Systems Integration

Randell Alexander, MD, PhD

Awareness and knowledge of ACEs,1 the effects of toxic stress on the brain,2 neuroendocrine pathways,3 and epigenetics4 do not improve health if it is not translated into practical ways for others to implement.  Thus, juvenile court judges may wonder how this scientific evidence translates into decisions they make each day.  Child abuse prevention specialists may question how to re-tool their messages or approaches. How should health professionals re-design their clinical approaches?  Such concerns make it imperative to adopt a strategic and systemic approach.

Primary prevention should be the most important goal even though it is necessary to provide interventions for those already affected by adverse childhood experiences. While the consequences of child abuse ought to permeate all of society and its systems, the following systems deserve special attention.


The opportunities for prevention begin with early childhood education and extend into adult learning.  Areas of focus can include teaching or modeling of psychologically supportive interactions, messages about not using physical means when frustrated or angry, sexual boundaries, and getting help when confronted with inappropriate feelings.

Primary prevention

Because educators work with children though much of their life, this is an opportunity for teaching and modeling ways to interact with others, conflict resolution, respect for others, sexual boundaries and appropriate behaviors, and reinforcement of positive feelings and behaviors.


The educational system could help with early identification of children displaying apparent mental health problems, knowing the high prevalence of ACEs and how symptoms of ADHD, learning problems, and behavior problems may not be a primary condition but the effects of ACEs.  By knowing about a child’s ACEs (at multiple points in time), a school could better understand academic performance and help to tailor compensatory strategies. 


Primary prevention

Knowing that more than half of children will eventually have one or more ACEs, proactive programs to protect and enhance brain development should be a priority.  Often children do not see any professional except a physician until they go to kindergarten. This point of entry then becomes crucial to convey messages to parents about optimal brain development issues such as behavioral management, understanding development and when to be concerned, and positive ways a parent can interact with their child.


In the primary care physician’s office, routine knowledge of a parent’s and child’s ACEs can lead to early referral to helpful services. Some parents might alter their adverse behaviors when they learn that child abuse can even change the expression of a child’s genes. Pediatricians are in a good position to advocate for policies that promote child development with the goal of creating healthy, well-functioning adults.

Child Welfare

Primary prevention

Child abuse prevention programs are not merely to stop various types of abuse but can be re-conceptualized as developing alternative positive realities whereby children are safe and brains are stimulated to develop optimally. Presumably, most parents would be enthusiastic in wanting the most for their children but would appreciate assistance about how to achieve these goals.


When a parent does not comply well with a case plan, it is tempting to use labels such as unwilling, bad, or lazy. It may be more helpful to consider that a parent with adverse childhood experiences likely has no personal experience with supportive parenting.  This leads to differences in brain development (e.g., decreased activity of the prefrontal cortex, which mediates executive functions) that make scheduling and sustaining tasks very difficult.  This enables professionals to understand that the parent’s behavior reflects the brain they have—as a consequence of their own childhood adversities. The question then becomes whether services that exist (or could exist) are able to bridge the gap or whether the parent is unable to function well enough to promote the brain development of his or her own children. 

Legal/Law Enforcement

Primary prevention

Community programs can be explored that reduce exposure to community violence and violence within the home. This could begin in cooperation with schools.


Laws and approaches can be structured to encourage a parent who has abused a child to tell the truth, so that quick and sometimes vital health and mental health intervention can be started sooner. This approach encourages the parent to be part of the team trying to lessen the effects of abuse on the child’s health and brain. 


Primary prevention

Businesses have a vested interest in helping employees manage whatever dysfunction arises through adverse childhoods. Absenteeism, health care costs, and retention all are improved in those with healthy childhoods.5 The Centers for Disease Control and Prevention (CDC) has worked with business leaders to explore ways that businesses can play a role in preventing child abuse, and CDC’s Essentials for Childhood Initiative partners around the country are engaging business leaders in work to promote safe, stable, nurturing relationships and environments for children.


Businesses have employees who already experienced adverse childhoods.  Rather than taking a passive, sometimes punitive approach to the problems that ACEs create in the workplace, the business community could promote forms of employee wellness that better understand ACEs and attempt to compensate for ACE-related adversities. A better workforce is the prime goal.

In all of these approaches, a common theme is being proactive in advancing what enhances the safe, stable, and nurturing development of the developing child. Working together as systems, society can optimize the child’s brain and their health now and in the future.6


1.  Felitti VJ, Anda RF, Nordenberg D, 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. American Journal of Preventive Medicine. 1998;14:245-58.

2. Shonkoff J, Garner A, and the Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and the Section on Developmental and Behavioral Pediatrics. American Academy of Pediatrics.  The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-46.

3. DeBellis M, Spratt E, Hooper S.  Neurodevelopmental biology associated with childhood sexual abuse.  Journal of Child Sexual Abuse. 2011;20:548-87.

4.  Shalev I, Moffitt TE, Sugden K, et al. Exposure to violence during childhood is associated with telomere erosion from 5 to 10 years of age: a longitudinal study. Molecular Psychiatry. 2013;18:576-581.

5. Anda RF, Fleisher VI, Felitti VJ, et al. Childhood Abuse, Household Dysfunction and Indicators of Impaired Worker Performance in Adulthood.  The Permanente Journal. 2004;8(1):30-38.

6.  CDC, Division of Violence Prevention. Essentials for Childhood: Steps to create safe, stable, nurturing relationships and environments. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2014. Available from: 

© 2015 by Academy on Violence and Abuse