Adverse childhood experiences
Adverse childhood experiences (ACEs) are extremely stressful events that a child encounters before age 18 that lead to an inflammatory response in the body. These inflammatory responses can then lead to adverse physical and developmental outcomes, such as chronic diseases and social determinants.1 For the past 20 years, research has helped us understand the relationship between dysfunctional physiological stress response and negative long-term health outcomes.2,3 Known stressors include emotional, physical, or environmental experiences and can be classified into three different categories: abuse, neglect, and household dysfunction.
Types of stressors
The human body has been designed to adapt to stress with the complex fight-or-flight response.3 The American Academy of Pediatrics provides three general categories of stress response: positive stress, tolerable stress, and toxic stress.4 Positive stress is part of normal healthy development and is short-lived; it can be counteracted by affection and protection from a caring adult.4 For example, when a child experiences a frightening situation, there is an adrenaline rush and an increase in blood pressure, heart rate, and stress hormones. But the sense of protection the child receives from a caregiver can help these fears subside, and so does the body’s physiological response. In turn, this leads to manageable stress responses that have no long-term effects on the body.4
Tolerable stress is similar to positive stress; however, stress is a serious threat that exacerbates the body’s response. Supportive and caring relationships are critical in managing tolerable stress as they create a sense of safety. The activated response is time-limited and buffered by a protective adult, allowing the body to recover and prevent permanent damage.5
The last stressor response and the one we will be focusing on is toxic stress. Toxic stress occurs with prolonged, frequent, or strong exposure to adversity without the presence of a buffer, such as caring adults, to mitigate the stress. It is the lack of caring and support from adults that prevents toxic stress from being converted into tolerable stress. Toxic stress disrupts the brain architecture, cognitive impairment, and can cause other health-related diseases.5
The stress response catalyzes the derangement of the neuroendocrine-immune response, resulting in increased levels of stress hormones, such as corticotropin-releasing hormone, cortisol, norepinephrine, and adrenaline. These responses coincide with other integrators that include inflammatory cytokines and the response of the parasympathetic nervous system. When cortisol levels are constantly elevated, they can cause suppression of the immune function, cognitive impairment, and metabolic syndrome.5,6 Sustained elevated levels of cortisol can affect gene expression, disrupt brain architecture, and lead to permanent impairments in learning, decision-making, memory, and ability to regulate future stress responses.3,5,6 Some of the poor health and behavioral outcomes associated with ACEs include ischemic heart disease, chronic pulmonary disease, asthma, pneumonia, cancer, depression, alcoholism, obesity, hyperthyroidism, diabetes, learning behaviors, Alzheimer’s disease, suicide, and many other noncommunicable diseases. Furthermore, research shows that adults who have experienced toxic stress have a 20-year decrease in life expectancy.3,4,5,7
Much like dentistry, prevention is the goal for making an impact on health and wellness. We also need to teach skills that can help build resilience for those unavoidable exposures to stress. Unfortunately, most children who experience ACEs in their early childhood continue to experience them throughout their childhood. This gradual increase in adverse events presents an opportunity to identify and intervene with children who are at greatest risk for ACEs. ACEs can be detrimental to overall health, but once identified, measures can be put in place to help mitigate the negative effects. The negative effects of ACEs can be neutralized through safe, nurturing, and stable relationships.3,5
It is important to note that not all children who experience toxic levels of stress have poor health outcomes. Children who have nurturing relationships with parents or caregivers can have higher IQs and the ability to build resiliency, positive self-worth, and problem-solving skills.3 In addition to nurturing relationships, building protective resilience to stress levels can be as simple as participating in meditation and breathing exercises. Acute exercises have proven to create endorphins that enhance neuroplasticity and hippocampal function. These exercises can also lead to increased memory function and a reduction in depression and other effects of stress. Some proven buffering techniques include balanced nutrition, regular sleep, guided imagery, established routines, words of affirmation, support from community members, and, if needed, psychotherapy and/or psychiatric care.3,6,8,9
The dental professional’s role
Dental hygienists have a unique opportunity to provide multiple touchpoints throughout the year with their patients. Increased patient access allows us to expand our care to include screenings and promotion of health and wellness. Screening tools and referrals can be used to identify ACEs and aid patients who need additional support.
The Centers for Disease Control and Prevention (CDC) is currently using a survey instrument for screening that was developed by Nadine Burke-Harris at the Center for Youth Wellness. The CDC provides a nonidentifying survey, corresponding scripts, and instructions on how to administer the survey.10 While the application of screening tools for ACEs is not widely used in dentistry, we believe that as we collaborate with other health professionals, the dental setting can be a place of support for individuals and family members. Further, the educational background of dental hygienists is an asset in prevention of diseases and promotion of patient health, which makes us ideal screeners for ACEs.
The role of dental hygienists has expanded beyond oral health to overall health and wellness. Our roles can easily expand to include screening for ACEs through the administration of a survey. When filling out the survey, patients can designate how many ACEs they have been exposed to, but not what those ACEs are. If the patient is 12 or younger, the parent or guardian is asked to fill out the survey. For adolescents, either the child or the parent may answer the questions. The number of ACEs a child has will help determine next steps. The CDC gives recommendations that guide health professionals on when a referral to a mental health professional is indicated.9
Why should we screen for ACEs?
Screening for ACEs can decrease the risk for the top two causes of death in the United States and the top seven globally.2,3,5,7,9 Current research shows that the higher the score for ACEs, or the number of experiences a child has, the greater the risk for a negative health outcome.8 These experiences could be abuse, violence in the home, neglect, household dysfunction, and/or environment. Currently, one out of three children and more than 60% of adults suffer from at least one ACE, with one out of every six adults experiencing four or more.2,3,5,8,9 These exposures can disrupt brain development, immune dysfunction, reduce cognitive functions, hinder social development, and lead to unhealthy social behaviors.5,11 With four or more ACEs, an individual is likely to suffer from heart disease, cancer, diabetes, and chronic lower respiratory disease, and is 11 times more likely to develop Alzheimer’s disease. The most alarming stat is that an individual who experiences four or more ACEs is 30 times more likely to end their own life.3,4,8,9,11
While we know there is a systemic link between oral disease and chronic disease, it would not be difficult to deduce the correlation of ACEs to oral disease. Beyond that, one of our many responsibilities—and one of our most important roles as dental hygienists—is to be a patient advocate. As such, we can make a difference as we reduce one of the greatest risk factors for poor health. The dental office setting offers a unique opportunity to implement universal de-identified screening for ACEs and is an important place for dental professionals to start having open discussions with patients. Hygienists effectively make a difference in patients’ overall health by screening for high blood pressure and blood glucose levels, as well as educating about suicide prevention and human trafficking. This is a call to action for all hygienists to be informed about how they can start collaborating with other health professionals. Dental professionals who are interested in learning more about ACEs can receive free training through the CDC’s website.12 Remember, if something is predictable, it is preventable.
Editor's note: This article appeared in the July 2021 print edition of RDH.
- Brown DW, Anda RF, Tiemeier H, et al. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med. 2009;37(5):389-396. doi:10.1016/j.amepre.2009.06.021
- Felitti VJ. Adverse childhood experiences and adult health. Acad Pediatr. 2009;9(3):131-132. doi:10.1016/j.acap.2009.03.001
- Franke HA. Toxic stress: effects, prevention and treatment. Children (Basel). 2014;1(3):390-402. doi:10.3390/children1030390
- Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 1998;14(4):245-258. doi:10.1016/s0749-3797(98)00017-8
- Shonkoff JP, Garner AS, Siegel BS, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-e246. doi:10.1542/peds.2011-2663
- Center on the Developing Child at Harvard University. From best practices to breakthrough impacts: a science-based approach to building a more promising future for young children and families. 2016. www.developingchild.harvard.edu
- Dong M, Anda R, Felitti V, Giles W. The relationship of childhood abuse, neglect and household dysfunction to premature death of family members: findings from the adverse childhood experiences study. Am J Epidemiol. 2005;161(Suppl 1):S110. https://doi.org/10.1093/aje/161.Supplement_1.S110a
- Harris NB. How childhood adversity affects health across a lifetime — and what we can do about it. Center for Youth Wellness. February 28, 2018. https://snohomishcountywa.gov/DocumentCenter/View/50320/Snohomish-Resilience-Conference_NBH
- Preventing adverse childhood experiences. National Center for Injury and Prevention Control. Division of Violence Prevention. Centers for Disease Control and Prevention. Updated April 6, 2021. https://www.cdc.gov/violenceprevention/acestudy/fastfact.html
- Transcript of CDC telebriefing: at least 5 of the top 10 leading causes of death are associated with adverse childhood experiences (ACEs). US Department of Health and Human Services. Centers for Disease Control and Prevention (CDC). November 6, 2019.
- Monnat SM, Chandler RF. Long-term physical health consequences of adverse childhood experiences. Soc Q. 2015;56(4):723-752. doi:10.1111/tsq.12107
- Preventing adverse childhood experiences: we all have a role in preventing ACEs. Injury Prevention & Control: Division of Violence Prevention. Centers for Disease Control and Prevention. October 19, 2018. Accessed June 9, 2021. https://vetoviolence.cdc.gov/apps/aces-training/#/
Amber Lovatos, BSDH, RDH, is the clinical director of dental services at TOMAGWA HealthCare Ministries. She is a professional speaker, key opinion leader for Crest Oral-B and PDT Instruments, and governmental affairs consultant for MouthWatch. Lovatos is the cofounder of Dental Hygiene Spark, a social media page dedicated to empowering dental hygienists. Her passions and expertise include teledentistry, abuse, public health, and human trafficking. She can be reached at [email protected].
Sara Orr, MS, RDH, CHES, is an adjunct dental hygiene instructor at Pima Medical Institute in Houston, Texas. She recently completed her master’s degree from Texas Women’s University. Throughout her 20-year career, she has had the opportunity to work in various settings, including clinical hygiene, education, and public health. Orr can be reached at [email protected].