Promoting Early and Lifelong Health: The Challenge of Adverse Childhood Experiences and the
Promise of Resilience
Summary of Key Themes
A meeting coordinate by CAHMI, AcademyHealth and a meeting planning committee was held on June 6,
2014 in conjunction with the AcademyHealth Annual Research Meeting. The meeting consisted of
several presentations summarizing participant input provided prior to the meeting as well as regarding
efforts underway in this area that would be essential to coordinate with. Most of the day was spent in
small group discussions, reporting out and group discussion (see agenda). Several themes emerged
throughout the day. Those that most stood out are summarized here. Where possible quotes have been
attributed and some additional information and references have been added.
Clarity of definitions and landscape
The landmark Adverse Childhood Experiences study identified 10 events associated with significant
impact on children and in some cases toxic stress and long term trauma (cite and add list as an
attachment). Since then, additional adverse experiences have been identified. Participants noted that
these terms often come up in many contexts and some may
Words are very important; they should
dilute the severity of the occurrences. Not all stress is toxic
bring us together rather than separate us.
and not all children exposed to high levels of adversity
experience trauma. Adversity and adverse childhood
Sandy Hassink, MD
experiences are what children are exposed to whereas some
President-Elect
suggest that toxic stress and trauma are the lived experience
American Academy of Pediatrics
representing only a subset of those children. Chronic stress
is also now suggested to be more harmful than single event
There is a tendency for us to focus on the
adversity. These issues pose key priorities for research A key
super traumatized. The population that is
factor in predicting impact of ACEs may be the extent to which
one notch above that is the important
children, families and communities are resilient and able to
population to recognize.”
ameliorate the impact and cope with adverse experiences. A
public health practice to address chronic stress may also be
Neal Halfon MD, MPH
Professor
important to evaluate. Ensuring that all stakeholders
University of California Los Angeles
understand the full range of terms is a first step to developing
a clear agenda for research and action.
Beyond clarity of definitions we also need to have an understanding of what initiatives are currently in
place so that gaps can be identified and progress coordinated and more rapidly shared. Given that
children experiencing ACEs are identified through a variety of “doors” – medical care, community based
social services, child protection, juvenile justice, education, etc…- these siloed policy communities are
often unaware of others’ efforts. Our project is specifically intended to both fill a gap in the pediatrics
health services area and also do so in a way that integrates with existing and emerging efforts in this and
other areas.
Clarity on the characteristics of healthy, resilient communities and safe, stable, nurturing relationships and
homes is also needed so that the goals of any intervention or strategy are clearly defined; perhaps
minimizing the importance of knowing the specific type or types of trauma and instead focusing on the
impact regardless of the type of adversity and advancing to promotion of positive health and resilience.
These are key issues to consider when framing this project and the research and action agenda.
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The importance of good measures and data to monitor progress
Who is accountable for the child? Just because
Building on clear terminology and definitions, participants
you're screening, does not mean you are being
agreed that data and robust measures at the national,
accountable. No one is actually responsible
state, and community levels (ideally) are needed to
right now. …We need to understand the
understand which children and families are most at risk,
population with more robust data; we need to
associations with positive and negative health indicators
know how and where these kids are affected.
and life course health development metrics, identify which
conditions/contexts contribute to the development of
adverse experiences, trauma and toxic and chronic stress (and visa versa), track the impact of policy,
program and practice interventions, and hold decision makers and stakeholders accountable for progress.
Importantly, measuring the contribution of each to addressing and appropriately attributing accountability
(and shared accountability) is challenging and should be examined.
Measurement innovation was also called for as current measures used in clinical settings are not
specified clearly or fully tested for enabling a focus on ACEs in practices (e.g. Health Data Consortium,
Electronic Data Methods Forum, etc…). Advances and growth in new data sources and data analytics
capabilities, including electronic health records, bring the potential to think about two-generation data
(parent and child), measuring impact and outcomes in real time so that quicker learning occurs and the
potential for intervention adaptation. Another dimension of innovation what considering which are the
right incentives to get different systems and agencies (across both the public and private sectors) to
share data? What can be learned from the experience of building the Title V data system?
The Landscape of Existing and Emerging Efforts (to be summarized in future meeting summary
version)
Specific Research Questions
Several questions emerged in discussions including the need to:
 Better understand what protects children who are at risk from experiencing ACEs or minimizing
impact of ACEs when they occur-perhaps even leveraging adversity to build greater strength;
 Understand whether and how to uncouple adversity from negative outcomes associated with
chronic and toxic stress so as to effectively target intervention resources
 Understand what population-wide
When does the role of health care
efforts/interventions/education/communication might be
professionals fit in? We may need a
recommended based on the known prevalence and
new role all together, a new type of
normed impact of ACEs in the public at large
provider.
 Better characterize the presumed gradient in the
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experience of adversity; especially for those not studied
Robert Blum, MD, PhD
well (those below the “stage 4” level of ACEs)
Professor & Chair
Know what a healthy community is and how we move
Department of Population & Family Health
that information to others to promote positive health,
Johns Hopkins Bloomberg School of
resilience, SSNR and prevent ACEs; and define, test
Public Health
and enable early efforts to minimize impact across life.
Define and measure the return on investment of programs to prevent and/or address ACES;
Learn from work in other countries on these issues;
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Understand what evidence and structures are needed in order to spur and sustain collective
action;
Need population based associational studies and also to go beyond associational studies (of
which there are many at the specific ACEs and specific samples ) and focus on causal studies
and longitudinal studies.
Actions Needed
Synthesis and Dissemination of Existing Models, Methods and Practices
Discussion of needed actions emphasized integration and identifying/disseminating models that work.
The need for integration & coordination included integration between primary care and mental health;
integration at the national level between the AAP and the Association of Child and Adolescent Psychiatry;
integration between health and early childhood education and care settings, the community, etc…
Given the current opportunities spurred by the ACA and new payment models, development and testing
of aligning payment incentives was seen as important to identify successful models. Another
contextual/systems level feature is the widespread implementation of electronic health records (EHRs)
raising the possibility of testing whether embedding ACES identification and management tools in the
EHRs is effective. Finally, simply documenting and disseminating information about existing models was
seen as helpful.
Provider/Practitioner, Community, and Family Education & Training:
Discussions about the critical need for training of health professionals, families and all who work with
children in educational and community settings emerged in subgroup discussions about engagement.
Participants pointed out the importance of legitimizing training in ACEs and to do so in a way that is
respectful of all disciplines. For example, pediatric and mental health providers need to understand how
to integrate physical and mental health and the wellness
One of the issues is vicarious trauma,
community. The issue of “secondary trauma” and ensuring
if all of your staff have not dealt with it,
parents, providers and others also are aware of and address
it may burn them out.
their own trauma histories was noted repeatedly.
Elisa Nicholas
Long Beach Children’s Clinic
Throughout the discussions it was clear that this is an interprofessional movement. For example, not all screening for
ACES needs to be done by a pediatrician; it could be a number of other providers or community leaders.
At the same time, empowering parents to recognize the potential of the well visit was also discussed: it is
not just for vaccinations.
Other dimensions of training needs included:
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Building motivational knowledge and awareness and supporting both provider and patient
activation;
Teaching providers a common vocabulary and dialogue;
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Creating a compendium of practice efforts, beginning with the most basic of knowing about the
building awareness between families, youth and their providers (building on Dr. Felitti, et al’s work
showing that even simple solutions have an impact)
Physicians to be practice active, compassionate listening, model implicit acceptance, listening
and reflecting
Understanding the idea that family engagement is practitioner engagement
Framing so that practitioners see value in their role;
Addressing the complexities of ACEs so that practitioners need to not be paralyzed by the issue,
just focus on the necessity of moving forward; advance positive health development as cross
cutting goal regardless of specific ACEs experienced.
Training entire practice teams about toxic and chronic stress, ACEs and resilience; and
Training for entire communities of the very real effects of children's development on the
community’s health.
Another dimension of professional development was the need to also pay attention to the wellbeing of all
providers: working with children and families experiencing ACEs creates significant psychic and
emotional pressures for providers and burnout is all too frequent. Methods exist to enable authentic care
and action without reaching burnout and preventing a cycle of “overcare” or “undercare” while allowing
continuous caring stance to be maintained. Provider stress management, self-regulation and mindfulness
methods are critical to further test and evaluate for this and other aspects of addressing ACEs and
promoting resilience. The importance of giving providers the time to get to know the child was also raised
as well as the opportunity to learn from work being conducted in the field of disaster preparedness by the
American Academy of Pediatrics (AAP) where first responder and others may come to experience
compassionate fatigue.
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