State Public Health Strategies for Preventing Adverse Childhood Experiences

July 12, 2018|3:43 p.m.| Community Health and Prevention Team

Adverse childhood experiences (ACEs) are stressful or traumatic events during childhood where continual exposure to stressors in the absence of nurturing relationships, known as toxic stress, can damage a child’s developing brain. For this reason, ACEs are a major risk factor for poor early brain development. ACEs not only contribute to suboptimal brain development in children, but they also have lasting effects on overall health and are linked to causes of morbidity and mortality in adults.

The relationship between ACEs and health and social outcomes has been well-documented: the more ACEs a child experiences, the greater the risk for lower educational attainment, along with unemployment and poverty later in life. Recent studies have also shown an association between ACEs and chronic diseases, such as hypertension and addiction. Among patients seeking treatment for opioid addiction, for example, researchers found that 80 percent were exposed to at least one form of childhood trauma, and about two-thirds witnessed violence during childhood. These poor outcomes are also influenced by the social determinants of health, including access to healthcare and the ability to maintain a healthy lifestyle. Research shows that children in low-income households or those belonging to racial and ethnic minority groups have disproportionally greater exposure to ACEs compared to white children, and that they experience significant disparities in both early brain development and healthcare access as a result of increased exposure.

While ACEs are common, they are also preventable. State and territorial health departments can prevent ACEs, improve health equity, and reduce health disparities among children and families by bolstering protective factors, including strong, interactive relationships with caregivers, and by providing access to preventive services. Protecting against ACEs with preventive services can ensure healthy brain and child development. Recognizing this association, Tennessee’s Building Strong Brains program aims to promote healthy brain development statewide and change the culture around ACEs and trauma by developing prevention-focused early childhood policies, programs, and practices. The program’s goal is to provide every child in Tennessee with an opportunity to experience lifelong success and health.

State and territorial health departments can also protect children from ACEs and toxic stress by encouraging nurturing relationships and positive parenting. Parents and caregivers can be positive influences in children’s lives by creating supportive bonds and safe environments, both of which are essential for healthy brain development.

The Positive Parenting Program (Triple P) is one evidence-based program that can be implemented to encourage positive child-parent relationships in all families. Texas incorporates Triple P in its home visiting programs, an approach that has successfully increased protective factors against ACEs in the state. For example, in Houston, parents participating in the Triple P parenting pilot program learned how to appropriately manage their child’s behavior. The pilot also contributed to statistically significant decreases in antisocial child behavior and led to improvements in positive parenting. Overall, participating parents felt that their child’s problems had improved and that they were better equipped to understand and respond to their child’s behavior.

The Nurse-Family Partnership (NFP) is another evidence-based program that targets young, first-time, low-income mothers. A registered nurse provides home visits at least once every other week during a woman’s pregnancy until her child reaches age two. The program helps mothers reduce unhealthy behaviors, such as smoking and drinking, and create safe environments for their children. Mothers in the program also learn how to positively interact with their child to promote social and emotional competence. Currently, 42 states, the U.S. Virgin Islands, and five Tribal communities have NFP programs. Evidence shows that this program has successfully led to reductions in child abuse, neglect, and injury. For example, findings from a randomized trial of NFP in New York state showed decreases in state-verified rates of child abuse and neglect, as well as reductions in emergency department visits for injuries and ingestions for children.

States can quantify the success of programs like Triple P and NFP by measuring common ACEs. Since 2009, 32 states and Washington, D.C., have collected information about ACEs through their Behavior Risk Factor Surveillance System (BRFSS) surveys. States can include the optional BRFSS ACE module, adapted from the original CDC-Kaiser ACE study, to ask questions about abuse and family and household challenges.

A child’s earliest experiences are foundational for brain development, lifelong physical and mental health outcomes, educational attainment, and other important milestones. By addressing ACEs with positive parenting skills and abundant preventive services, state and territorial health departments can help prevent chronic diseases, enhance mental and behavioral health, and help children and families thrive.


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