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Population Health for Nurses

27.6 Impact of Adverse Childhood Experiences

Population Health for Nurses27.6 Impact of Adverse Childhood Experiences

Learning Outcomes

By the end of this section, you should be able to:

  • 27.6.1 Define adverse childhood experiences (ACEs).
  • 27.6.2 Describe the health needs of individuals who have experienced ACEs.
  • 27.6.3 Examine how the health needs of individuals with ACEs intersect with the social determinants of health.
  • 27.6.4 Identify the nurse’s role in preventing ACEs and caring for those who have experienced ACEs.

Adverse childhood experiences (ACEs) are traumatic childhood events that can have a lifelong negative impact on health (CDC, 2021a; CDC 2022a). Traumatic events may include experiencing violence or neglect, witnessing violence in the home or community, or having a family member attempt or die by suicide. Growing up in an environment that undermines a sense of safety, stability, or bonding—for example, in a household with substance use or mental health problems, instability due to parental separation, or a family member being incarcerated—also contributes to ACEs (CDC, 2022a). ACEs create toxic stress, or the prolonged activation of the stress response system, which disrupts the development of brain architecture and increases the risk for stress-related disease and cognitive impairment (Figure 27.8) (Harvard University Center on the Developing Child [HUCDC], 2023). A normal positive stress response is characterized by short increases in heart rate and mild elevation in hormone levels, as occurs commonly when receiving an injection. A tolerable stress response results in a greater degree of activation of the body’s stress response due to a more severe obstacle, such as the loss of a loved one or a natural disaster. If the duration of activation is limited and supported by caring relationships with adults, the brain can recover. The toxic stress response occurs when the child experiences frequent and prolonged adversity such as abuse, neglect, caregiver mental illness, or the accrued burden of economic hardship without adequate caregiver support.

Toxic stress from ACEs negatively affects children’s developing brains, immune systems, and stress-response systems, in turn affecting their attention, decision-making, and learning abilities (CDC, 2022a). ACEs’ effects increase over time, impacting lifelong health and opportunities (CDC, 2021b). The more ACEs an individual experiences, the higher their ACE score, and the more at risk they become for various poor health outcomes. Associated with chronic health problems, mental illness, and substance use in adulthood, ACEs are entirely preventable. In the United States, 61 percent of adults have at least one ACE, and 16 percent, one out of every six adults, have four or more ACEs (CDC, 2021b). Females and racial and ethnic minority groups are at greater risk for experiencing four or more ACEs (CDC, 2021b).

An illustration shows how adverse childhood experiences can effect people throughout their lives. In childhood, repeated chronic adversity can cause toxic stress, which releases fight or flight hormones like cortisol. Toxic stress increases heart rate and blood pressure and damages the digestive and immune systems. Toxic stress can disrupt organ, tissue, and brain development. This can impede a person's mental and social abilities, extending the consequences of toxic stress from A C E throughout a person's life.
Figure 27.8 This infographic demonstrates the lasting impact of ACEs. (See CDC, 2023a; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Health Needs of Children Experiencing ACEs

ACEs are linked to chronic health problems such as heart disease, diabetes, COPD, asthma, cancer, depression, and substance use problems (CDC, 2022a). Five of the leading causes of death are associated with ACEs, with higher numbers correlated with higher risks for poor health outcomes (CDC, 2019a). Preventing ACEs could reduce many adverse health conditions. The CDC estimates that preventing ACEs could help alleviate up to 21 million cases of depression and almost 2 million cases of heart disease; a 10 percent reduction in ACEs could save 56 billion dollars (CDC, 2022a; CDC, 2023b). Evidence shows that preventing ACEs could also positively impact socioeconomic challenges, such as reducing the number of adults who are unemployed or who do not graduate high school (CDC, 2021b). Data suggest that the best way to address these health care needs is to prevent ACEs from occurring in the first place. For those who have already experienced ACEs, many interventions can help the individual recover from the trauma caused by the toxic stress (HUCDC, 2023a).

How ACEs Intersect with the Social Determinants of Health

ACEs intersect with the social determinants of health related to economic stability, education, neighborhood and built environment, and social and community context. Individuals living with economic insecurity or poverty are at increased risk of experiencing ACEs or exposing their children to ACEs. Child maltreatment is more common among families experiencing poverty (Hargreaves et al., 2019). Experiencing food insecurity, moving residences frequently, and generally living in under-resourced neighborhoods all contribute to ACEs and cause toxic stress. ACEs negatively impact education, job opportunities, and income potential, resulting in increased risks of injury, sexually transmitted infections, maternal and child health problems, and involvement in sex trafficking (CDC, 2022a). Children who grow up with toxic stress face many struggles throughout life, such as difficulty forming stable relationships, maintaining a job, and staying financially secure. Adults can pass these effects on to their children, who may face additional exposure to toxic stress from poverty resulting from limited opportunities (CDC, 2022a).

The Nurse’s Role in Caring for Children Experiencing ACEs

To prevent ACEs, nurses must understand and address factors that put individuals at risk for violence (CDC, 2022a). Creating a safe and stable environment for children and families, with healthy relationships, is essential to helping children reach their full potential. The CDC encourages communities to adopt and utilize their six strategies for preventing ACES (CDC, 2022a):

  • Strengthen economic supports to families
  • Promote social norms that protect against violence and adversity
  • Ensure a strong start for children
  • Teach skills
  • Connect youth to caring adults and activities
  • Intervene to lessen immediate and long-term harms

The CDC also recommends raising awareness of ACEs to help change their perception and shift the focus from individual responsibility to broader solutions. Reducing the stigma around seeking help for parenting challenges, substance misuse, depression, and suicidal thoughts is another community-level strategy. These steps help create safe and stable neighborhoods and communities where each child can thrive (CDC, 2022a). Primary prevention is best, but when this is not possible, community and public health nurses can work with clients to assist them in accessing mental health counseling and treatment specific to trauma. Nurses can also utilize a trauma-informed approach grounded in trust and building rapport with the client, acknowledging that trauma and harm have occurred and finding ways to engage these clients in necessary health care. Some studies have demonstrated that meditation and breathing exercises can assist clients in reducing the effects of toxic stress (HUCDC, 2023a). Nurses have a role in primary, secondary, and tertiary prevention of ACEs (Table 27.7).

Primary prevention
Prevent early trauma to improve adult health by reducing sources of stress (CDC, 2021b)
  • Advocate for affordable housing
  • Advocate for a living wage
  • Advocate for more food assistance programs
  • Advocate for quality early childhood education programs that are accessible and affordable
  • Refer those with mental health disorders to appropriate counseling and therapy
  • Provide violence prevention and anger management classes
  • Provide parenting classes on how to build healthy, responsive relationships with children
  • Advocate for substance use disorder services management and treatment in every community
Secondary prevention
Identify clients with ACEs
  • Advocate for universal adoption of trauma-informed care in health care practice
  • Screen with a standardized ACEs-based tool to assign clients an ACE score based on a brief survey of their personal history
  • Assess clients for protective factors against ACEs
  • Refer clients to resources such as social work, school agencies, care coordination, and community health workers as appropriate
  • Screen for substance use issues and mental health illnesses annually, with referrals as necessary
Tertiary prevention
Reduce the impact ACEs have on health and promoting rehabilitation
  • Assist clients in creating their “own village” of social supports in their neighborhood
  • Educate clients on how to meditate and participate in breathing exercises
  • Encourage clients to participate in physical exercise
  • Advocate for more community-based health centers that focus on serving vulnerable populations
Table 27.7 Nurses’ Role in Primary, Secondary, and Tertiary Prevention of ACEs

Caring for vulnerable and disadvantaged populations and communities requires an interprofessional approach involving many community partners. It will take a concerted effort by health care professionals, government bodies, community organizations, school districts, and local and state policymakers to address the inequitable policies and discriminatory behaviors that affect disadvantaged populations. Nurses and other health care professionals have a major role to play in reducing health inequities in these populations. These professionals can work to change negative attitudes toward the disadvantaged, remove stigma, and advocate for more equitable policies to achieve health equity and social justice. Each of the six disadvantaged populations discussed in this chapter requires nurses who are caring, empathetic, and understanding of their unique lived experiences. Just as nurses should assess for the SDOH at every health encounter, nurses need to assess the lived experience of their clients and recognize that certain risk factors or characteristics place some individuals at inherent disadvantage.


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