Recently I was asked to give a presentation for an audience of early childhood educators about the Adverse Childhood Experiences (ACE) Study. I jumped at the opportunity to frame this powerful research linking early adversity with long-term health consequences into a message of both hope and action. Thus I was particularly pleased to receive an email from an audience member with the following message: “Thank you for your work, the workshop left me with hope. It makes me think of tikkun olam.” I looked up this familiar phrase from Judaism to find its exact meaning: “World Repair.”
Somehow in the presentation I had at least for this one person, accomplished what I set out to do. So how did that happen? A colleague who attended a similar presentation which she found “revolutionary” said that the “granular” nature of the talk accounted for its power. I wonder if conveying in both words and images the experience of babies in relationship with caregivers explained the impact of the message. D.W. Winnicott, T. Berry Brazelton, and Ed Tronick, three who have had profound influence on my thinking, all had the privilege of spending lots of time in the presence of parents and young infants. When I originally set out on my professional path, I was already interested in promoting the health and wellbeing of children. While at first I planned to be a child psychiatrist, I decided that studying pediatrics would be the best way to learn about children. It was among the best decisions I’ve made.
For my talk, after offering a brief overview of the ACE study, I showed a video of a father comforting his newborn daughter. We hear her piercing newborn cry and see her flailing body on the warmer fresh from her mother’s safe womb. Her father stands by as the nurses manage this transition. As he speaks to her in a calm quiet voice, we see her arms and legs becomes still as the crying subsides. But then life happens again. The nurses continue their work, putting on her diaper. Again she becomes disorganized, the loud cry and frantic movements return. Once again Dad speaks to her. This time not only does her body organize itself. She turns her head to find her father’s voice and opens her eyes as he says, “I love you.”
I shared with the audience that this brief video contains the entire message of the talk. It shows how humans develop the capacity for intimacy and self-regulation in moment-to-moment interactions with caregivers who help them navigate disruptions. We can conceive of “adversity” as any number of factors- within the baby, within the caregiver, and within the environment- that deprive a child of sufficient interactive regulation in the face of life’s inevitable stressors.
I then introduced the Repair Theory of Human Development. Derived from the groundbreaking research of psychologist Ed Tronick, the core principle of this theory state that healthy relationships are characterized not by perfect attunement but by a continuous, ongoing, messy process of mismatch and repair. As we had just see in in the video, our sense of self and ability to be close with others both grow out of moment-to-moment interactions in our earliest relationships. These experiences change our brain and body, organizing the way we function in new relationships throughout our lives.
I concluded with another powerful video, the trailer for the documentary STEP about a dance team in a charter high school for girls in Baltimore. It reveals the central role of human interaction in growth and healing. When the teenage girls-all of whom have experienced significant adversity- move together in in hundreds of thousands of moments in rehearsals-messing up and trying again- to win a major competition, we see individuals succeed and relationships flourish.
The ACE study offers evidence that what happens early in development continues to have a profound impact on our health and wellbeing throughout our lives. Since the study has become more well-known over the past decade, different schools of thought have emerged regarding how to take the evidence the study offers and turn it into action. One involves teaching about brain science. If parents, clinicians, and policy makers only knew how important early relationships were in building healthy brains, then things would change in terms of both prevention and treatment. Another involves screening; knowing one’s ACE score (the absolute number of adversities from the list of ten in the original study) will point people with high levels of adversity in the right direction.
But both these approaches have their limitations. A 2016 survey conducted by Zero to Three in collaboration with the Bezos Foundation of over two thousand parents of young children revealed that the majority found information about their role in building healthy brains both motivating and terrifying, with 35% of parents equally or more terrified than motivated. As I describe in a previous post, giving information in the absence of an emotional connection in a relationship may be ineffective or even harmful. The ACE score, derived from studies of populations, was never intended to be used for screening individual people. As a 2021 article in JAMA Pediatrics states: “ACE scores can forecast mean group differences in later health problems; however, ACE scores have poor accuracy in identifying individuals at high risk for future health problems.”
It is becoming increasingly well recognized that early relational health has as much if not more impact than early adversity. In a course for the Hello It’s Me Project that brings together a variety of practitioners who work with parents and young children I recently interviewed a mother with her 6-week old daughter and 2-year-old son on a Zoom call. We see the beautiful intricate dance among the family members as she shares with the class her process of navigating pregnancy and childbirth during the pandemic. Her confidence and presence as she listens to her children’s wordless communication burst through the limitation imposed by the screen. It felt like witnessing the birthplace of hope.
We learn from babies to conceive of world repair as a relational, interactive, and messy process. It begins with supporting parents and young children in proportion to their role in getting things right from the start. When parents themselves feel held, they naturally move through moments of discord with their children to impart a core sense of trust. This developmental concept translates across the lifespan. When we move through messy moments in interactions with others, letting ourselves be in the uncomfortable times when we don’t quite know what’s going on. we learn to trust each other. We learn that when things go wrong, as they inevitably do, together we will be able to repair the problem. With each repair we grow and change, over time building a better world.