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Promoting Lifelong Health and Well-being: Staying the Course to Promote Health and Prevent the Effects of Adverse Childhood and Community Experiences

      Safe, stable, nurturing families and communities are at the heart of healthy child development. Decades of research has shown that supporting a child's physical, cognitive, social, and emotional development sets them on a healthy path. For example, children with strong social competency (eg, recognizing feelings in themselves and others, managing their thoughts and emotions, and solving interpersonal problems) are more likely to go to college or hold a full-time job, and less likely to abuse drugs or alcohol or break the law.
      • Jones D.E.
      • Greenberg M.
      • Crowley M.
      Early social-emotional functioning and public health: the relationship between kindergarten social competence and future wellness.
      When parents read to young children, they form healthy attachments and have healthier cognitive development.

      Child Trends. Reading to young children: indicators on children and youth. Available at: http://www.childtrends.org/?indicators=reading-to-young-children. Accessed July 19, 2017.

      These are just a few of the ways we can give children the tools for healthy, productive lives.
      In contrast, adversity at a young age can have profound long-term effects. Children who face physical or emotional abuse, who reside with family members who abuse drugs or alcohol, or whose family lives in extreme poverty, are at higher risk for heart disease, cancer, and other illnesses.
      • 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.
      With a focus on leveraging children's health services, the research and commentaries in this issue of Academic Pediatrics synthesize perspectives across sectors and advance knowledge and models for measuring and addressing adverse childhood experiences (ACEs) in policy and practice, as part of the larger goal to promote early and lifelong health of children and strengthen families and communities, and also reflect the growing understanding that the early years are critical to creating a foundation, while emphasizing the possibility for promoting well-being in the face of adversity at all ages.
      For the Robert Wood Johnson Foundation, this commitment to supporting children and families from the start is foundational to our vision to build a culture of health: where everyone has an equal opportunity to be healthy, regardless of who they are, where they live, or how much money they have. Our Action Framework (www.cultureofhealth.org) translates that vision into steps for making real change and promoting health equity. We focus on equity because we recognize that health outcomes for many children are significantly worse than for others, and we know that is unjust.
      Early childhood is an opportune time to promote equity, because unaddressed disparities during the earliest years lead to intensified health problems and widening social, educational and economic gaps.

      Center for Disease Control Prevention. About the CDC-Kaiser ACE study. Available at: http://www.cdc.gov/violenceprevention/acestudy/about.html. Accessed July 19, 2017.

      Children who grow up in low-income families experience greater trauma and in turn suffer worse health and can have poorer educational outcomes, creating the cycle of poverty.
      • Dreyer B.
      • Chung P.J.
      • Szilagyi P.
      • et al.
      Child poverty in the United States Today: introduction and executive summary.
      These lifelong burdens can be attributed, in part, to the early life timing of adversities.
      • Szilagyi M.
      • Halfon N.
      Pediatric adverse childhood experiences: implications for life course health trajectories.
      However, studies show that interventions occurring in early childhood are effective in creating positive health outcomes for children and families.
      • Flynn A.B.
      • Fothergill K.E.
      • Wilcox H.C.
      • et al.
      Primary care interventions to prevent or treat traumatic stress in childhood: a systematic review.
      This special issue of Academic Pediatrics is the culmination of a 3-year initiative launched by the Child and Adolescent Health Measurement Initiative to raise awareness and motivate action to prevent and address ACEs among children. It began with the Spring 2013 publication of findings from the nation's first population-based assessment of ACEs and resilience among children, on the basis of data from the 2011/2012 National Survey of Children's Health. The article in this issue of Academic Pediatrics by Bethell and colleagues
      • Bethell C.D.
      • Solloway M.R.
      • Guinosso S.
      • et al.
      Prioritizing possibilities for child and family health: an agenda to address adverse childhood experiences and foster the social and emotional roots of well-being in pediatrics.
      on prioritizing possibilities continues the effort, summarizing findings from an in-depth, cross-sector research and policy agenda-setting process led by the Child and Adolescent Health Measurement Initiative and AcademyHealth. Biglan and colleagues'
      • Biglan A.
      • Van Ryzin M.
      • Hawkins J.D.
      Evolving a more nurturing society to prevent adverse childhood experiences.
      and Halfon and colleagues'
      • Halfon N.
      • Larson K.
      • Son J.
      • et al.
      Income inequality and the differential impact of adverse childhood experiences in US children.
      articles explain that to improve child health, there must be a reduction in health disparities by socioeconomic status, such as through community-building efforts. Bruner
      • Bruner C.
      ACE, place, race and poverty: Building hope for children.
      further explores how, for children to thrive, we must reduce exposure to racism and discrimination; reduce exposure to environmental toxins like lead, mold, and pollution in the buildings where they live or go to school; and create safe, stable places such as libraries and parks for children when they are not at home—a difficult task. The role of community-building is crucial because adversity faced by children early on is not just limited to experiences within their home, but also in their communities. This emphasizes the need for a cultural shift within communities that reduces adversities and promotes health, whether through interventions in schools, social services, and primary care settings, as suggested by Biglan,
      • Biglan A.
      • Van Ryzin M.
      • Hawkins J.D.
      Evolving a more nurturing society to prevent adverse childhood experiences.
      Porter,
      • Porter L.
      • Martin K.
      • Anda R.F.
      Culture matters: direct service programs cannot solve widespread, complex, intergenerational problems. Culture change can.
      Vu,
      • Vu C.
      • Rothman R.
      • Kistin C.J.
      • et al.
      Adapting the patient centered medical home to address psychosocial adversity: results of a qualitative study.
      and their coauthors.
      In addition to examining cross-sector strategies that children's health services can advance to reduce the effect of child adversity, articles in this issue of Academic Pediatrics compare and evaluate the validity of methods to measure ACEs in the larger context of promoting positive health. Bethell et al
      • Bethell C.D.
      • Carle A.
      • Hudziak J.
      • et al.
      Methods to assess adverse childhood experiences of children and families: towards approaches to promote child well being in policy and practice.
      explain that measuring and assessing adversities might contribute to promoting healthy development and social and emotional capacities of children and families. The articles in this issue of Academic Pediatrics also explore what can be done in systems of care and clinical practice, as highlighted by the examinations of the role of pediatricians written by Hassink.
      • Hassink S.
      Reclaiming the patient encounter.
      Vu et al
      • Vu C.
      • Rothman R.
      • Kistin C.J.
      • et al.
      Adapting the patient centered medical home to address psychosocial adversity: results of a qualitative study.
      and Brown and colleagues
      • Brown J.D.
      • King M.A.
      • Wissow L.S.
      The central role of relationships to trauma-informed integrated care for children and youth.
      amplify the importance of the provider training and the relational skills needed to address trauma and adversity. There is also a focus on how communities and families interact around issues of adversity and the implication for policies that can build family and community resilience. In their commentary, Jones and colleagues
      • Jones J.
      • Reidy M.C.
      • Hargreaves M.
      • Rog D.
      Translating brain science research into community level change.
      highlight the Change in Mind effort and the Mobilizing Action for Resilient Communities initiative, which together support a total of 30 communities across the United States and Canada, with a focus on changes to systems that can prevent childhood trauma and contribute to creating healthy, resilient communities. Furthermore, Beckmann
      • Beckmann K.A.
      Mitigating adverse childhood experiences through investments in early childhood programs.
      comments on the importance of investment in reducing child adversity and calls for greater investment of early childhood programs. Finally, Steverman and Shern
      • Steverman S.M.
      • Shern D.L.
      Financing mechanisms for reducing adversity and enhancing resilience through implementation of primary prevention.
      review existing means of financing such methods and discuss innovative approaches, such as pay for success funding mechanisms.
      There is still a long way to go in putting the research and policy agenda, study findings, and perspectives reflected in this special issue of Academic Pediatrics into practical action. However, we know it can be done. For example, in New Hampshire, Manchester's swift and compassionate response to the emerging opioid and heroin epidemic successfully mobilized first responders, school officials, and health care providers to connect residents with critical treatment services, setting a national example for other communities. Manchester's Police Department and local partners launched a first-in-the-nation Adverse Childhood Experiences Response Team in which police bring a crisis worker and case manager when responding to an incident where children are present. Two local schools welcomed staff from the city and local nonprofit organizations to help children and families apply for Medicaid, get dental treatment, talk to the electric company about a disputed balance, or find housing. They help keep kids engaged in their school, serve as mentors for students who are struggling, address behavior issues, and provide brief mental health interventions. Work like this—ensuring that schools and communities are working together to support children and families—earned Manchester a 2016 Robert Wood Johnson Foundation Culture of Health prize.
      Building a Culture of Health nationally requires cities and small towns across the country to follow Manchester's model and address the challenges their residents are facing in a way that is locally and culturally appropriate. This work will help support healthy development in our youngest citizens from the start, mitigating adversity so that we can promote equity and lifelong well-being. This special issue of Academic Pediatrics, aimed for child health practitioners, policy makers, researchers, and other key leaders and stakeholders, bolsters the case for why this effort is necessary, and how we can get there. We hope you will read it and respond with your own reflections.

      Acknowledgments

      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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