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Prevent, Screen, Heal: Collective Action to Fight the Toxic Effects of Early Life Adversity

      Exposure to adverse Childhood Experiences (ACEs), including abuse, neglect, household dysfunction, and other early life adversities, have been associated with negative health outcomes across the life span.
      • Felitti V.J.
      • Anda R.F.
      • Nordenberg D.
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study.
      • Gilbert L.K.
      • Breiding M.J.
      • Merrick M.T.
      • et al.
      Childhood adversity and adult chronic disease: an update from ten states and the District of Columbia, 2010.
      • Kerker B.D.
      • Zhang J.
      • Nadeem E.
      • et al.
      Adverse childhood experiences and mental health, chronic medical conditions, and development in young children.
      Though the precise biological mechanisms explaining the association between ACEs and negative health outcomes are still being investigated, promising studies suggest that the chronic dysregulation of the stress response, often referred to as the toxic stress response, may result from exposure to severe or frequent stressors in the absence of protective or buffering factors. Effective intervention has a powerful potential to arrest the pathway between early adversity and negative health outcomes, improving the health and well-being of children. Sustaining widespread impact, however, will require collective action by multiple sectors, and with an understanding that children's health is a reflection of their socioecological realities.
      The Center for Youth Wellness, located in San Francisco, California, was created to apply the science on the biological impact of early adversity to improve the health of children. In partnership with the Bayview Child Health Center, a pediatric primary care clinic, we provide medical care and a range of wellness, mental health, and behavioral health interventions for children who screen positive for exposure to ACEs. This work has shown us both the opportunities and challenges of addressing early adversity and promoting resilience in a medical setting.
      As pediatric practitioners, we enjoy long-term relationships with our patients. We routinely assess our patients' health and development, and we are experienced in working with families to address developmental concerns and early signs of longer-term health risks. This facilitates our ability to introduce screening for ACEs and to engage families in conversations about childhood exposure to adversity.
      • Szilagyi M.
      • Halfon N.
      Pediatric adverse childhood experiences: implications for life course health trajectories.
      Kerker et al,
      • Kerker B.D.
      • Storfer-Isser A.
      • Szilagyi M.
      • et al.
      Do pediatricians ask about adverse childhood experiences in pediatric primary care?.
      however, found that only 4% of pediatricians surveyed routinely asked patients about 7 ACEs, indicating that there is opportunity to expand this effort considerably.
      In our practice, the clinical challenge has been the lack of clear pathways for clinical care. While ACEs screening has been an important step forward, we are in need of a standardized risk profile. A standardized risk profile would allow for more precise diagnostic and treatment options in the pediatric primary care setting as well as provide better information for research and evaluation on ACEs. Our current conceptualization of risk for long-term negative health outcomes is largely guided by findings from retrospective population level studies with adults. Development of a risk profile for the pediatric population requires greater investment and focus on research in prospective studies in pediatric populations.
      While screening is important, it cannot happen in isolation of treatment services. There is an insufficient body of evidence for interventions that address the physiological impact of ACEs. While the mental and behavioral health community has made strides in addressing the impact of trauma on children's developing brains, the primary care medical home has not translated the evidence on increased disease risk over the life course into clinical interventions. Furthermore, the current model of care lacks a focus on prevention. When a patient presents for a mental health issue, the neuroendocrine immune system has already reached a point of severe dysregulation resulting from exposure to ACEs. Deeper investigation into the causal mechanisms of the toxic effect of early adversity is necessary to develop appropriate primary care interventions. In addition, rigorous evaluation of interventions across disciplines and sectors is needed to ensure that efforts to improve the mental, behavioral, and physical health of individuals produce the intended effect.
      While pediatric practitioners have a critical role to play in identifying and addressing ACEs, we know large-scale impact will require collective action by multiple sectors. In particular, we see a need for research, intervention, and policy that address the 3 levels of prevention: primary, secondary, and tertiary.
      • Primary prevention requires preventing ACEs by addressing the root causes of childhood adversity. The increased attention to the topic of ACEs and their effects on children and families is creating greater awareness of the magnitude of the issue.
        • Nixon L.
        • Somji A.
        • Mejia P.
        • et al.
        Talking About Trauma: Findings and Opportunities From an Analysis of News Coverage.
        Continued efforts to educate families, child- and youth-serving professionals, and policy makers on impactful ways to prevent ACEs, including sector-specific and cross-sector initiatives, will help drive efforts toward primary prevention.
      • Secondary prevention requires reducing the duration of exposure to ACEs and preventing the onset of a toxic stress response. Thompson et al
        • Thompson R.
        • Flaherty E.G.
        • English D.J.
        • et al.
        Trajectories of adverse childhood experiences and self-reported health at age 18.
        found that children accumulate ACEs gradually over the course of their childhood. Early detection of ACEs and effective intervention could therefore have a powerful potential to decrease the impact of early adversity on negative health outcomes, improving the health and wellbeing of children. At the individual level, screening every child for ACEs exposure will aid in early identification. At the population level, surveillance efforts can do the same.
      • Tertiary prevention requires treating the effects of a toxic stress response. Medical interventions for the clinical management of pediatric diseases that are linked to the physiological effects of early adversity need to be developed and disseminated. As the science evolves to identify the precise clinical manifestations of a toxic stress response in children, health care organizations can work toward integrating behavioral and mental health services and improve institutionalized practices that promote healing for individuals exposed to trauma.
      Pediatric practitioners are well positioned to transform the way society responds to children exposed to significant ACEs, but they cannot resolve this public health crisis alone. Collective action is required to prevent, screen, and heal the toxic effects of early adversity. Together we can help children thrive.

      Acknowledgment

      Financial disclosure: Publication of this article was supported by the Promoting Early and Lifelong Health: From the Challenge of Adverse Childhood Experiences (ACEs) to the Promise of Resilience and Achieving Child Wellbeing project, a partnership between the Child and Adolescent Health Measurement Initiative (CAHMI) and Academy-Health, with support from the Robert Wood Johnson Foundation (#72512).

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        Adverse childhood experiences and mental health, chronic medical conditions, and development in young children.
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