Adverse Childhood Experiences: Primary Prevention
February 25, 2019
Adverse childhood experiences (ACEs) refer to harmful events during the formative years of a person’s life, such as child abuse and neglect (CAN) or household challenges stemming from parental substance misuse, incarceration, or untreated mental health issues. These events can lead to chronic physical and behavioral health issues and, ultimately, early death. Primary prevention of ACEs is characterized by evidence-based interventions designed to enhance protective factors and reduce risk factors for ACEs before they occur. Strategies include building skills and promoting social norms for positive parenting, strengthening economic supports for families, and providing quality education and enrichment early in life.
Primary prevention differs from trauma-informed care (TIC), which involves a service delivery approach rooted in the understanding that trauma impacts a person’s everyday life and needs to be addressed in collaboration with multidisciplinary partners. Although it has been receiving increased attention from state policymakers, TIC is not the same as primary prevention of ACEs. TIC intervenes after ACEs have occurred, whereas primary prevention focuses on stopping the occurrence of ACEs altogether. A comprehensive approach that utilizes primary prevention strategies and TIC is necessary to fully address ACEs.
Primary Prevention…
- Prevents ACEs before they occur.
- Focuses on enhancing protective factors, such as positive parenting, education, and family economic supports.
- Strategies can focus on the micro- or macro- level, e.g., home visiting or strengthening economic supports for families.
Trauma-Informed Care…
- Prevents poor health and life outcomes from occurring after ACEs or other trauma occurs.
- Focuses on screening and providing services for recovery.
- Strategies are often organizational and clinical, e.g., training workforce and involving the patient in the treatment process.
Primary Prevention: Benefits for States
The economic costs of ACEs emphasize the need to focus on primary prevention. CDC estimates the lifetime costs associated with CAN are $2 trillion, which includes healthcare, special education, child welfare, criminal justice, and lost earning potential. States can offset lifetime costs by investing in evidence-based strategies, such as home visiting programs and state paid family and medical leave policies. Home visiting was found to reduce healthcare costs, reduce the need for remedial education for children, and increase family self-sufficiency, including mother’s education and job training. Paid family and medical leave is associated with various positive health outcomes for families. Researchers estimated that providing 12 weeks of job-protected paid leave would result in 600 fewer infant and post-neonatal deaths annually.
Examples of Evidence-Based ACEs Primary Prevention Strategies
Early Head Start Programs
Early Head Start (EHS) is a program focusing on child development and parent education. A recent longitudinal study examined the long-term benefits of EHS on child maltreatment and short-term child, parent, and family outcomes that are linked to child maltreatment. The study found that participating in EHS led to a long-term reduction in the number of children involved in the child welfare system. Family outcomes include an increase in parental emotional response, lower levels of parental stress, and less family conflict. EHS is currently federally funded to serve a small percentage of families. Broadening the criteria of EHS could be beneficial to addressing CAN at the population level.
Dual Generational Approaches to Address the Needs of Children and Their Caretakers
Dual generational approaches focus on creating opportunities and addressing the needs of both children and their caretakers. Two examples include substance misuse treatment with a parenting component and rooming-in for newborns with neonatal abstinence syndrome (NAS). A systematic review of the outcomes of dual treatment for substance misuse and parenting found an overall positive outcome for dual treatment programs compared to programs without a parenting component. Rooming-in, the practice of keeping the newborn with the mother after birth, is associated with immediate and long- term health benefits for both the mother and newborn, and is an emerging promising practice to address NAS.
Strengthening Economic Supports for Families
Economic supports for families are key to helping lift working families out of poverty and reducing parental stress, which are risk factors for CAN. Two promising practices include enhancing the state and federal Earned Income Tax Credit (EITC) and increasing the minimum wage. The EITC raises more than 6 million people—half of them children—above the poverty line each year. Economic support from EITC is associated with favorable socioeconomic effects, such as improved school performance for children. Regarding minimum wage, a study found that increases in the federal baseline minimum wage of $7.25 per hour led to a decline in overall child maltreatment reports for states. In the study’s analysis, a $1 increase in the minimum wage led to a statistically significant 9.6 percent decline in child neglect reports.
Conclusion
State health leadership has a role in preventing ACEs by supporting evidence-based primary prevention strategies that build skills and promote social norms for positive parenting, strengthen economic supports for families, and provide quality education and enrichment early in life. Primary prevention is shown to be cost effective and can address the prevention of ACEs with a multi-generational approach, leading brighter childhoods and healthier futures.