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Teen Newsletter: Adverse Childhood Experiences (ACEs)

March 2023

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The David J. Sencer CDC Museum (CDCM) Public Health Academy Teen Newsletter was created to introduce teens to public health topics. Each newsletter focuses on a different public health topic that CDC studies. Newsletter sections include: Introduction, CDC’s Work, The Public Health Approach, Out of the CDC Museum Collection, and Teen Talk.

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Introduction – Adverse Childhood Experiences

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). ACEs can include abuse, neglect, household challenges, or other sources of adversity. This newsletter includes content on topics that may be difficult for some people to process, so take a minute to think about whether you want to continue reading.

Some specific examples of ACEs include emotional, sexual or physical abuse; emotional or physical neglect; household substance misuse, mental illness, suicide, divorce, incarceration, or violence; and other adversity like bullying, violence, natural disasters, war, or terrorism.

ACEs are linked to chronic health problems, mental illness, and substance use problems in adulthood. ACEs can also negatively impact education, job opportunities, and earning potential. These experiences can increase the risks of injury, sexually transmitted infections, involvement in sex trafficking, and maternal and child health problems (including teen pregnancy, pregnancy complications, and fetal death). They may also lead to a wide range of chronic diseases and leading causes of death such as cancer, diabetes, heart disease, and suicide.

Early adversity has lasting impacts on the future, include impacts leading to injury, poor mental health, poor maternal health, infectious disease, chronic disease, risky behaviors, and reduced opportunities.

 

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. These effects can also be passed on to their own children. Some children may face further exposure to toxic stress from historical and ongoing traumas due to systemic racism or the impacts of poverty resulting from limited educational and economic opportunities. Additionally, toxic stress from ACEs can change brain development and affect how the body responds to stress.

Some groups are more likely to have experienced ACEs, including: Black, Hispanic/Latino, or multiracial people; people with less than a high school education; people making less than $15,000 a year; people who are unemployed or unable to work; and lesbian, gay, bisexual, or transgender people.

ACEs are common. About 61% of adults surveyed across 25 states reported that they had experienced at least one type of ACE, and nearly 1 in 6 reported they had experienced four or more types of ACEs. Women and several racial/ethnic minority groups were at greater risk for having experienced 4 or more types of ACEs.

Preventing ACEs could potentially reduce a large number of health conditions, including up to 21 million cases of depression, 1.9 million cases of heart disease, and 2.5 million cases of overweight/obesity. Prevention can also save hundreds of billions of dollars in economic and social costs to families, communities, and society. To prevent ACEs, we must understand and address the factors that put people at risk for or protect them from violence. Creating and sustaining safe, stable, nurturing relationships and environments for all children and families can prevent ACEs and help all children reach their full potential.

CDC’s Work – Adverse Childhood Experiences

CDC’s National Center for Injury Prevention and Control (NCIPC) has helped protect Americans from injury and violence for more than 20 years. They work to understand how injury and violence impact all of us and what they can do to prevent it.

Within NCIPC, the Division of Violence Prevention (DVP) is focused on preventing violence and its consequences so that all people, families, and communities are safe, healthy, and free from violence. DVP works to understand Adverse Childhood Experiences (ACEs) and is committed to:

  • Preventing ACEs before they happen
  • Identifying those who have experienced ACEs
  • Responding to them using trauma-informed approaches to lessen future harms of ACEs

One example of DVP’s work is the VetoViolence website, which provides training resources about how to identify and protect people who are more likely to experience multiple types of violence in early childhood. Their Connecting the Dots tool helps explore links between different types of violence and their connection to ACEs.

The Public Health Approach – Adverse Childhood Experiences

Public health problems are diverse and can include infectious diseases, chronic diseases, emergencies, injuries, environmental health problems, as well as other health threats. Regardless of the topic, we take the same systematic, science-based approach to a public health problem by following four general steps.

For ease of explaining and understanding the public health approach for ACEs, we will focus on ACE prevention, strategies, and how surveys can incorporate questions to give us a better understanding of the effects of ACEs throughout adulthood.

  1. Surveillance (What is the problem?). In public health, we identify the problem by using surveillance systems to monitor health events and behaviors occurring among a population.

The original ACE study was conducted as a partnership between CDC and Kaiser Permanente and was administered from 1995 to 1997, with two waves of data collection. More than 17,000 Kaiser members from Southern California received physical exams and completed confidential surveys regarding their childhood experiences and current health status and behaviors. The ACE study allowed CDC to monitor ACE frequency and collect information on child abuse and neglect, household challenges, and other socio-behavioral factors.

Today, CDC’s Behavioral Risk Factor Surveillance System (BRFSS) is an annual, state-based, random-digit-dial telephone survey that collects data from U.S. adults regarding health conditions and risk factors. Since 2009, all 50 states plus the District of Columbia have included ACE questions for at least one year on their survey to collect data on how past ACEs may affect current health.

  1. Risk Factor Identification (What is the cause?). After we’ve identified the problem, the next question is, “What is the cause of the problem?” For example, are there factors that might make certain populations more susceptible to diseases, such as something in the environment or certain behaviors that people are practicing?

The results of these surveys have provided some key insights into factors that are linked to higher rates of adverse childhood experiences. Some of these risk factors include:

Individual and Family Risk Factors:

  • Experiencing caregiving challenges related to children with special needs (for example, disabilities, mental health issues, chronic physical illnesses)
  • Families with young caregivers or single parents
  • Low income
  • Adults with low levels of education
  • Experiencing high levels of parenting stress or economic stress
  • Caregivers who use spanking and other forms of corporal punishment for discipline

Community Risk Factors:

  • High rates of violence and crime
  • High rates of poverty and limited educational and economic opportunities
  • High unemployment rates
  • Easy access to drugs and alcohol
  • Communities where neighbors don’t know or look out for each other and there is low community involvement among residents
  • Few community activities for young people
  • Unstable housing and where residents move frequently
ACEs can accumulate and last beyond childhood. Children who repeatedly experience adversity can suffer from toxic stress. When toxic stress occurs, the brain releases fight or flight hormones like cortisol. This increases heart rate and blood pressure and damages the digestive and immune systems. Toxic stress can disrupt organ, tissue, and brain development. This can limit a person’s ability to process information, make decisions, interact with others, and regulate emotion. These consequences may follow a person into adulthood.
  1. Intervention Evaluation (What works?). Once we’ve identified the risk factors related to the problem, we ask, “What intervention works to address the problem?” We look at what has worked in the past in addressing this same problem and if a proposed intervention makes sense with our affected population.

Relationships with caring adults who are positive role models can prevent ACEs and improve future outcomes for young people. Caring adults could include teachers, coaches, extended family members, neighbors, or community volunteers. Connecting youth to caring adults and activities helps to ground them, improve their engagement in school, and establish positive networks and experiences.

Mentoring and after-school programs are ways to connect youth to other caring adults and activities. Mentoring programs pair youth with an adult volunteer with the goal of fostering a relationship that will contribute to the young person’s growth opportunities, skill development, academic success, and future schooling and employment outcomes. Mentoring programs may be delivered in a school or community setting and to youth of all ages, from early childhood through adolescence.

Big Brothers, Big Sisters is the oldest and best-known example of a one-on-one mentoring program. Evaluations of the program show that mentored youth are less likely to skip classes, skip school, initiate drug and alcohol use, or engage in physical fighting.

We can create positive childhood experiences by strengthening families’ financial stability, promoting social norms that protect against violence, helping kids have a good start, teaching healthy relationship skills, connecting youth with activities and caring adults, and intervening to lessen long-term harms.
  1. Implementation (How did we do it?). In the last step, we ask, “How can we implement the intervention? Given the resources we have and what we know about the affected population, will this work?”.

CDC’s goal is to stop violence before it begins. Prevention requires understanding the factors that influence violence. CDC uses a four-level social-ecological model to better understand violence and the effect of potential prevention strategies.

Diagram showing four shapes, each laid over the next, from top to bottom: individual, relationship, community, and societal.

This model considers the complex interplay between individual, relationship, community, and societal factors. It allows us to understand the range of factors that put people at risk for violence or protect them from experiencing or perpetrating violence. The overlapping rings in the model illustrate how factors at one level influence factors at another level.

Besides helping to clarify these factors, the model also suggests that to prevent violence, it is necessary to act across multiple levels of the model at the same time. This approach is more likely to sustain prevention efforts over time and achieve population-level impact.

Childhood experiences, both positive and negative, have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity. As such, ACEs are an important public health issue. In the video below, learn how everyone can help prevent ACEs by using strategies to create safe, stable, nurturing relationships and environments for all children.

Using The Public Health Approach helps public health professionals identify a problem, find out what is causing it, and determine what solutions/interventions work.

Out of the CDC Museum Collection – Adverse Childhood Experiences

In this month’s Out of the CDC Museum Collection we are featuring two publications on ACEs created by CDC in 2019. While these publications may not seem particularly historic in nature, our collections team works to preserve CDC’s present as well as its past so that it may be remembered by future generations. These publications show how CDC uses the communication of science and data in the critical work of effective education on Adverse Childhood Experiences.

The covers of the two CDC publications about ACEs that are described below. Each cover features photos of kids, families, and community members.

 

Preventing Adverse Childhood Experiences (ACEs) is a resource that helps states and communities prevent ACEs from happening and to lessen harms when ACEs do occur. It features six areas of focus that are based on evidence and describes why each is an effective approach using scientific data. Essentials for Childhood puts the research into action by providing concrete goals and steps a community or individual can take to reduce ACEs.

In 2020, CDC announced funding to support adverse childhood experiences (ACEs) monitoring and prevention. As part of this agreement, CDC supports six recipients that are implementing two or more prevention strategies from Essentials for Childhood. CDC has produced this resource to help states and communities take advantage of the best available evidence to prevent ACEs.

This publication outlines prevention strategies including:

  • strengthening economic supports to families
  • promoting social norms that protect against violence and adversity
  • ensuring a strong start for children
  • teaching skills
  • connecting youth to caring adults and activities
  • intervening to lessen immediate and long-term harms

To learn more about how the six organizations are implementing the CDC framework, visit the Preventing Adverse Childhood Experiences: Data to Action website.

 

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