The term Adverse Childhood Experiences (ACEs) comes from the landmark 1998 study by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente. (1) (2) It describes 10 categories of adversities in three domains experienced by age 18 years:

• Abuse: physical, emotional, or sexual

• Neglect: physical or emotional

• Household challenges: growing up with household incarceration, mental illness, substance dependence, parental separation or divorce, or intimate partner violence

Data show that 62% of California residents have experienced at least one ACE and 16% have experienced four or more ACEs, using 2011-2017 Behavioral Risk Factor Surveillance System (BRFSS) data from a random-digit-dialed telephone survey. (3)

Key findings of the ACE Study and subsequent body of research include:

1. ACEs are highly prevalent. Two thirds of respondents in the ACE Study reported at least one ACE and one in eight reported four or more ACEs. Subsequent studies have shown a rate of four or more ACEs that is closer to one in six. (4) (5)

2. ACEs are strongly associated, in a dose-response fashion, with some of the most common and serious health conditions facing our society today, including at least nine of the 10 leading causes of death in the U.S. (6) (7)

3. ACEs affect all communities. The original ACE Study was conducted among a population that was mostly Caucasian, middle class, employed, college educated, and privately insured. Subsequent studies have found higher prevalence rates of ACEs in people who are low-income, of color, justice-

involved, and/or part of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community. (8) (9) (10) (11) (12)

Several decades of scientific research have identified the biological mechanisms by which early adversity leads to increased risk of negative health and social outcomes through the life course. Repeated or prolonged activation of a child’s stress response, without the buffering protections of trusted, nurturing caregivers and safe, stable environments, leads to long-term changes in the structure and functioning of the developing brain, metabolic, immune, and neuroendocrine responses, and even the way DNA is read and transcribed. This is known as the toxic stress response. (13) (14) (15) (16)

These biological changes play an important role in the clinical progression from ACE exposure to negative short- and long-term health and social outcomes. Further, both the disrupted biology and the associated negative outcomes demonstrate a pattern of high rates of intergenerational transmission. Development of the toxic stress response is influenced by a combination of cumulative adversity, buffering or protective factors, and predisposing vulnerability.

In addition to ACEs, social determinants of health (SDOH), such as poverty, discrimination, and housing and food insecurity, are associated with health risks and may also be risk factors for toxic stress. While validated odds ratios are available in large, population-based studies utilizing the 10 standardized ACE criteria, the strengths of associations between SDOH and health outcomes have not been similarly standardized.

These ACE-Associated Health Conditions include:

• Pediatric Health: The effects of toxic stress are detectable as early as infancy. In babies, high doses of adversity are associated with failure to thrive, growth delay, sleep disruption and developmental delay. School-aged children may have increased risk of viral infections, pneumonia, asthma and other atopic diseases, as well as difficulties with learning and behavior. Among adolescents with high ACEs, somatic complaints – including headache and abdominal pain, increased engagement in high-risk behaviors, teen pregnancy, teen paternity, sexually transmitted infections (STIs), mental health disorders, and substance use – are common.

• Adult Health: ACEs are associated with some of the most common and serious health conditions facing our communities. (18) People with 4 or more ACEs are: o 37.5 x as likely to attempt suicide (19) o 3.2 x as likely to have chronic lower respiratory disease (20) o 2 to 2.3 x as likely to have a stroke, (21) cancer, (22) or heart disease (23) o 1.4 as likely to have diabetes (24)

The higher the ACE score, the greater the risk for ACE-Associated Health Conditions.

• Mental and Behavioral Health: The higher the ACE score, the greater the likelihood an individual may experience mental health disorders such as depression, post-traumatic stress disorder, anxiety, and sleep disorders, and to engage in risky behaviors such as early and high-risk sexual behaviors and substance use. (25) (26) High doses of childhood adversity are associated with increased risk of engaging in high-risk behaviors that can lead to negative health outcomes.

However, even in the absence of health-damaging behavior, strong associations between cumulative childhood adversity and increased risk of serious health conditions persist. Evidence suggests that the toxic stress response likely plays a role in mediating both behavior-related and non-behavior-related pathways.

By screening for ACEs, providers can better determine the likelihood a patient is at increased health risk due to a toxic stress response, a critical step in responding with trauma-informed care.

Trauma-informed care recognizes and responds to the signs, symptoms, and risks of trauma to better support the health needs of patients who have experienced ACEs and toxic stress.

Trauma-informed care is a framework that involves: (1)

• Understanding the prevalence of trauma and adversity and their impacts on health and behavior;

• Recognizing the effects of trauma and adversity on health and behavior;

• Training leadership, providers, and staff on responding to patients with best practices in trauma-informed care;

• Integrating knowledge about trauma and adversity into policies, procedures, practices and treatment planning; and

• Resisting re-traumatization by approaching patients who have experienced ACEs and/or other adversities with non-judgmental support.

Principles of Trauma-Informed Approaches to Care

The following key principles of trauma-informed care should serve as a guide for all health care providers and staff:

• Establish the physical and emotional safety of patients and staff

• Build trust between providers and patients

• Recognize the signs and symptoms of trauma exposure on physical and mental health

• Promote patient-centered, evidence-based care

• Ensure provider and patient collaboration by bringing patients into the treatment process and discussing mutually agreed upon goals for treatment

• Provide care that is sensitive to the patient’s racial, ethnic, and cultural background, and gender identity

Anticipating Patient Emotional Responses & Avoiding Re-Traumatization

ACE screening can induce a spectrum of emotional reactions in patients. Screening requires patients to reflect on and revisit upsetting parts of their lives, which may activate distressing feelings or thoughts for patients and for providers conducting the screenings.

Some people who have experienced ACEs or other adversities may feel shame, blame, anger, sadness, and/or embarrassment. However, some patients find the experience empowering and report a positive emotional response to being able to make important connections between ACEs, toxic stress, and their current health, and to receiving appropriately focused care.

Patients with higher ACE scores with an identified screen were more likely to have strong emotional reactions, both positive and negative, according to pilot data. De-identified ACE screening was much less likely to elicit a strong emotional reaction for patients, either positive or negative.

Therefore, it is important for providers to administer screenings in a trauma-informed manner that avoids re-traumatization. There are several ways providers can avoid re-traumatization:

• Maintain emotional safety by approaching patients who have experienced ACEs and other adversities with non-judgmental support. Assess for, recognize, and integrate patient strengths and experiences into a jointly formulated treatment plan.

• In the primary care context, providers can provide supportive, compassionate responses to trauma histories of ACEs or other adversities without eliciting specific details.

• Empower patients by providing education on simple things they can do every day, at home, to recognize how stress shows up in their bodies and help regulate their stress response system and buffer the negative impacts of toxic stress. Find these strategies to regulate the stress response.

• Refer patients to mental health providers who are trained in evidence-based trauma-specific therapy, if necessary.

• Practice compassionate resilience to maintain provider well-being while caring for patients to be able to combat compassion fatigue, burnout, secondary traumatic stress, vicarious trauma, and related concerns.

It is well established that early identification and intervention are key to ameliorating the impacts of toxic stress and reducing the risk of negative health and social outcomes. The ACEs and Toxic Stress Risk Assessment Algorithms (ADA version) help providers assess whether a patient is at low, intermediate or high risk of a toxic stress physiology. The algorithm’s toxic stress risk assessment is based on a combination of both the ACE score and the presence or absence of ACE-Associated Health Conditions.

The treatment strategy consists of education to help patients recognize and respond to the role past or present stressors may be playing in their current health conditions and addressing toxic stress physiology as a core component of treating ACE-Associated Health Conditions.

For both children and adults, addressing current stressors, increasing the total dose of buffering and protective factors such as safe, stable and nurturing relationships and environments are associated with decreased

metabolic, immunologic, neuroendocrine, and inflammatory dysregulation, and improved physical and psychological health.

When treatment comes later in life, it is known that for individuals with ACEs, addressing the resulting toxic stress physiology is important for improving ACE-Associated Health Conditions, as well as for averting future consequences.

Clinical response to identification of ACEs and increased risk of toxic stress should include:

1. Applying principles of trauma-informed care including establishing trust, safety, and collaborative decision-making

2. Identification and treatment of ACE-Associated Health Conditions by supplementing usual care with patient education on toxic stress and strategies to regulate the stress response including:

   • Supportive relationships, including with caregivers (for children), other family members, and peers

   • High-quality, sufficient sleep

   • Balanced nutrition

   • Regular physical activity

   • Mindfulness and meditation

   • Access to nature

   • Mental health care, including psychotherapy or psychiatric care, and substance use disorder treatment, when indicated

3. Validation of existing strengths and protective factors

4. Referral to needed patient resources or interventions, such as educational materials, social work, care coordination or patient navigation, community health workers, as well as the seven pillars listed above

5. Follow-up as necessary, using the presenting ACE-Associated Health Condition(s) as indicators of treatment progress