Childhood experiences, both positive and negative, have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity. As such, early experiences are an important public health issue. Much of the foundational research in this area has been referred to as Adverse Childhood Experiences (ACEs).
Adverse Childhood Experiences have been linked to
- risky health behaviors,
- chronic health conditions,
- low life potential, and
- early death.
As the number of ACEs increases, so does the risk for these outcomes. The wide-ranging health and social consequences of ACEs underscore the importance of preventing them before they happen. CDC promotes lifelong health and well-being through Essentials for Childhood – Assuring safe, stable, nurturing relationships and environments for all children. Essentials for Childhood can have a positive impact on a broad range of health problems and on the development of skills that will help children reach their full potential.
Adverse Childhood Experiences
ACE stands for Adverse Childhood Experiences which occur prior to your 18th birthday. Examples of adverse childhood experiences are physical, sexual and emotional abuse, as well as physical and emotional neglect. They also include, having a parent who is mentally ill, an alcoholic or substance abuser, in jail, or a victim of domestic violence, as well as the absence of a parent through divorce, death or abandonment. These are all ACEs.
Research has shown that traumatic, or stressful events in childhood (ACEs), injure a child’s brain, impairing the brain’s physical development and function. ACEs may cause kids to have difficulties learning, making friends, and trusting adults.
Your health could be impacted by your childhood experiences.
As adults, these experiences don’t go away. Multiple stressful events in childhood, may resurface in adulthood. The ACE Study found a stunning link between multiple stressful events in childhood (ACEs) and chronic diseases, as well as social, emotional and behavioral problems. These included heart disease, lung cancer, diabetes and many autoimmune diseases, as well as depression, mental illness, suicide, and being a victim of violence.
Each type of trauma counts as one. At least 70% of our population has an ACE score of at least one. As your ACE score increases, so does the risk of disease, social and emotional problems.
Your ACE Score
There are 10 types of stressful events in childhood in the ACE Study.
Five are Personal
emotional abuse
physical abuse
sexual abuse
emotional neglect
physical neglect
Five are Related to Other Family Members
absence of a parent though divorce, death or abandonment
a mother or stepmother who was treated violently
a household member who abused alcohol or drugs
a household member who was diagnosed with a mental illness
a household member who went to prison
Each type of event counts as one point of your ACE Score.
The higher the ACE Score is, the more likely a person is to experience an increased risk for the following health problems and diseases:
- Alcoholism and Alcohol Abuse
• Illicit Drug Use
• Early Initiation of Smoking
• Smoking
• Early Initiation of Sexual Activity
• Adolescent Pregnancy
• Multiple Sexual Partners
• Sexually Transmitted Diseases (STDs)
• HIV - Unintended Pregnancies
• Fetal Death
• Risk for Intimate Partner Violence
• Depression
• Suicide Attempts
• Health-Related Quality of Life
• Chronic Obstructive Pulmonary Disease (COPD)
• Ischemic Heart Disease (IHD)
• Liver Disease
*Note: Of course, there are many other types of stressful childhood events — watching a sibling being abused, losing a caregiver (grandmother, mother, grandfather, etc.), homelessness, surviving and recovering from a severe accident or experiencing a natural disaster, etc. The ACE Study includes the 10 most common stressful childhood events experienced by the 17,000 participants in the Kaiser ACE Study. These 10 stressful childhood events have been well studied in research literature. Your ACE score is meant to be a guideline. If you experienced other types of toxic stress as a child, over months or years, these events would likely increase your risk of disease, social and emotional problems in adulthood.
Treatment:
“We had been talking about historical trauma for ten years and the impact of poverty in our community,” said Hietpas. “When we heard the message about trauma and the science of ACEs, it just made sense.”
The clinic started with educating parents: encouraging kindness, love, and positive tactics that add to a child’s resiliency. Their next focus was the Menominee Indian School District, making resiliency a part of the everyday education system in hopes of stopping the cycle of intergenerational trauma. Then, they moved to the community, holding trainings to build trauma-informed care awareness at all levels in the tribe.
Learn more about Fostering Futures in Menominee Nation in RHIhub’s Rural Health Models and Innovations.
Much like Buncombe County’s ACE Learning Collaborative, champions for Fostering Futures represent an array of organizations that work alongside the Menominee Tribal Clinic. Agencies that were once hesitant to get involved with helping youth have become some of the most engaged. “It’s finally happened and we are expanding our partnerships within the community. We are now on a journey to improve the health of our community that will include cross-sector collaboration with a patient-centered care approach,” said Waukau.
Treating ACEs: “The Doctor Will Question You Now”
While mental health practitioners are essential in the effort to treat ACEs, it’s the primary care providers who often are the first responders to ACEs in rural communities. CDC’s Essentials for Childhood Framework states that providers conducting well-child visits can capitalize on the opportunity to do something about them by talking with parents about the importance of healthy family relationships and practices.
ACE screenings also help determine a patient’s ACE score, which can identify an increased risk of behavioral and physical health problems. Coopey is part of an ACE Learning Collaborative workgroup that educates primary care and mental health providers on the benefits of using the ACE questionnaire in their practices. The group has been pleasantly surprised by the number of medical providers who have agreed to give ACE screenings, but still receive some pushback. “It’s hard because I think physicians are doers and they want a solution, but with ACEs, there’s not necessarily one answer,” explained Coopey. Although the ACE questionnaire gives a score based on the answers, there aren’t set guidelines on how to treat patients based on their score.
The Menominee Tribal Clinic displays information about ACEs on their lobby’s bulletin board.
Coopey advises providers to start with compassion, because a patient’s noncompliance could be the result of a multitude of reasons the patient can’t even put into words. “Understand that a person often isn’t trying to be defiant or doesn’t care about taking their medicine,” said Coopey. “People’s adverse experiences affect how they interact with medical care – their ability or desire to take their medications and do what they need to do to care for themselves.”
Coopey also suggests that providers can learn from MAHEC’s obstetrics program that uses motivational interviewing during prenatal visits to discuss how parental ACE scores could affect childrearing. “To be able to present it to someone in a non-judgmental way can be difficult, so this is a good way to do it.”
You can’t just give a stranger this ACE test and expect that everything’s going to be fine. There has to be a good, trusting relationship there. People need to be ready to talk about it because it’s very personal.
The Menominee Tribal Clinic will soon start ACE screenings and resiliency questionnaires for WIC families and obstetrics patients. Hietpas is training staff on how to preface ACE questionnaires with an explanation. She added, “You can’t just give a stranger this ACE test and expect that everything’s going to be fine. There has to be a good, trusting relationship there. People need to be ready to talk about it because it’s very personal.”
This is where rural providers have an advantage — because of their close-knit environments, many rural clinicians have already built those trusting relationships, making it easier to ask personal questions and receive an honest response.
Hope for Menominee and Buncombe County Youth
Hietpas and Waukau recognize that, with the amount of trauma and transgenerational trauma, progress to reach their goal of “no child in Menominee County ever having an ACE again” most likely won’t be in their lifetime. But there is hope. “If we don’t create hope for those kids, it becomes a hopeless situation, and then what? They’re another statistic and they’ll continue the same cycle their parents were in,” said Waukau.
In the past, Menominee Nation has rallied behind efforts to reduce alcohol abuse and other harmful behaviors. With this new focus on ACEs and trauma-informed care, they are hoping for the same spirit. “Come back and talk to us in five, ten years, but for right now, we’ll take those little wins – one family at a time. That’s how we are going to build this change process,” stated Waukau.
The question ‘What is wrong with this child?’ is being replaced with ‘What has happened to this child?’
Buncombe County School District has learned many lessons through the implementation of Compassionate Schools. There are pockets of evidence proving their efforts are paying off. “Principals are saying, ‘This makes a difference, more than anything we have ever done,’” relays Thompson. He has also seen a shift in the way teachers look at their students. The question “What is wrong with this child?” is being replaced with “What has happened to this child?”
As with any new initiative, there is still work to be done, but Thompson is encouraged by the potential this model has to launch healthy students into the world. “We want our students to be both college, career, and community-ready,” he stated. “You are not going to ever be able to avoid problems in life, but how you are able to bounce back and respond is the key.”
When working with children affected by ACEs, Coopey tries to identify with their needs, remembering that their experiences carry on into adulthood and, ultimately, form our future societies. Coopey reminds educators, medical providers, psychiatrists, and advocates of mental health of their significant role in a child’s life: “There are plenty of people who have a high number of ACEs and are doing alright,” she said. “Often, they had that one safe, stable, nurturing adult who was able to give them skills to cope in their situation and to support them.”
Prior to your 18th birthday:
- Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
No___If Yes, enter 1 __ - Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
No___If Yes, enter 1 __ - Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
No___If Yes, enter 1 __ - Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
No___If Yes, enter 1 __ - Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
No___If Yes, enter 1 __ - Was a biological parent ever lost to you through divorce, abandonment, or other reason ?
No___If Yes, enter 1 __ - Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
No___If Yes, enter 1 __ - Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
No___If Yes, enter 1 __ - Was a household member depressed or mentally ill, or did a household member attempt suicide? No___If Yes, enter 1 __
- Did a household member go to prison?
No___If Yes, enter 1 __
Now add up your “Yes” answers: _ This is your ACE Score
