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Adverse childhood experiences as a population health issue
The Adverse Childhood Experiences (ACE) Study mailed a questionnaire to 13,494 adults who had completed a medical evaluation at a large health maintenance organization, and 9,508 responded. It asked about seven categories of childhood exposure: psychological, physical or sexual abuse; violence against the mother; and living with household members who misused substances, were mentally ill or suicidal, or had been imprisoned (Felitti et al., 1998).
More than half of respondents reported at least one category, and one in four reported two or more. The study found a graded relationship: the more categories of exposure, the higher the risk of adult health problems. People with four or more categories, compared with none, had a 4- to 12-fold increase in risk for alcoholism, drug use, depression and suicide attempts, a 2- to 4-fold increase in smoking and sexually transmitted infections, and more heart disease, cancer, chronic lung disease and liver disease (Felitti et al., 1998).
Because ACEs are common and linked to many leading causes of death, they are a population-level issue rather than only an individual one.
Trauma-informed care
The Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) describes a trauma-informed approach as one that realizes how widespread trauma is, recognizes its signs, responds by building that knowledge into policies and practice, and resists re-traumatization. It sets out six principles:
- Safety
- Trustworthiness and transparency
- Peer support
- Collaboration and mutuality
- Empowerment, voice and choice
- Cultural, historical and gender issues
Applying the principles in a community clinic
| Principle | Nursing practice |
|---|---|
| Safety | A calm waiting area; explaining every step before touching a patient; offering a chaperone for exams |
| Trustworthiness and transparency | Being clear about what information is recorded and who sees it |
| Peer support | Partnering with community health workers and peer recovery specialists |
| Collaboration and mutuality | Setting care goals with patients rather than for them |
| Empowerment, voice and choice | Offering choices, such as which arm for a blood draw or whether to change into a gown |
| Cultural, historical and gender issues | Interpreters, staff training on historical trauma, and respecting gender identity |
Prevention at the population level
Public health nurses can also work upstream: home visiting for families with young children, parenting support, and linking families to food, housing and mental health services that reduce stress in the household. These help prevent ACEs, not only respond to their effects.
Limits of the evidence
The ACE Study relied on adults' recall of childhood, and its participants were mostly insured and middle class, so findings may differ in other groups. A high ACE score shows risk at the population level and should never be used to label an individual.
Conclusion
ACEs help explain why health problems cluster in some lives and communities. Trauma-informed care gives nurses a practical way to respond, and prevention work in families and communities can reduce ACEs in the next generation.
References
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/S0749-3797(98)00017-8
Substance Abuse and Mental Health Services Administration. (2014). SAMHSA's concept of trauma and guidance for a trauma-informed approach (HHS Publication No. SMA 14-4884). U.S. Department of Health and Human Services.
