In the late 1990s, a large research study evaluated the impact of adverse childhood experiences on adult health and health behaviors in over 17,000 participants. This research is referred to as the Adverse Childhood Experiences Study.  Adverse childhood experiences (ACE) include neglect, abuse, witnessing violence, or experiencing substance abuse, mental illness, divorce, or imprisonment of a family member. The findings showed that the more negative events a child experienced, the higher the likelihood they had behavior problems and participated in adolescent risky behaviors, including substance abuse and unprotected sexual activity resulting in pregnancy. In addition, the findings showed that adults also struggled with substance abuse and had a higher likelihood of suffering with chronic illness, including alcoholism, chronic pulmonary disease, depression, liver disease, and many more.^[1] Additionally, adults with the highest level of ACEs had a 20-year lower life expectancy than those without high levels of ACEs.^[2] See Figure 15.1^[3] for an infographic of ACEs.

Although many people who experience individual trauma continue to live their lives without lasting negative effects, others experience traumatic stress reactions causing lasting difficulties. Various biopsychosocial and cultural factors influence an individual’s immediate response and long-term reactions to trauma. For most individuals, regardless of the severity of the trauma, the effects of trauma are met with resilience, defined as the ability to rise above circumstances or meet challenges with fortitude. Resilience includes the process of using available resources to negotiate hardship and/or the consequences of adverse events.^[5]

The Centers for Disease Control and Prevention (CDC) created a resource titled Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence. This resource contains these six strategies:

• Strengthen economic supports to families
• Promote social norms that protect against violence and adversity
• Ensure a strong start for children
• Teach skills
• Connect youth to caring adults and activities
• Intervene to lessen immediate and long-term harms

Risk Factors, Protective Factors, and Prevention Strategies

By bringing attention to the powerful impact that negative childhood experiences have on future health and functioning, the ACE study demonstrates the importance of designing early intervention programs that target abuse, neglect, and violence.^[7] Nurses can help prevent ACEs by educating parents, communities, and policymakers about how to help families provide safe and stable environments for children.

Risk Factors

Risk factors are conditions that increase the likelihood of experiencing ACEs. There are individual, family, and community risk factors for ACEs.

Individual and Family Risk Factors

Individual and family risk factors include the following^[8]:

• Families experiencing caregiving challenges related to children with special needs (for example, disabilities, mental health issues, and chronic physical illnesses)
• Children and adolescents who don’t feel close to their parents/caregivers and feel as though they can’t talk to them about their feelings
• Youth who start dating or engaging in sexual activity at an early age
• Children and youth with few or no friends or with friends who engage in aggressive or delinquent behavior
• Families with caregivers who have a limited understanding of children’s needs or development
• Families with caregivers who were abused or neglected as children
• Families with young caregivers or single parents
• Families with low income
• Families with adults who have low levels of education
• Families experiencing high levels of stress from parenting or economic issues
• Families that have inconsistent discipline, use corporal punishment, and/or have low levels of parental supervision
• Families who are isolated from and not connected to other people (e.g., extended family, friends, neighbors)
• Families with high conflict and negative communication styles
• Families with attitudes accepting of or justifying violence or aggression

Community Risk Factors

Community risk factors include communities with these attributes^[9]:

• High rates of violence and crime
• Limited educational and economic opportunities
• High rates of poverty, unemployment rates, and food insecurity
• Easy access to drugs and alcohol
• Low community involvement among residents
• Few community activities for youth
• Unstable housing where residents move frequently

Protective Factors

Protective factors are conditions that protect people and decrease the possibility of experiencing ACEs.

Individual and Family Protective Factors

Individual and family protective factors against ACEs include the following^[10]:

• Families where caregivers can meet basic needs of food, shelter, and health services for children
• Families that create a consistent family life where children feel safe, stable, and supported in nurturing relationships
• Children who have positive friendships and peer networks
• Children who experience academic success
• Children who have caring adults outside the family who serve as mentors/role models
• Families where caregivers have a college degree or higher education
• Families where caregivers have steady employment
• Families with strong social support networks and positive relationships with the people around them
• Families where caregivers engage in parental monitoring, supervision, and consistent enforcement of rules
• Families where caregivers/adults work through conflicts peacefully
• Families where caregivers help children work through problems
• Families that engage in fun, positive activities together
• Families that encourage the importance of school for children

Community Protective Factors

Communities can intervene to lessen the harms from ACEs and prevent future risks. Community protective factors include communities that demonstrate these qualities^[11],[12]:

• Families have access to education and support regarding positive parenting
• Families have access to economic and financial help
• Families have access to medical care and mental health services
• Individuals and families have access to safe, stable housing
• Families have access to nurturing and safe child care
• Families have access to high-quality preschool programs
• Families have access to safe, engaging after-school programs and activities
• Adults have work opportunities with family-friendly policies
• There are strong partnerships among the community and business, health care, government, and other sectors
• Residents feel connected to each other and are involved in the community
• Violence is not tolerated or accepted in the community
• Positive parenting strategies are social norms in the community

Many factors contribute to ACEs, including personal traits and experiences, parents, the family environment, and the community itself. ACEs can have lasting negative effects on health and well-being, but these harms can be preventable. To prevent ACEs and protect children from neglect, abuse, and violence, nurses are involved in addressing these risk factors and protective factors with prevention strategies.^[13]

Appropriately addressing traumatic experiences and promoting resilience are important parts of effective mental health care and integral for the healing and recovery process.^[14]