Make ACEs a Topic in Healthy People 2030!

The Salud America! team, along with Dr. Colleen Bridger of San Antonio Metropolitan Health District and Dr. Joe Hendershott of Hope for the Wounded Student, believe that adverse childhood experiences (ACEs) should be is own topic as part of Healthy People 2030.

Below is our full proposed ACEs topic, description, objectives, and rationale.

Click here to email this request to make ACEs its own topic to the U.S. Department of Health and Human Services by Jan. 17, 2019.

Proposed Topic Area: Adverse Childhood Experiences

An adverse childhood experience (ACE) is a stressful or traumatic experience during childhood that can impact lifelong health and well-being.

Early adversity, including child maltreatment, family member substance abuse, discrimination, and chronic poverty, can be toxic to developing brains and bodies, affecting mental and physical health, social development, and risk-taking behavior through the lifespan.

Decades of evidence confirms that exposure to ACEs increases the risks of injury, sexually transmitted infections, mental health problems, delayed cognitive development, reproductive health problems, involvement in sex trafficking, and chronic health conditions, which, in turn, can cause damage to the nervous, endocrine, circulatory, musculo-skeletal, reproductive, respiratory, and immune systems.

Lifetime costs from child maltreatment, for example, are approximately $124 billion each year in child and adult medical costs, productivity losses, child welfare, criminal justice and special education costs.

Many family, individual, and community risk factors for adverse emotional, behavioral, and relationship health outcomes, including low-income status, exposure to toxic stressors, and parental mental health problems, can be identified early using systematic surveillance and screening.

Proposed Developmental Objectives

1. Reduce the number of children and youth exposed to adverse childhood experiences.
   • Objective Rationale: Early exposure to adversity and individual, family or community stressors has notable effects on the hypothalamic-pituitary-adrenal axis and epigenetic processes, with short-term and long-term consequences, including early-onset of mental and physical health problems.
2. Increase the number of children and youth exposed to adverse childhood experiences who are identified and receive evidence-based trauma-informed care services.
   • Objective Rationale: Homelessness, poverty, heart disease, mental health deterioration, suicide, obesity, unintended pregnancy, sexually transmitted diseases, substance abuse, and countless other coping behaviors and physical ailments have been shown to be the direct result of adverse childhood experiences. If a person has six or more adverse childhood experiences, that person is more likely to die twenty years earlier than someone with no adverse childhood experiences.
3. Increase the proportion of Data Sources that report on adverse childhood experiences among adults.
   • Objective Rationale: Many family, individual, and community risk factors for adverse emotional, behavioral, and relationship health outcomes, including low-income status, exposure to toxic stressors, and parental mental health problems, can be identified early using systematic surveillance and screening.
4. Increase the proportion of physician office visits where children, youth, pregnant women, and adults are screened for adverse childhood experiences.
   • Objective Rationale: Many family, individual, and community risk factors for adverse emotional, behavioral, and relationship health outcomes, including low-income status, exposure to toxic stressors, and parental mental health problems, can be identified early using systematic surveillance and screening. In 2017, 18 states were considering 38 bills specifically targeting ACEs, to include appropriating funds for ACEs prevention, establishing task forces or study committees, and requiring or encouraging health care providers to use an ACE screening tool with their patients.
5. Increase the proportion of insurance companies that reimburse providers for screening for adverse childhood experiences.
   • Objective Rationale: Systems issues, including graduate medical education systems, access to trained providers of evidence-based treatment’s for very young children, and coding, billing, and payment structures all interfere with access to effective interventions.
6. Increase the proportion of local jurisdictions that include trauma-related indicators in their health improvement plan.
   • Homelessness, poverty, heart disease, mental health deterioration, suicide, obesity, unintended pregnancy, sexually transmitted diseases, substance abuse, and countless other coping behaviors and physical ailments have been shown to be the direct result of adverse childhood experiences. If a person has six or more adverse childhood experiences, that person is more likely to die twenty years earlier than someone with no adverse childhood experiences.
7. Increase the number of jurisdictions with accredited trauma-informed public health agencies.
   • Objective Rationale: Homelessness, poverty, heart disease, mental health deterioration, suicide, obesity, unintended pregnancy, sexually transmitted diseases, substance abuse, and countless other coping behaviors and physical ailments have been shown to be the direct result of adverse childhood experiences. If a person has six or more adverse childhood experiences, that person is more likely to die twenty years earlier than someone with no adverse childhood experiences.
8. Increase the number of accredited trauma-informed community-based organizations serving children and families.
   • Objective Rationale: For disadvantaged children, high-quality child care, education, and family support programs appear to act as buffers against physical and psychosocial adversity by providing stability and stimulation for the children themselves and by strengthening their parents’ abilities to meet their developmental and health needs at home.
9. Increase the number of schools that are trauma-informed accredited.
   • Objective Rationale: In Pennsylvania, 40.7% indicated that they had experienced the death of a close family member or friend in the past year. Making trauma-informed care available in schools will build resilience, help children overcome the impact of trauma, enable learning in school and reduce misbehavior and engagement in coping/risky behaviors.Trauma-informed schools promote (a) feelings of physical, social, and emotional safety in students; (b) a shared understanding among staff about the impact of trauma and adversity on students; (c) positive and culturally responsive discipline policies and practices; (d) access to comprehensive school mental and behavioral health services; and (e) effective community collaboration.
10. Increase the number of schools that have accredited trauma-informed discipline practices.
    • Objective Rationale: Children of color are more likely than white children to be expelled from school for misbehavior and are more likely to fall behind academically and engage in risky behavior, negatively affecting their health. Behavioral interventions are important because student’s behavior affects the social and learning environment of every student.
11. Increase the proportion of school staff that have received accredited trauma-informed training.
    • Objective Rationale: In the United States, 90 percent of students attend public schools and most children remain in the public school system for thirteen years. At any given time, two-thirds of American students are vulnerable to the effects of complex trauma. If subjected to prolonged, severe, unpredictable stress, a child in school may experience either hyperarousal or hypoarousal and may be in constant fight, flight, or freeze mode, causing other higher order functions to become secondary in importance. Children experiencing hyperarousal or hypoarousal are less able to learn and more likely to misbehave.
12. Increase the proportion of early care providers that have received accredited trauma-informed training.
    • Objective Rationale: For disadvantaged children, high-quality child care, education, and family support programs appear to act as buffers against physical and psychosocial adversity by providing stability and stimulation for the children themselves and by strengthening their parents’ abilities to meet their developmental and health needs at home. Making trauma-informed care available in schools will build resilience, help children overcome the impact of trauma, enable learning in school and reduce misbehavior and engagement in coping/risky behaviors.
13. Increase the number students who report school is a safe physical and emotional environment.
    • Objective Rationale: In Pennsylvania, 28.2% of students indicated they had been bullied at school in the past year, and 5% have been threatened at school at least once in the past year. Of students who indicated they had skipped school due to bullying fears in the past year, 65.8% had felt so sad or hopeless almost every day for at least two weeks that they stopped doing usual activities, 55.5% had considered suicide, 46.2% had made a suicide plan, and 44.8% had attempted suicide.

Proposed Research Objectives

1. Increase the proportion of health care providers that have received accredited trauma-informed training.
   • Objective Rationale: If a person has six or more adverse childhood experiences, that person is more likely to die twenty years earlier than someone with no adverse childhood experiences. Pediatricians and other child health care providers can reduce the risk of childhood emotional and behavioral problems by reducing exposure to toxic stress, promoting protective factors, and systematically screening for risk factors for emerging clinical problems. Pediatricians are a source of advice for parents and guardians concerning the management of child behavior, including discipline strategies that are used to teach appropriate behavior and protect their children and others from the adverse effects of challenging behavior.
2. Increase the proportion of physician office visits made by children, youth, pregnant women, and adults who have been exposed to ACEs that include evidence-based, trauma-informed counseling, education or referral.
   • Objective Rationale: Evidence-based treatment can address early childhood mental health problems effectively, reducing symptoms and impairment and even normalizing biological markers. Currently, most young children with an emotional, relationship, or behavioral problem receive no interventions for their disorder.
3. Increase the proportion of law enforcement and juvenile and criminal justice officers that have received accredited trauma-informed training.
   • Objective Rationale: Homelessness, suicide, substance abuse, and countless other coping behaviors and physical ailments have been shown to be the direct result of adverse childhood experiences.
4. Increase the proportion of academic institutions with health professions education programs whose prevention and population health curricula include accredited trauma-informed care training.
   • Objective Rationale: Pediatricians and other child health care providers can reduce the risk of childhood emotional and behavioral problems by reducing exposure to toxic stress, promoting protective factors, and systematically screening for risk factors for emerging clinical problems.
5. Increase the inclusion of accredited trauma-informed curriculum in early childhood education degree programs, undergraduate and graduate education, social work, counseling, and psychology degree programs.
   • Objective Rationale: Children respond to adversity differently. All adults with professional responsibilities for children need to know about biological and environmental factors, like adverse childhood experiences, that can contribute positively to or interfere with development, behavior, and learning. Supportive and stable relationships with adults can help develop children’s adaptive capacities and provide them with a significant stress buffer
6. Increase the number of states that require trauma-informed care training and best practices as core competencies and for teaching certifications.
   • Objective Rationale: In the United States, 90 percent of students attend public schools and most children remain in the public school system for thirteen years. At any given time, two-thirds of American students are vulnerable to the effects of complex trauma. If subjected to prolonged, severe, unpredictable stress, a child in school may experience either hyperarousal or hypoarousal and may be in constant fight, flight, or freeze mode, causing other higher order functions to become secondary in importance. Children experiencing hyperarousal or hypoarousal are less able to learn and more likely to misbehave.
7. Increase the inclusion of accredited trauma-informed curriculum in medical schools, undergraduate nursing, graduate nursing practitioner programs, physician assistant training, and schools of pharmacy.
   • Objective Rationale: Pediatricians and other child health care providers can reduce the risk of childhood emotional and behavioral problems by reducing exposure to toxic stress, promoting protective factors, and systematically screening for risk factors for emerging clinical problems. Pediatricians are a source of advice for parents and guardians concerning the management of child behavior, including discipline strategies that are used to teach appropriate behavior and protect their children and others from the adverse effects of challenging behavior.
8. Increase the number of schools that monitor absenteeism, suspensions, expulsions, and behavioral referrals that can be caused by exposure to adverse childhood experiences and connect students to accredited trauma-informed care services.
   • Objective Rationale: ACEs can affect children’s ability and willingness to attend school. In Pennsylvania, 28.2% of students indicated they had been bullied at school in the past year, and 5% have been threatened at school at least once in the past year. Of students who indicated they had skipped school due to bullying fears in the past year, 65.8% had felt so sad or hopeless almost every day for at least two weeks that they stopped doing usual activities, 55.5% had considered suicide, 46.2% had made a suicide plan, and 44.8% had attempted suicide.