Understanding Adverse Childhood Experiences, Pediatric SDOH

August 29, 2022 - As part of their pursuit of understanding and addressing social determinants of health, medical professionals should also consider adverse childhood experiences (ACEs).

According to data from the National Survey of Children’s Health, 34.8 million children across the US are impacted by ACEs, known as traumatic events experienced during childhood.

Figures from the Centers for Disease Control and Prevention show that 61 percent of adults can recount at least one ACE from their childhood, and about one in six were able to report they’d experienced four or more types of ACEs.

And considering the downstream impacts adverse childhood experiences can have on adult health, these issues are costly. CDC said the economic and social cost of ACEs rounds out to hundreds of billions of dollars annually. The agency said reducing ACEs in North America by 10 percent could result in $56 billion in cost savings each year.

Below, PatientEngagementHIT defines ACEs, outlines the consequences of adverse childhood experiences, and reviews the current state of ACE mitigation strategies.

What are adverse childhood events (ACEs)

According to the CDC, ACEs are “potentially traumatic events that occur in childhood (0-17 years).”

ACEs often relate to experiences of neglect, abuse, and family dysfunction, but according to Carmela Sosa, MD, the medical director of the Guilds Center for Community Health with Valley Children’s Hospital, ACEs can also be more expansive. Serious issues with common social determinants of health, like housing insecurity or food insecurity, can also make for potentially traumatic events.

“ACEs are just one piece of the complex interplay that makes up SDOH, and all are beyond a child’s control,” Sosa wrote in a resource for Central California Pediatrics.

Examples of ACEs

There is no exhaustive list of adverse childhood experiences, according to the CDC. However, some common adverse childhood experiences may include:

• Experiences of abuse, violence, or neglect
• Witnessing community or family violence
• Having a family member attempt or die by suicide
• Growing up in a household with substance use or mental health problems
• Family instability, like parental separation or household members being incarcerated

It’s important to note that many ACEs can compound. A child may experience abuse while also experiencing homelessness. Just like other social determinants of health, ACEs are complex and require serious study.

How ACEs affect adult health outcomes

Medical researchers have begun to quantify a link between ACEs and health outcomes into adulthood, finding that ACEs can affect heart health, mental health diagnoses, and other medical conditions.

Per the CDC, ACEs can result in risky behaviors that have further downstream impacts on health. Toxic stress, a significant consequence of ACEs, can have physical health impacts on brain development, immune systems, and stress response systems, which can impact attention, decision-making, and learning.

In August 2022, researchers from the National Institutes of Health and Eunice Kennedy Shriver National Institute of Child Health and Human Development identified a link between ACEs and premature death. Kids who experienced poverty in childhood saw a 41 percent increased risk for premature death compared to kids who did not have an ACE.

Living in poverty and being separated from a parent resulted in a 50 percent increased risk for premature death, while those who saw parental harshness and neglect had a 16 percent higher risk. Kids who experienced family instability had a 28 percent higher risk for premature death.

Kids who experienced two ACEs had a 27 percent higher risk of early death. For three ACEs, that figure was 29 percent, and for four, it was 45 percent.

According to Nemours Children’s Health, preventing ACEs can have positive impacts down the line. Preventing ACEs could reduce heart disease diagnoses by up to 1.9 million people and depression diagnoses by nearly 21 million people.

Preventing the consequences of ACEs

Importantly, not every child who experiences an adverse event struggles into adulthood, Sosa, from Valley Children’s, said.

“Studies show that protective factors such as having a nurturing bond with a caring adult, or having parents with a social support network can ameliorate the negative effects,” Sosa wrote. “Providers who work with children are optimally positioned to significantly impact the trajectory and long-term health and well-being of children’s lives by intervening through screening, referral, intervention and advocacy – being or connecting children and families to those protective, buffering supports.”

The CDC said preventing ACEs starts by protecting children from violence and other forms of neglect that constitute adverse experiences. That can foremost start with providing economic support for families and launching public education and bystander training campaigns.

Promoting social-emotional learning, increasing access to early childhood education, teaching parenting skills and family relationship approaches, and offering mentoring programs and connecting kids with other trustworthy adults outside the home may also be helpful.

When a kid has had an adverse experience, CDC said it will be important to intervene immediately. Strategies may include:

• Enhanced primary care
• Victim-centered services
• Treatment to lessen the harms of ACEs
• Treatment to prevent problem behavior and future involvement in violence
• Family-centered treatment for substance use disorders

Early intervention decreases the odds that a child will see a negative health impact into adulthood.

ACEs versus SDOH

Many pediatric healthcare organizations consider ACEs a subdomain of social determinants of health. Some common social determinants of health, like housing insecurity, are also considered adverse childhood experiences.

While SDOH and ACEs are not entirely one and the same, they are two sides of a similar coin, and some pediatric healthcare organizations are targeting them through similar initiatives.

Where SDOH and ACEs overlap is generally in the realm of trauma. Experiences with or witnessing violence is considered both an SDOH and an ACE, as are serious economic instability or homelessness.

But not every SDOH is an ACE. Social determinants of health like access to green space or access to transportation aren’t usually considered ACEs.