ACEs Connection

Healthy, happy kids grow up to create a healthy, happy world.

Part Three of Six: Stress in the City: Urban ACE Studies

Part Three of Six:  Stress in the City: Urban ACE Studies 

Here is part three of our six-part report on last month's National Summit on Adverse Childhood Experiences, which brought nearly 200 health care providers, educators, child advocates and policy makers to Philadelphia to examine the newest research and practice on ACEs.


While the original ACEs study showed troubling rates of childhood adversity among 17,000 Kaiser Permanente members in San Diego, the experiences of children raised in urban poverty may be even more alarming. This report, Stress in the City, looks at the particular stresses that come with growing up poor, experiencing racial discrimination or living in violent communities.


A new video from Harvard University's Center on the Developing Child,, also examines community stresses, with line drawings and a clear message: to improve child outcomes, we must give adults the skills they need to work, teach and parent well.


"Children at greatest risk...are children who experience a pile-up of risk factors-mental illness, poverty, abuse, neglect, violence," says Jack P. Shonkoff, M.D., narrator of the video, titled "Building Adult Capabilities to Improve Child Outcomes: A Theory of Change."


As he speaks, we see a cartoon figure of a child facing a stack of boulders that block the path forward. Adults who want to help need to build their own skills: the ability to focus attention, delay gratification, solve problems, work in teams and self-regulate, Shonkoff says.


"We need to focus on the development of adults who are important in kids' lives so they can be better parents, workers and teachers," he says. And-as the video shows a forklift removing the boulder labeled "poverty"-Shonkoff reminds us to look at the ways public policy adds to or alleviates sources of community stress.


Our report on Stress in the City shows how researchers in Philadelphia and elsewhere are starting to understand the nuances of toxic stress in urban environments-a first step toward helping children, adults and communities create a healthier future.


I hope you have a great week!


Martha Davis

Executive Director, Institute for Safe Families


Stress in the City: 



The original ACEs study, published in 1998, outlined a grim picture: childhood adversity was widespread and consistently linked to poor health outcomes.


But that snapshot didn't describe stress in the city. The study of 17,000 Kaiser Permanente members in San Diego didn't take into account the corrosive effect of living in urban poverty-the daily stresses of food scarcity, community violence, drug culture or racial discrimination.


At the National Summit on ACEs in May, several physicians and scholars released results of urban ACE studies-research designed to learn whether there are adverse experiences linked to poverty, social class and ethnic minority status, and how those experiences shape future health.


Lee Pachter, chief of general pediatrics at St. Christopher's Hospital for Children, said researchers are still unsure how multiple experiences of toxic stress-for instance, being bullied because of your skin color, living near a drug house and waking regularly to the sound of gunshots-combine and amplify in the lives of urban children.


He and colleagues developed a questionnaire intended to look specifically at experiences of racial discrimination. More than 250 children in Hartford, Connecticut and Providence, Rhode Island-the majority of them Latino, African American or Afro-Caribbean-filled out the survey: Had they been followed by a security guard while shopping in a store? Had they been called names because of their race, ethnicity, accent or gender? Had they ever felt someone was afraid of them? Eighty-eight percent of respondents perceived racial discrimination in at least one of the 23 items.


Pachter explained how perceived racism can literally get under your skin, leading to physiological or psychological stress that wrenches the body's biological regulatory systems off balance, a dysregulation that can set the stage for chronic illnesses such as diabetes, obesity, asthma and other health problems. "We may be finding a mechanism through which psycho-social stressors contribute to racial and ethnic health disparities," he said.


The Philadelphia Urban ACE Survey, a telephone survey of Philadelphia residents given to more than 1700 adults, showed that respondents had higher ACE scores than those in the Kaiser study. Mary Harkins-Schwarz, senior research associate at Philadelphia Health Management Corporation, which co-led the study with ISF, shared findings from the survey.


Philadelphia adults had higher rates of experiencing childhood physical abuse compared to those in the Kaiser study.  Philadelphia adults also had higher rates of having lived with someone who was mentally ill, who abused substances or who had spent time in prison.           


The Philadelphia Urban ACE Survey also assessed the childhood experiences of toxic stress that may occur when living in an urban environment.  The survey found that 40.5% of Philadelphia adults saw or heard violence-someone being beaten up, stabbed or shot-while growing up. And 34.5 percent of Philadelphia adults said they were treated badly as children because of their race or ethnicity, As ACE scores climbed, so did the incidence of smoking, depression, mental health conditions, substance abuse and suicide.


The numbers may startle, but the words of Philadelphia youth made the impact of ACEs come painfully alive. Roy Wade, a Robert Wood Johnson Clinical Scholar and pediatrician at the Children's Hospital of Philadelphia, described the work of focus groups involving 119 low-income youth between the ages of 18 and 26. The youth described adversity that included family relationships-including the loss of love and support-community stressors, economic hardship and discrimination:


"My mom said, 'I ain't teach you nothing because I want you to go through the same thing I went through.'...It's just like heartless, like you just don't care."           


"There were shootings every night, so much that the kids couldn't play outside."


"The hardest thing for me was watching my mom struggle [financially to pay for] food, utilities and bills."


"I've seen white people follow [black people] around the store. They don't even know who we are."


A deeper examination of stress in the city, Wade said, will need to include youth perspectives and a broader understanding of what urban adversity looks like and how it affects the body and brain.

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