Poverty as an Adverse Childhood Experience

Poverty is the most pressing public health issue facing the state, as it negatively impacts nearly every indicator of child well-being and affects more than 1 in 5 children [1, 2]. Poverty is a strong reinforcing factor in the accumulation of adverse childhood experiences (ACEs) and subsequent toxic stress correlated with unfavorable health outcomes in adulthood [3, 4]. Being poor is associated with so many childhood adversities that it may be considered an ACE in itself, more pervasive and persistent than all others. As children's economic circumstances are inextricably tied to those of their families, promoting family financial health by mitigating poverty as an ACE is critical to expanding opportunity for every child in North Carolina.

A growing body of evidence indicates that poverty is highly comorbid with ACE exposure [5] and that children living in poverty are more likely than their peers to experience frequent and intense adversities [6]. Such cumulative exposure to adversity causes stress that behaves as a toxin in the developing brain of a child. In the absence of protective factors, this toxic stress can change a child's neural architecture and result in emotional disorders and cognitive deficits [7]. A variety of childhood adversities have a root cause in family economic insufficiency [3], indicating that poverty may likely be the first adversity that many children experience. Poverty acts as a reinforcing mechanism, disproportionately burdening low-income families with stressors that give rise to adverse conditions, which then convey additional stress and cognitive dysfunction [8]. The devastating effect of this negative feedback loop on the development of children is well documented, and childhood poverty has been strongly linked to a variety of negative outcomes across the life course, including low educational attainment [9], increased exposure to violence [10], hunger [11], parental incarceration [12], and increased likelihood of being subject to abuse and neglect [13].

More than 490,000 children in North Carolina lived in families with incomes at or below the federal poverty level (FPL; $24,600 for a family of 4) in 2016, indicating a statewide public health crisis of massive scope. One in every 5 children in North Carolina is at risk of facing the adverse effects of poverty [2]. The crisis is even more pressing considering the state's continuing legacy of racial discrimination in access to capital and wealth accumulation, which has resulted in a higher incidence of poverty among racial/ethnic minority groups. In 2016, 12% of white children in North Carolina lived in families with incomes below the FPL. During the same year, poverty rates for many children of color were 3 times as high—33% for American Indian children, 34% for black children, and 36% for Hispanic/Latino children [14].

Researchers estimated in 2013 that child and youth poverty costs the United States nearly $500 billion each year in reduced economic output and increased health and criminal justice expenditures [15]. If North Carolina is to mitigate these largely avoidable costs, family economic security must become a public health priority. The state can decrease some of the impacts of poverty related toxic stress on children when their caretakers are able to afford access to basic needs, quality health care, education, and social experiences that promote optimal child development. Public policy investments can have a measurable impact on the economic well-being of children and families, and a variety of policy strategies are available to strengthen families in North Carolina.

• ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.