Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Adverse childhood experiences increase the risk of poor long-term health

Key clinical point: Reducing childhood exposure to adverse experiences could reap long-term health benefits.

Major finding: Preventing ACEs could prevent 1.9 million cases of heart disease, 2.5 million cases of overweight or obesity, and 21 million cases of depression.

Study details: The survey yielded responses from more than 144,000 adults.

Disclosures: Dr. Merrick and associates had no relevant financial disclosures.


Adverse childhood experiences (ACEs) trigger pathophysiologic responses that exert real physical and psychological harm. Thus, clinicians can and should address them as part of good medical care, Christopher M. Jones, PharmD, Melissa T. Merrick, PhD, and Debra E. Houry, MD, MPH, said in a JAMA commentary.

“A large and growing body of research indicates that the underlying mechanism by which ACEs are associated with health outcomes is through the development of toxic stress, a chronic activation of the stress response system. Toxic stress results in dysregulation of the limbic-hypothalamic-pituitary-adrenal axis, elevating levels of catecholamines (“fight or flight” response), cortisol, and proinflammatory cytokines, leading to cascading effects on the nervous, endocrine, and immune systems. These changes can affect attention and other executive functioning, impulsive behavior, brain reward systems, decision-making, and response to stress throughout the life span,” they said.

While societies and communities at large must work together to reduce ACE exposure, clinicians also have a role. Research indicates that many don’t routinely ask questions about these issues, in a large part because they lack training in how and when to screen.

“Incorporating components of primary ACEs prevention into everyday clinical practice may be achievable through talking with parents and caregivers about creating safe, stable, nurturing environments and protective relationships, and reinforcing positive parenting techniques and coping skills at routine clinical visits,” the editorialists said. “In addition, clinicians can refer parents to parenting skills classes or refer higher-risk parents to home visitation programs such as Healthy Families America and Nurse-Family Partnership. Home visitation programs have demonstrated significant reductions in rates of child abuse and neglect and have improved substance use, violence, and parenting outcomes.”

Clinicians also may have a role to play in mitigating the harms of ACEs, by incorporating trauma-informed care and services into their daily practice.

“Important elements of trauma-informed care include understanding how trauma affects health, routinely screening for ACEs and trauma, using culturally responsive assessments, promoting resilience and protective factors, addressing trauma-related somatic and mental health issues, and ensuring appropriate linkage to services and supports for identified issues,” the editorialists concluded.

Dr. Jones is associate director in the Office of Strategy and Innovation in the CDC Injury Center. Dr. Merrick is president and CEO of Prevent Childhood Abuse America, Chicago. Dr. Houry is director of the National Center for Injury Prevention and Control at the CDC, Atlanta. They discussed the MMWR analysis in a commentary (JAMA. 2019 Nov 5. doi: 10.1001/jama.2019.18499). They had no relevant financial disclosures.