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.
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