The Impact of Adverse Childhood Experiences—And How NPs Can Help

As nurse practitioners, we have an opportunity to help create the conditions for families and communities to thrive, to strengthen families so all children and adolescents are free from harm and all people can have lifelong health and wellbeing. Unfortunately, not all children live in a safe and stable home with nurturing relationships.

Adverse childhood experiences (ACEs) have an enormous impact on future substance abuse, violence, victimization and perpetration, sexually transmitted infections, delayed brain development, lower educational attainment, reduced employment opportunities, and a lifetime of increased negative health outcomes and increased risk of disease. It is estimated that in the United States this costs hundreds of billions of dollars each year (CDC 2021). The emotional cost is immeasurable.

But what are ACEs? And what can we as nurse practitioners do about them?

What are Adverse Childhood Experiences?

Adverse childhood experiences erode a child’s sense of stability, safety, and bonding. There are three categories of ACEs: abuse, neglect, and household challenges.

Child abuse is generally defined as physical, cruel, or violent treatment or sexual molestation of a child (CDC 2021). Nurse practitioners are mandated reporters—if abuse is suspected, it must be reported to state authorities. Each state has its own agency, contact information by state can be found at the Child Welfare Information Gateway. There is also the Childhelp National Child Abuse Hotline that can receive calls or text 1-800-4-A-CHILD.

Neglect is not always as clear but can be defined as “the failure to meet a child’s basic physical and emotional needs. These needs include housing, food, clothing, education, and access to medical care” (CDC 2021). Suspected neglect must also be reported.

Not all ACEs are direct abuse of a child but entail environmental or household challenges. This can include experiencing or witnessing violence, abuse, or a family member dying by suicide. ACEs can result from growing up in a household with substance use, mental health problems, instability due to parental separation, or a household member being incarcerated.

How Common are Adverse Childhood Experiences?

According to the Robert Wood Johnson Foundation (RWJF 2017), “Nationally, more than 46 percent of U.S. youth—34 million children under age 18—have had at least one ACE, and more than 20 percent have had at least two.” There are areas with higher prevalences. An analysis of state-by-state percentages of children with ACEs, ranged from 37 percent in Minnesota to 56 percent in Arkansas.

Children who experience ACEs are at risk for emotional and mental harm and ACEs also carry with them an increased risk of physical illness and disease or negative health outcomes. Recent data shows that 33 percent of children with two or more ACEs have a chronic health condition, compared to 13.6 percent of children who have not experienced ACEs (RWJF 2017).

ACEs affect not only children but the adults they become. We know that ACEs increase the long-term risk for depression, alcoholism, smoking, heart and liver diseases, and dozens of other illnesses and unhealthy behaviors (RWJF). It is estimated that up to 1.9 million cases of heart disease and 21 million cases of depression could have been potentially avoided by preventing ACEs.

This is reflected in my own practice as a family nurse practitioner. In conversations with those seeking treatment for depression or mood disorders, I see a high correlation between mental health problems and a history of adverse childhood experiences.

How Can NPs Help People Address Adverse Childhood Experiences?

Children often lack the vocabulary to tell you what they are experiencing at home. It is their “normal” and they may not know their lives could be different. Improving the lives of children can be achieved and it begins with screening for ACEs and connecting parents to needed resources.

Integrating screening tools into your practice can promote a more holistic and trauma-informed approach. ACEs can be mitigated by high-quality care that uses evidence-based solutions and is integrated with social work and community resources.

The Safe Environment for Every Kid parental questionnaire is one available resource recommended for use at childhood wellness examinations. It is also available in Spanish and other languages.

This data is sensitive, as it can be uncomfortable to divulge financial resources, addiction, and intimate partner violence; however, as certified healthcare professionals, we have the training and ability to have these difficult conversations, which may help an at-risk child and their caregiver.

Nurse practitioners utilizing these tools must also be prepared to intervene and adjust their plan of care based upon the results. Deep knowledge of the resources available within the community is helpful, as well as referrals to social services, mental health providers, or additional screening for chronic health conditions. These tools can be utilized as part of a social history.

Screening adults can also help to better inform care and heighten concerns for both physical and mental wellness. For those over 18, ACE scores can be calculated.

Beyond the exam room, it is important to be civically engaged, as policy decisions directly affect our patients, communities, and thus our practices. Obviously, not all problems can be solved by government intervention, but we can advocate for data-driven solutions and policies that improve health outcomes.

The CDC (2021) offers five strategies that help prevent ACEs:

  • Strengthening economic aid for families
  • Changing social norms to support parents
  • Providing quality early education
  • Enhancing parenting skills
  • Offering early intervention to prevent harm and lessen the future risk

Nurse practitioners are respected experts in healthcare with a deep knowledge of the problems experienced within their communities. We can use our influence to help prevent ACEs by advocating for evidence-based policy.

To learn what bills may be before your state or federal legislators or to learn more about policy, you can go to ACE Response. A call or email is the easiest way to communicate with your representative, and participating in a “lobby day” with your professional organization is a great way to meet your state or federal legislators.

As nurse practitioners, we have a duty to provide evidence-based care and the expertise to advocate for policy that strengthens families and communities so that children and adolescents are free from harm—a crucial first step for lifelong health and wellbeing.

Celeste Williams, MSN, APRN, FNP-BC

Celeste Williams, MSN, APRN, FNP-BC

Writer & Contributing Expert

Celeste Williams is a family nurse practitioner and alumna of Southern Nazarene University and the University of Arkansas for Medical Sciences. Celeste is passionate about healthcare policy, especially its effects on rural and other underserved communities. She believes more nurses belong in all levels of government and places where decisions are made. She is active in her community through her professional organizations, local political organizations, Rotary, and her church. She lives in NW Arkansas with her husband, four children, two cats, a dog, chickens, ducks, turkeys, peacocks, and a bearded dragon.