What are ACEs and Why Do They Matter?

In 2016¹, nearly half of U.S. children – 34 million kids – had at least one Adverse Childhood Experience (ACE) and more than 20 percent experienced two or more.  The new brain sciences and science of human development explain how ACEs can have devastating, long-lasting effects on children’s health and wellbeing. These events resonate well beyond the individual child to have far-reaching consequences for families, neighborhoods, and communities.

ACEs disrupt a child’s sense of safety and the nurturing they need to develop, thrive and learn.  ACEs include household issues like alcohol or substance abuse, untreated mental illness like depression, death or incarceration of a parent, family discord leading to divorce or separation of parents, child physical or emotional neglect and/or abuse and experiencing or witnessing any type of violence in the home or the community.  ACEs also include being judged or treated unfairly due to race or ethnicity and living in homes where parents have difficulty getting by on their income.  Most children with any one ACE have at least one other.^1,2

Fewer than two in five children flourish when they have had two or more of ACEs.  They are more likely to have a chronic condition, miss school, bully or be bullied, have emotional and behavioral health problems and mothers who are not in good physical and mental health.^3,4  Wide variation exists in the impact of ACEs and many thrive despite adversity; which is driven by helping children learn resilience, identifying and addressing trauma and toxic stress early and restoring safe, stable and nurturing relationships and environments.⁵  The science of ACEs and healing point to the urgent need to promote healthy parenting, teach resilience and address social and economic inequities limiting family and community capacity to heal and prevent ACEs.

Developing a National Agenda

Over a four-year period, the Child and Adolescent Health Measurement Initiative (CAHMI)  and Academy Health engaged more than 500 people across multiple sectors in a rigorous process to establish a national agenda to address ACEs. It began with the first-ever available national and state level data on ACEs, resilience, and family functioning from the 2011–12 National Survey of Children’s Health. To develop the agenda, a series of in-person meetings and listening forums were conducted along with several rounds of online crowdsourcing to identify goals and priorities across 10 stakeholder groups; educational sessions with stakeholders; and a range of research-in-action; coupled with community efforts.

From this process, the following emerged:

• A special issue of Academic Pediatrics devoted to ACEs.
• Four overarching agenda priorities to address ACEs and promote child well-being in children’s health services;
• Four specific areas of research that will advance these agenda priorities;
• Sixteen short-term actions and recommendations, each of which leverages existing research, policy, and practice systems and structures.

 
September 2017 Special Issue of Academic Pediatrics: Child Well-Being and Adverse Childhood Experiences in the U.S.

A special issue of Academic Pediatrics highlights new national research with 28 inspiring commentaries and research articles across a wide range of leaders, each of whom focuses on the critical importance of an immediate, strong and collective policy response to ACEs.  They also highlight the critical roles for Medicaid and private sector health plans, children’s hospitals, primary care providers and all children’s health services as key partners with families and communities. Science-driven methods to proactively promote resilience and healthy relationships is central to mitigate the far-reaching consequences of ACEs for children, families and communities.

The journal issue sets forth a collectively developed action agenda to promote the possible — flourishing for all — by healing the effects of current and accumulated individual, intergenerational, systems and community-level ACEs. 

Four Priorities to Address ACEs and Promote Child WellBeing

1: Translate the science of ACEs, resilience, and nurturing relationships.

• There is urgency for rapid and widespread training about the science of ACEs. We must prioritize strategies to translate the science of ACEs and thriving in both children’s health services and all sectors working with children, youth and families.
  
  

2: Cultivate the conditions for cross-sector collaboration to incentivize action and address structural inequalities.

• Adverse Childhood Experiences can be linked to a number of structural inequalities, such as poverty, discrimination, opportunities for employment, and access to health care. Addressing these inequalities will require effective collaboration and partnerships within and between child and family health-related systems, as well as across sectors, including between schools, health services, social services, businesses, and more.
  
  

3: Fuel “launch and learn” research, innovation, and implementation efforts.

• To address ACEs and promote healing and positive health, we must establish a purposeful research, policy analysis, technical assistance, and funding-assistance infrastructure that enables innovation and real-time learning, improvement, and implementation.
  
  

4: Restore and reward safe and nurturing relationships and self-, family-, and community-led prevention and healing.

• Create widespread understanding in pediatrics about safe and nurturing relationships, ways to advance them, and the environments to promote healthy child development and wellbeing. This would include training and financing to build a caring capacity, and would reward providers who focus on establishing and restoring safe and nurturing relationships and helping families engage in methods to promote healing.
   

PRIORITY AREAS FOR RESEARCH

To address Adverse Childhood Experiences and promote child wellbeing, we need more research on:

• Clinical protocols: Specify and test family- and youth-centered methods to assess and discuss ACEs and foster essential self-care, resilience, and relationship skills in clinical and other settings.
• Outcomes and costs: Evaluate the effects of alternative clinical and self-care interventions, including effects on health outcomes, utilization, and health care costs.
• Capacity building and accountability: Define and cultivate provider, health care system, and community-based core competencies related to ACEs, and the training, payment, and accountability models that will be effective in establishing these competencies.
• Provider self-care: Promote and examine the effects of provider self-care related to ACEs, resilience, and relationship skills on quality of care and other outcomes.

 
Short-term Research, Policy and Practice opportunities to address ACEs

Leverage existing policy-driven systems, structures, and innovation platforms

• Make early and periodic screening, diagnosis, treatment, and prevention of ACEs a priority.
• Integrate ACEs and positive health topics into hospital community benefits standards and community needs assessment efforts. Make available local data on ACEs, resilience, protective factors, and other social determinants.
• Advance trauma-informed and positive health-oriented payment reform, accountability measurement, and integrated systems efforts in practice innovation models, as well as through the range of maternal, child, youth, and family and school health programs.
• Develop and demonstrate models for addressing ACEs, promoting resilience, and healthy parenting in the context of addressing other social determinants of health in Medicaid.
• Make recommendations for and evaluate the effects of legislation, regulations, and related actions to address ACEs. Proactively ensure ACEs and childhood trauma are considered in health policies.

 
Leverage existing and evolving practice transformation efforts

• Use existing primary care medical home demonstrations and related efforts to address social and emotional determinants of health to focus on ACEs and promote safe and nurturing relationships in families and communities.
• Evaluate and advance efforts to engage children, youth, and families by including them in measurement and improvement efforts and IT tools to support learning and healing.
• Evaluate the use of nontraditional “providers,” such as peer-to-peer and family-to-family supports, as well as community health workers and others trained to promote healthy parenting, stress management, trauma healing, and building resilience.
• Empower community-based services and resource brokers such as Head Start and Help Me Grown as well as school health and afterschool programs, to educate and engage parents, youth, and families.
• Integrate trauma and resilience-informed knowledge, policies, and practices into existing initiatives, such as complex chronic condition care, early childhood systems, childhood obesity, school health, and social and emotional learning in schools.
  
  

Leverage existing research and data platforms, resources, and opportunities

• Optimize existing federal surveys and data that can inform, monitor, and build knowledge on ways to prevent ACES and promote positive health development.
• Optimize state surveys to gain access to critical data on children, youth, and families in state-led surveys.
• Liberate available data on ACEs, resilience, and related information by removing barriers to using data and making information to support national, state, and local efforts available in real-time.
• Allow data collected through crowdsourcing and citizen-science methods that engage people and communities in self-led learning and healing around ACEs and resilience to fast-track learning about “what works for whom” and enable rapid discovery and spread of knowledge.
• Integrate research questions, as well as measurement and analytic methods, into existing longitudinal and birth cohort studies to address questions about prevention, risk, and mitigation effects associated with ACEs.
• Link to collaborative learning and research networks to advance ACEs, resilience, and positive health-related research.
  
  

Our Vision to Address Childhood Trauma 

Adopting and implementing these priorities and actions can lead to:

• Improved resilience, positive health and healthy social-emotional skills for children and families.
• Higher rates of children who are healthy and ready to learn and positively engaged in school and life.
• Increase in families providing safe, stable, and nurturing relationships and environments for children.
• Increases in self, family, and community self-care and use of evidence-based mind-body and related trauma healing and stress reduction methods.
• Trauma-informed systems of care and workplaces.
• Reductions in health problems and costs associated with ACEs, trauma, and chronic and toxic stress, including social costs due to poor health behaviors, loss of hope and crime.
• Reduced provider burnout.
• Reduced structural inequities that contribute to stress, ACEs, and pose barriers to healing trauma.
• Reduction in ACEs.

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This fact sheet has been adapted from:

Prioritizing Possibilities for Child and Family Health: An Agenda to Address Adverse Childhood Experiences and Foster the Social and Emotional Roots of Well-being in Pediatrics. Bethell, C.D., Solloway, M.R., Guinosso, S., Hassink, S., Srivastav, A., Ford, D., & Simpson, L.A. pp. S36-S50: http://www.academicpedsjnl.net...-2859(17)30354-6/pdf

References

1. Bethell, CD, Davis, MB, Gombojav, N, Stumbo, S, Powers, Fact Sheet: Adverse Childhood Experiences Among US Children, Child and Adolescent Health Measurement Initiative, Johns Hopkins Bloomberg School of Public Health, October 2017 www.cahmi.org/projects/adverse-childhood-experiences-aces
2. Bethell, CD, Carle, A, Hudziak, J, et al. Methods to Assess Adverse Childhood Experiences of Children and Families: Towards Resilience and Well-Being Based Approaches in Policy and Practice. Academic Pediatrics (In Press; Sept 2017
3. Bethell CD, Newacheck P, Hawes E, Halfon N. Adverse Childhood Experiences: Assessing the Impact on Health and School. Engagement and the Mitigating Role of Resilience. Health Affairs, 33, no.12 (2014):2106-2115. doi: 10.1377/hlthaff.2014.0914
4. Bethell CD, Gombojav N, Solloway M, Wissow L. Adverse Childhood Experiences, Resilience and Mindfulness-Based Approaches: Common Denominator Issues for Children with Emotional, Mental, or Behavioral Problems. Child Adolesc Psychiatr Clin N Am. Dec 2015. doi:10.1016/j.chc.2015.12.001
5. Sege, RD, Harper Brown, C. Responding to ACEs With HOPE: Health Outcomes From Positive Experiences. Academic Pediatrics, Sept 2017 pp. S79-S85: http://www.academicpedsjnl.net...-2859(17)30107-9/pdf