Reducing the Scale and Impact of Adverse Childhood Experiences in the United States

Although adverse childhood experiences (ACEs) negatively impact many people's health and life outcomes, most people are unfamiliar with the concept. ACEs are defined as ten potentially traumatic experiences categorized as abuse, neglect, or other household challenges that occur before a child reaches their 18th birthday. In the United States, ACEs are unfortunately common. More than half of adults have reported one ACE, and 13 percent of adults have reported four or more ACEs. 

Despite the prevalence of ACEs, prevention and mitigation of ACEs is lacking. While state child welfare departments respond to reports of child abuse, in general, they do not work in a coordinated manner to prevent or reduce the negative impact of ACEs.

The hallmark 1998 ACEs study “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study” first brought national attention to ACEs. This report identified the long-term impact of ACEs on range of poor health outcomes and health risk factors as well as the adoption of health-damaging behaviors, such as smoking cigarettes. The study found more than half of respondents reported at least one ACE. This is notable, as the sample was likely over representative of adults with higher household incomes, as the study was limited to adults who were members of the same HMO that visited the same clinic in Southern California between 1995 and 1996, and was likely not representative of all adults in the United States. 

Individuals with at least four ACEs are at an increased risk of poor health. These individuals are more susceptible to disease because the experience of chronic stress both compromises physiological development and leads to stress-reducing but ultimately health-damaging behaviors like smoking and alcohol consumptions. ACEs are costly. According to the Centers for Disease Control and Prevention, child abuse and neglect, which accounts for half of ACEs, costs the United States $124 billion a year.

However, it doesn’t have to be this way! Victims of trauma can recover. Research shows interventions can prevent and reduce the negative impact of ACEs. 

Policy makers who want to reduce the scale and impact of ACEs have many options. Four national-level policy options are outlined below.

Reimbursements for checkups that include ACEs screenings: Amending the Patient Protection and Affordable Care Act to require that insurance companies to provide reimbursements for ACEs screenings would encourage physicians to incorporate ACEs screenings into regular checkups. Most people are unfamiliar with ACEs, so providing individuals with their ACEs score could help people take better care of themselves. Studies show that people with an ACEs score of four or more are seven times more likely to become an alcoholic. Information is power. For example, this fact could inspire impacted individuals to approach drinking alcohol differently. Also, many individuals could benefit from screenings and being connected to resources, which could yield great economic returns. However, making this happen would require a great deal of political will. 

Ensure medical programs educate medical students on ACEs:  Setting up a national task force to investigate how to ensure medical programs educate medical students on ACEs is the first step to implementing this option. Along with the general public, most physicians are not familiar with ACEs, with one study reporting 76 percent of pediatricians as unfamiliar with the ACEs study. Adding to the issue, individuals with ACEs are more likely to distrust medical professionals. This may contribute to individuals with ACEs not getting the medical care they need. Educating medical professionals about ACEs would ensure they know how to best care for their patients with ACEs. One trade-off for this policy option is increasing physician’s responsibilities. However, this policy option would be low cost, and could yield great economic returns by reducing the impact of ACEs. 

Incorporate ACEs into health education for students: Amending the Common Core State Standards, which 41 states and Washington D.C. have adopted, to include ACEs in health education would ensure most students know about ACEs. Students would be educated about ACEs, their impact, and available resources that could help stop abuse or neglect and facilitate healing – all within their existing health class. The operational viability of this option is likely high, as schools already provide health education. One downside would be that nine states would be left out of this option. Again, there would likely be a great economic return although mitigating the impact of ACEs is difficult to quantify, and political feasibility would again depend on will. 

Require physicians to screen for ACEs and report data:  Amending the Patient Protection and Affordable Care Act to require physicians to screen for ACEs and report the data to the national government would ensure more individuals are aware of their ACEs score and the United States has a more accurate understanding of the prevalence of ACEs. This may be a difficult policy option to implement operationally; specifically, the implementation of a widespread, cohesive data collection system with robust security measures to ensure patient privacy could be a substantial undertaking. However, accurate data would allow for targeted interventions, and interrupting the development of ACEs in children and addressing existing ACEs in children and adults would benefit society as a whole.

This final option is the recommended policy option, as requiring all physicians to screen for ACEs and report data to the federal government would not only ensure individual ACEs are addressed as soon as possible, but also that the United States has a more accurate understanding of the prevalence of ACEs.

ACEs is not a diagnosis, but a tool. While opponents may argue that limited services – such as addiction services – may be available to deal with the impact of ACEs, especially in rural areas, an individual understanding their ACEs score is powerful. I know mine. I also know that people with an ACEs score of six or higher may get stuck on facts like that they are at risk of their lifespan being shortened by 20 years. But there are things we can do to mitigate this. Remember: we are more susceptible to disease because of differences in our development, but also because of increased likelihood of adoption of health-damaging behaviors. Knowing your ACEs score can empower you to change your life and better understand your coping mechanisms. You cannot control what happened to you as a child, but you can understand how it impacts you as an adult, and understand how you can best take care of yourself.

But ACEs are not just an individual or a family problem. It is a societal problem. ACEs impact our schools, our work places, our hospitals, our prisons, our communities. The economic cost of not screening for ACEs is evident. It is imperative that we begin to treat ACEs like the public health crisis that it is. 

Eliminating the Achievement Gap in New Mexico

Throughout the United States, low-income and minority students enter kindergarten less prepared than their peers, creating an achievement gap that never closes.

The achievement gap became a nationally-recognized hot topic in education with the 1966 publication of the Coleman Report, a wide-reaching report on educational equity commissioned by what was then known as the U.S. Office of Education. The study found, among other things, a significant gap in achievement between white and black students that only widened with each passing grade.  After the Coleman Report sounded the alarm, many other studies followed, finding that all across the United States low-income and minority students enter school behind.

New Mexico mirrors the nation in that low-income and minority students enter kindergarten less prepared than their peers.

Universal prekindergarten is more effective at boosting achievement than voluntary or targeted prekindergarten, particularly for students from low-income households. Research indicates that racially and socioeconomically diverse classrooms benefit all students. While this intrinsically makes sense (we learn most from people who are different from us!) this is useful information for New Mexico, as the state currently uses a targeted model that can lead to segregation of students by income. Braiding funding sources, for example between federally-funded Head Start and state-funded prekindergarten, would lead to more diverse prekindergarten classrooms and benefit both students and the state.

Prekindergarten programming quality matters. For example, research shows that teachers matter more to student success than any other aspect of schooling. Some research also suggests that a prekindergarten teacher’s level of education impacts student success.  This is important as New Mexico state-funded prekindergarten is split between the Public Education Department and the Children Youth, and Families Department – which have different prekindergarten teacher licensure requirements.  Lead prekindergarten teachers funded through the Public Education Department need a bachelor’s degree, while prekindergarten teachers funded through the Children, Youth, and Families Department do not.  Clearly, equality in licensing requirements is needed to ensure equality in prekindergarten programs.  Equal quality is important as research shows low-income and minority students receive substandard programming, even in state-funded prekindergarten.

In addition to prekindergarten, extending the school year is a promising strategy to eliminate the achievement gap. New Mexico’s K-3 Plus program, which extends the school year for 25 days for students in kindergarten through third grade, is shown to improve student performance when executed correctly. Students who participated in K-3 Plus were more likely to be on grade level according to standardized tests than students who did not participate.

So, what do we do to ensure school does not reproduce the social and structural inequalities that arguably created the achievement gap in the first place? Combining universal prekindergarten and K-3 Plus programming would help narrow our persistent achievement gap. 

Research shows that universal prekindergarten is more effective than voluntary prekindergarten at improving outcomes for low-income and minority students.  While this would be a costly policy to implement, early education is cheaper than later education. The average per pupil spending on prekindergarten in 2017 was $5,008, which is cheap compared to New Mexico’s total per pupil spending of $9,693. However, implementing universal prekindergarten would not be easy, as it would require infrastructure investments to build new prekindergarten classrooms as well as hiring new and assistant teachers when New Mexico is experiencing a teacher shortage. That said, prekindergarten is a sound financial investment for the state, especially as recent research from the Legislative Finance Committee finds state-funded prekindergarten improves student outcomes through the eleventh grade.

K-3 Plus has been shown to improve student performance, but currently only one in three students have access to K-3 Plus in New Mexico. However, for K-3 Plus to be effective, it must be implemented correctly. For this reason, schools should be required to keep K-3 Plus students with the same teacher they had during the regular school year, and programs should end no more than two weeks before the start of the regular school year.  While implementing K-3 Plus will incur additional costs such as staffing and maintenance due to the nature of extending the school year, it will help mitigate summer learning loss for students.

Stacking these early childhood education intervention strategies will allow for a greater impact than if they are implemented on their own. Prekindergarten has the potential to boost achievement for low-income and minority students, and K-3 Plus has the potential to build on the gains made in prekindergarten. Implementing both these programs will likely lead to a narrowing of achievement gaps in New Mexico. The cost of making both of these programs universal will be substantial. However, the U.S. Department of Education asserts that high-quality prekindergarten not only narrows achievement gaps, but increases earnings for students when they become adults, and provides a return on investment of $8.60 for every $1 spent. For these reasons, it’s time to implement universal prekindergarten and K-3 Plus in New Mexico.