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Priority Area 5: Adverse Childhood Experiences

Adverse Childhood Experiences (ACEs) are traumatic events and include physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, intimate partner violence, substance misuse within the household, household mental illness, parental separation or divorce, and having an incarcerated household member. The harmful effects of ACEs on health status throughout the lifespan have been well documented.

Studies have shown an association between ACEs and chronic disease, behavioral health issues, and initiation of risky health behaviors. Studies have also documented a dose-response relationship between ACEs and adverse health and behavioral health outcomes, meaning that persons with more ACEs (a higher ACE score) are more likely to have more adverse health outcomes. A recent systematic review and meta-analysis of the published literature on ACEs indicated that persons with four or more ACEs were at increased risk for all negative health outcomes examined in the study. The strongest associations were found with problematic drug use, interpersonal and self-directed violence, sexual risk taking, poor mental health, and problematic alcohol use, followed by moderate associations with smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease. While considered weak or modest, associations were nonetheless documented with physical inactivity, overweight or obesity, and diabetes.

Since multiple ACEs can be considered a major risk factor for many health conditions, a public health approach to ACEs and childhood trauma is warranted. While clinical treatment of psychological trauma is well-established, population-based strategies for prevention are still emerging. Recognizing ACEs/trauma informed strategies need to be applied across the health priorities addressed in this plan, the State Health Improvement Coalition determined this special section of the plan should describe key cross-cutting strategies.

Every effort should be made to support populations that are potentially disproportionately affected by this issue. In 2011, 60% of Montana adults reported having one or more ACEs. A higher percent of American Indian than white non-Hispanic adults reported experiencing four or more ACEs, as did adults who had not completed high school compared to those who had more education, adults with lower annual incomes compared to those with higher incomes, and adults with disabilities compared to those without disabilities.

ACEs are the SHIP cross-cutting strategy. The bulk of the conversation about ACEs will take place within the Healthy Mothers, Babies, and Youth workgroup, although all workgroups will have opportunities to discuss how ACEs impact their work.


  • Implement community-based strategies recommended by the Centers for Disease Control and Prevention to prevent ACEs and trauma, and increase resiliency, including: providing quality and affordable child care and education early in life; strengthening economic supports for families;changing social norms to support parents and positive parenting; enhancing parenting skills to promote positive child development; and intervening to lessen harms and prevent future risk to children.
  • Integrate knowledge about the wide-spread effects of ACEs and trauma into policies, procedures, practices, and environments of health, human service, education, and other organizations serving children, with the goals of providing trauma-informed approaches and reducing re-traumatization. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides direction in implementing trauma-informed approaches across 10 organizational domains in its publication, “Concept of Trauma and Guidance for a Trauma-Informed Approach.” Those domains are:governance and leadership; policy; physical environment; engagement and involvement; cross-sector collaboration; screening, assessment and treatment services; training and workforce development;progress monitoring and quality assurance; financing; and evaluation.
  • Implement resiliency-building and trauma informed educational and behavioral approaches in schools and early childhood settings (e.g., Montana Behavioral Initiative, social-emotional learning practices,and restorative rather than punitive disciplinary practices).
  • Promote the use of early childhood home visitation programs as recommended by the Community Preventive Services Task Force based on strong evidence of effectiveness in reducing child maltreatment among high-risk families. Home visitation to prevent violence includes programs in which parents and children are visited in their home by nurses, social workers, paraprofessional and community peers. Visits must occur during the child’s first two years of life, but they may be initiated during pregnancy and may continue after the child’s second birthday.
  • Increase awareness of and referrals to evidence-based early childhood home visitation programs among healthcare, human service, and other professionals.
  • Develop and maintain a state-level resource to share information about ACEs and trauma-informed approaches (e.g., resources for various fields of practice, training and education opportunities,support for organization moving toward trauma-informed approaches, and resources for individuals,families, and communities).
  • Continue to support training and train-the-trainer initiatives addressing ACEs and trauma-informed approaches for health and human service providers, educators, early childhood service providers, schools, communities and other organizations, including those provided by the DPHHS, ChildWise Institute, Elevate Montana, and the National Native Children’s Trauma Center.
  • Screen for ACEs and trauma among high-risk parents and children using age-appropriate and setting-specific screening tools as recommended in professional guidelines for various disciplines. When results are positive, assure appropriate referrals and follow-up services. 
  • Promote the use of group and individual cognitive-behavioral therapy for symptomatic youth who have been exposed to traumatic events as recommended by the Community Preventive Services Task Force based on strong evidence of effectiveness in reducing psychological harm.
  • Promote the use of evidence-based clinical interventions included in the Substance Abuse and Mental Health Services Administration National Registry for Evidence-Based Programs. This registry includes 14 evidence-based interventions that are targeted to specific populations and/or settings.
  • Implement strategies described in this plan to mitigate the health consequences of ACEs/trauma which include increased prevalence of chronic disease; increased risk for depression, mental illness,substance use disorders and suicide attempts; early initiation and continued misuse into adulthood of alcohol, tobacco and other drugs; and increased prevalence of high risk sexual behaviors.
  • Continue to collect and analyze data to monitor the burden of ACEs and trauma in Montana, and progress toward reducing it (e.g., data regarding the prevalence of ACEs, the extent to which training and education regarding ACEs is being provided, implementation of trauma informed approaches,provision of home visitation services).