call to come take custody of his son — an emergency phone call, no warning — he'd been an alcoholic for years.
"Right when I got the phone call, I was just getting ready to take a drink," Silvester remembers. "So I put the alcohol down, and went straight to pick him up."
Silvester Fullard encourages his son during a workout at the Christian Street YMCA in Philadelphia. Tavestsiar once relied on food as a comfort to deal with his trauma, his dad says. But no more.
He says he hasn't had a drink since. He also started cooking healthier meals at home, and going to the gym with Tavestsiar.
These are the sorts of shifts in family dynamics that intrigue Roy Wade. He thinks getting an adversity score from kids could give him a way in — a way to be a doctor to a whole family.
It's easy from that launching pad to start talking with the adults about their own smoking, or drinking, Wade says. "Instead of looking at the parent, you say, 'Well, these are the impacts that [your smoking or drinking] could have on your kid.' It helps you address an array of different problems within a family."
So how early can you start? At Tavestsiar's age? Or even earlier — age 5 or 6?
Across town, at a community clinic in North Philly — the Stephen and Sandra Sheller 11th Street Family Health Services Center — the staff is determined to start even earlier than that.
In the clinic's prenatal groups for expectant parents, each adult routinely fills out an ACE questionnaire, which asks them about some of their own difficult experiences from childhood.
The survey's 10 questions cover things like physical and sexual abuse, neglect, death of a parent, and alcohol or drug use in the home; each participant winds up with an ACE score of between 0 and 10.
Research suggests that an ACE score of 4 is the threshold where health risks start to climb. In one prenatal group at 11th Street, everyone scored between 3 and 5. A few years ago, researchers screened a larger sample of 11th Street patients and found that 49 percent had an ACE score of 4 or higher, says Patty Gerrity, founder and director of the center, which is affiliated with Drexel University.
"We knew that we were working with a very traumatized population," Gerrity says, "but we were sort of astounded at the numbers." The hope is that talking in the prenatal group about childhood will help break generational cycles of trauma and abuse.
"We can't go back and change it, but the patients can change," says Gerrity. "They really don't want this to happen to their children."
Silvester Fullard (right) says helping his son Tavestsiar get in better shape — through twice a week gym sessions together, and healthier home-cooked meals — has improved his own health.
Ashley Brant, one of the moms in the 11th Street prenatal group, was about eight months pregnant with her third child when she took the ACE survey last summer. Her own childhood was tough, Brant says. She doesn't remember ever living with her mom, who had a drug problem. Her dad was murdered. And she had her first baby when she was only 12 years old.
She now has one big goal in doing things differently for her kids: "Just to be able to give them a mom, to know what it feels like to have a mother, because I don't," she says. "Seeing them smile, having me around and relying on me so much ... it's like, I'm doing something good, positive."
Research shows that a child who has a bond with at least one caring adult is more likely to overcome the lasting effects of adversity. Brant may be giving her kids more than a great childhood — she may be giving them a better shot at a healthy adulthood, too.
This story is part of the NPR series, What Shapes Health? The series explores social and environmental factors that affect health throughout life. It is inspired, in part, by findings in a poll released Monday by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.
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Transcript
MELISSA BLOCK, HOST:
A majority of Americans believe adverse events during childhood can have a harmful effect on their health as adults. That was one of the major findings in NPR's latest poll with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. And we've been exploring this idea in our series, What Shapes Health? Today, NPR's Laura Starecheski takes us to two Philadelphia clinics. They're trying to intervene at an early age to prevent health problems like heart disease, diabetes, depression and addiction.
LAURA STARECHESKI, BYLINE: At the Cobbs Creek Clinic in West Philly, pediatrician Roy Wade uses the tools every doctor uses when he does an exam - blood pressure cuffs, a stethoscope and, of course, tongue depressors.
ROY WADE: Can I look into your mouth really quickly? Can you go ah for me?
STARECHESKI: He also uses questions to get at something not too many doctors try to measure - adversity.
WADE: If you only have five minutes with the kid, what would be the five most relevant questions that you would need to ask in order to assess the kid's adversity? You don't have time to ask 20 questions or 10 questions.
STARECHESKI: Dr. Wade is designing a simple screening tool - a short list of questions that would give every young patient here an adversity score. It'll include abuse and neglect - things pediatricians look for already - and also poverty, discrimination, bullying. Wade wants to take action because research has shown that the stress of a tough childhood can raise your risk for later disease, mental illness and addiction. He knows he's got a special chance to head off those bad outcomes early, so if he sees a kid with a high adversity score...
WADE: ...That's not going to be a kid who I say, you know, come back to me in a year. That's going to be a kid who I say, come back to me in three months or two months. Let's see how you're doing. Let's check in.
STARECHESKI: Take 11-year-old Tavestsiar Fullard. When I met him, he was just about to start middle school, and he was really excited about one thing.
TAVESTSIAR FULLARD: In middle school the fifth grade is going on a camping trip.
STARECHESKI: Tavestsiar likes school now, but he didn't used to. Just a few years ago he was really struggling.
T. FULLARD: I was living with my mom, and I was in a shelter with my mom. And then I moved with my dad.
SYLVESTER FULLARD: He wouldn't talk. He didn't want to be around other kids.
STARECHESKI: Tavestsiar's dad, Sylvester, started taking care of him about five years ago, after his mom grabbed his face on a city bus one morning, leaving scratch marks with her nails. Child Protective Services intervened.
S. FULLARD: You know, if you just say something, he'd just, you know, go into, like, a little shell.
STARECHESKI: It's hard for him to talk about, but this information is really important for Tavestsiar's care because one of his health problems is severe obesity.
S. FULLARD: I felt, you know, like it was my fault that he added that weight, you know, because I started, you know, just giving him whatever he wanted to make him feel better after all the things he's been through. So I'm like, oh, maybe this will make you feel better. And then I look at his old clothes, and I could fit them. So I was like, OK then, you know, it's the time.
STARECHESKI: Time to get Tavestsiar signed up for a weight loss program at Children's Hospital.
And what were you worried about?
S. FULLARD: Losing him. Yeah, that's the main thing. I didn't want nothing to happen to him.
STARECHESKI: Being a father to Tavestsiar changed Sylvester's life. When he got the call to come take custody - an emergency phone call - no warning - he'd been an alcoholic for years.
S. FULLARD: Right when I got the phone call I was just getting ready to take a drink. So I put the alcohol down and went straight to pick him up. And I've been - I haven't drank since - since that day.
STARECHESKI: He also started eating better and going to the gym with Tavestsiar. It's these kinds of family dynamics that intrigue Dr. Wade. He thinks getting an adversity score from kids could give him a way to be a doctor to a whole family.
WADE: It's an easy conversation talking about things like smoking. Instead of looking at the parent, you say, well, you know, these are the impacts that could have on your kid. It helps you to address an array of different problems within the family.
STARECHESKI: So how early can you start? At 11, like with Tavestsiar - 5 or 6? Across town at the 11th Street Clinic in North Philly, they're determined to start even earlier than that, before a kid is even born.
UNIDENTIFIED WOMAN: I'm telling you, when I get the epidural, I'm only five centimeters. Like, that ain't nothing.
UNIDENTIFIED MAN: That's halfway there. That's something.
STARECHESKI: This is what a prenatal visit looks like at 11th Street. It happens with a group of other parents. It's a few hours long, with time for a physical exam and lots of discussion. Today, Aisha Walters, the family and child support coordinator who runs this group, is trying something new for the first time.
AISHA WALTERS: These surveys that you took - nobody was going to look at them or see them, but share, you know, things that...
So the questionnaire I gave each participant was the ACEs questionnaire.
STARECHESKI: This questionnaire is another way to measure adversity. ACE stands for adverse childhood experience. When you fill it out, you get an ACE score from 0 to 10, depending on how many of the experiences you had growing up - things like physical and sexual abuse, neglect, death of a parent.
WALTERS: The lowest score that I saw was three ACEs.
STARECHESKI: And all the scores fell between three and five. That's important because an ACE score of four is the threshold that's considered a high ACE score, where health risks really start to rise. But Walters wasn't surprised by the high scores of these parents-to-be because a few years ago, researchers asked about 800 11th Street patients for their ACE scores.
PATTY GERRITY: And 49 percent - I should say a whopping 49 percent - had four or more ACEs.
STARECHESKI: That's Patty Gerrity, the founder and director of this place.
GERRITY: We knew we were working with a very traumatized population, but we were sort of astounded at the numbers.
STARECHESKI: They were astounded because the landmark study on ACEs was done with mostly white, mostly middle-class people in San Diego back in the '90s. And back then, researchers were shocked that 1 in 10 people had a high ACE score. Compare that with 1 in 2 - half of the patients at 11th Street.
GERRITY: We can't go back and change it, but the patients can change.
STARECHESKI: A big part of that is working with parents before their kids are even born. The hope is that if the adults talk about their childhood in the prenatal group, it'll help break generational cycles of trauma and abuse.
GERRITY: And when they learn about it, they really - they don't want this to happen to their children.
STARECHESKI: I talked to one of the moms in the prenatal group about this. Ashley Brant was about eight months pregnant with her third child when I met her.
ASHLEY BRANT: I kind of have a feeling it's coming (laughter). It's coming soon.
STARECHESKI: Ashley told me her own childhood was tough. She doesn't remember ever living with her mom, who had a drug problem. Her dad was murdered, and she had her first kid when she was only 12 years old.
What do you want to do for your kids as a parent that maybe is different than how you grew up?
BRANT: Just to be able to give them a mom - to know what it feels like to have a mother 'cause I don't. And I guess just seeing them smile, having me around and relying on me so much - it was like I'm doing something good - positive.
STARECHESKI: Research shows that having a bond with a caring adult is one of the best ways kids can overcome adversity. So Ashley could give her kids more than a great childhood. She could also give them a better shot at being healthy when they're grown. Laura Starecheski, NPR News. Transcript provided by NPR, Copyright NPR.
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