To Calculate True Cost of Adverse Childhood Experiences, We Must Factor in Racism

We have long been aware of the impact of adverse childhood experiences (ACEs) on our long-term health and well-being. Because toxic stress from ACEs can change brain development and how the body responds to stress, their occurrence in childhood has a direct correlation to increases in substance abuse, mental illnesses, and poor health outcomes.

The Journal of the American Medical Association (JAMA) recently published a new study that puts a staggering dollar figure on that impact. Researchers found that ACEs cost our nation $14.1 trillion annually because of related adult health conditions, including direct medical spending and lost productivity.

However, the study is limited, in that it doesn’t identify the disparities in the number of ACEs impacting children and families of color, and the exponentially higher costs for this segment of our population. In fact, a recent Child Trends report indicates that 61% of Black children in the U.S. have experienced at least one ACE, as compared with 40% of white children and 23% of Asian children.

Researchers have long identified ACEs based on the Felitti scale, which identifies 10 items under two categories:

• Maltreatment: Physical, sexual, and psychological abuse and physical and emotional neglect
• Parental Problems: Psychopathology, substance misuse, and three forms of family instability

What’s missing is the impact of generational and historical trauma, especially racism.

Impact of Generational Trauma and Systemic Racism

Racism has a direct and measurable impact on children’s health. More families of color live in poverty than white families, which can lead to food insecurity, lack of safe housing, and reduced access to health care and education. All of these increase chronic stress in children and can have long-term health consequences, with African Americans at a higher risk for heart disease, stroke, cancer, asthma, influenza, diabetes, and HIV/AIDS. This disproportionality also is evident in incarceration rates, child welfare system involvement, and educational outcomes for African American youth, and disparities are often linked to systemic biases.

Research backs this up. A study from Princeton University sociologist Devah Pager showed that young Black men with similar education and no criminal record were much less likely to be offered a job than similar white men. It went on to show that white men with criminal records had an equal or better chance of being hired than Black men with no record. We see the same biases in housing discrimination, child separation rates in child welfare, and more.

There has been some progress in expanding the ACEs scale to reflect the toxic stress that bias and racism impart on children. For example, the team at RYSE Youth Center in Oakland expanded the original ACEs pyramid from the CDC, adding layers of collective and multigenerational thinking, layers of historical, cultural, and social context, to highlight the deeper roots of trauma and explore why these traumatic experiences occur in the first place. The CDC has since adopted the more complete picture offered by this pyramid.

For those of us who work in health and human services, it is critical that we expand our understanding of trauma and adversity beyond the 10 ACEs questions, and work to integrate both trauma-informed and antiracist efforts across the systems we support.

Embracing a Trauma-Informed Approach

One example can be found in Zero to Three’s Safe Babies Court Team™ (SBCT) approach, which focuses on minimizing trauma and its impact on early development by improving how the courts, child welfare agencies, and related child-serving organizations come together to partner with families to support their young children. This approach recognizes that some families experience great stress while raising their children due to environmental conditions—community violence, systemic racism, trauma, or health issues—that make it difficult to provide safety and stability. The Safe Babies Court Team approach does not promote a “one-size-fits-all” solution to the challenges faced by families within the child welfare system or by the system itself. By addressing the needs of each family, through housing, work opportunities, job training, transportation, substance use counseling, and more, Safe Babies Courts are showing that their children are reaching permanency three times faster than infants and toddlers in the general foster care population. Almost two-thirds of babies and toddlers are reunified or find permanent homes with members of their families.

This approach calls for practitioners to ensure all equity efforts include knowledge and practices that embed brain science concepts, including understanding the areas of our nervous system that are activated when we discuss, experience, or perpetrate racism, and how that activation creates barriers for connection.

A core concept of the trauma-informed approach is, “healing happens in relationships.” The development of safe, stable, and nurturing relationships can help build greater resilience in individuals. In its July 2021 policy statement, the Academy of Pediatrics emphasized the need to shift from toxic stress to building relational health. As Dr. Andrew Garner with the American Academy of Pediatrics notes: “The concept of drawing on positive relationships as a shield against the toxic stress caused by adverse experiences has never been more relevant. Over the past few years, we’ve experienced a socially isolating pandemic and reckoned with centuries of structural racism. We must take steps to help kids form close, healthy, and nurturing bonds, whether it is within family, school, or community.”

Policymakers have a role to play as well, by promoting concrete, economic supports and family strengthening policies, such as expanded family medical leave, child tax credits, access to safe and affordable housing, access to early childhood education and mental health services, and more. Research from Chapin Hall at the University of Chicago has demonstrated that connecting families to a well-resourced, community-driven prevention system can meaningfully address the root causes of adverse experiences, including racism, child abuse and neglect and trauma. 

Despite the terrible cost of ACEs, both in economic dollars and lifelong negative impacts, the latest research has demonstrated the potential for safe, stable, and nurturing relationships to act as a protective buffer against the harm of toxic stress on children. When we expand our view of ACEs to include the impact of generational racism, and lift up community efforts focused on building relationships and an understanding that our diversity as a nation is our strength, we have a better roadmap to addressing disparities and incorporating trauma-informed approaches that can help provide all children with a foundation for building resilience that leads to safer, healthier outcomes throughout their life.