Abstract
In working to improve the health of North Carolinians, a broader emphasis has been placed on determinants of health, or non-medical drivers of health. Critical examples of health determinants are adverse childhood experiences, or ACEs, that affect early brain development and lifelong health and function. Multiple organizations and communities have come together to acknowledge the importance of prevention, address toxic stress and trauma in childhood, promote resiliency and trauma-informed care, and invest in the future of North Carolina through its children. This issue of the NCMJ highlights the prevalence and magnitude of ACEs in North Carolina and the effects on our children and the impact into adulthood, and how people and communities can come together to improve public health over the life course by addressing ACEs.
In 1998, a landmark study was published that looked at childhood experiences and current health status and behaviors, becoming one of the largest investigations of childhood abuse and neglect on lifelong health and well-being. The Adverse Childhood Experiences (ACE) study, conducted at Kaiser Permanente, focused on traumatic or stressful events experienced during childhood, such as abuse (physical, sexual, and emotional), neglect (physical and emotional), and household dysfunction (incarceration, mental illness, substance abuse, violence in home, or parental separation or divorce) [1]. Expansive research on the topic has consistently confirmed the critical importance of early childhood experiences on lifelong health and behaviors and multiple studies have evaluated the relationship between ACEs and different risk factors for disease, disability, and premature death [1, 3, 4]. In addition, ACEs often co-occur and are interrelated [2], with a strong cumulative, dose-response relationship with the number of ACEs, adoption of health risk behaviors, and both child and adult health outcomes [3, 4].
Beyond the risk factors identified in the ACE landmark study, additional toxic stress that affects child health and development has been considered [5, 6, 7]. The term toxic stress refers to excessive or prolonged activation of the stress response in the absence of protective factors due to ACEs such as child maltreatment, parental substance abuse, maternal depression, family violence, and even extreme poverty [8].
The understanding of how a child's experiences impact future life course has become more clear. Firstly, a child's experiences start prenatally and include previous intergenerational family trauma. Secondly, prolonged activation of the stress response system in the absence of protective factors is toxic to the developing brain, disrupting brain architecture and thus learning, memory, behavior, physiology, emotional regulation, and executive functioning [9]. The evidence from neuroscience, molecular biology, epigenetics, and genomics has demonstrated that early experiences and early stress become part of our bodies—stress can be “biologically embedded” in our physiology [10]. This disruption in physiology alters the stress response system, which in turn affects other organ systems, and the effects are lifelong and widen health disparities [11]. The ACEs Pyramid (see Figure 1) demonstrates the lifelong cascade of trauma and toxic stress leading to impaired neurodevelopment and social, emotional, and cognitive impairment. This then leads to adoption of health-risk behaviors, resulting in disease, disability, social problems, and early death [12].
Mechanism by Which Adverse Childhood Experiences Influence Health and Well-being Throughout the Lifespan
The health, social, and economic costs associated with ACEs and toxic stress are significant, and even more so when one considers the breadth of impact through adulthood and over generations. ACEs contribute to a variety of behavioral, mental, and physical health conditions, including smoking, cardiovascular disease, diabetes, emphysema, cancer, obesity, alcohol abuse, liver disease, drug abuse, high-risk sexual behavior, sexually transmitted infections, adolescent pregnancy, depression, anxiety, suicide, headaches, autoimmune disease, disability, and fetal death [13]. Those with 6 or more ACEs were found to have a 20-year shorter life expectancy than those with no ACEs [14]. A modeling study in England estimated that 11.9% of binge drinking, 13.6% of poor diet, 22.7% of smoking, 52.0% of violence perpetration, 58.7% of heroin/crack cocaine use, and 37.6% of unintended teenage pregnancy prevalence could be attributed to ACEs [15]. In addition, when considering the societal impact of ACEs such as job problems, work absenteeism, homelessness, exposure to violence, juvenile and criminal justice system involvement, poor academic achievement, and residential mobility, the impact is even larger. The lifetime economic toll for child maltreatment alone is over $124 billion, and this does not take into account other ACEs [16]. When considering poverty as an ACE, as highlighted in this issue by Hughes and Tucker [17], the costs to the United States are even higher (up to $500 billion) in reduced economic output and increased health and criminal justice spending [18].
Resilience
Resilience is considered the ability to withstand, adapt to, and recover from adversity [19]. Just as evidence has emerged on ACEs, research has also determined protective factors that dampen the adverse impact of ACEs and promote resilience. Protective factors include characteristics of family, community, and systems, such as safe, stable, nurturing relationships with adult caregivers; socioeconomic advantages or supports; and cohesive social networks and communities.
Protective factors can be both preventive and can contribute to resilience and recovery. In this issue, Austin takes a closer look at the prevalence of ACEs in North Carolina, the effects within the life course and development of children, and promotes an opportunity for improving population health [20]. Hirsch considers upstream prevention of ACEs as a preventive public health problem on which we spend countless resources and provides an example of efforts in Cumberland County [21].
Interventions
A number of policies and programmatic strategies have also emerged to promote family, community, and social supports that reduce or mitigate the impact of ACEs and toxic stress. Interventions to address poverty as an ACE include policies and programs that strengthen economic supports for families and promote family friendly work policies [22]. In this issue, Hughes and Tucker explore the effects of poverty, a pressing issue in North Carolina, and offer potential recommendations in quality child care, strengthening public supports, Earned Income Tax Credits, and family health care coverage as a means to promote family financial security to address poverty [17]. Among multiple other studied interventions, quality child care and early education have been shown to promote positive early childhood development and improve outcomes in adulthood, including by reducing criminal involvement, raising earnings, and improving adult health status [23].
In addition to prevention or mitigation strategies, the ability to address ACEs and recover from adversity has led to systems and organizations recognizing the necessity of trauma-informed philosophy that integrates understanding of trauma into policies and practices. The Substance Abuse and Mental Health Services Administration outlines 6 guiding principles of effective trauma-informed practice in the proposed framework: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment; voice and choice; and cultural, historical, and gender issues. These principles are also centered around 4 assumptions: 1) full realization of the widespread impact of trauma; 2) recognition of the signs and symptoms of trauma; 3) response with knowledge about trauma integrated into policies, procedures, and practices; and 4) resistance of retraumatization [24].
In the article “Trauma-informed primary care: prevention, recognition, and promoting resilience,” Earls further explains the importance of being trauma-informed, additional components of trauma-informed care, and building resilience—especially as it relates to the medical home, employing screening for social/emotional well-being, and providing trauma-informed care as key components of a holistically designed health care system [25]. Preisler and Stewart describe the importance of identification of trauma through child welfare screening to better address a high-need population, with an intentional approach to avoid re-traumatization [26]. Innovation in the delivery of trauma-informed care is highlighted in schools [27, 28], the justice system [29], child welfare systems [30], and communities [28]. All are necessary in the need for collaborative commitment and collective efforts to accomplish common goals.
As many are considering changes in structure and a trauma-informed approach to support addressing toxic stress in childhood, the article by Starsoneck and Ake examines innovative and proactive designs related to North Carolina's domestic violence response [31], and Idzikowski and Zachary look at available payment mechanisms for mobile crisis response teams under EPSDT and Medicaid, while acknowledging preventive mental health care is critical [32]. Steinberg and Lassiter explain how the Juvenile Justice Section of North Carolina's Department of Public Safety is working toward becoming trauma-informed [33], and Murphy discusses the role of payers in supporting ACE-informed, evidence-based treatment [34]. Innovation is emerging with this change in mindset throughout the nation, the state, and many localities including but not limited to Watauga, Buncombe, Cumberland, New Hanover, Edgecombe, and Halifax counties.
Conclusion
In summary, ACEs increase the risk of subsequent health issues, toxic stress converts adversity to impairment, and trauma-informed care provides guidelines for treatment, providing an opportunity to bring it all together for an integrated approach to health starting in the earliest years [35]. The growing body of evidence and literature around ACEs and toxic stress, in addition to expanding emphasis and public awareness, is a call to action, not only for North Carolina, but beyond. There is much interest, motivation, and innovation among individuals, communities, and organizations in North Carolina, and we need to continue the momentum moving forward with a common vision: to prioritize prevention of ACEs while developing appropriate trauma-informed responses, to break the cycle of trauma, and to promote resilient North Carolinians while becoming resilient as a state ourselves.
The toll on our children, their future, and our society, in the context of clear evidence, should motivate us all to look at opportunities to prevent adverse outcomes and to embrace the idea that adult diseases can be seen as early childhood developmental disorders due to ACEs, with opportunities for prevention and early intervention [11]. Medical innovations and technology have evolved over time, but so has our understanding of the root causes of disease to be better equipped for a prevention and public health strategy. Not only would we be caring for the child and the family, but also the community to further influence population health outcomes. The public health community, medical community, and others strive every day to combat health conditions such as chronic disease and mental illness, but often we are not focusing early enough or addressing true determinants. This frequently requires a multisector response.
ACEs are a risk factor more common and causal to many other public health issues facing our state, including tobacco use and opioid addiction. If we want to conceptualize broad population health and health equity, we have to recognize ACEs as a public health issue and address it from the very beginning, prior to each new life, thus investing in the well-being of current North Carolinians and generations ahead. It is time to come together with a strategic, coordinated public health approach to this crisis, invest in the future through our children, and promote supportive communities; safe, stable and nurturing environments; and strong, resilient children and families for a life course approach to North Carolina's health.
Acknowledgments
Thanks to Victoria Revelle for editorial assistance.
Potential conflicts of interest. K.K. and S.K. have no relevant conflicts of interest.
- ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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