Adverse childhood experiences (ACEs) represent a significant public health threat. As the most trusted health care professionals, nurses should be in the forefront of efforts to mitigate ACEs. We can educate the public on the importance of this threat, screen children and adults for ACE exposure, educate patients on the effects of ACEs, and care for patients whose chronic illness is associated with high levels of ACEs. These actions align with our professional ethic to prevent illness and protect the health of individuals, families, and communities.

ACEs are widespread and the costs are substantial. Felitti and colleagues (American Journal of Preventive Medicine, 1998) defined ACEs as exposure to one or more categories of childhood mistreatment (physical, emotional, or sexual abuse or neglect) or family challenges such as separation or divorce, incarceration, caregiver mental illness, substance abuse, or domestic violence. Higher ACE scores are associated with increased risk of chronic illness and a shortened life span through prolonged exposure to toxic stress, an overactivation of the stress response system. Research studies confirm strong associations between high ACE levels and nine of the 10 leading causes of death in the United States; impaired learning; and unfavorable behavioral, mental health, and social outcomes.

The Centers for Disease Control and Prevention (CDC) has reported that one in six adults in a recent survey had experienced four or more ACEs. Women, younger adults, sexual minorities, and individuals who are non-White or lower income report higher exposure to ACEs, as do children of color. The CDC estimates that the economic toll of ACEs is billions of dollars annually. According to the California surgeon general's 2020 report Roadmap for Resilience, toxic stress costs the state an estimated $10.5 billion in personal health care spending and $102 billion in years of productive life lost.

We cannot vaccinate for ACEs or cure toxic stress with a prescription pad. Nurses, however, can lead and participate in efforts to reduce ACEs across communities and health care settings. We are ideally suited to develop and conduct screening programs. Although the standard ACE screening tool developed by Felliti and colleagues is most often utilized, recent studies support expanding it to include additional childhood adversities, including exposure to bullying, community violence, economic hardship, absence or death of a parent or caregiver, living in foster care, and discrimination. Nurses can champion universal screening programs and ensure staff are trained to provide trauma-informed care (TIC).

In caring for patients who may have developed disease secondary to childhood trauma, nurses rely on TIC principles to reduce the risk of retraumatizing them. Nurses help to arrest the toxic stress response by educating patients with chronic illnesses on the restorative effects of physical activity, healthy nutrition, sleep, meditation, and supportive relationships. Nurses can also support patients with symptoms of toxic stress to seek mental health care and community resources.

Calls for action are growing. The magnitude of ACEs and toxic stress is so compelling that the California surgeon general's 2020 report included an initiative to train health professionals on ACEs and toxic stress and reimburse for ACE screenings of patients enrolled in the state's health insurance program. This landmark decision may lead other states and health care systems to invest in screening programs and early treatment. We welcome such efforts but emphasize that screening for ACEs and treating toxic stress are premature until health care systems invest in training all staff in TIC, modify their organizational cultures in line with TIC principles, and provide resources for successful implementation. Nurse executives can spearhead these efforts.

We urge readers to learn about toxic stress, become trauma informed, and promote community efforts to prevent ACEs. As citizens and professionals, we should also address the conditions that contribute to ACEs, which requires urging our elected representatives to expand access to health and mental health care, promote economic security and a living wage, thwart all forms of discrimination, and implement programs that reduce violence and substance abuse.