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. Author manuscript; available in PMC: 2019 Jan 24.
Published in final edited form as: Rep Emot Behav Disord Youth. 2017 Winter;17(1):19–24.

Perspectives From the United States and Australia on Adverse Childhood Experiences and School Behavioral Health

Melissa Strompolis 1,✉, Jennifer Payne 2, Aylin Ulker 3, Lee Porter 4, Mark D Weist 5
PMCID: PMC6345404  NIHMSID: NIHMS982092  PMID: 30686939

Adverse Childhood Experiences

Adverse childhood experiences, or ACEs, a term coined by Drs. Vincent Felitti and Robert Anda, is used to describe traumatic events that occur during a child’s life. During the mid-1980s, Dr. Felitti was employed as a specialist in preventative medicine at Kaiser Permanente in San Diego, California (Anda & Felitti, 2003). During this time, he was assisting obese adults with weight loss through the Positive Choice program. He was perplexed that persons who were successfully losing weight were also most likely to drop out of the program. Upon further investigation, Dr. Felitti discovered that many of these patients reported abuse during their childhoods and were likely using obesity as a defense against further unwanted sexual attention or physical aggression. His clients also reported excessive use of alcohol, tobacco, and other drugs (Anda & Felitti, 2003).

To further examine the relationship between adversity in childhood and adult outcomes, Dr. Felitti partnered with Dr. Robert Anda, a researcher at the Centers for Disease Control and Prevention (CDC), in Atlanta, Georgia. Dr. Anda had particular interest in the broad impact of childhood adversity on subsequent social and public health outcomes. Together, Drs. Felitti and Anda designed the first ACE questions and added them to a comprehensive health survey that was administered to more than 17,000 adults aged 18 to 94 who were enrolled in the Kaiser Permanente health insurance plan in the early 1990s. The ACE questions assessed the presence of childhood abuse (emotional, physical, and sexual), neglect (emotional and physical), and household dysfunction (battered mothers, criminal behavior, parental divorce or separation, mental illness, and substance abuse). Additionally, the survey also included health behaviors, disease and disease risks, mental health and substance issues, and other health and social problems (Felitti et al., 1998).

This effort became known as the ACE Study, and the data supported three important conclusions. First, ACEs were common. Although the study included participants with health insurance who were mostly well-educated middle class whites, two-thirds of those surveyed reported at least one ACE. The most commonly reported ACE was physical abuse (28%) followed by substance abuse (27%), parental divorce or separation (23%), sexual abuse (21%), mental illness (17%), emotional neglect (15%), battered mothers (13%), emotional abuse (11%), physical neglect (10%), and criminal behavior (6%).

Second, ACEs were interrelated, tending to cluster in predictable patterns. For participants who had at least one ACE, 87% reported at least one additional ACE, 70% reported at least two additional ACEs, and 52% reported at least three additional ACEs. These multiple ACEs tended to occur within interrelated clusters; for example, the presence of domestic violence increased the risk of all forms of childhood abuse (Dong et al., 2004).

Third, ACEs were powerful, having a cumulative impact on the risk of social, mental health, and medical problems for adults with multiple ACEs and also for their children having multiple ACEs and poor adult outcomes (Anda et al., 2006). Because of the interrelatedness of ACEs, Drs. Felitti and Anda developed the ACE Score (i.e., a count of the number of categories of ACEs that a person reports) to examine the relationship of cumulative exposure to childhood adversity and negative health and social outcomes.

Given the impact of the original ACE Study on medical and public health research and practice (Felitti et al., 1998), the CDC continues to follow the original study participants to track incidence of risk factors, health outcomes, and mortality (CDC, 2016). The idea of trauma-informed approaches to healthcare is beginning to take hold in many clinics and centers (Machtinger et al., 2015; Muskett, 2014), and interest in replications and extensions of the original ACE Study continues to grow. Currently, efforts to replicate the ACE Study or use the ACE questions are underway in Canada, China, Jordan, Norway, the Philippines, and the United Kingdom (CDC, 2016). Similarly, many U.S. states are beginning to research the impact of ACEs.

In 2010, five states collected ACE data through the CDC’s national Behavioral Risk Factor Surveillance System (BRFSS; CDC, 2014). As of 2015, the number of states that have collected ACE data increased to 31 plus the District of Columbia. For a more detailed review of the BRFSS, see Morse and Strompolis (2016). A sampling of states that have created initiatives to understand and respond to ACEs includes, but is not limited to, the following: Alaska, California, Illinois, Iowa, Maine, Minnesota, Nebraska, New York, Pennsylvania, South Carolina, Tennessee, Vermont, Washington, and Wisconsin.

In South Carolina, the Children’s Trust of South Carolina, a nonprofit focused on the prevention of child maltreatment and injuries, has spearheaded the dissemination of ACE information and data. The Children’s Trust ACE Initiative has four components:

  1. ACE data collection and dissemination;

  2. ACE Interface© Master Training (to equip ACE presenters across the state);

  3. Development of the South Carolina Prevention Framework (a tool to guide local communities in developing their own response plans to ACE data); and

  4. ACE legislative policy (Children’s Trust of South Carolina, 2015).

Currently, South Carolina has 50 certified ACE Interface Master Trainers who conduct ACEs prevention-focused trainings throughout the state.

The purpose of the ACE Interface© Master Training is to disseminate information about the original ACE Study, brain development and neurobiology, the impact of ACEs on individuals and communities, and broad strategies for prevention and promotion. Although this training is not a prescription for preventing ACEs or mitigating their impact, it does serve as a bridge to connect disparate groups and disciplines with a shared understanding and lexicon around childhood adversity. The power of the ACE Interface© Master Training lies in the ability to integrate ACE information into preexisting frameworks and structures. The content empowers communities, programs, and services to examine and change how they support children and families and how they operate. For example, given the impact of ACEs on mental health and the relationship between ACE exposure and poor educational outcomes, ACEs information and knowledge could benefit school-based initiatives to improve the mental health of students and their educational outcomes.

School Behavioral Health

Weist and Stevens (2017) have noted that school mental health (SMH) programs help to bridge the gap between youth who need, and youth who actually receive, mental health services (Weist, 1997); they present a range of advantages in reducing barriers to care (e.g., transportation, child care, stigma) and in enabling promotion, prevention, early intervention, and treatment in a setting encountered by almost all youth (Stephan et al., 2007). In recent years, there has been growing emphasis on joining SMH with Positive Behavioral Intervention and Supports (PBIS), a three-tiered education-based framework. PBIS focuses on improving data-based decision making, implementing evidence-based practices, emphasizing positive and reducing punitive approaches, and providing implementation support for effective promotion/prevention at Tier 1, early intervention at Tier 2, and intervention at Tier 3 (Sugai & Horner, 2002). PBIS has scaled up to more than 21,000 schools in the United States (U.S. Office of Special Education Programs [OSEP] Technical Assistance Center on PBIS, see www.pbis.org). Mark Weist and numerous collaborators have been working for a number of years to systematically join SMH and PBIS efforts through an Interconnected Systems Framework (ISF) to enable greater depth and quality in Tiers 1, 2, and 3 of the multi-tiered system of support (Barrett et al., 2013; Monahan et al., 2014). The term “school behavioral health” (SBH) is used to convey SMH and PBIS efforts working together as in the ISF and is the focus of the SBH community driving the work highlighted in this issue of EBDY.

ACEs, Child and Adolescent Functioning, and School Behavioral Health

ACEs affect numerous dimensions of child and adolescent functioning that directly relate to their connection to and potential benefit from SBH programs and services. For example, school attendance is a significant predictor of academic success (Zubrick, 2014). Youth with increased ACEs often experience family and life stressors that can make school attendance and participation difficult, including early childbirth or fathering a child (Hillis et al., 2004), periods of homelessness and running away from home to a youth shelter (Farber et al., 1984), and juvenile justice involvement (Kohlenberg et al., 2013). In addition, youth with increased ACEs experience much higher rates of school absences, suspensions, and expulsions than same-age peers (Cheung et al., 2012; Eckenrode et al., 1993; Ferguson & Wolkow, 2012; Flynn et al., 2012; Harper & Schmidt 2012) and are more likely to drop out (Kohlenberg et al., 2013).

Further, ACEs have been consistently linked to psychiatric difficulties in children and adults (Harkness & Lumley, 2008; Widom, 2000; Wolfe, 1999; Wolfe et al., 2001). Risk for mental health problems rises dramatically for youth with progressively more ACEs. In one study, only 11% of those with no ACEs had a mental health problem, compared to 44% of youth with five or more ACEs (Lucenko et al., 2012). ACEs are also associated with aggression, disruptive behaviors, inappropriate sexual behavior, and hyperactivity (Australian Institute of Family Studies, 2010; Ethier et al., 2004; Mills, 2004; Shaffer et al., 2008) as well as suicidal ideation and attempted suicide (Brodsky & Stanley, 2008; Evans et al., 2005; Miller et al., 2013).

Connecting ACES and School Behavioral Health: Paper Tigers®

The integration of ACEs and SBH is exemplified in the documentary Paper Tigers®, directed by James Redford. Set in Lincoln High School, an alternative high school in Walla Walla, Washington, Paper Tigers® documents the changes that occur when school leaders and staff embrace ACEs as a framework for understanding the external behaviors and school performance issues of their students. The film captures the positive evolution of the school’s culture, the improvements in school attendance and academic achievement, and the reduction in problem behaviors and school suspensions.

Under the leadership of then-principal Jim Sporleder, Lincoln High School transformed into a trauma-informed school by changing school processes and policies to better meet the needs of students who had experienced (or were experiencing) adversity. After learning about ACEs, Principal Sporleder supported and led internal changes that reflected the recommendations referenced above by:

  • Reducing practices that could be trauma-inducing or retraumatizing;

  • Providing appropriate supports within the school itself from staff who were trained in understanding ACEs; and

  • Providing services consistent with trauma awareness.

Essentially, Lincoln High School integrated one of the key cultural shifts highlighted in the ACE Study—reframing questions about student behavior and performance from “What’s wrong with you?” to “What happened (is happening) to you?” Lincoln staff also enabled students to build their own self-awareness around ACEs. For example, the documentary begins with a science teacher’s efforts to relate brain development to early adversity and then connect that learning to his students’ behaviors, experiences, emotions, and academics.

Paper Tigers® captured additional substantive changes that Lincoln staff made in supporting students more appropriately. Staff used early intervention strategies when students showed signs of stress, assessed students’ decision-making abilities and emotional state prior to having difficult conversations with them, and focused conversations at staff meetings on how to support students and their families as opposed to student discipline. Guidance staff regularly conducted home visits to encourage attendance and deepen the understanding of students’ home environments. A new in-school suspension environment was created to provide students with emotional and academic support and to reduce out-of-school time. One of the most significant service delivery changes was the creation of a health center within the school campus where students could receive health and mental health assistance (Redford & Pritzker, 2015).

The film follows the academic year of a number of students and staff where the changes in the school community are made evident. One of many examples of the transformative nature of the mindset shift that occurred at Lincoln High School was captured in an interaction between Principal Sporleder and a student, Steven. The interaction was described from the perspective of both parties around an incident that occurred when Steven was violating a school safety policy. Steven was using a lighter inside the school building and was asked by Sporleder to turn over the lighter. After refusing to turn over the lighter several times, Steven left campus. In the pre-ACE Lincoln world, this type of behavior would have resulted in an automatic suspension; however, Sporleder called Steven’s home and learned that Steven’s mother had abandoned him. After learning this information, the principal asked Steven’s father to ensure that Steven returned to school the very next day, where Sporleder was able to provide emotional support to Steven during this difficult time. This event radically changed Steven’s view of the principal and also provided Principal Sporleder with the background information needed to understand Steven’s behavior which, as Sporleder states in the film, “had nothing to do with the lighter.” Some of the significant outcomes that this trauma-informed school approach has yielded include 60% fewer referrals, 75% fewer fights, 90% fewer suspensions, a 55% increase in math assessment scores, a five fold increase in graduation rates, and a threefold increase in seniors accepted to college (Redford & Pritzker, 2015).

Integration of ACEs and SBH in Australia

Many countries, especially the United States, have undertaken research studies to examine the prevalence and impact of ACEs, but our review found only one study with this emphasis from Australia (Rosenman & Rodgers, 2004). Although ACE research is more limited in Australia compared to other countries, many research investigations in the country have examined childhood trauma. Using the childhood trauma lens, work in Australia has linked the prevalence and impact of trauma and the need for trauma-informed care into its schools. For example, communities in Australia have integrated childhood trauma and SBH approaches to raise awareness of trauma and the impact of trauma, to improve implementation of services and programs, and to reduce harm.

Raising awareness of the effects of ACEs and childhood trauma by school staff is a critical strategy for recognizing and responding to trauma-related behaviors and is a precursor to implementing evidence-based interventions (Taylor & Seigfreid, 2005). For example, there is evidence that increased understanding of trauma and its impact on the brain can have a positive influence on the climate within residential treatment settings (Perry, 2015). The Australian Childhood Foundation therefore offers Strategies for Managing Abuse Related Trauma (SMART; Australian Childhood Foundation, 2011), an online training aimed at increasing awareness by school staff of the impact of trauma on children and providing practical strategies for assisting these students in class. Several South Australian schools examined the impact of these strategies, with data showing a reduction in the number of violent incidences and student suspensions (Australian Childhood Foundation, 2011). Finally, the Department of Education in Western Australia has included mental health and well-being as strategic foci, with the intent of improving educational outcomes for students with ACEs (Department of Education, Western Australia, 2015). The strategic plan will include education on ACEs and the impact of trauma.

In Australia as in the United States, there is increasing recognition that schools are an ideal entry point for improving access to mental health services for children (Allensworth et al., 1997; Weist, 1997). Furthermore, delivering mental health services through the school system can address key barriers that often prevent students, especially those from lower socioeconomic backgrounds, from receiving mental health services (Garrison et al., 1999; Stephan et al., 2007).

Well-developed programs focused on student mental health can also help to shine a light on policies and practices that may be harmful to students. For example, with regard to students who have experienced ACEs:

The public institutions and service systems that are intended to provide services and supports to individuals are often themselves trauma-inducing. The harsh disciplinary practices in educational/school systems . . . can be re-traumatizing for individuals who already enter these systems with significant histories of trauma (SAMHSA, 2014, p. 2).

Schools in a number of Australian states are using PBIS as a framework for responding to student behavior, and there are also efforts to integrate with SMH as in the ISF. This approach is highly consistent with trauma-informed practices, with emphasis on educators’ understanding and meeting the needs of students, and redesigning the school environment to promote student success (Sugai & Simonsen, 2012). The use of PBIS as a guiding framework is a significant step forward in the reduction of the use of restrictive, punitive, or exclusionary practices known to be retraumatizing to students. Further, efforts are beginning in some western Australian schools to build from PBIS to implement the ISF to address concerns increasingly expressed by school and community members about students’ experience of ACEs and associated problems such as anxiety, depression, suicidality, and trauma. Although it is a new initiative, there is considerable enthusiasm for implementing the ISF to assist students experiencing ACEs, and a more formal evaluation of these efforts is targeted for completion within the next two years.

Integration of ACEs and SBH in the United States

Numerous research studies and community-based efforts are taking place across the United States to improve educational outcomes for children, including the integration of ACEs into these efforts. Within South Carolina, these efforts have mirrored work that is taking place in Australia to increase awareness of ACEs, facilitate student advocacy, build school-based and community capacity to prevent and address mental and behavioral health problems for students, and promote safer school settings and learning environments.

As noted by Weist and Stevens (2017), South Carolina and neighboring states are building the Southeastern School Behavioral Health Community, including training events showing the ACE–SBH connection. For example, at the 2016 conference held in Myrtle Beach, the PaperTigers® documentary was shown to more than 50 participants, and a lively dialogue followed on the implications for improving school environments and programs. A number of plans to improve SBH policy and practice ensued, including plans to show the documentary to South Carolina alternative school principals to raise awareness and increase support for trauma-sensitive and compassionate approaches to students’ emotional and behavior problems. In addition, a youth forum was held with more than 20 older youth (ages 18 to 25) who had experienced these problems and received mental health services, and a major recommendation from them was to expand and improve these approaches. Plans are in place to show the documentary and hold an additional youth summit at the next Southeastern School Behavioral Health Conference, to be held again in Myrtle Beach in late April 2017 (see www.school-behavioralhealth.org). In addition, led by the South Carolina Department of Mental Health (SCDMH), SBH programs in the state are expanding to elementary schools in areas characterized by high poverty, rurality, and elevated ACE experiences among students in families. In this initiative, termed Carolina CARES (Children and Resilience in Elementary Schools), the University of South Carolina School Behavioral Health Team has partnered with SCDMH and Children’s Trust of South Carolina to implement the ISF systematically augmented to include a focus on ACEs. For example, school and community-wide training events for diverse stakeholders on ACEs are scheduled, and interdisciplinary school teams will plan for and deliver programs that are trauma sensitive and that focus on reducing risk and enhancing protective factors among students within 12 elementary schools in the Pee Dee region of the state (Browne, 2014).

Conclusion and Future Directions

Reflecting a community-of-practice emphasis (Cashman et al., 2014; Wenger et al., 2002), collaborations regarding ACEs and SBH are occurring at multiple levels of scale; for example, within school buildings, within school districts, across counties in states, across states (see www.carolinanet-work.org), at national forums (see www.pbis.org,http://csmh.umaryland.edu), and across countries (see www.smhile.org). The authors for this article are involved in building a partnership between the southeastern region of the United States and the western region of Australia, including collaborating in building the ISF as applied to communities in the two countries and presenting on this work at representative national conferences in the late fall in the United States and in the summer in Australia. In this work, there is a particular emphasis on multitiered prevention, early intervention, and intervention for students who may be experiencing ACEs and presenting with internalizing problems such as depression, anxiety, social withdrawal, and trauma.

As mentioned, plans are in place to use the Paper Tigers® documentary to raise awareness of the emotional/behavioral needs of children and to assist school and community agency leaders and staff in moving from a traditional focus on discipline to a compassion-focused and trauma-sensitive approach. This is consistent with a growing emphasis in both countries on reducing student encounters with school discipline, which has increasingly been found to have toxic and damaging effects on children and youth and to contribute to the “school to prison pipeline” (see http://www.ed.gov/news/press-releases/educators-gather-white-house-rethink-school-discipline); Flannery, 2015).

All of this work prioritizes the involvement of all relevant stakeholders, including children and youth, families, and staff, and leaders from family advocacy, education, mental health, allied health services (e.g., occupational and speech therapy) juvenile justice, child welfare, disabilities, primary health care, and faith and business communities. Increasingly organizers of local, state, and national forums and conferences recognize that SBH, if well done, is a highly relevant agenda for all of these groups, necessitating diversity and inclusiveness in participants, which also assists in breaking down organizational silos between youth-serving systems (Lever et al., 2003).

The emphasis is also on removing and reducing barriers to learning for all students, including the many who have experienced or are experiencing ACEs. As discussions on ACEs increase in communities and states—for example, as sponsored by the Children’s Trust of South Carolina—there is also an emerging theme of transparency in discussions as people openly acknowledge that they have experienced ACEs and have emotional/behavioral and other struggles in their lives. Importantly, such transparency helps to create a safe space to examine school policies and procedures that are detrimental to successful educational outcomes and builds energy to move toward more progressive and supportive policies and approaches.

Finally, numerous research opportunities exist to strengthen the integration of ACEs and SBH to positively affect educational outcomes. Important areas of inquiry include:

  • The impact of ACE knowledge on school staff and student interactions, particularly for students with ACEs and/ or emotional/behavioral issues;

  • The effect of ACE knowledge on program and service implementation;

  • Changes to perceptions of school safety and well-being; and

  • The relationship of ACEs to immediate (e.g., standardized tests, grades) and long-term (e.g., middle/high school graduation, postsecondary attainment) educational outcomes.

For this article, our review found no empirical studies on ACE-SBH integration. We hope this article serves as an initial first step to develop this research avenue, along with needed developments in policy and practice.

Contributor Information

Melissa Strompolis, Director of research and evaluation at Children’s Trust of South Carolina

Jennifer Payne, School psychologist in the Department of Education, Western Australia

Aylin Ulker, Research assistant in the Department of Psychology at the University of South Carolina

Lee Porter, Chief program officer at Children’s Trust of South Carolina.

Mark D. Weist, Professor in the Department of Psychology at the University of South Carolina

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