Traditional Medical Models that Manifest in Childhood

Interventions for ACEs have been mainly grounded in the sectors of medical care, mental health services or public health. This over reliance on more narrowly constructed paradigms has yielded little progress in effectively addressing ACEs. Traditional medical models do not address the root cause of ACEs, which are readily apparent in childhood when the health system has ample opportunity to intervene and prevent the long-term medical. Therefore, medical models are not an effective intervention, as they do not implement prevention of ACEs.

The root cause of ACEs originate from an accumulation of factors and issues associated with failed attachment, family history, abuse and neglect, poverty, safety, security and neighborhood risks, which are often addressed in limited ways, such as welfare or through the justice system. However, these approaches do not build resilience in the individuals, families or communities that experience ACEs, and they fail to stop the growing epidemic of family and community violence. According to Peter Levine, PhD (2010), “Trauma is not a disease but rather a human experience rooted in survival instinct”.

What is needed is an intervention that steers away from the health model and toward a model that recognizes social-relational and cultural factors. The Community and Well-Being Model suggests that the community works together collectively, utilizing solutions across agencies such as police, schools (trauma-informed curriculums), social welfare, and justice. This model focuses on overall well-being and resilience within the community, as well as on the root cause of ACEs, including the intergenerational violence of parents and caregivers, abuse, neglect, bullying, the absence of food security, adequate housing, sustainable income and neighborhood safety. This is done through community coordination, organizational and professional knowledge of trauma, trauma informed care, and trauma response strategies.

The Greater Cincinnati Foundation’s Collective Impact Movement is an example of sectors working together to make changes in their community. According to the movement, all sectors work together, investing in 7 non-profit organizations, in order to make a large-scale impact in the community, which would not be possible if each sector worked alone, isolated. These interventions are beginning to show effect on child development and well-being.

Family-Centered Medical Home Model

This model focuses on a cultivated partnership between children, their family and their primary medical provider, as well as support from the community. According to a 2013 study done using the 2011-12 National Survey of Children’s Health using a sample of children aged 0-17 (95,677 children with approximately 1,800 per state), they found lower rates of school engagement and higher rates of chronic disease among children with ACEs and that building resilience, defined in the survey as “staying calm and in control when faced with a challenge”, for children aged 6-17- can ameliorate the negative impact of ACEs. These findings are consistent with previous studies about mediating the impact of ACEs through parental coping and well-being and the promotion of both child resilience and safe, stable, and nurturing environments in the home, school, and community.

According to these writers, they suggest using a coordinated effort using existing knowledge about ACEs and resilience into national, state and local policies with a focus on addressing childhood trauma in health systems. However, there is a need for further research on how to optimize the effectiveness of this model to address ACEs.

Ecological Model

The ecological model is a valuable framework to examine the incidences of ACEs, as it can elucidate the interacting nature of how the different environments, from the microsystem of the individual and family up to the macrosystem of cultural values and beliefs of a society impact the degree, impact, type and potential preventative measures that can be taken to alleviate the occurrence of ACEs in our society.

The model, beginning with the Bronfenbrenner’s Ecological Systems Theory, has undergone various adjustments such as social and biological elements that have enabled researchers and clinicians to apply the underlying concepts to understand ACEs more accurately. Culture has proven to be an important factor that has cut across all the different systems in terms of parenting style, individual characteristics, and community relationships.

The preventative measures that have been suggested under the framework of the ecological model inherently take into account the interrelations between the different systems, from the micro to the chronosystem. This also includes the nucleus of the concentric circles: the individual characteristics or personality of the child. In this way, prevention must examine the different levels of ACEs and its etiology in the sense of its historical roots from intergenerational behavior of parents to the cultural and societal values and beliefs. In other words, there is not one model that can be imposed on every circumstance and individual and work to prevent ACEs. The solutions must be both customized to fit the individual characteristics of the microsystem, as well as be flexible enough to incorporate the governmental agencies, as well as the cultural norms within each community. It is for this reason devising solutions are difficult and require evidence-based, practical solutions that, like the ecological model, includes the web of systems in the solutions.

Ling & Kwok (2017) found that the simple attitude of forgiveness was an essential ingredient to promote a positive relationship between the parent and child that could reduce the presence of ACEs in the household. They also found that improved parenting skills worked to reduce potential ACEs, while the cultural aspect of the parenting environment can be counterproductive, or even negative such that it promotes ACEs in the household. This same idea of parental education has been echoed by others. Directing a lot of attention on the microsystem in the form of reducing domestic violence, which means improving the marital relationship, improving communication between parent and child that build a supportive and understanding environment and promoting stable attachments between parents and children would further work to alleviate the occurrence of ACEs in the households.

Moving to the higher systems of the exo, meso and macrosystems, education was advocated to reduce the ignorance of practitioners of mental and medical health services to identify the signs of ACEs before it gets out of control (Wang & Heppner, 2011 and Evans, et al., 2014). One of the problems pointed out by Mohr, et al. (2000) was that there was a lack of standardized definitions concerning ACEs in the legal and jurisdictional areas, which blurs the lines for taking legal action to protect the children against ACEs. They go on to say that better exactitude and standardization in the self-reporting data collection process would also help promote more accurate assessments of ACEs. Finally, they, as well as Evans, et al. (2014) highlight the need for increased governmental agency collaboration and data sharing to create a more efficient system.

Evans, et al. (2014) provide extensive details of various program options for prevention of ACEs that include, but are not limited to focusing on proactive programs that can flag early signs of the presence of ACEs, using a skills-oriented approach focusing on individual characteristics of the children, looking at factors form a multiple life perspective, both parenting and cognitive skills training to build more stable households and increase resilience, helping parents gain a sense of control over their household and life, and looking at the psychological relationship of attachment between parent and child. In short, they focus on grassroots, bottom up approach rather than a top down approach that integrates the child’s perception in the empowerment process. 

On a more concrete level, they go on to define clinic-based programs for infants, young children and mothers, home visiting programs, parent and community educational programs, peer-parenting support groups, media messaging, educational programs for children, abusive head trauma educational programs such as shaken baby syndrome for parents, and so on. In the end, Evans et al. (2014) note that from a survey of 12 European child protection systems, they found that co-operation and communication between health and welfare services resulted in more effective practices.

Looking at the interrelationship between the microsystem and mesosystem or community, Garbarino (2001) found that programs that changed the legitimization of aggression among children and youth was invaluable, as in these violent communities, morals and values become distorted in terms of survival. In addition, he believes early childhood training support workers and educators need to be aware of trauma-induced behavioral changes. Mobilizing pro-social adult and youth members of the community to take more control over their communities in an effort to eradicate the levels of violence would also be a step in the right direction. Finally, he points out that there must be a form of rehabilitation on the levels of trust and security children feel that could alleviate the trauma surrounding community invoked ACEs.

If we were to examine how resilience can be enhanced using the ecological model, we can turn to the study by Unger, et al. (2013), who explains that resilience can be improved when we form a cohesive concept of a child embedded within the social and physical systems where parents and communities interact between themselves, as well as with governmental agencies. In this way, equifinality is the idea that from many different situations, all potential solutions are equally possible in human development. The second aspect is how the differential impact of encountered by a child will be impacted by the child’s individual characteristics or personality, which will determine, to a degree, the child’s reaction to such environmental stimuli.

Finally, and potentially most importantly, is the cultural context of the child’s situation, which has been emphasized across the different studies, as how this factor impacts the degree and type of ACEs experienced, as well as the potential insulating effects of resilience.

In conclusion, it is clear that each model focuses on the same ideas of child resilience, the role of the family unit and communities working together to make a change. Specifically, the ecological model is a robust and valid framework to examine not only the impacts of ACEs on children, but also devise multifaceted prevention programs that are proactive. Whether we look at the individual level of the child’s characteristics in terms of their personality, the marital condition and parenting skills, the community where the child is embedded, or the various institutions, educational or governmental that are responsible for overseeing the community, the ecological model is an ideal lens through which to examine ACEs and what can be done to screen for and prevent this epidemic.

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