Academic Literature

PUBLISHED STUDIES

Adverse Childhood Experiences and Mental Health in Young Adults: A Longitudinal Survey

Schilling, Elizabeth A., Robert H. Aseltine, Jr., and Susan Gore. “Adverse Childhood Experiences and Mental Health in Young Adults: A Longitudinal Survey.” BMC Public Health 7 (March 7, 2007). http://www.biomedcentral.com/1471-2458/7/30.

IMPORTANT DATA AND TAKEAWAYS

From the Abstract:
"Where racial/ethnic differences existed, the adverse mental health impact of ACEs on Whites was consistently greater than on Blacks and Hispanics." (1)

Study Design:
The current study investigates the prevalence of a variety of lifetime ACEs reported by a sample of racially and economically diverse high school seniors, and estimates the impact of these experiences on three mental health outcomes–depression, drug use, and antisocial behavior–assessed two years later. In addition, this study investigates under-explored gender
and racial/ethnic differences in these associations. (2)

Significant racial/ethnic differences are also evident in the prevalence data in Table 2. Approximately 1 in 6 White
respondents reported that one of their parents had a drinking or drug problem, a rate approximately 50% higher than the rate reported by Blacks, and 30% higher than the rate reported by Hispanics. 1 in 4 Black and Hispanic respondents reported witnessing a serious injury or murder, a rate twice as high as that reported by Whites. Finally, about 1 in 6 Hispanics reported being threatened with a weapon, held captive, or kidnapped. This rate was 43% higher than the rate reported by Whites and almost two times higher than the rate reported by Blacks.

Hispanics reported the highest depressive symptoms (M =1.88, SD = .55) followed by Blacks (M = 1.80, SD = .52)
and Whites (M = 1.65, SD = .49). Whites reported the highest levels of drug use (M = 1.34, SD = .57) followed by Hispanics (M = 1.13, SD = .31) and Blacks (M = 1.08, SD = .15). The frequency of antisocial behaviors did not differ between these three groups: Whites (M = .14, SD =.53), Blacks (M = .14, SD = .52), Hispanics (M = .12, SD =.31). Table 5 presents racial/ethnic differences in the effects of ACEs among Whites, Blacks, and Hispanics. These data indicate that the mental health effects of a number of ACEs are consistently stronger among Whites than among Blacks or Hispanics. In fact, the cumulative effect of adversity as well as three individual ACEs–(a) sent away from home, (b) parent with drinking/drug problem and, (c) being threatened with a weapon or held captive–are significantly associated with drug use among Whites only.

Because of the fluidity and malleability of roles during this period (see [40]), the transition to adulthood offers a potential "turning point" in the lives of disadvantaged youth. For example, previous research has shown that both post-secondary education and supportive romantic relationships positively influence the lifecourse trajectories of at-risk young adults [41-45]. Moreover, these roles are likely synergistic in their influence: One of the benefits of higher education in women is that it delays establishment of committed romantic relationships, resulting in higher quality marriages [43,44] which promote better mental health [46]. Clearly, strategies for preventing serious childhood adversity would be most beneficial: however, the malleability of young adulthood may provide additional opportunities to re-direct lifecourse trajectories in a positive direction and to prevent the adult mental health consequences of ACEs. (8)

Our results indicate that when racial/ethnic differences exist, young Whites consistently
exhibit greater vulnerability to ACEs, particularly for externalizing behaviors. One explanation is that these results may illustrate a "steeling effect" [48] in which youths in some ethnic groups are better able to successfully cope with stress and adversity and are consequently less prone to mental health difficulties. Research on coping processes may provide support for this explanation, as there is evidence that cognitive coping styles more typical among ethnic subcultures may explain differential racial/ethnic vulnerability to stress [26]. For example, differences in coping styles partially explain greater vulnerability to PTSD among Hispanic compared to Black and White police officers (see [27]), and greater religiosity, found among Blacks compared to Whites, has been found to be protective [49]. (8)

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Adverse Childhood Experiences and Sexual Risk Behaviors in Women: A Retrospective Cohort Study

Hillis, Susan D., Robert F. Anda, Vincent J. Felitti, and Polly A. Marchbanks. “Adverse Childhood Experiences and Sexual Risk Behaviors in Women: A Retrospective Cohort Study.” Family Planning Perspectives 33, no. 5 (October 2001): 206–11.

From the Abstract:

Results: Each category of adverse childhood experiences was associated with an increased risk of intercourse by age 15 (odds ratios, 1.6-2.6), with perceiving oneself as being at risk of AIDS (odds ratios, 1.5-2.6) and with having had 30 or more partners (odds ratios, 1.6-3.8) After adjustment for the effects of age at interview and race, women who experienced rising numbers of types of adverse childhood experiences were increasingly likely to see themselves as being at risk of AIDS: Those with one such experience had a slightly elevated likelihood (odds ratio, 1.2), while those with 4-5 or 6-7 such experiences had substantially elevated odds (odds ratios, 1.8 and 4.9, respectively). Similarly, the number of types of adverse experiences was tied to the likelihood of having had 30 or more sexual partners, rising from odds of 1.6 for those with one type of adverse experience and 1.9 for those with two to odds of 8.2 among those with 6-7. Finally, the chances that a woman first had sex by age 15 also rose progressively with increasing numbers of such experiences, from odds of 1.8 among those with one type of adverse childhood experience to 7.0 among those with 6-7.

Conclusions: Among individuals with a history of adverse childhood experiences, risky sexual behavior may represent their attempts to achieve intimate interpersonal connections. Having grown up in families unable to provide needed protection, such individuals may be unprepared to protect themselves and may underestimate the risks they take in their attempts to achieve intimacy. If so, coping with such problems represents a serious public health challenge. (206)

The ACEs examined in this study: Physical abuse, verbal abuse, sexual abuse, witnessing of intimate partner violence, living with adult family members who are substance abusers, who are mentally ill or suicidal, or who have ever been imprisoned. [7 of 10 ACEs] (206)

Earlier publications from the Adverse Childhood Experiences Study have also demonstrated a strong association between exposure to adverse childhood experiences and two reproductive health outcomes--unintended pregnancy and sexually transmitted disease (STD) infection. (206)

"Among the women who had had any one of the types of adverse experiences, the proportion who had had sex by age 15 ranged from 12% to 17%, while among those who had not had an adverse childhood experience, these proportions ranged from 6% to 8%. Thus, the relative risks of having intercourse before age 15 were significantly associated with each of the seven categories of adverse childhood experiences..."

Of all associations between individual categories of adverse childhood experiences and sexual risk behaviors in women that were considered, the strongest association was between verbal abuse and having 30 or more sex partners (relative risk, 3.8). (208)

"Unadjusted odds ratios for sexual risk behavior generally rose with increasing exposure to adverse childhood experiences." (209)

"When we adjusted for the effects of age and race, the odds ratios for having 30 or more partners and for perceiving oneself as being at risk for AIDS steadily increased with increasing exposure to types of adverse childhood experiences." (209)

"Our finding regarding the dose-response association between sexual risk behaviors and adverse childhood experiences were robust: After adjusting for age and race, we found that the odds ratios for sexual risk behaviors increased along with the frequency of childhood exposure to physical and verbal abuse." (210)

"...it is possible that the sexual risk behaviors of individuals with histories of adverse childhood experiences represent desperate attempts to achieve intimate interpersonal connections. Growing up in families unable to provide needed protection, these individuals may be unprepared to protect themselves and may grossly underestimate the risks they are taking in their hopeful, yet potentially misguided, attempts to achieve the intimacy that may have been lacking in their childhood. If hope and optimism for the future are meager, risky behaviors may appear to have less potential for negative impact." (210)

"To date, common public health interventions that have focused on reducing sexual risk behaviors include delaying initiation of sexual intercourse and increasing use of condoms. Interventions that have focused on changing these sexual risk behaviors have met with only modest success, which suggests that programs attempting to alter sexual behavior after their development may be insufficient to achieve their desired magnitude of change." (210)

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Assessment for and Response to Adverse Childhood Experiences

Waite, Roberta, Patricia Gerrity, and Roxana Arango. “Assessment for and Response to Adverse Childhood Experiences.” Journal of Psychological Nursing & Mental Health Services 48, no. 12 (December 2010): 51–61.

Abstract: Literature strongly suggests that early exposure to adverse childhood experiences (ACEs) disrupts crucial normal stages of childhood development and predisposes these individuals to subsequent psychiatric sequelae. Even with these data, little is found in nursing literature that discusses ACEs and their impact on adult mental health. Therefore, the purpose of this article is to address how nurses approach communication with clients about and assess for traumatic life experiences. In addition, screening measures for ACEs will be presented, along with discussion about ethical responsibilities of health professionals and researchers in asking about abuse. (51)

A helpful summary of the original ACE Study:
"Thus, the ACE study shows that time alone does not heal certain adverse experiences; undeniably, time conceals these adversities." (53)

About the importance of screening for ACEs, despite the possible discomfort involved:
Becker Blease and Freyd (2006) noted that it is not disclosure by itself that appears to result in harm, but rather negative responses the victim receives when disclosing trauma. Mental health clinicians and primary care providers must therefore receive training in how to ask about traumatic experiences and respond to disclosures. Not only do they need to be prepared to provide referral sources to clients, but also to respond in a supportive manner to such disclosures (i.e., with emotional support, belief, validation, information, or tangible aid) and to avoid negative exacerbations in reactions to what the victim shares (Read, Hammersley, & Rudgeair, 2007). (53)

NOTE: This is ultimately a call for empathy and solidarity. These values are best articulated and embodied from an explicitly Christian, theological perspective, and can be integrated into such practices as those explored in this study.

Becker-Blease and Freyd (2006) described that most communication targeting the ethics of self-report research on abuse focuses on the risks of asking participants about experiences with violence and assumes participants receive no direct benefits. This perspective is based on commonly held beliefs and suppositions that asking about abuse is disconcerting, harmful, and stigmatizing. Further embedded in these assertions are implicit assumptions that survivors are not emotionally secure enough to assess risk or seek help, and that researchers have an responsibility
to protect survivors from questions about their experiences (Becker-Blease & Freyd, 2006). These researchers also recognized that concern about the vulnerability of survivors and the desire to protect them from harmful questions about their experiences is based chiefly on researchers’ personal beliefs. Notably, individuals are grateful to know that others care about these issues (Becker-Blease & Freyd, 2006). For example, Lothian and Read (2002) indicated that when mental health service users were asked whether questions about sexual abuse should be included in mental health assessments, the overall response from service users was:

There are so many doctors and registrars and nurses and social workers and psychiatric district nurses in your life asking you about the same thing, mental, mental, mental, but not asking you why. It took ten years, many admissions, a lot of different medication, ECTs [electroconvulsive therapies]. No-one was able to draw out any abuse issues until my very last admission when a psychologist asked me, “Have you been abused?” I think there was an assumption that I had a mental illness and you know because I wasn’t saying anything about my abuse I’d suffered no-one knew. I just wish they would have said, “What happened to you? What happened?” But they didn’t. (p. 101) (53-54)

When nurses ask about childhood abuse and the answer is “yes,” it is paramount they respond fittingly. All patients need to be asked about abuse because of the high prevalence of maltreatment across nearly all mental diagnostic categories. The temptation to query only patients with select symptoms (e.g., PTSD) reflects a restricted, linear view of the impact of trauma. Also, spontaneous disclosure rates are low; hence, waiting for patients to disclose abuse is not useful (Havig, 2008). Nurses must actively elicit each person’s narrative and be ready with facts about what procedures need to be in place to support patients if and when disclosure about abuse occurs. (55-56)

Delay of inquiry at an initial assessment should be clearly recorded, including why, and the clinician needs to take responsibility for following up with the patient. Clinicians who wait for a “magic moment” or when rapport is on target should remember that, for many abused patients, asking may be a necessary act that encourages rapport, rather than creating a barrier to it. Lothian and Read (2002) reported that for some patients, asking about child abuse may even be a condition for gaining rapport. (56)

When framing questions, asking “Were you sexually (or physically) abused?” is not an effective form of inquiry. Many patients may not use these terms in relation to their experiences. If asked directly, some individuals may report that they were not physically abused; however, if asked how discipline was managed in their family, the patient may respond, “Oh, I was whipped often with a branch, extension cord, anything my mom could get her hands on.” (56)

Practice guidelines and recommendations for a number of specific psychiatric and non-psychiatric medical conditions include an assessment of abuse history; however, no published guidelines exist for how and under what conditions adults should be screened for childhood abuse histories in primary care settings. This is remarkable, considering Springer et al. (2003) reported that 20% to 50% of patients in adult primary care settings have a history of physical or sexual abuse. (57)

Culturally sensitive assessment of ACEs necessitates that screening questions and understanding patient responses accurately reflect their experiences, without any bias projected through the assessment process. (57)

Foremost, it is important to focus more on the relationship with the client than on the abuse and to respond appropriately to what the client disclosed (Young et al., 2001). Validation of the person’s experience and reactions to disclosure will communicate both the understanding and the nonjudgmental stance of the clinician. It is best not to imply that the person “should” have treatment of any kind; however, it is important that the clinician describe what services are available. (58)

Moreover, we propose that it is an ethical imperative for nurses to ask about ACEs; not doing so further supports the social forces that perpetuate trauma and violence as pervasive social
and public health problems. Consideration should not focus on whether to ask, but how to
ask about peoples’ experiences with abuse, given the enormous mental and physical health implications from unrecognized and untreated abuse. (59)

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Association Between Adverse Childhood Experiences and Diagnosis of Cancer

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Community Violence Exposure, Adverse Childhood Experiences, and Posttraumatic Distress Among Urban Development Workers

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Do Adverse Childhood Experiences Increase the Risk of Postdeployment Posttraumatic Stress Disorder in US Marines?

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Gender Differences in the Association of Adult Hopelessness with Adverse Childhood Experiences

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Population Attributable Fractions of Psychiatric Disorders and Suicide Ideation and Attempts Associated with Adverse Childhood Experiences

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Predictability of Physical and Psychological Violence by Early Adverse Childhood Experiences

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Risk Factors for Unfavorable Pregnancy Outcome in Women with Adverse Childhood Experiences

Leeners, Brigitte, Werner Rath, Emina Block, Gisela Görres, and Sibil Tschudin. “Risk Factors for Unfavorable Pregnancy Outcome in Women with Adverse Childhood Experiences.” Journal of Perinatal Medicine 42, no. 2 (March 2014): 171–78.

ABSTRACT
Aims: To explore the association between childhood sexual abuse (CSA), physical abuse, as well as other
adverse childhood experiences (ACE), and different obstetrical risk factors/behaviors.

Methods: In this cohort study, obstetrical risk factors and perinatal outcome in 85 women exposed to CSA were compared to 170 matched unexposed women. CSA, physical abuse, and ACE were explored by face-to-face interviews and by questionnaire. Data on perinatal outcome were extracted from medical charts. Fisher’s exact, χ2-test, and multiple logistic regression were used for statistical analysis.

Results: During pregnancy women with CSA experiences were significantly more often smoking (31.7%/9.4%; P < 0.0001), had partners abusing drugs (10.6%/1.2%; P < 0.0005), experienced physical (16.5%/0; P < 0.0001), sexual (12.9%/0; P < 0.0001), and emotional abuse (44.7%/1.7%; P < 0.0001), reported depression (24.7%/1.8%; P < 0.0001), and suicidal ideation (10.6%/0; P < 0.0001) than women without CSA experiences. Differences in risk factors were more often correlated with physical than with sexual abuse during childhood. The probability for premature delivery was associated with CSA, physical abuse and ACE as well as with several of the risk factors investigated.

Conclusion: Women with CSA, physical, and ACE present with a variety of abuse-associated obstetrical risk factors and an increased risk for premature delivery. Therefore, all types of abusive and other ACE should be considered in prenatal care.

IMPORTANT DATA AND RESULTS

Note the multiple "0" ratings for Women not exposed to CSA.

The average time between the beginning of CSA and the index-pregnancy was 22.7 (range 0.5-40) years. (174)

During pregnancy 62.4% (n=52) of the women exposed to CSA and 95.9% (n=163) of the unexposed women were either married or in a stable relationship (P<0.0001) (174)

A total of 34 (40%) of women with a history of CSA and 22 (12.9%) of the women without such a history had experienced physical abuse during childhood (P < 0.001). Out of these, all women had experienced pain and 28.2% (n = 24) bruises, cuts, burns, and/or fractures. Other ACEs were reported by 47 (55.3%) of the women with CSA experiences and by 18 (10.6%) of those without (P<0.001). (174)

A total of 15 (17.6%) women with CSA experiences reported physical and/or sexual abuse during pregnancy compared to none of the women without such experiences (P < 0.001). (174)

The presented data show interesting details on potentially mediating factors between childhood experiences and premature delivery. The negative impact of smoking on pregnancy outcome has been known for decades [13, 23]. In addition to other results [6], the presented study showed that it is not CSA itself but physical abuse, likely in combination with CSA, which seems to be relevant for this association. Smoking is known to relieve stress, unhappiness, depression, and anxiety, which can be increased during pregnancies in women with abusive childhood experiences [11]. (176)

Depression, especially when associated with intimate partner violence, has been proven to further
increase the risk for unfavorable pregnancy outcome [7, 27]. Farber et al. [5] hypothesized that in women with CSA experiences pregnancy may reactivate feelings of helplessness and create fears to be unable to protect the child from similar experiences. In such situations, fantasies of the death of oneself and the unborn infant might be perceived as a solution. Our results are in line with those
of other authors who showed an association between a history of CSA and an increased risk for depression [14] as well as suicidal ideation [31] during pregnancy. The increase of the risk for prenatal depression following CSA is reported to be 2.6-fold [25], the increase following lifetime physical or sexual abuse to be 1.5-fold, and 1.7-fold, respectively [24]. (176)

As the number of low weight infants was rather small in the presented study group, we were unable to investigate the direct association between the investigated risk factors and birth weight on a reliable basis. However, in line with recently published data on the effect of posttraumatic stress disorder resulting from a childhood abuse history on gestational age at delivery [28], our study confirms a strong association between abusive and other ACE and premature delivery. ... However, recent results showing increased cortisol awakening responses, that is, a dysregulation of the hypothalamic-pituitaryadrenal axis might explain the underlying pathophysiological mechanism for causal relations between abusive childhood experiences and adverse pregnancy outcome [4]. (177)

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Setting the Stage for Chronic Health Problems: Cumulative Childhood Adversity among Homeless Adults with Mental Illness in Vancouver, British Columbia

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Suicidal Ideation, Parent-Child Relationships, and Adverse Childhood Experiences: A Cross-Validation Study Using a Graphic Markov Model

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The Relationship of Adverse Childhood Experiences to a History of Premature Death of Family Members

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The Role of Beliefs, Attitudes and Adverse Childhood Experiences in Predicting Men's Reactions Towards Their Spouses' Violence

JOURNAL ARTICLES // STUDY SUMMARIES

Adverse Childhood Experiences and Adolescent Violence

“Adverse Childhood Experiences and Adolescent Violence.” Brown University Child & Adolescent Behavior Letter 26, no. 6 (June 2010): 3.

IMPORTANT DATA AND TAKEAWAYS

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Adverse Childhood Experiences and Adult Health

Felitti, Vincent J. “Adverse Childhood Experiences and Adult Health.” Academic Pediatrics 9, no. 3 (June 2009): 131–32.

IMPORTANT DATA AND TAKEAWAYS

"The most important findings of the Flaherty article are that adverse childhood experiences are surprisingly common even in the earliest years, are generally unrecognized, can be identified during childhood by history from children and caretakers, and can start to manifest their damage as ill health and somatization during childhood itself." (131) [Article cited: Flaherty EG, Thompson R, Litrownik AJ, et al. Adversé childhood exposures and reported child health at age 12. Acad Pediatr. 2Ó09;9: 150-156.]

"As was demonstrated in the ACE Study, what happens in childhood--like a child's footprints in wet cement--commonly lasts through life. Time does not heal; time conceals." (131)

Two broad mechanisms exist by which adverse childhood experiences transform into biomédical disease:

  • disease as the delayed consequence of various coping devices like overeating, smoking, drug use, and promiscuity; for example, adverse childhood experiences —*depression or anxiety —> overeating —• type 2 diabetes—• coronary artery disease;
  • disease caused by chronic stress mediated by chronic hypercortisolemia and proinfiammatory cytokines; for example, chronic headache or back pain, primary pulmonary fibrosis, osteoporosis, coronary artery disease. (131)

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It's OK to Ask About Past Abuse

Edwards, Valerie J., Shanta R. Dube, Vincent J. Felitti, and Robert F. Anda. “It’s OK to Ask About Past Abuse.” American Psychologist 62, no. 4 (June 2007): 327–28.

IMPORTANT DATA AND TAKEAWAYS

The Acceptability of Asking about Previous Abuse and Trauma in the ACE Study

A 24-hour hotline was provided for participants in the original ACE Study  "if they experienced distress from receiving or completing the survey. However, over a 24-month period of data collection, the hotline did not receive a single call." (327)

 "The overall response rate to the survey (68%) is indicative of the acceptability of asking people about their possible childhood abuse experiences. ... The nonresponse rates to individual questions on the ACE study questionnaire among survey respondents were also low (1.3% to 6.9%), indicating that more than 90% of survey respondents found direct, behaviorally oriented questions about their childhood history of maltreatment and household dysfunction to be acceptable." (327)

IMPLICATION: In the right context, it should also be safe for these things to be explored within a Trauma-Informed Ecclesiology.  

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The Enduring Effects of Abuse and Related Adverse Experiences in Childhood: A Convergence of Evidence from Neurobiology and Epidemiology

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The Prevalence of Adverse Childhood Experiences (ACE) in the Lives of Juvenile Offenders

Baglivio, Michael T., Kimberly Swartz, Mona Sayedul Huq, Amy Sheer, and Nancy S. Hardt. “The Prevalence of Adverse Childhood Experiences (ACE) in the Lives of Juvenile Offenders.” OJJDP Journal of Juvenile Justice 3, no. 2 (Spring 2014): 1–23.

Summary: "Florida study confirms link between juvenile offenders, ACEs; rates much higher than CDC's ACE Study" (From Aces Too High)

IMPORTANT DATA AND TAKEAWAYS

From the Abstract:
This study examines the prevalence of ACEs in a population of 64,329 juvenile offenders in Florida. This article reports the prevalence of each ACE and assigns an ACE composite score across genders and a risk to reoffend level classification, and compares these with ACE studies conducted on adults. Analyses indicate offenders report disturbingly high rates of ACEs and have higher composite scores than previously examined populations. Policy implications underline the need to screen for and address ACEs as early as possible to prevent reoffending and other well-documented sequelae.

ACE Prevalence
The top three most prevalent ACE indicators were the same for both males and females: family violence, parental separation or divorce, and household member incarceration. Two-thirds or more of the Florida juvenile offenders reported these three ACEs. The least commonly reported ACE indicator for males were sexual abuse, household mental illness, and physical neglect, while the lowest three for females were household mental illness, physical neglect, and emotional neglect. Sexual abuse was reported 4.4 times more frequently by females than by males (31% and 7%, respectively). With the exception of sexual abuse, the ACE rank order by prevalence across genders was similar. However, as illustrated by Figure 1, females had a higher prevalence than males on every single ACE indicator. (8)

"The top three most prevalent ACE indicators were the same for both males and females: family violence, parental separation or divorce, and household member incarceration. Two-thirds or more of the Florida juvenile offenders reported these three ACEs. The least commonly reported ACE indicator for males were sexual abuse, household mental illness, and physical neglect, while the lowest three for females were household mental illness, physical neglect, and emotional neglect. ... These results are consistent with prior findings that the main gender difference in ACEs is the prevalence of sexual abuse." (9)

"Only 3.1% of males and 1.8% of the females reported no ACEs. ... These results indicated female youth reported more ACEs than males, and a higher percentage of those who reported at least one ACE also reported others. The average composite ACE score for females was 4.29, while the average for males was 3.48 (difference statistically significant at p < .001). That is, the average female in our sample reported at least four ACE indicators while the average male reported three or four ACE indicators." (9)

juvenile offenders are 13 times less likely to report zero ACES (2.8% compared to 36%) and four times more likely to report four or more ACEs (50% compared to 13%) than Felitti and Anda’s Kaiser Permanente–insured population of mostly college-educated adults. These results suggest that the juvenile offenders in this study were significantly more likely to have ACE exposure and to have multiple ACE exposures than the adults in Felitti and Anda’s study population. (10)

ACEs not only increase the chances of involvement in the juvenile justice system, but increase the risk of re-offense. A focused effort on early identification of ACEs, and intervention for ACEs with a goal of improving youth life circumstances and preventing criminal behavior, may reduce the likelihood of and costs related to juvenile criminal activities. Most current policies in child welfare focus on secondary prevention instead of primary prevention of ACEs. (11)

It is not too early to teach brain development skills in high school, since high school students are merely one sexual experience away from being tomorrow’s parents. Furthermore, many high school students participate in the care of smaller children. (11)

When school or health professionals observe behaviors such as overeating, substance abuse, smoking, disruptive classroom behavior, and bullying, a screening for a history of ACEs can be obtained and used
to determine the appropriate intervention. When school personnel observe such behaviors, suspending
or expelling students from school may deprive youth of the safest environment they can access. In-school programs to address bullying, disruptive classroom behavior, and aggression can keep youth in safe environments while they learn self-regulatory skills. Law enforcement and judicial awareness of ACES will enhance the likelihood that the root causes of problematic behaviors will be addressed with social and behavioral health services. Individuals with ACEs often use maladaptive or antisocial behaviors as strategies to cope with stress; such behaviors will not dissipate during periods of detention or incarceration without focused intervention. (11)

Early childhood intervention programs addressing ACEs have demonstrated significant benefit–cost ratios. One such intervention displayed a return of $5.70 for every dollar spent by the time a child reached age 27, $8.70 in life-cost savings, and notable cost savings in crime reduction (Larkin & Records, 2007). (12)

A school or community-based safe place that focuses on relaxation activities such as yoga, meditation, tai chi, and prayer can build resilience and reduce stress by empowering children to modulate their stress responses and enhance their personal perceptions of safety. Children with high resilience tend to be more successful in school, happier, and less depressed. Youth development programs for children, parents, and teachers should integrate activities that build resilience and address ACEs so that children develop confidence, self-control, and responsibility. These interventions and programs have the potential to keep children from engaging in risky social and health behaviors. (12)

A fundamental tool in secondary prevention is the implementation of Trauma-Informed Care (TIC), with a central precept of asking “What has happened to you?” rather than the customary “What is wrong with you?” The ACE composite score is precisely a measure of “what has happened to you.” (13)

In light of findings that females have higher rates of exposure to all ACE indicators than males (especially sexual abuse and the ACE composite score), yet have lower rates of delinquent involvement, gender-specific intervention strategies should be examined since there may be gender differences in response to exposure to traumatic circumstances. Exposure to ACEs manifests itself differently among females than males (e.g., females have more internalizing behaviors, mental health symptoms, and self-mutilation; males exhibit more externalizing and acting out behaviors). Furthermore, a much higher percentage of female violent offenses exclusively involve domestic violence, as opposed to more heterogeneous violent offenses for males (Herrera & McCloskey, 2001). (13)

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