Teresa Cox-Bates was only 11 years old when her father died, an event that dramatically altered her family's circumstances and shaped her childhood experiences.

"I really remember us not having enough food to eat," says Cox-Bates, 37. Her mother worked as a paralegal back then, but struggled financially. "It was just hard. My mom was trying her best to provide everything, but it just wasn't enough."

She remembers not having clean clothes and eating only one meal on most days – and food could spark literal battles with her mom.

"If we snuck into the kitchen to get something, she'd beat us," she says, adding that her mother struggled with alcoholism in those days. "So with little things, she'd just snap."

There was housing instability, too: "I didn't stay anywhere long enough to even have a best friend."

The hardships Cox-Bates endured during childhood are what researchers call Adverse Childhood Experiences (ACES). Studies show they can leave a profound impact on the brains and bodies of kids, affecting their health as adults, increasing their risks for chronic health issues like heart disease, obesity, depression and suicide attempts.

Studies also show that adults who experienced such traumas in childhood are likely to feel more stressed when they become parents, and their children are at a higher risk of developmental delays and mental health problems.

When Cox-Bates became a mother, she knew she didn't want her children to experience what she and her siblings did.

"I wanted to provide something better for my kids," says Cox-Bates, who now has two sons, ages 10 and 6, and a 4-year-old daughter. She and her husband, John Bates, wanted to give their kids a childhood free of hunger, neglect and violence and one filled with stability, love and connection.

And they have been able to accomplish that, thanks to the support they received from their pediatrician's office through HealthySteps, a program for families with lower incomes who face more stressors from their financial circumstances. Often these are the people who are more likely to have experienced childhood traumas.

HealthySteps helps families cultivate a healthy environment for their children in the earliest and most developmentally vulnerable age – 0 to 3 years – by connecting them with a child development specialist.

The specialist meets one-on-one with parents during pediatric appointments, educating them about their child's development, and doing screenings to catch any problems early on. They also offer practical support, addressing families' social and psychological needs: whether it is to find appropriate care for a parent's own history of trauma, or to connect families to stable housing and food.

"It's that kind of support that I think can disrupt that vicious cycle [of childhood traumas]," says Dr. Kevin Fiori, a pediatrician and director of social determinants of health for Montefiore Health System.

Nearly 250 clinics across the country use the program, mostly with philanthropic funding. They are reaching more than 370,000 children and seeing promising results.

Cox-Bates signed up for HealthySteps in 2017 when her second son, Isaac, was a few months old. Until recently, when her youngest graduated from the program, HealthySteps has supported her through many ordinary and unusually stressful periods of parenting.

"If I didn't have [HealthySteps], I don't think I would have been able to manage my mental health and for me to even press on to be the mother that I am today," she says.

Disrupting intergenerational cycles of trauma

When I meet Cox-Bates at her apartment in Brooklyn on a recent afternoon, she is sitting on the big red sectional in her living room, working on her laptop.

Her two boys, Eli, 10, and Isaac, 6, are engrossed with a video game on the large TV, barely a few feet from their mother. Their sister, 4-year-old Ava is skipping around the room, eating strawberries, her beaded braids rising and falling with each step. Their mother, unperturbed by their noise and chaos, occasionally looks up from her computer to check on them. When Ava becomes upset about something, Cox-Bates sets aside her laptop and gently pulls her daughter onto her lap, hugging her, and whispering in her ear to calm her down.

After her husband, John Bates, takes the children to a playground, she tells me she wasn't always as calm with her kids. When they were younger and always clamoring for her attention, she would feel easily overwhelmed.

"Sometimes I'd find myself getting so angry because I'd feel like I'm not doing enough," she says. "They always want more." She remembers snapping at her kids, then worrying that it "was her mom coming out," she says. "I didn't like it."

It was during times like these that she reached out to her HealthySteps specialist, Allison Lieber, who directs the HealthySteps program at Brookdale University Hospital and Medical Center.

"I would just call in, I would just talk to her even for 5 minutes, and I just felt better," says Cox-Bates.

Lieber, too, remembers those calls. "There were definitely conversations about wanting to parent differently and not knowing how to get there," says Lieber.

Cox-Bates also struggled with reading "her kiddos' cues and how to deal with those big feelings that came up for her when someone was tantruming or having a hard time," Lieber adds.

So, Lieber gave her tools to manage her own stress, like journaling, and regular self-care. She also gave her strategies to deal with her children's tantrums and meltdowns.

"She told me 'just think [that] these are little people, and they need more time to develop,'" recalls Cox-Bates. That reminder has helped her become a calmer, more compassionate and nurturing mother.

And she sees the results reflected in her children's happiness. "They seem pretty happy."

A parent with a history of childhood traumas may not always know how to forge a loving, nurturing bond with their infant, says Fiori.

"Families that I work with haven't had a good [parenting] model," he says, "either because they had challenges with their own parents not being there or not being in a setup to provide the kind of nurturing that they wanted."

So, they are more likely to use the kind of harsh parenting they grew up with, unless they're shown ways to do things differently, says Rahil Briggs, the national director for the program and a professor of pediatrics and psychiatry at Albert Einstein College of Medicine. "Without intervention and without treatment and without help, we see these intergenerational cycles of trauma," she says.

HealthySteps provides an alternative "parenting model" that is healthier for the parents and their children in the long run, says Fiori.

Supporting parents fosters healthier development in kids

A loving, responsive and nurturing relationship with a parent – what researchers call a secure attachment – is key to healthy childhood development, says Briggs.

"It's this incredibly predictive sense of a strong foundation moving forward," she says. "If this foundation is strong, you're set up with some of those skills [needed to succeed in life]."

Those skills include language, communication and the social and emotional skills that help kids navigate day-to-day interactions with other people, she explains.

Fiori points to the landmark study on the long-term impacts of ACES, which also found that "nurturing a healthy child-parent relationship, providing environments where a child and their caregiver can have those appropriate attachments and support" can mitigate the health effects of childhood traumas.

But when that secure parent-child bond is missing due to the parents' own history of trauma, or the stresses brought on by poverty, the child's development suffers.

Briggs points to a 2009 study where U.S. researchers found that children 0-3 years of age who experienced neglect, physical, emotional or sexual abuse had significant developmental delays.

"If they had experienced seven or more kinds of trauma, the kids in that group, 100% of them had a developmental delay," says Briggs. "Children who are spending all of their time and energy trying to stay safe, managing hunger, managing fear, a very stressful home – there's not a lot left to learn your ABCs."

Poverty, too, has serious developmental impacts.

"We see impacts on physical health, on developmental health," says Briggs. "You're seeing illness, hospitalizations, developmental delays, increased behavior problems, decreased cognitive functioning."

HealthySteps is trying to prevent these health inequities and give at-risk kids a healthier start.

And there's a growing recognition that a pediatrician's clinic is an obvious place to identify families who need extra support, says Dr. Tumaini Rucker Coker, a professor of pediatrics at the University of Washington School of Medicine.

"For many families, that could be the only opportunity they have to address some of the social or psychosocial needs that they have," she says.

The first few years of a child's life are also when parents need the most support, adds Rucker Coker, especially those who are struggling otherwise. "They have a whole host of needs during that early childhood period, and it can range from social and financial needs, to support on the day-to-day things of being a new parent, like sleep, feeding and safety."

Studies also show that investing in children and their families in these early years has "the biggest impact," says Fiori.

Impacts of HealthySteps

Research shows that HealthySteps is already making a difference.

Children enrolled in the program are more likely to attend all of the first 10 well-child visits, shrinking the gap in attendance between families on Medicaid and those with commercial insurance. HealthySteps kids are also more likely to be up to date on their vaccines by age 2 compared to kids from similar backgrounds who weren't part of the program.

Mothers report feeling more supported for breastfeeding, says Briggs, and they are more likely to discuss any depression symptoms and be connected to treatment. Children of mothers who reported childhood traumas scored higher on social-emotional screening after receiving support from HealthySteps compared to similar kids who didn't participate in the program.

"If every mom, every family had this opportunity, I really believe that depression will go down with the mothers and the family," says Cox-Bates, "because most of us feel like we don't have anybody to turn to. We don't have that help."

She wishes HealthySteps was around when she was born. "It would have probably benefited my mother," she says, and perhaps given her and her siblings a happier childhood.

Copyright 2023 NPR. To see more, visit https://www.npr.org.



From the time a child is born until they're 3 years old is a stage of development that lays the foundation for the child's future. But growing up in a financially stressed household can hurt a child's physical and emotional growth. Now a new intervention is trying to prevent those problems for at-risk kids by better supporting their parents in those early years. For our ongoing series Living Better, NPR's Rhitu Chatterjee reports the work starts in the pediatrician's office.


RHITU CHATTERJEE, BYLINE: It's a busy morning at this clinic in Brooklyn.

UNIDENTIFIED PERSON: She's waiting for shots, right?

CHATTERJEE: A young couple is here with their 11-month-old baby, Kayla, to see her pediatrician, Dr. Marilyn Arca.

MARILYN ARCA: Good morning. Kayla, good morning to you too, baby. Come. Let's go. Let's face Dr. Grandma now.

CHATTERJEE: But Kayla's appointment isn't just with Dr. Arca. Here at Brookdale Family Care Center, which mostly serves people on Medicaid and CHIP, families can also see a child development specialist. That specialist here is Allison Lieber.

ALLISON LIEBER: Like, a month ago, you guys were here. And you did ASQ. And development looks beautifully on schedule.


CHATTERJEE: Lieber spends nearly 30 minutes with Kayla and her parents, Chantel Springer Dowell and Tishon Dowell, asking them about their baby's development.

LIEBER: Oh, no. What happened?

SPRINGER DOWELL: She don't like to lay down.


LIEBER: Is she starting to cruise? You can pick her up.

SPRINGER DOWELL: She crawls. She climbs out of, like, her bassinet.

CHATTERJEE: Over the course of their conversation, Lieber gets a sense of what the couple is struggling with. She suggests a nighttime routine to help Kayla fall asleep more easily and how to help her try new foods.

LIEBER: What about doing, like, dinner together, where she gets her own little plate to play with while you guys are all eating?

SPRINGER DOWELL: Yeah. We can do that. Like an empty plate, right?

LIEBER: Well, no. Put a little food on her plate.


LIEBER: That way it's family dinnertime. Maybe...

CHATTERJEE: Then Lieber asks the parents how they're doing.

LIEBER: So what else is going on with you guys? How's work?


SPRINGER DOWELL: Work is good.

CHATTERJEE: Lieber directs a program here called HealthySteps. Her role is both of an educator and one of social and practical support for parents, teaching them about their child's development and how they can best facilitate that.

LIEBER: We want parents to be the hands that let their child go out and explore and welcome them back, but sometimes parents need hands, too, and so how can we be that support for them?

CHATTERJEE: And supporting parents also involves addressing other factors affecting their stress levels.

LIEBER: It's really hard to focus on tummy time or reading to your child if you're living in shelter or you're bouncing from couch to couch or you don't have enough food stamps to be able to put food on the table for your older children.

CHATTERJEE: So Lieber and her colleagues address those challenges. They help families find housing, sign up for food benefits, connect them with job opportunities and mental health care. One of the many mothers the program has helped is Teresa Cox-Bates, who calls Lieber by her first name, Allie.

TERESA COX-BATES: Allie is more like family to me. She's been the absolute best. Anytime I needed something, she was there. Even when I didn't need anything, she would just - she'll just call and check on me.

CHATTERJEE: Cox-Bates and her husband signed up for HealthySteps in 2017 after their second son was born. She says the program has seen her through many ordinary parenting struggles and some crises, like the time she had postpartum depression when her youngest, Ava, was still a baby.

COX-BATES: I was definitely sleep deprived because by then Ava still wasn't sleeping through the night. And I just felt really sad. I was crying uncontrollably at work.

CHATTERJEE: At home, she was irritable and impatient with her kids. One day, she found herself yelling at her two boys for something small.

COX-BATES: And I just started screaming out of nowhere, and then they got really scared. And I was like, oh. I felt really bad afterwards. I went in a room and I cried, and I told John that this is not me.

CHATTERJEE: Then she called Allison Lieber, and thanks to Lieber's prompt help, Cox-Bates was able to get admitted for inpatient care. Across the country, nearly 250 clinics are now using the HealthySteps program, mostly with grant funding. The program now reaches more than 370,000 children. Rahil Briggs is the national director for the program. She says the stress of poverty has serious consequences on children's development.

RAHIL BRIGGS: We see impacts on physical health, on developmental health. You're seeing illness, hospitalizations, developmental delays, increased behavior problems, decreased cognitive functioning.

CHATTERJEE: Factors that affect their lifelong health. Briggs says HealthySteps is trying to prevent these inequities and give children from disadvantaged backgrounds a healthier start. Studies show that the program is already succeeding on many fronts.

BRIGGS: We know that mothers felt significantly more supported to breastfeed, and we know that with HealthySteps, they had higher rates of continued breastfeeding.

CHATTERJEE: Briggs says when mothers have a history of trauma from their own childhood, it can affect how they parent. But she says research shows that HealthySteps prevents moms from passing on their trauma to their kids.

BRIGGS: So a bunch of children whose mothers had experienced trauma, some get HealthySteps; some don't. And when you look at the children who received HealthySteps, looking much better on a social emotional screening than the ones who didn't.

CHATTERJEE: Teresa Cox-Bates is among the healthy steps mothers with a history of childhood trauma. When she was only 11, her father died, and her mother struggled to provide for her five kids.

COX-BATES: Most of the time, my mom, she only fed us once a day. So if we snuck in the kitchen to get something, like, you know, she beat us.

CHATTERJEE: She says her mother struggled with alcoholism and was sometimes violent. So when Cox-Bates became a mother, she wanted to give her kids a better childhood, one filled with stability, love and connection. And she's been able to do that, she says, largely thanks to support from HealthySteps.

COX-BATES: Because I had the resources and I had to help, and I had Allie. And even if she couldn't do it, she would find somebody else that did. And if I didn't have that, I don't think I would have been able to manage my mental health and for me to even press on to be the mother that I am today.

CHATTERJEE: And she sees that reflected in her kids, who are happy and thriving.

Rhitu Chatterjee, NPR News.

(SOUNDBITE OF MUSIC) Transcript provided by NPR, Copyright NPR.

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