how health care can respond to the lifelong impact of adverse childhood experiences

based on  real events , the lyrics shone a light on the tragic cycle of poverty, abuse, substance use and the lack of social supports for vulnerable people. they necessitate the question: how do we support children like brenda who have been exposed to such trauma on an ongoing basis, and recognize its impact on the adults we live and work with?

adverse childhood experiences and social determinants of health

adverse childhood experiences  (aces) include:

• emotional, physical or sexual abuse,
• emotional or physical neglect, and
• household challenges such as violence toward the mother, substance abuse or mental illness at home, separation or divorce, or a member of the household being incarcerated.

exposure to aces, as well as disparities in  social determinants of health  — described by the world health organization as the “ conditions in which people are born, grow, work, live and age ” — can significantly affect development and health in children.

exposure to aces is associated with  physical trauma, such as traumatic brain injuries and burns; mental health issues, including depression, anxiety, suicide and ptsd; as well as other medical issues such as chronic pain, obesity and heart disease.

beyond physical health conditions , aces are also associated with  risky behaviours  such as unsafe sex, as well as poor social outcomes such as lower education levels and income. chronic stress can result in what is described as an  allostatic load , or “wear and tear” on the body and also causes poorer health outcomes.

the pervasiveness of exposure to these negative factors is staggering.  a recent canadian study  found that over 60 per cent of adults reported experiencing at least one ace as a child, with over one-third experiencing two or more. poverty, a major social determinant of health, affects  one in seven canadians , and during the covid-19 pandemic  almost 15 per cent of canadians experienced food insecurity .

social determinants of health amount to severe disparities in health outcomes in high-income countries: for example, in baltimore, the poorest neighbourhoods have infant mortality rates  comparable to the west bank , over ten times higher than the rates in  baltimore’s richer areas .

what can be done about aces and social determinants?

the first is to transform how we practice medicine. as clinicians, our tool is “ the social history ” where we ask the questions: who lives with you? are there any smokers in the home? what do you do for work? and so on. but while this standard set of questions is drilled into us from medical school, their relevance can vary.

some researchers  suggest a more practical approach, focusing on domains that can be directly addressed to improve health: income, housing, education, legal status and immigration, literacy and personal safety.

trauma-informed care

beyond taking a better patient history, medical professionals can  incorporate trauma-informed care  — which recognizes the pervasiveness of trauma and responds to its effects — into our practice. we should accommodate for families in precarious social situations, whether by adapting our language to support parents with learning difficulties or by offering virtual appointment options for families with limited access to transportation.

we should recognize that  intergenerational trauma  and previous experiences may result in mistrust of the medical system, and focus on building bridges.

advocating for change

as caregivers, clinicians can advocate for safe environments in homes, schools and communities. research demonstrates that children with positive childhood experiences, such as being able to talk to family members about their feelings, feeling supported by friends or having non-parent adults take genuine interest in them,  may improve adult mental health and relational health  (emotional and social support networks and relationships).

positive childhood experiences help foster resilience in children to help negate aces, and the  strongest protective factor against aces is a stable relationship with an adult .

the concept of health equity focuses on allowing individuals to “ reach their fullest health potential ” by addressing disparities in access to care and other social determinants of health, and we should actively work to reduce these disparities. on a societal level, we can incorporate an understanding of aces and social determinants of health into community programming.  schools with trauma-informed practices  have better results for children with exposure to aces.

increased community funding for mental health supports, substance use treatment programs and universal childcare can help address household challenges. incorporating perspectives around aces and social determinants of health on a community level — such as a pilot project in tarpon springs, florida which incorporated a “ trauma-informed lens ” into policy-making — can help bring systemic change.