Making the case for ACEs: adverse childhood experiences, obesity, and long-term health

Abstract

Adverse childhood experiences are traumatic events suffered by people aged <18 years. These adverse experiences can include abuse, neglect, and witnessing crime, parental conflict, mental illness, and substance abuse. Adverse childhood experiences have been linked to risky behaviors, chronic health conditions, and early death, resulting in stress that can derail healthy brain development. Adverse experiences also increase risks for dozens of illnesses and unhealthy behaviors, including smoking, alcoholism, depression, heart disease, suicide, unintended pregnancy, human immunodeficiency virus/sexually transmitted diseases, and cancer. The risk for these poor outcomes increases with each adverse experience. In this month’s issue of Pediatric Research, Gardner et al. describe how adverse childhood experiences before age 9 years increases the odds of obesity in adolescence. Of note, the authors considered the effects of many adverse childhood experiences beyond those included in an earlier study known as the “ACEs study”; for simplicity, we refer here to all such adverse childhood experiences as ACEs. Among these additional, stress-inducing experiences were death of a parent, close family member or a close friend; relocation; need for a foster home; serious illness of the child or a family member; and parental conflict. These results contribute substantially to the collective evidence that ACEs adversely impact the subsequent health of children, an effect compounded by poverty. Collectively, these findings support the need to consider social determinants when developing behavioral strategies for promoting healthy development, including weight status, particularly in early adolescence. The presence of ACEs does NOT condemn a child to poor adultonset outcomes. Protective factors prevent children from experiencing adversity and can defend against many associated, negative health outcomes. The Centers for Disease Control (CDC) has recommended five activities to prevent the impact of ACEs: strengthen economic supports to families, change social norms to support parents and positive parenting, provide quality early-life child care and education, enhance parenting skills, and intervene to mitigate harm and prevent future risk (i.e., enhanced primary care, parenting programs, treatment to lessen harms of abuse and neglect). For instance, Brotman et al. demonstrated that supporting parents by offering evidence-based parenting interventions during preschool can promote healthy child development and prevent obesity during adolescence. The weight of this evidence has already motivated changes in clinical practice, school policies, and legislation at state and local levels, all aiming to mitigate the long-term effects of ACEs. For example, the California legislature passed ACR 155, encouraging policies to reduce ACEs, in 2014; and in 2017, Vermont passed bill No. 43, H. 508, aiming to screen for and address ACEs in schools and health-care clinics. In response to the growing evidence for lasting and progressive adverse effects of ACEs on diverse health outcomes and recognizing the complexity, scale, and difficulty involved in addressing this issue, the CDC now provides extensive educational resources and prevention strategies, including information to foster safe and nurturing environments and relationships for children, and technical packages to prevent childhood abuse and neglect. Efforts such as these demonstrate the growing recognition that the health-care industry plays a critical role in screening our pediatric patients for ACEs and intervening appropriately. Increased attention to early childhood adversity may achieve multiple public health benefits. However, modern pediatric practices face daunting hurdles in operationalizing recommendations to screen for ACEs. Despite the evidence for benefit, thirdparty payors are not widely incentivizing screening with additional reimbursement. Screening for ACEs necessitates access to referral sources, which are often lacking. Obtaining mental health services, for example, is becoming increasingly difficult as psychiatric providers participate in fewer insurance plans. For instance, <50% of psychiatrists nationwide currently accept Medicaid, the primary insurer (with the Children’s Health Insurance Plan [CHIP]) for 45 million (48%) US children. Unfortunately, Medicaid enrollment is itself a risk factor for ACEs. For other referrals indicated by ACEs screening, pediatric insurance networks limit access to subspecialists, further impeding access to care. In the face of these challenges, it is unsurprising that only ~4% of pediatricians reportedly screen for all major ACEs known to be associated with long-term sequelae. As payors migrate toward value-based payment strategies, however, opportunities exist to incentivize widespread screening for ACEs. Payment reform advocates maintain that the primary value of pediatric care is prevention of adult-onset disease. Following this logic, small, highly vulnerable pediatric populations should warrant increased, earlier attention and increased health-care resources. States are actively adopting screenings for parental health issues, such as post-partum depression and smoking, as part of both pediatric and maternal value-based care. Reporting these metrics and achieving performance targets would merit increased