Early Intervention and Parent-Child Interactive Therapy May Mitigate the Effects of Toxic Stress in Children

 “It is easier to build strong children than to repair broken men.”
–  Frederick Douglass

Over two decades of extensive research have shown that childhood adversity can chemically interrupt and alter a child’s brain development. This causes an increased likelihood of mental health issues, substance abuse risk, juvenile delinquency, and teen pregnancy, as well as proven negative long-term health outcomes.

Basically, it is a simple cause and effect – the more adverse experiences and situations a child is exposed to, the higher the risk of learning difficulties, emotional problems, developmental issues and long-term illness. On the other hand, healthy developmental functioning combined with a nurturing environment helps children thrive into physically healthy and emotionally balanced adults.

Adverse Childhood Experiences (ACE)

The Substance Abuse and Mental Health Services Administration (SAMHSA) describes adverse childhood experiences (ACEs) as stressful or traumatic events, including abuse and neglect. They may also include household dysfunction such as witnessing domestic violence or growing up with family members who have substance use disorders. ACEs are strongly related to the development and prevalence of a wide range of health problems throughout a person’s lifespan, including those associated with substance misuse.

ACEs include:

  • Physical abuse
  • Sexual abuse
  • Emotional abuse
  • Physical neglect
  • Emotional neglect
  • Mother treated violently
  • Substance misuse within household
  • Household mental illness
  • Parental separation or divorce
  • Incarcerated household member

The Adverse Childhood Experiences Study (ACE Study) is a long-term research study conducted by the American health maintenance organization Kaiser Permanente and the Centers for Disease Control and Prevention . Participants were recruited to the study between 1995 and 1997 and have been in long-term follow-up for health outcomes. The study has demonstrated an association between adverse childhood experiences (ACEs) with health and social problems as an adult. The study is frequently cited as a notable landmark in epidemiological research and has produced more than 50 scientific articles and more than 100 conference and workshop presentations that look at the prevalence and consequences of ACEs.

The ACE Study found the following:

Adverse childhood experiences are common. For example, 28% of study participants reported physical abuse and 21% reported sexual abuse. Many also reported experiencing a divorce or parental separation or having a parent with a mental and/or substance use disorder.

Adverse childhood experiences often occur together. Almost 40% of the original sample reported two or more ACEs and 12.5% experienced four or more. Because ACEs occur in clusters, many subsequent studies have examined the cumulative effects of ACEs rather than the individual effects of each.

Adverse childhood experiences have a dose–response relationship with many health problems. As researchers followed participants over time, they discovered that a person’s cumulative ACEs score has a strong, graded relationship to numerous health, social, and behavioral problems throughout their lifespan, including substance use disorders.

Furthermore, many problems related to ACEs tend to be comorbid, or co-occurring. About two-thirds of individuals reported at least one adverse childhood experience; 87% of individuals who reported one ACE reported at least one additional ACE. The number of ACEs was strongly associated with adulthood high-risk health behaviors such as smoking, alcohol and drug abuse, promiscuity, and severe obesity, and correlated with ill-health including depression, heart disease, cancer, chronic lung disease and shortened lifespan. Compared to an ACE score of zero, having four adverse childhood experiences was associated with a seven-fold increase in alcoholism, a doubling of risk of being diagnosed with cancer, and a four-fold increase in emphysema; an ACE score above six was associated with a 30-fold increase in attempted suicide.

The ACE study’s results suggest that maltreatment and household dysfunction in childhood contribute to health problems decades later. These include chronic diseases—such as heart disease, cancer, stroke, and diabetes—that are the most common causes of death and disability in the United States. The World Health Organization writes that the study’s findings while relating to a specific population within the United States, might reasonably be assumed to reflect similar trends in other parts of the world.


Toxic Stress

Neurological research confirms that children carry the effects of childhood experiences into adulthood. Learning how to handle adversity is a healthy part of normal child development. Our bodies have a biological response to stress – our heart quickens, blood pressure rises, and the body produces adrenaline and stress hormones, like cortisol.

When a child or preadolescent experiences stress or adversity within an environment of supportive adults, they are offered coping mechanisms and taught how to address the physiological effects. Through this process, the individual develops a healthy stress response systems.

However, if the stress is extreme and long-lasting, and the child is not taught coping mechanisms, the result is toxic stress. Such toxic stress can weaken developmental systems and brain architecture and has been shown to have damaging effects on learning, behavior, and health across the lifespan.

The Center on the Developing Child at Harvard University states:

Toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support.


Early Intervention for Improved Child Development Outcomes.

Early intervention has been shown to significantly reduce the effects of childhood adversity and toxic stress by helping kids develop stable, caring relationships with parents and guardians. These protective and supportive relationships are essential for healthy childhood development. Intervention can take place in the form of child and family counseling, foster care and adoption services, access to primary care, or child advocacy focused on family support and preservation.

Focus on enhancing parents’ ability to provide a nurturing and supportive environment, with open communication, has been shown to improve family safety, stability, permanency, progress toward milestones, developmental functioning, and overall well-being. A strengths-based approach which incorporates the abilities and interests of each child and family can improve child development outcomes in areas such as reading level, academic achievement, problem-solving skills, and the ability to develop healthy relationships.

Parent-Child Interaction Therapy (PCIT)

Strong, supportive family connections help children grow into well-adjusted, healthy adults. Families sometimes need help to address social and emotional challenges. Counseling services can minimize conflict, reduce stress, improve communication, and strengthen family ties. Family counselors and therapists can assist families to deal with traumatic situations, address behavioral and social difficulties, and address issues such as depression, anxiety, low self-esteem, anger management, and insecurities related to adoption or foster care placement.

Parent-child interaction therapy (PCIT) is a behavior-based, family-oriented therapy that places emphasis on improving the quality of the connection and interaction between the child and their primary caregiver. It is designed to help improve the parent-child relationship through guided and deliberate interaction.

Children and their caregivers are typically seen together in PCIT sessions. Most of the time a therapist will coach caregivers in the application of specific communication or parenting skills. Therapists usually coach from an observation room where the child can not see them and use a Bluetooth or in-ear system to communicate with the parents as they play with their child.

PCIT has been shown to:

  • Emphasize the bond between child and caregiver
  • Build positive parent-child interactions,
  • Improve child’s negative behaviors (anger, aggression, defiance)
  • Reduce caregiver stress
  • Provide continual feedback regarding progress
  • Develop positive child-rearing strategies
  • Reduce the likelihood of child physical and verbal abuse
  • Increase communication and interaction skills within the family

GoodTherapy.org reports:

Children who participate in PCIT may develop greater self-esteem, experience less anger and frustration, see an improvement in social, organizational, and play skills, feel safer and calmer, and communicate more effectively. Parents typically learn consistent, predictable techniques for parenting and may experience greater confidence when dealing with behavioral concerns, whether publicly or in the home.

Life’s Onion for Child and Family Counseling

There are a number of reasons why Life’s Onion is perfectly aligned with the best practices of Parent-Child Interactive Therapy and makes an outstanding activity for family counseling and coaching.

Life’s Onion® is a handheld, onion-shaped device with 3 layers of 4 peels each, 12 total. The peels/petals are made of a soft, pliable, non-toxic material, and are available in both natural color and pink. They can be removed, replaced, and exchanged – and can be written on or decorated on both sides with sharpie markers.

Life’s Onion can encourage anyone, even a child, to find words, dig deeper, look within, get to the core, and express themselves more fully. Much of its power lies in its simplicity. Its central metaphor allows even the youngest of minds to communicate in deep symbolic language.

A secretary at a public intermediate school (grades 5-8) located in South Bend, Indiana describes the interaction she would observe children have with the Life’s Onion on her desk:

“Occasionally students would come into my office to either cool off, or separate from other students whom they had a physical altercation. Other times, younger siblings came in with their parents to fill out paperwork. Whatever the age level was, they would inevitably approach my desk and pick up the Life’s Onion.  Boys tended to take the Onion apart and reassemble it, and girls tended to decorate it. It was intriguing to them and they were very engaged with it in one way or another. Many children grew up either aware of or having a toy called Transformers. Then subsequent movie(s) called The Transformers were made. I said the onion was a “vegetable transformer” as it transformed from an onion into a flower. Children related well with the Life’s Onion and I encouraged them to write positive behaviors and thoughts on the peels and petals.”

Life’s Onion is also unique from other toys and interactive play objects in that it has a memory. Words and symbols are often used to decorate the onion during a counseling session. This increases engagement by turning what are typically verbal, intangible counseling exercises into palpable actions – writing down progress and marking up the peels and petals. Literally peeling away the layers of Life’s Onion. Bending them back to reveal the petals of a flower. This process gives the child or family a physical, visible reminder of their discoveries which remains long after the sessions have ended.

Parenting PRIDE Exercise

A simple yet extremely powerful family counseling exercise derived from PCIT which is easily adapted for Life’s Onion is based on the acronym PRIDE. The child chooses an activity or is given a toy to play with (see below for examples of counseling activities using Life’s Onion) and the parent or caregiver plays along (under the guidance of a counselor) while using the positive reinforcement skills represented by the letters P-R-I-D-E:

  • Praise: The child is praised for good or appropriate behavior.
  • Reflection: The child’s words are repeated and expanded upon by parents, which encourages communication.
  • Imitation: Parents teach and show approval by mimicking what their child is doing.
  • Description: Parents describe what the child is doing in order to help their child build vocabulary and show that they (the parents) are paying attention to the child’s activities.
  • Enjoyment: Parents demonstrate enthusiasm for the child’s activities.


This acronym is a reminder that parents should Praise their child’s positive actions, Reflect upon what their child says, Imitate the play of their child,  Describe the actions of their child, and try to Enjoy the special time. During the practice, parents are encouraged to avoid questions, commands, and criticism.

Life’s Onion’s Versatility

Life’s Onion is limited only by your imagination and can be the foundation of many different types of activities and counseling exercises. It’s a touchstone, an outline, a shorthand journal, a puzzle, a focal point, a framework, an activator, a reminder, an art project….

Our blog has frequently addressed the strengths and advantages of Life’s Onion when applied to work with children and families. Please review the articles below to discover some of the ways Life’s Onion might be used to empower children struggling with adverse childhood experiences and toxic stress.


Power of Words

John Lennon once said, “When you’re drowning you don’t think, I would be incredibly pleased if someone would notice I’m drowning and come and rescue me. You just scream.”

I’m sure you have had an experience where you might be feeling anxious or sad or annoyed but you don’t quite know why. Then, a very clear word that explains or describes how you are feeling comes into your mind and it is accompanied by a feeling of relief. Once you have a word for it, once you have named how you are feeling or why (ie. ‘I’m jealous’) then you have some control over it and you can begin to process and understand.

One of Life’s Onion’s great strengths is that it requires you to identify and externalize key thoughts, feelings, and intentions surrounding whatever issue you are exploring. The tool’s purpose is to encourage you to articulate and express yourself on increasingly deeper levels until you reach the core of an issue or idea.

–  See more at: http://www.lifesonion.com/power-of-words/

One Petal at A Time

When first introducing the onion I ask my clients, ‘What do you see?’ They say many different things: anger, disgust, frustration, ‘a bulb’, ‘a plastic thingy’… Then I put the workbook in their hands and let them talk about what is causing all the trouble, frustration, anger, and disgust they just mentioned to me. What was it that made them have that initial reaction? This usually becomes a great conversation piece and allows us to talk about how each petal of the onion is a layer of their growth and movement in therapy.

–  See more at: http://www.lifesonion.com/one-petal-at-a-time/

Life’s Onion & Expressive Arts Therapy

With its focus on creative thought, design, and personal expression it should come as no surprise that the principles of Expressive Arts Therapy and individual art therapies were guiding elements in the creation of Life’s Onion. Its flexibility and adaptability make it a good fit for use in Expressive Arts Therapy treatment programs, or any context where creative action is used to reinforce healing and personal development.

– See more at: http://www.lifesonion.com/expressive-arts-therapy/

Use of Metaphors in Counseling

When Mark Wetherbee first envisioned the Life’s Onion tool, one of his central purposes was to create a physical, tangible METAPHOR that could be used to enhance therapy, coaching, and personal development work. The powerful transformation of Life’s Onion from a closed onion to an open flower is rich with meaning and perspective.

– See more at: http://www.lifesonion.com/use-metaphors-counseling/


American Academy of Pediatrics 


The Lifelong Effects of Early Childhood Adversity and Toxic Stress


ACE Score Generators:

ACE Quiz http://www.npr.org/sections/health-shots/2015/03/02/387007941/take-the-ace-quiz-and-learn-what-it-does-and-doesnt-mean

Got Your ACE Score? https://acestoohigh.com/got-your-ace-score/

Annual PCIT conference http://alliance1.org

Get more ideas for therapeutic techniques involving Life’s Onion –  Visit us on youtube