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At the Intersection of Health, Health Care and Policy
doi: 10.1377/hlthaff.2014.0914
, 33, no.12 (2014):2106-2115Health Affairs
Engagement And The Mitigating Role Of Resilience
Adverse Childhood Experiences: Assessing The Impact On Health And School
Christina D. Bethell, Paul Newacheck, Eva Hawes and Neal Halfon
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By Christina D. Bethell, Paul Newacheck, Eva Hawes, and Neal Halfon
Adverse Childhood Experiences:
Assessing The Impact On Health
And School Engagement And The
Mitigating Role Of Resilience
ABSTRACT
The ongoing longitudinal Adverse Childhood Experiences Study
of adults has found significant associations between chronic conditions;
quality of life and life expectancy in adulthood; and the trauma and
stress associated with adverse childhood experiences, including physical
or emotional abuse or neglect, deprivation, or exposure to violence. Less
is known about the population-based epidemiology of adverse childhood
experiences among US children. Using the 2011–12 National Survey of
Children’s Health, we assessed the prevalence of adverse childhood
experiences and associations between them and factors affecting
children’s development and lifelong health. After we adjusted for
confounding factors, we found lower rates of school engagement
and higher rates of chronic disease among children with adverse
childhood experiences. Our findings suggest that building resilience—
defined in the survey as “staying calm and in control when faced with a
challenge,”for children ages 6–17—can ameliorate the negative impact of
adverse childhood experiences. We found higher rates of school
engagement among children with adverse childhood experiences who
demonstrated resilience, as well as higher rates of resilience among
children with such experiences who received care in a family-centered
medical home. We recommend a coordinated effort to fill knowledge gaps
and translate existing knowledge about adverse childhood experiences
and resilience into national, state, and local policies, with a focus on
addressing childhood trauma in health systems as they evolve during
ongoing reform.
The Affordable Care Act (ACA) and
associated health system trans-
formation models—including the
patient-centered medical home
and accountable care organizations
(ACOs)—promote a model of health and health
care that focuses on “whole person”and “whole
population”health and well-being.1,2 These re-
form models have emerged against the back-
drop of a growing interdisciplinary consensus—
supported by a critical mass of social science,
health services, epigenetic, neurodevelopmen-
tal, and biological research3–14—that it is para-
mount to view health development in childhood
and across life through the lens of childhood
trauma and stress associated with adverse child-
hood experiences.2,15
Adverse childhood experiences were first as-
sessed through the Adverse Childhood Experi-
ences Study, a longitudinal study of adults con-
ducted by the Centers for Disease Control and
Prevention (CDC) and Kaiser Permanente.8,16
doi: 10.1377/hlthaff.2014.0914
HEALTH AFFAIRS 33,
NO. 12 (2014): 2106–2115
©2014 Project HOPE—
The People-to-People Health
Foundation, Inc.
Christina D. Bethell
(CBethell@jhu.edu) is director
of the Child and Adolescent
Health Measurement Initiative
(CAHMI) and a professor of
population, family, and
reproductive health at the
Johns Hopkins Bloomberg
School of Public Health, in
Baltimore, Maryland.
Paul Newacheck is a
professor at the Philip R. Lee
Institute for Health Policy
Studies at the University of
California, San Francisco.
Eva Hawes is a research
associate at CAHMI.
Neal Halfon is a professor of
pediatrics at the Geffen
School of Medicine; a
professor of health policy and
management at the Fielding
School of Public Health; and a
professor of public policy at
the Luskin School of Public
Affairs, all at the University
of California, Los Angeles
(UCLA), and is director of the
UCLA Center for Healthier
Children, Families, and
Communities.
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These experiences include exposure to violence;
emotional, physical, or sexual abuse; depriva-
tion; neglect; family discord and divorce; paren-
tal substance abuse and mental health problems;
parental death or incarceration; and social dis-
crimination.
Studies have linked adverse childhood experi-
ences with increased chronic disease and higher
costs of care across a person’s life course.17–19
Such findings make addressing a history of child-
hood trauma relevant to the patient-centered
medical home and ACO models of care. Some
patient-centered medical homes and ACOs now
recognize the economic and health costs of not
addressing adverse childhood experiences and
the opportunity to improve individual and pop-
ulation health using childhood trauma-informed
approaches.20
The national Bright Futures guidelines, which
list preventive care screenings and services that
health insurance plans must cover under the
ACA, further support a focus on childhood trau-
ma.21 These guidelines, sponsored by the federal
Maternal and Child Health Bureau in partner-
ship with the American Academy of Pediatrics,
include guidelines for screening for behavioral
and psychosocial risks, including many adverse
childhood experiences. The guidelines also pro-
mote resilience (defined in the survey as “staying
calm and in control when faced with a chal-
lenge,”for children ages 6–17) and the provision
of care using a family-centered medical home
model that seeks to identify and address the so-
cial determinants of health, such as childhood
trauma.21–23
Addressing adverse childhood experiences is
now among the priorities of several other federal
agencies, including the Substance Abuse and
Mental Health Services Administration,24 the
Centers for Medicaid and Medicare Services,25
and the Administration on Children and Fami-
lies.26 State governments,20 private foundations
and nongovernmental organizations,27,28 local
health departments,29 hospitals,30 and primary
care providers29,31 are also prioritizing address-
ing adverse childhood experiences. This is in
addition to the long-standing focus on such ex-
periences within the child welfare and educa-
tional sectors.32,33
The prevalence of adverse childhood experi-
ences among adults is now evaluated by numer-
ous states through their Behavioral Risk Factor
Surveillance System surveys.33 For children, lim-
ited data on adverse childhood experiences are
available from the National Child Abuse and
Neglect Data System, which counts reported
cases of child abuse and neglect. According to
the system’s data, 12.5 percent of all US children
have had a documented episode of child abuse or
neglect reported by age eighteen.34
In 2013, prevalence data for all US children
became available from the 2011–12 National
Survey of Children’s Health (NSCH), conducted
under the leadership of the Maternal and Child
Health Bureau.35 These data include child-level
information on adverse childhood experiences
similar to those included in the CDC and Kaiser
Permanente adult study. They are the first na-
tional and state child-level data on adverse child-
hood experiences.36
This study adds to previous reports based on
the NSCH and other more narrow US studies on
childhood trauma 30,33,37,38 by further evaluating
the population-based epidemiology of adverse
childhood experiences among all US children.
Specifically, we evaluated associations between
the experiences and childhood chronic condi-
tions, health risks, and school success factors
such as school engagement and grade repetition.
We also assessed the potential mitigating ef-
fects of resilience39 and receiving care in a family-
centered medical home. The identification of so-
cial determinants of health, such as adverse
childhood experiences, and the promotion of
resilience and other positive health capacities
important to attenuating impacts of childhood
trauma are core principles for the delivery of
high-quality children’s health care at family-
centered medical homes.21,22
We hypothesized that children who had ad-
verse childhood experiences would have worse
health outcomes and more school problems,
compared to children who did not have such
experiences.We also hypothesized that learning
and exhibiting resilience, as well as having ac-
cess to a high-quality medical home, might miti-
gate these outcomes.
Study Data And Methods
Population And Data We used data from the
2011–12 NSCH.35 The NSCH surveyed a represen-
tative sample of children ages 0–17 (95,677 chil-
dren, with approximately 1,800 per state). Child-
level household surveys were conducted with
parents or guardians under the leadership of
the Maternal and Child Health Bureau and im-
plemented through the National Center for
Health Statistics. Data were weighted to repre-
sent the population of noninstitutionalized chil-
dren ages 0–17 nationally and in each state.
The Child and Adolescent Health Measure-
ment Initiative (CAHMI), a national initiative
based in the Johns Hopkins Bloomberg School
of Public Health, prepared the data files and
constructed variables in collaboration with the
Maternal and Child Health Bureau and the
National Center for Health Statistics. This work
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was performed by the National Maternal and
Child Health Data Resource Center, which is
led by CAHMI.39
Key Measures The 2011–12 NSCH list of ad-
verse childhood experiences is based on that
used in the adult study, with modifications over-
seen by a technical expert panel and evaluated
through standard survey item testing through
the National Center for Health Statistics.40 The
NSCH included nine adverse childhood experi-
ences deemed valid for reporting by parents and
guardians, which are listed in online Appendix
Exhibit A4.41
To evaluate key associations, variables were
constructed to assess whether a child had special
health care needs; experienced specific types of
chronic conditions such as asthma, attention
deficit hyperactivity disorder (ADHD), and obe-
sity; demonstrated aspects of resilience (as not-
ed above, defined in the survey as “staying calm
and in control when faced with a challenge,”for
children ages 6–17); was engaged in school; had
repeated a grade in school; and received care in a
family-centered medical home, as measured in
the NSCH.42 The prevalence of these positive and
negative health factors according to the number
of respondents’adverse childhood experiences
is reported in the online Appendix.41 Because
of their relevance to child health, aspects of
parental health and family and community
factors were also evaluated (for a list, see the
Appendix).41
All items on the NSCH were developed under
the direction of two technical expert working
groups. The items were finalized after repeated
rounds of cognitive testing as well as best prac-
tice language translation and pilot testing
through the National Center for Health Statis-
tics. All variables used in this study have been
documented previously, and their properties
and coding are presented in publicly available
NSCH variable codebooks.39
Analytic Methods National and state-level
prevalence on all of the nine adverse childhood
experiences that we assessed were calculated
across the range of child subgroups and
health-related variables. We used multivariate
and multilevel regression models to examine as-
sociations among adverse childhood experienc-
es; child and family demographic characteris-
tics; health and school factors; child resilience;
and other parental health, family, and commu-
nity factors. We also examined whether or not
children had a primary care medical home, using
a robust, multidomain, and widely used measure
of medical home that reflects the definition of
medical home set forth by the American Academy
of Pediatrics and endorsed by the National Qual-
ity Forum.42
Nested t-tests compared state and national dif-
ferences in the prevalence of adverse childhood
experiences. A multilevel logistic regression
model was fitted to examine the association be-
tween individual child, family, and health care
characteristics and the prevalence of adverse
childhood experiences. The model allowed for
variations across states in these associations
and, after accounting for the individual child-
level demographic and health factors included
as level 1 independent variables (age, sex, race/
ethnicity, household income, and special health
care needs status), assessed the state variation
in the prevalence of the experiences that re-
mained.43 For additional details on the methods,
see Appendix Exhibit A3.41
Logistic regression models were run to calcu-
late adjusted odds ratios that indicated whether
certain subgroups of children were more or less
likely to have adverse childhood experiences and
whether or not the experiences predicted the
likelihood that children would have the chronic
conditions, risks, resilience, school success, and
other factors evaluated in our study. All models
controlled for child-level characteristics. These
were the child’s age, sex, race/ethnicity, and
household income and whether the child quali-
fied as a child with special health care needs,
using the CSHCN Screener,37 or had been evalu-
ated as having a chronic condition requiring an
above-average type or amount of services.
We used SPSS, version 19. Unless otherwise
noted, all adjusted odds ratios that we report
were significant based on their 95 percent confi-
dence intervals.
Li mi tati on s A primary limitation of this study
is the cross-sectional nature of the NSCH. Unfor-
tunately, the United States does not have a lon-
gitudinal population-based study that includes
information on adverse childhood experiences.
Such data are needed to document the experienc-
es’causal effects on the development of health
problems and the mitigating effects of protective
Addressing a history
of childhood trauma is
relevant to the
patient-centered
medical home and
ACO models of care.
Changing Epidemiology Of Children’sHealth
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factors, such as resilience or having a high-
quality medical home. In the absence of a nation-
al longitudinal study that includes such data,
follow-back surveys among cohorts of children
included in the 2011–12 NSCH hold promise.
Study Results
Prevalence Of Adverse Childhood Experi-
ences As previously reported,30,33,37,38 48 percent
of US children have had at least one of the nine
key adverse childhood experiences evaluated in
the NSCH. This translates into an estimated
34,825,978 children nationwide. Older children
and those living in homes with lower household
incomes are more likely to have had one or more
of the nine experiences, as shown in Appendix
Exhibit A1.41
Nationwide, 22.6 percent of children ages 0–
17 have had two or more of the nine adverse
childhood experiences evaluated in the NSCH,
with a nearly twofold difference in prevalence
across states (Exhibits 1 and 2). Among US youth
ages 12–17, 30.5 percent have had two or more of
the experiences, ranging from a low of 23.0 per-
cent in New Jersey to a high of 44.4 percent in
Arizona (data not shown). Eighteen states had
significantly higher prevalence rates of adverse
childhood experiences than the national rate,
which was 47.9 percent (Exhibit 1).
Across-state variations in the prevalence of
children with one or more adverse childhood
experiences remained significant after we ad-
justed for child-level characteristics using multi-
level modeling. In fact, child-level characteristics
explained only 33 percent of cross-state variation
in the prevalence of adverse childhood experi-
ences. The random effects median odds ratio of
1.21 (interclass correlation coefficient: 0.012)
was significant, after individual-level child de-
mographic characteristics and status as a child
with special health care needs were adjusted for.
Associations With Child Health Condi-
tions And Risks As was expected based on pre-
vious research,8,9 if children had existing chronic
conditions and health risks, they were more like-
ly to have had adverse childhood experiences
(Exhibit 3). Conversely, children who had had
such experiences were more likely than those
who had not to have each of the health condi-
Exhibit 1
Prevalence Of Children Ages 0–17, By State, Who Experienced Two Or More Of The Nine Adverse Childhood Experiences
Evaluated In The 2011–12 National Survey Of Children’s Health
SOURCE Authors’analysis of data from the 2011–12 National Survey of Children’s Health. NOTES Themapshowsprevalenceineach
state compared to the US average. In the key, lower indicates better performance. Nationwide, 22.6 percent of children experienced
two or more of the nine adverse childhood experiences. The state with the lowest percentage of such children (16.3 percent) was New
Jersey; the state with the highest percentage (32.9 percent) was Oklahoma. Statistical significance indicates p<0:05.
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tions and risks evaluated. Children who had had
two or more of the nine adverse childhood expe-
riences evaluated were also more likely than
those who had only one such experience to have
each of the health problems evaluated. This mir-
rored the dose-response effect of adverse child-
hood experiences observed in the CDC’s adult-
focused longitudinal study of the experiences.6
For example, children with two or more of the
adverse childhood experiences examined were
significantly more likely to qualify as children
with special health care needs, compared to chil-
dren with none of the experiences (31.6 percent
versus 14.6 percent; Exhibit 3). Children without
adverse childhood experiences had 0.44 lower
odds of qualifying as having special health care
needs, compared to children with two or more
adverse childhood experiences.
Associations With Child Resilience And
Family And Neighborhood Factors Children
with adverse childhood experiences were less
likely than those without such experiences to
demonstrate resilience, live in a protective home
environment, and have mothers who were
healthy and parents who were not unusually
aggravated with them (Exhibit 2 and Appendix
Exhibit A2).41 They were also less likely to live in
safe and supportive neighborhoods. A notable
dose-response effect existed in nearly all cases:
Children with only one adverse childhood expe-
rience versus two or more were more likely to
have positive health factors and less likely to
have negative health factors.
It is important to note that many children who
have positive health factors have also had ad-
verse childhood experiences. For example,
33.1 percent of children who had a protective
home environment nonetheless had had adverse
childhood experiences (data not shown). Simi-
larly, 48.4 percent of children who demonstrated
Exhibit 2
Prevalence Of Nine Adverse Childhood Experiences (ACEs) Among US Children Ages 0–17, By Selected Characteristics, 2011–12
Characteristica
ACEs
National
preva-
lence
Prevalence range
across states
Child has
chronic
condition
and special
need
Child shows
resilienceb
Child
repeated
a gradeb
Child has a
high-quality
medical
home
Mother’s
health is
excellent or
very good
No ACE reported 52.1% 42.5% (AZ)–59.4% (CT) 14.6% (0.44) 71.7% (1.62) 5.6% (0.59) 61.4% (1.43) 68.3% (2.52)
At least 1 ACE reported 47.9 40.6 (CT)–57.5 (AZ)c20.3 (0.63) 62.9 (1.25) 9.1 (0.75) 50.4 (1.17) 48.6 (1.47)
2 or more ACEs reportedd22.6 16.3 (NJ)–32.9 (OK) 31.6e54.6e15.0e43.5e35.8e
Individual ACEs
Experienced extreme
economic hardship 25.7 20.1 (MD)–34.3 (AZ) 26.0 54.6 14.1 41.5 36.6
Parents divorced or
separated 20.1 15.2 (DC)–29.5 (OK) 28.8 59.1 12.5 50.8 46.5
Lived with someone
with an alcohol or
drug problem 10.7 6.4 (NY)–18.5 (MT) 31.7 55.1 14.7 45.8 38.4
Witnessed or was victim
of neighborhood
violence 8.6 5.2 (NJ)–16.6 (DC) 37.1 50.5 18.5 38.4 32.8
Lived with someone
who was mentally ill
or suicidal 8.6 5.4 (CA)–14.1 (MT) 37.6f54.6 13.2 48.6 31.6f
Witnessed domestic
violence 7.3 5.0 (CT)–11.1 (OK) 34.0 50.5f17.9 41.8 33.2
Parent served time
in jail 6.9 3.2 (NJ)–13.2 (KY) 33.5 51.5 19.5f42.2 37.7
Treated or judged
unfairly due to race/
ethnicity 4.1 1.8 (VT)–6.5 (AZ) 30.1 56.1 9.8 37.8f41.6
Death of parent 3.1 1.4 (CT)–7.1 (DC) 30.0 53.9 18.0 43.5 39.7
SOURCE Authors’analysis of data from the 2011–12 National Survey of Children’sHealth(NSCH).NOTES Resilience is defined in the NSCH as “staying calm and in control
when faced with a challenge.”Adjusted odds ratios (adjusted for age, sex, household income, and race/ethnicity and special health care needs status) are from logistic
regression. All are significant based on their 95 percent confidence intervals. aAdjusted odds ratio is in parentheses. bAges 6–17. cSignificant across-state variation
remains (ICC: 0.012; median odds ratio: 1.21), after adjustment for child-level characteristics across states using multilevel modeling. dThe distribution of ACEs
among children ages 0–17 is as follows: 0: 52.1 percent; 1: 25.3 percent; 2: 10.6 percent; 3–4: 8.60 percent; 5 or more: 3.40 percent. eReference category. fACE for
which the health risk was highest or protective factor was lowest.
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resilience had had adverse childhood experienc-
es, as had 49.2 percent of children who were
usually or always engaged in school.
Associations With School Success Fac-
tors Children with two or more adverse child-
hood experiences were 2.67 times more likely to
repeat a grade in school, compared to children
without any of the experiences. This effect re-
mained after we adjusted for children’s demo-
graphic characteristics and health status factors
(Exhibit 2). Similarly, children without adverse
childhood experiences had 2.59 greater odds of
usually or always being engaged in school, com-
pared with their peers who had had two or more
of the experiences (Appendix Exhibit A2).41
Resilience mitigated the impact of adverse
childhood experiences on grade repetition
and school engagement. Among children with
special health care needs who had had two or
more of the experiences, those who had learned
and showed aspects of resilience were 1.55 times
more likely to be engaged in school and nearly
half as likely to have repeated a grade in school,
compared to those not exhibiting resilience
(Exhibit 4).
Associations With Receiving Care In A Fam-
ily-Centered Medical Home Children with two
or more adverse childhood experiences were 1.41
times less likely than those who did not have any
to have parents who reported that their child
received health care that met “family-centered
medical home”criteria (43.5 percent versus
61.4 percent; Exhibit 2). These criteria include
being family centered, having providers who
know the child and child’s health history well,
receiving needed help coordinating the child’s
care, and ensuring that the child receives needed
referrals for services outside of his or her prima-
ry provider setting. The effect of having a family-
centered medical home remained after con-
founding factors such as household income
Exhibit 3
Prevalence Of Adverse Childhood Experiences (ACEs) Among Children Age 0–17, By Eleven Child Health And Health Risk Factors, And Prevalence Of Health
And Risk Factors, By Number Of ACEs, 2011–12
Study
population
(%)
Prevalence of health problems and risks
Prevalence of ACEs (%) 0 ACEs 1 ACE 2 or more
ACEsCategory of children 1 ACE 2 or more ACEs Percent AOR Percent AOR
All 100.0 25.3 22.6 52.1 —a25.3 —a21.6
In fair or poor overall health 3.2 31.8 39.3 1.7 0.75b3.9 1.05 5.5c
With special health care needs 19.8 25.9 36.0 14.6 0.44 20.3 0.63 31.6c
With special health care needs and EBD 7.2 23.7 51.9 3.4 0.35b6.8 0.52b16.6c
At high or moderate risk for developmental,
behavioral, or social delays 26.2 26.9 18.8 22.5 0.68b29.1 0.76b37.4c
With asthma 8.8 27.3 33.4 6.7 0.63b9.5 0.79b13.1c
With ADHD 7.9 24.8 45.2 4.8 0.37b7.7 0.57b14.6c
With autism spectrum disorder 1.8 27.1 34.4 1.4 0.55b1.9 0.77b2.5c
Who are overweight or obese 31.3 25.5 37.1 26.5 0.79b31.5 0.85b38.6c
With a behavior problem 3.2 23.6 61.4 1.0 0.26b3.0 0.56b8.0c
Who bullyd2.2 23.0 55.4 1.0 0.44b1.9 0.60b4.4c
SOURCE Authors’analysis of data from the 2011–12 National Survey of Children’s Health. NOTES AOR is adjusted odds ratio (adjusted for age, sex, household income, and
race/ethnicity). EBD is emotional, behavioral, or developmental problems. ADHD is attention deficit hyperactivity disorder. aNot applicable. bSignificant across-state
variation remains (p<0:05), after adjustment for child-level characteristics across states using multilevel modeling. cReference category. dUsually or always bullies
or is cruel to others.
Exhibit 4
Prevalence Of School Success Factors Among Children With Special Health Care Needs Who
Had Two Or More Adverse Childhood Experiences, By Resilience, 2011–12
SOURCE Authors’analysis of data from the 2011–12 National Survey of Children’sHealth(NCSH).
NOTES Resilience is defined in the NSCH as “staying calm and in control when faced with a challenge. ”
All differences are significant (p<0:05). For missing more than two weeks of school in the past year,
the adjusted odds ratio (AOR; adjusted for age, sex, household income, and race/ethnicity) was 1.24
(p¼0:02). For repeating a grade, the AOR was 1.66 (p<0:001). For being engaged in school, it was
0.26 (p<0:001).
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and the race/ethnicity or health status of the
child were adjusted for (Appendix Exhibit A3).41
When we looked at specific components of a
medical home, we found that children with two
or more adverse childhood experiences were
1.90 times more likely than those without any
to have problems getting needed referrals and
1.73 times more likely to experience problems
getting needed care coordination. These results
also remained significant after child demograph-
ic characteristics and health status factors were
adjusted for (Appendix Exhibit A2).41
Anticipated improvements in health have, in
part, motivated the national movement to estab-
lish patient-centered medical home models of
care. In this study we observed such positive
effects. Importantly—considering our findings
that linked resilience to greater school engage-
ment for children with adverse childhood expe-
riences—we found that when children who had
had such experiences did not have health care
that met family-centered medical home criteria,
they were also less likely to exhibit key aspects of
resilience. Specifically, among children with one
or more adverse childhood experiences, those
who did not have a family-centered medical
home were significantly less likely than those
who did to exhibit resilience (adjusted odds
ratio: 0.69; data not shown).
Moreover, after we adjusted for confounding
factors, we found that children who had had
adverse childhood experiences and who received
health care that met family-centered medical
home criteria had 0.52 lower odds of having
parents who reported that they were usually or
always aggravated with their child (data not
shown).
Discussion
Similar to the results of localized studies with
less representative data,13,19 findings from this
national representative sample of all US children
confirm a high prevalence of adverse childhood
experiences, significant relationships between
them and both positive and negative health fac-
tors, and the fact that the impact of adverse child-
hood experiences begins early in childhood.
Even with the use of the small set of items related
to adverse childhood experiences in the NSCH,
which do not include information about the se-
verity, frequency, scope, and specific impact of
the experiences on children, associations be-
tween the experiences and health are readily ap-
parent in childhood—which is when the health
system has ample opportunity to intervene and
prevent the long-term medical complications de-
scribed in the adult-focused Adverse Childhood
Experiences Study.
Our findings demonstrate the need for further
research and exploration of hypotheses regard-
ing the potential causal role that exposure to
adverse childhood experiences may play in the
development or exacerbation of certain child-
hood diseases, such as asthma, ADHD, and obe-
sity, as well as in the risk for developmental,
behavioral, and social delays during childhood.
Our findings also demonstrate the need for con-
tinued research on how to optimize the effective-
ness of the family-centered medical home model
to address social determinants of health, such as
adverse childhood experiences.
The findings are consistent with conclusions
from previous studies about mediating the im-
pact of adverse childhood experiences through
mechanisms such as parental coping and well-
being and the promotion of both child resilience
and safe, stable, and nurturing environments in
the home, school, and community.12,20,28,37,39,42
Neuroscience suggests that mediating the im-
pact of adverse childhood experiences involves
not only education and emotional and practical
support, but also the introduction and applica-
tion of neurological repair methods, such as
mindfulness training.44 Such methods are being
implemented in numerous school settings
across the country.25 Given the high prevalence
of adverse childhood experiences among both
adults and children in the United States and
the potentially cross-cutting benefits of promot-
ing resilience for all people, a population-based,
public health approach to understanding ad-
verse childhood experiences and promoting
resilience and neurological repair after trauma
should be considered, in addition to high-risk-
group interventions.
It is essential that the United States continue to
collect population-based data on adverse child-
hood experiences and resilience. It should also
enrich these data by combining longitudinal
cohorts of children that will further elucidate
causality and the multidimensional dynamics
Our findings confirm
the fact that the
impact of adverse
childhood experiences
begins early in
childhood.
Changing Epidemiology Of Children’sHealth
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associated with the occurrence and impact of
adverse childhood experiences and the role of
mitigating factors, including resilience, and
the promotion of such protective factors as the
family-centered medical home. Qualitative stud-
ies that examine cases in which adverse child-
hood experiences are prevalent but hypothe-
sized negative outcomes are not observed may
also be beneficial in developing understanding
of and methods to prevent negative impacts of
adverse childhood experiences across life.
We conclude that there is sufficient evidence
on the prevalence and cross-cutting impact of
adverse childhood experiences—as well as on
promising ways to prevent or ameliorate the neg-
ative impact of childhood trauma—to support a
coordinated, collective effort to rapidly advance
needed new research on assessing and address-
ing adverse childhood experiences and to syn-
thesize and translate existing research into
concrete national, state, and local policies and
practices. In keeping with the call by Clyde
Hertzman for an “era of experimentation,”5(p128)
we recommend the formulation of a collabora-
tively endorsed research and policy agenda de-
signed to be enduring, so that priorities and
lessons learned are updated and integrated over
time.
Integrating information about adverse child-
hood experiences and resilience into the delivery
and real-time evaluation of health services may
require routinely including patient-reported in-
formation on adverse childhood experiences and
relevant health assets such as resilience in elec-
tronic medical records.45 This would allow for the
integration of information reported by patients,
parents, and children with clinical diagnostic
and treatment information. Such integration
would reveal important opportunities for pro-
moting health and clarify the impact of ap-
proaches to address adverse childhood experi-
ences on overall health outcomes and healthy
development.
It is important to note that screening children
and parents for adverse childhood experiences
across a population and in clinical practice
would require further research to demonstrate
its unique value in contrast to existing standard
screening practices. It will also be important to
further develop and evaluate information on the
impact of responses to adverse childhood expe-
riences to promote health and ameliorate hy-
pothesized negative and lifelong effects.
Screening practices that are based not on
specific adverse events (such as violence) but
on evidence of any type of past or existing trau-
matic event and the presence of toxic or chronic
stress—regardless of the specific adverse event
experienced—could be useful. In other words,
the screening practices would be based on
consequences instead of events. Because of the
large number of potentially relevant adverse
childhood experiences that could be included
in a screening tool, and the anticipated varia-
tions of impact across developmental age groups
of children, such practices may be relevant when
the goals for screening are to identify children
experiencing toxic or chronic stress and to target
efforts to promote resilience and health. When
the goal is the specific identification of events,
many events are best verified using other validat-
ed screening methods. The CSHCN Screener
uses a consequence-based method and could
be a model for screening for adverse childhood
experiences.46
Screenings for adverse childhood experiences
are not meant to replace diagnostic screening
methods for conditions such as post-traumatic
stress disorder, sexual abuse, or maternal de-
pression. Instead, screening for adverse child-
hood experiences might be most useful in iden-
tifying the subset of the children with social
determinants of poor health who may most need
attention, as well as the subsets of children with
special health care needs and children with
physical and mental or behavioral health diag-
noses who may benefit most from integrated
health care approaches requiring medical, so-
cial, mental, and emotional attention.
Some integrated care models that address
health in the context of social determinants of
health, such as adverse childhood experiences,
and a variety of so-called trauma-informed care
models are emerging.20,32,47 However, it is neces-
sary to demonstrate and scale up these models to
measure, assess, and address childhood trauma.
This is particularly true of the most promising
models related to building child resilience and
improving family dynamics and community and
school environments.28,37,39
Paying special
attention to children
at risk of adverse
childhood experiences
may yield both
immediate and long-
term benefits.
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Conclusion
This study enriches the rapidly expanding liter-
ature on social determinants of health, as well as
the neurodevelopmental, epigenetics, biologi-
cal, social psychological, and intervention liter-
ature by documenting, at the population level,
the potential role of adverse childhood experi-
ences in the healthy development and lifelong
well-being of children in the United States.
As the nation continues to seek to improve its
health care system and population health, pay-
ing special attention to children with or at risk of
adverse childhood experiences may yield both
immediate and long-term benefits. These in-
clude the promotion of health and well-being
and the reduced impact and severity of chronic
conditions in children and in the adults they will
become. ▪
Portions of the research and findings
presented here were presented at the
annual meeting of the Association for
Adolescent and Child Psychiatry, San
Diego, California, October 23, 2014; at
the National ACEs Summit, convened by
the Robert Wood Johnson Foundation,
Philadelphia, Pennsylvania, May 14,
2013; and as posters at the annual
meeting of the American Public Health
Association, Boston, Massachusetts,
November 5, 2013; the AcademyHealth
Annual Research Meeting, San Diego,
California, June 7, 2014; the annual
meeting of the Pediatrics Academic
Societies, Vancouver, British Columbia,
May 2, 2014; and the annual meeting of
the Association for Maternal and Child
Health Programs, Washington, D.C.,
January 26, 2014. The authors thank the
leadership of the Maternal and Child
Health Bureau for making available the
data used in this study. The authors
acknowledge assistance from Narangeral
Gombojav of the Child and Adolescent
Health Measurement Initiative (CAHMI)
in the running of the multilevel
regression model reported here and
from other CAHMI staff members in the
collection of pertinent publications.
NOTES
1HHS.gov/HealthCare. Read the law:
the Affordable Care Act, section by
section [Internet]. Washington
(DC): Department of Health and
Human Services; [cited 2014 Oct 31].
Available from: http://www.hhs
.gov/healthcare/rights/law/1
2Accountable Care Facts. Top ques-
tions about ACOs and accountable
care: what is the difference between
a medical home and an ACO? [In-
ternet]. Alexandria (VA): Account-
able Care Facts; c2011 [cited 2014
Oct 31]. Available from: http://www
.accountablecarefacts.org/topten/
what-is-the-difference-between-a-
medical-home-and-an-aco-1
3Halfon N, Hochstein M. Life course
health development: an integrated
framework for developing health,
policy, and research. Milbank Q.
2002;80(3):433–79.
4Shonkoff JP, Garner AS, Committee
on Psychosocial Aspects of Child and
Family Health; Committee on Early
Childhood, Adoption, and Depen-
dent Care; Section on Developmen-
tal and Behavioral Pediatrics. The
lifelong effects of early childhood
adversity and toxic stress. Pediatrics.
2012;129(1):e232–46.
5Hertzman C. The significance of
early childhood adversity. Paediatr
Child Health. 2013;18(3):127–8.
6De Bellis MD, Zisk A. The biological
effects of childhood trauma. Child
Adolesc Psychiatr Clin N Am. 2014;
23(2):185–222.
7Ehlert U. Enduring psychobiological
effects of childhood adversity. Psy-
choneuroendocrinology. 2013;
38(9):1850–7.
8Centers for Disease Control and
Prevention. Injury prevention and
control: division of violence pre-
vention: major findings by publica-
tion year [Internet]. Atlanta (GA):
CDC; [last reviewed 2014 May 13;
cited 2014 Oct 31]. Available from:
http://www.cdc.gov/violence
prevention/acestudy/year.html
9Anda RF, Felitti VJ, Bremner JD,
Walker JD, Whitfield C, Perry BD,
et al. The enduring effects of abuse
and related adverse experiences in
childhood. A convergence of evi-
dence from neurobiology and epi-
demiology. Eur Arch Psychiatry Clin
Neurosci. 2006;256(3):174–86.
10 Dube SR, Felitti VJ, Dong M, Giles
WH, Anda RF. The impact of adverse
childhood experiences on health
problems: evidence from four birth
cohorts dating back to 1900. Prev
Med. 2003;37(3):268–77.
11 Johnson SB, Blum RW. Stress and
the brain: how experiences and ex-
posures across the life span shape
health, development, and learning
in adolescence. J Adolesc Health.
2012;51(2 Suppl):S1–2.
12 Schofield TJ, Lee RD, Merrick MT.
Safe, stable, nurturing relationships
as a moderator of intergenerational
continuity of child maltreatment: a
meta-analysis. J Adolesc Health.
2013;53(4 Suppl):S32–8.
13 Flaherty EG, Thompson R, Litrownik
AJ, Zolotor AJ, Dubowitz H, Runyan
DK, et al. Adverse childhood expo-
sures and reported child health at
age 12. Acad Pediatr. 2009;9(3):
150–6.
14 Jaffee SR, Christian CW. The bio-
logical embedding of child abuse and
neglect: implications for policy and
practice. Social Policy Report. 2014;
28(1):3–19.
15 Kuehn B. AAP: toxic stress threatens
kids’long-term health. JAMA. 2014;
312(6):585–6.
16 Felitti VJ, Anda RF, Nordenberg D,
Williamson DF, Spitz AM, Edwards
V, 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. Am J Prev
Med. 1998;14(4):245–58.
17 Smith JP, Smith GC. Long-term
economic costs of psychological
problems during childhood. Soc Sci
Med. 2010;71(1):110–5.
18 Florence C, Brown DS, Fang X,
Thompson HF. Health care costs
associated with child maltreatment:
impact on Medicaid. Pediatrics.
2013;132(2):312–8.
19 Chartier MJ, Walker JR, Naimark B.
Separate and cumulative effects of
adverse childhood experiences in
predicting adult health and health
care utilization. Child Abuse Negl.
2010;34(6):454–64.
20 Fraser JG, Griffin JL, Barto BL, Lo C,
Wenz-Gross M, Spinazzola J, et al.
Implementation of a workforce ini-
tiative to build trauma-informed
child welfare practice and services:
findings from the Massachusetts
Child Trauma Project. Child Youth
Serv Rev. 2014;44(C):233–42.
21 Rushton FE, Kraft C. Family support
in the family-centered medical
home: an opportunity for preventing
toxic stress and its impact in young
children. Child health care providers
offer valuable support and connec-
tions for families. Child Abuse Negl.
2013;37(Suppl):41–50.
22 Ghandour RM, Perry DF, Kogan MD,
Strickland BB. The medical home as
a mediator of the relation between
mental health symptoms and family
burden among children with special
health care needs. Acad Pediatr.
2011;11(2):161–9.
23 American Academy of Pediatrics.
Health reform and the AAP: what the
new law means for children and pe-
diatricians [Internet]. Washington
Changing Epidemiology Of Children’sHealth
2114 Health Affairs December 2014 33:12
at University of Pennsylvania Library on December 10, 2014Health Affairs by content.healthaffairs.orgDownloaded from
(DC): AAP Department of Federal
Affairs; [cited 2014 Oct 31]. Available
from: http://www.aap.org/en-us/
advocacy-and-policy/federal-
advocacy/Documents/ACA
ImplementationFactSheets.pdf
24 Substance Abuse and Mental Health
Services Administration. Adverse
childhood experiences [Internet].
Rockville (MD): SAMHSA; [cited
2014 Oct 31]. Available from: http://
captus.samhsa.gov/prevention-
practice/targeted-prevention/
adverse-childhood-experiences/1
25 Administration on Children and
Families. Stress, neurodevelopment,
and programs that promote the well-
being of children and families: early
childhood: March 13–14, 2012,
Washington, DC, meeting summary
[Internet]. Washington (DC): De-
partment of Health and Human
Services; [cited 2014 Oct 31]. Avail-
able from: http://www.research
connections.org/files/childcare/
pdf/StressNeurodevelopment.pdf
26 Sheldon GH, Tavenner M, Hyde PS.
Letter to state directors [Internet].
Washington (DC): Department of
Health and Services; 2013 Jul 11
[cited 2014 Oct 31]. Available from:
http://medicaid.gov/Federal-Policy-
Guidance/Downloads/SMD-13-07-11
.pdf
27 Robert Wood Johnson Foundation.
Adverse childhood experiences [In-
ternet]. Princeton (NJ): RWJF; [cit-
ed 2014 Nov 7]. Available from:
http://www.rwjf.org/en/aboutrwjf/
newsroom/features-and-articles/
ACEs.html
28 AcademyHealth. Promoting early
and lifelong health: the challenge of
adverse childhood experiences
(ACEs) and the promise of resilience
[Internet]. Washington (DC):
AcademyHealth; [cited 2014 Oct 31].
Available from: http://www
.academyhealth.org/aces
29 Sege R, Linkenbach J. Essentials for
childhood: promoting healthy out-
comes from positive experiences.
Pediatrics. 2014;133(6):91.
30 Phoenix Children’s Hospital. Over-
coming adverse childhood experi-
ences: creating hope for a healthier
Arizona [Internet]. Phoenix (AZ):
The Hospital; [cited 2014 Oct 31].
Available from: http://childhealth
data.org/docs/drc/arizona-aces-
efinal.pdf
31 Marie-Mitchell A, O’Connor TG.
Adverse childhood experiences:
translating knowledge into identifi-
cation of children at risk for poor
outcomes. Acad Pediatr. 2013;13(1):
14–9.
32 Center for Advanced Studies in Child
Welfare. Trauma-informed child
welfare practice (CW360°) [Inter-
net]. Minneapolis (MN): University
of Minnesota; [cited 2014 Oct 31].
Available from: http://cascw.umn
.edu/portfolio-items/winter-2013-
cw360/
33 Sacks V, Murphey D, Moore K. Ad-
verse childhood experiences: na-
tional and state-level prevalence
[Internet]. Bethesda (MD): Child
Trends; 2014 Jul [cited 2014 Oct 31].
(Research Brief). Available from:
http://www.childtrends.org/wp-
content/uploads/2014/07/Brief-
adverse-childhood-experiences_
FINAL.pdf
34 Wildeman C, Emanuel N, Leventhal
JM, Putnam-Hornstein E, Waldfogel
J, Lee H. The prevalence of con-
firmed maltreatment among US
children, 2004 to 2011. JAMA Pe-
diatr. 2014;168(8):706–13.
35 National Center for Health Statistics.
Frequently asked questions: 2011–
2012 National Survey of Children’s
Health [Internet]. Hyattsville (MD):
NCSH; [cited 2014 Oct 31]. Available
from: ftp://ftp.cdc.gov/pub/
Health_Statistics/NCHS/slaits/
nsch_2011_2012/01_Frequently_
asked_questions/NSCH_2011_
2012_FAQs.pdf
36 Data Resource Center for Child and
Adolescent Health. Overview of ad-
verse child and family experiences
among US children [Internet]. Bal-
timore (MD): Child and Adolescent
Health Measurement Initiative; [re-
vised 2013 May 10; cited 2014
Oct 31]. Available from: http://
www.childhealthdata.org/docs/drc/
aces-data-brief_version-1-0.pdf
37 Bethell CD, Newacheck PW, Fine A,
Strickland BB, Antonelli RC,
Wilhelm CL, et al. Optimizing health
and health care systems for children
with special health care needs using
the life course perspective. Matern
Child Health J. 2014;18(2):467–77.
38 Ager A. Annual research review: re-
silience and child well-being—public
policy implications. J Child Psychol
Psychiatry. 2013;54(4):488–500.
39 National Survey of Children’s
Health. 2011–2012 National Survey
of Children’s Health: SPSS code for
data users: child health indicators
and subgroups, Version 1.0 [Inter-
net]. Baltimore (MD): Child and
Adolescent Health Measurement
Initiative; 2013 Apr [cited 2014
Oct 31]. Available from: http://
childhealthdata.org/docs/nsch-
docs/spsscodebook_-2011_2012_
nsch_v1_all.pdf
40 National MCHB Technical Expert
Panel Life Course Working Group.
Recommendations memo to MCHB:
life course measurement in the 2011–
12 National Survey of Children’s
Health. Rockville (MD): Maternal
and Child Health Bureau; 2010
Sep 10. Available upon request from
lead author: cbethell@jhu.edu.
41 To access the Appendix, click on the
Appendix link in the box to the right
of the article online.
42 Child and Adolescent Health Mea-
surement Initiative. Measuring
medical home for children and
youth: methods and findings from
the National Survey of Children with
Special Health Care Needs and the
National Survey of Children’s
Health: a resource manual for child
health program leaders, researchers,
and analysts [Internet]. Baltimore
(MD): CAHMI; 2009 May [cited
2014 Oct 31]. Available from: http://
www.childhealthdata.org/docs/
medical-home/mhmanual_with
appendices-updated-12-7-10-pdf.pdf
43 Carle AC. Fitting multilevel models
in complex survey data with design
weights: recommendations. BMC
Medical Research Methodol. 2009;9:
49.
44 Bryck RL, Fisher PA. Training the
brain: practical applications of neu-
ral plasticity from the intersection of
cognitive neuroscience, develop-
mental psychology, and prevention
science. Am Psychol. 2012;67(2):
87–100.
45 Glasgow RE, Kaplan RM, Ockene JK,
Fisher EB, Emmons KM. Patient-
reported measures of psychosocial
issues and health behavior should be
added to electronic health records.
Health Aff (Millwood). 2012;31:
497–504.
46 Bethell C, Blumberg SJ, Stein REK,
Strickland B, Robertson J,
Newacheck P. Taking stock of the
CSHCN Screener: a review of com-
mon questions and current reflec-
tions. Acad Pediatr. Forthcom-
ing 2014.
47 Dworkin P, Honigfeld L, Meyers J. A
framework for child health services:
supporting the healthy development
and school readiness of Connecti-
cut’s children. Farmington (CT):
Child and Health Development In-
stitute; 2009 Mar.
December 2014 33:12 Health Affairs 2115
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