1. Public Health Impact of Adverse Childhood Experiences: Final Recommendation for
the Center for Human Services Out-of-School Time Program
Gabriel Hardt
SPH 492 A

2. Public Health Problem
Stressors, particularly adverse events, during childhood are linked to the several of the
leading causes of death in the adult population.123 In fact, researchers found a dose-
response relationship between the number of adverse childhood events and the prevalence
of cognitive, behavioral, and physical health problems later in life.1 The 1998 ACEs study
found that up to 67% of the population reported at least 1 ACE, with over 12.6% reporting
12 or more.3 Risk factors for ACEs include poverty, parental mental illness, substance
abuse, and maltreatment, all of which often co-occur.3 The disproportionate risk for low-
income children may be a major contributing factor in the perpetuated poor health
outcomes in low-income communities.24 In order to prevent ACE exposure from
manifesting into poor health outcomes later in life, organizations that work with children
should become familiar with the problem and the strategies to prevent future
implications.5 The following paper will provide a synthesis of the public health impact of
ACEs, best practices, as well as an evidence-based recommendation for how the Out-of-
School Time program at the Center for Human Services can address ACEs.
Population:
The Out-of-School Time Program is located in the Ballinger Homes Public Housing
Community and managed by the King County Housing Authority (KCHA). To be eligible for
housing, KCHA requires applicants to have an annual household income at or below 80% of
the area median income (AMI). The housing communities are culturally and linguistically
diverse, with up to 20 different languages spoken in a single unit. Approximately 40% of
the residents are Caucasian, 22% Latino, and the remaining 38% other ethnicities. Families
1 Felitti VJ; Anda RF 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): 245-58.
2 Krueger PM, Change VW. Being poor and coping with stress: health behaviors and the risk of
death. Am J Public Health. 2008.
3 Tyrka, AR. Burgers D.E, Philip NS, Price L.H, Carpenter L.L. 2013. The neurobiological
correlates of childhood adversity and implications for treatment.
4 Wade, Roy et. Al. Adverse Childhood Experiences of Low-Income Urban Youth. July 1 2014.
Pediatrics Vol 134.
5 Overcoming Adverse Childhood Experiences. Injury Prevention Center. Phoenix Children’s
Hospital. http://www.acf.hhs.gov/initiatives/early-adversity

3. that seek services face a complex array of physical, behavioral, social and economic
challenges that limit their ability to retain jobs and support their family, such as refugee
status, substance abuse, mental health conditions and physical disability.6
Children, ages K-5 who live in the Ballinger Homes community are eligible to attend
program. Although attendance is not mandatory, an average of 20 to 40 students attend
daily. ACE risk is particularly high among the students who attend program, as many face
stressful home-life conditions, such as parental substance abuse, buying or selling drugs
from the home, parents engaging in multiple relationships, acting aggressively towards
family members or others, frequent moves, language barriers, or nutritional deficiencies.
Additionally, some of the students have displayed homicidal or suicidal behaviors, carry
and or posses weapons, and demonstrate emotional or anger issues.7 As research about
ACE exposure indicates, these resulting behaviors can lead to severe health implications
later in life. 1234
Impacts:
ACE exposure causes a complex array of health, social, and economic impacts for the entire
US population, not only low-income individuals.12 The CDC estimates the lifetime cost of
ACEs to be $124 billion, largely due to productivity loss and health care expenses.8 ACEs
have been found to decrease life expectancy and increase susceptibility to a variety of
harmful behavior and physical outcomes, including (but not limited to) severe obesity,
diabetes, depression, teen pregnancy, suicide, cancer, heart disease, stroke, smoking,
alcoholism, missed work, and drug use.3 ACE exposure is a cyclic in nature, as many of the
consequent diseases and behaviors put future generations at greater risk for ACEs.5
6 Subsidized Housing Eligibility. King County Housing Authority. (2015).
www.kcha.org/housing/subsidized/eligibility.
7 Center for Human Services Annual Report. (2013) http://www.chs-nw.org/wp-
content/uploads/2014/04/Center-for-Human-Services_2013-Annual-Report.pdf
8 Fang et al.The Economic Burden of Child maltreatment in the United States and implications
for prevention. Child Abuse and Neglect. Vol 36 (2012)

4. Children are particularly vulnerable to ACE exposure due dependency and cognitive
developmental factors. During development, children are entirely reliant on their
caregivers for their basic physical, social, and emotional needs.9 Therefore, an adverse
environment in the household undermines the ability to access basic needs. At the same
time, a child’s brain is undergoing rapid and large-scale developmental changes in neural
pathways that regulate emotion and behavior.4 9 Chronic stress can alter the physical
dendritic structure of the brain, and manifest in impaired functioning of goal driven,
flexible behavior, and an increase in top town, habit driven behavior.10 This is especially
damaging when an individual is faced with an adverse situation, as it impairs creative
problem solving needed to foster resiliency.10 Because of the risk factors reported about
the Out-of-School-Time Program in the CHS annual report, I strongly believe that ACEs
should be addressed in the program to prevent the manifestation of negative behavioral
and physical health outcomes in adulthood.
Best Practices
To interrupt the cycle of ACEs, the CDC suggests efforts should focus on early detection of
ACEs in children, so they can receive treatment and prevent problems from manifesting
later in life. Of specific interest is the concept of resiliency.9 11 12 A study conducted at the
University of Wisconsin found that stress was only associated with negative health impacts
if the individuals perceived that stress as detrimental to their own health. If stress was
perceived as motivational, rather than harmful, the individual was protected. 12 Therefore,
many interventions focus on resiliency as a main way to combat ACE exposure.
9 Springer, Kristen W MPH, MA. Sheridan, Jennifer PhD. Kuo, Daphne PhD. Carnes, Molly,
MD, M.S. The Long-term Health Outcomes of Childhood Abuse: An Overview and a Call to
Action. J Gen Intern Med. 2003 Oct; 18: 864-870.
10 Ferreira, Eduardo Dias et. al. Chronic stress causes frontostriatal reorganization and
affects decision-making. Science. 325, 621-625. (2009).
11 Centers for Disease Control and Prevention. Preventing Child Maltreatment Through the
Promotion of Safe, Stable, and Nurturing Relationships between Children and Caregivers.
12 Keller, Abiola; Litzelman, Kristin; Wisk, Lauren E.;Maddox, Torsheika; Cheng, Erika Rose;
Creswell, PaulD.; Witt, Whitney P.Does the perception that stress affectshealth matter? The
association withhealth and mortality. Health Psychology,Vol31(5), Sep 2012, 677-684

5. Caitlin Ormsby, 8th grade science teacher in a low-income school district emphasized the
need for strong, community based, adult mentors to help foster resiliency. “As a teacher,
the biggest barrier to helping students with traumatic events is trust,” says Ormsby. “If
you’re not from the community, you don’t know the context, it can be difficult to build the
trust you need to support the students.” However, when an adult is familiar with the child’s
culture and environment, they are more easily able to connect and offer support. In fact,
strong adult mentors and communities are a key focus of trauma resiliency research.1113
In addition to fostering resiliency, Marit Murry, on-site behavioral coordinator for
Ormsby’s school, identified a need to create a systematic way to detect and offer support
for traumatic events early, rather than letting them manifest as harmful behaviors later in
life. Their school is developing a web-based student tracking system that will monitor each
student’s academic and behavioral information, enter in family and medical history, and
help identify students who need support. The use of mental health tracking systems is
proven to increase provider and patient satisfaction, as well improve mental health
symptoms at a greater rate than standard care.14 Screeners, such as the PHQ-9 depression
scale, ADD or trauma screener are built-in to the software, facilitate early detection and
treatment monitoring. All of the student’s providers have access to this information,
effectively facilitating communication and avoiding the “Silo Effect” of isolated treatment.15
In conjunction with the aforementioned stakeholders and research, the Phoenix Children’s
Hospital identified key focal points for further progress preventing and treating ACEs.
 Promotion:
13 Hall, Judy et al. Reducing Adverse Childhood Experiences (ACE) by Building Community Capacity.
PreventionandInterventioninthe Community. (2012)
14 Unützer, Jürgen, et al. "Clinical computing: a web-based data management system to improve care
for depression in a multicenter clinicaltrial." Psychiatric Services (2002).
15 UWAIMS Center: Advancing Integrated Mental Health Solutions. University of Washington
Department of Psychiatry and Behavioral Sciences: Division of Integrated Care & Public Health.
Web. 2015. Pages accessed: In the News: Telehealth Improves ADHD;Collaborative Care; Our
Projects;Resource Library. www.aims.uw.edu

6. 1) Promote identification and early intervention on ACEs through universal
screening or assessment within early childhood and family service systems.
2) Continue to collect information about the relationship between ACEs, health
outcomes, and resilience.
 Treatment:
3) Stable, nurturing relationships with caring adults can prevent or reverse the
damaging effects of toxic stress.
4) Safe spaces and strong, healthy communities for children.
 Prevention:
5) Increase public understanding of ACEs and their impact on health and
wellbeing
6) Enhance ability of families and providers to prevent and respond to ACEs
7) Improve the effectiveness of public health campaigns by refining their
messages regarding ACEs.16
The Center for Human Services as an organization already addresses several of these
points. I have applied these principles specifically to the Out-of-School Time Program to
formulate an idea as to how the program can strengthen ACE prevention, treatment and
promotion.
Barriers:
The degree to which a given stressor affects an individual is complicated, and is dependent
on the type, frequency, and nature of the stressor, co-occurrence with multiple stressors,
and the developmental period when the stress occurs.4 Stress “toxicity” or “tolerability” is
difficult to measure in humans, as a stressor deemed toxic for one individual may be
completely tolerable for another. The subjective perception of certain stressors is a major
challenge in ACE impact research, as it determines the level of support an individual will
need to overcome the situation. 5 In order to move forward, the ability to accurately
measure the toxicity of a given stressor for a specific individual, as well as the most
prevalent stressors for a given community, must be improved.5 10

7. Specifically at the After-School-Time Program, ACE detection and treatment is limited by
the focus of the program itself. While Marta Buell, the on-site coordinator, is a mental
health therapist, the program is not designed to have a mental health focus. Although she
does offer behavioral guidance, she cannot legally diagnose or treat students for mental
health conditions without parental consent. The program is intended to create academic
support and a safe space for students to interact after-school17. Additionally, the high
quantity of volunteers that cycle through each day causes potential miscommunication and
therefore failure to address student concerns or behaviors. However, because the
population is extremely vulnerable to ACEs, and the Center for Human Services already
provides Parental, Child, and Substance Abuse Counseling, I believe the ACEs can be
addressed within the Out-of-School Time Program without much structural adjustment.
Additionally, academic organizations are identified as a key stakeholder ACE prevention,
promotion, and treatment.11
Recommendation: Track Student Progress Over Time, and Educate Volunteers and
Staff about ACEs
As mentioned, Marta Buell is a certified mental health therapist and on-site coordinator at
the Center for Human Services. Marta’s training allows her to offer brief behavioral
guidance and conflict resolution for students. In this way, mental health care is already
integrated into the Out of School Time Program. However, Marta is only one person serving
approximately 116 different students who are enrolled in the program.7 Staff and
volunteers (who may or may not have prior knowledge and training about ACEs) work
with Marta to ensure the program runs smoothly. It would be costly to incorporate an ACEs
specialist into the program. Therefore, it is more efficient to leverage the ability of Marta,
volunteers and staff to address ACEs. This can be implemented in two ways: tracking and
regularly reviewing student information over time, and providing staff and volunteers with
a brief training about ACEs and strategies to address them.
17 Center for Human Services. Pages accessed: Programs and Services; Family Counseling,
Substance Abuse. 2015. http://www.chs-nw.org/programs-services/family-counseling/

8. First, by tracking student information over time, caseload level behavior and academic
outcomes can be monitored, and any students who are at particular risk, experiencing
significant academic or behavioral problems, or whose behaviors are worsening can be
more easily identified and addressed. At the same time, student academic and behavioral
achievement can be identified and monitored, which can benefit the student’s own
motivation, program evaluation, and grant application.14
Mental health providers in the evidence based, UW model of integrated mental health care
use an electronic mental health system to monitor and track patient progress.14 13 Upon
enrollment, a care coordinator will enter in the patients demographic information,
including family history, risks, concerns, and assets. At each following appointment, the
care manager will enter in information to track patient progress over time. 14 This model
has also been found beneficial in schools, where mental health and academic information
can be tracked.15 There are grants available for organizations to purchase a web-based
software, but it is also possible to use an excel spread sheet if funding is a problem. 14
Since the Out-of-School-Time program is not a mental health organization, official ACE
screening and treatment would not necessarily be conducted onsite. However, the system
can be used to provide more effective community-based support and referral if necessary.
With such a high quantity of students, staff, and volunteers, it would be highly beneficial to
have a single, organized location to record student information. If a volunteer detects and
records an adverse situation in a student’s life, it will be more efficiently brought to Marta’s
attention. Early detection and treatment are a key component of ACE promotion.11 If the
problem is continuously recorded or worsened, Marta can take further steps to address the
situation or refer the family to other support services provided by the Center for Human
Services before the problem worsens.
Each day that a student attends program, staff and volunteers who worked with that
student should record information about any behavioral or academic problems and
achievements, as well as any concerns about the student’s family life or environment. The

9. volunteer can also record any difficulties they had interacting with students, so that Marta
can review and address any key concerns during the daily debrief. This recording can be
done during or after the daily de-brief session. Weekly review of the records will allow staff
to target specific behaviors or subjects for specific students. Therefore strengthening adult
support in the After School Time Program. For more information about the benefits of
using a tracking system, I have included a link to information about a UW-Developed
tracking system at the end of this document.
Detection and monitoring is only one step in ACE prevention and treatment. Strong adult
mentors are a key factor in promoting resiliency in students who are experiencing ACEs. 11
The quantity of volunteers and staff members who attend the Out-of-School Time Program
are an asset to this prevention strategy. However, it is essential that these mentors are
educated about ACEs that are most prevalent in the community, and how they can
effectively support to students when they open up about trauma or stressors. Since Marta
has a background in mental health, it would be beneficial if she provided a brief training
about key stressors and trauma that are prevalent for the Ballinger Homes Community, and
ways volunteers and staff can support students. In addition to verbal training, there are
multiple websites with useful about ACEs that Marta can distribute or provide a link to,
when a new volunteer or staff member joins the team. I have attached a few links to helpful
resources that can guide this process at the end of this document.
Reflection
I am interested in working in pediatric mental health. Volunteering at the Center for
Human Services taught me valuable lessons about working with children who are
experiencing hardship, whether it be familial, economic, medical, or behavioral. When I
started my service learning, I couldn’t stop thinking about all of the statistics and outcomes
that I’ve learned throughout my public health coursework, and how they were directly
impacting the students’ lives.
The more I went, however, the more I realized that I wasn’t benefiting anyone by dwelling
on the statistics. I realized the students wanted a space where they can be a kid, end of

10. story. They want a safe space where they can play, and get support, and learn, and grow,
regardless of what’s going on in their lives. Knowing the background issues is important,
but when you are interacting with a kid, they deserve to be treated based on their actions
in that moment, not their personal history or clinical outcomes. I’m excited to have
accepted a position as a Pediatric Mental Health Assistant for Seattle Children’s Hospital,
and I will definitely keep this concept in mind throughout the experience.
Helpful Resources
UW Care Management Tracking System:
https://aims.uw.edu/resource-library/care-management-tracking-system-cmts
About ACEs:
CDC: Division of Violence Prevention: ACEs Study.
http://www.cdc.gov/violenceprevention/acestudy/index.html
 Includes links to prevention strategies, research publications, podcasts, and
statistics
Adverse Childhood Experiences: How ACEs affect our lives and society:
https://vetoviolence.cdc.gov/apps/phl/images/ACE_Accessible.pdf
 Informational poster about the ACEs study and prevention strategies
SAMHSA: Substance Abuse and Mental Health Services Administration:
https://captus.samhsa.gov/prevention-practice/targeted-prevention/adverse-childhood-
experiences/1
 ACEs videos, resources, and research