[Cause Exploration Prizes] Adverse Childhood Experiences

This essay was submitted to Open Philanthropy's Cause Exploration Prizes contest.

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Human well-being can be modeled using a utility function that is some combination of:

• freedom from poverty: the ability to meet basic consumption needs, even during shocks. Consumption can be sustained through social protection mechanisms (formal and informal) as well as through labor/earning opportunities plus access to savings/assets, insurance, and other investment vehicles.
• health: enjoyment of a long and healthy life, with freedom from disease and disability. This can be produced through access to life-saving care and nutritious food, preventive health knowledge, and a safe living environment.
• social needs: prevention (and mitigation) of adverse social experiences, particularly during childhood, as well as the accrual of positive and satisfying social experiences.

According to this definition, well-being is jointly produced by individuals and by the people and institutions they interact with. Arguably, this utility function could include myriad other inputs - from education and political enfranchisement, to environmental sustainability. But for the purposes of this worldview investigation, we favor simplicity.

Givewell currently focuses on the first two of these inputs: individual economic outcomes, and individual health outcomes. Here we argue that this worldview excludes the essential role of individual-level social outcomes, or social experience – which can profoundly affect an individual's welfare. (See https://online.ucpress.edu/gp/article-abstract/1/1/11867/105160/Recoupling-Economic-and-Social-Prosperity)

How, exactly, do social experiences affect well-being? There is ample evidence that social exclusion alters our ability to achieve good health (see https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0138511, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2015.1357 & https://www.sciencedirect.com/science/article/abs/pii/S014067361730569X). It also prevents equitable participation in local economic activity. Beyond this, there is evidence that negative social experiences re-architect the brain, particularly during childhood development, and affect properties like agency and self-concept (or self-esteem). Negative social or interpersonal experiences can erode agency and diminish or distort self-concept, whereas positive life experiences can be empowering and affirming. 

Adverse Childhood Experiences

Economists have made some efforts to identify the social determinants of human behavior, e.g. https://www.sciencedirect.com/science/article/pii/S016726811600007X. The WHO has tried to formalize social experiences through the concept of "social determinants of health" (SDH). However, the SDHs are difficult to measure, and they cover far more than just social experiences. Here, we propose an alternative approach: use of the Adverse Childhood Experiences Scale (ACES) to understand the role of social and interpersonal experience in human welfare. 

The ACES was developed as a method for predicting the risk of negative health outcomes in adulthood (particularly mental health and substance use problems) based on early childhood experiences (see meta-analysis at https://www.sciencedirect.com/science/article/pii/S2468266717301184). Further research has established a biological/physiological basis for the impact of ACEs on child and adult health and well-being: See https://www.bmj.com/content/371/bmj.m3048, https://link.springer.com/article/10.1007/s10643-017-0869-3

In a nutshell, the toxic stress induced by ACEs can result in altered brain development, including the epigenetic restructuring of DNA, which can be passed onto offspring. 

We argue that Open Phil should explore the use of ACEs as a framework for charitable giving. This would reduce the universe of all possible “social needs” interventions to a more tractable set of activities, namely:

1. preventing ACEs (e.g. through parenting interventions that disrupt intergenerational transmission of PTSD related to ACEs, or through social and emotional learning);
2. mitigating the impacts of ACEs, both in children and adults (e.g. through psychotherapy); and
3. investing in positive childhood experiences (PCEs), which promote resilience and may themselves mitigate the impacts of ACEs.

We are intrigued by ACES because these experiences directly affect well-being, while also acting as a potential mediator of health outcomes and poverty. That is, people with a greater burden of ACEs are more likely to suffer negative health outcomes and live in poverty: there is a common antecedent. In this sense, ACEs seem like a missing link - a missing ingredient in our current view of well-being. We know that human welfare must include an interpersonal or social dimension, yet it is largely missing from the global health and development literatures.

Other attractive features of ACEs are that they can be: 

• monitored readily through existing public health and social welfare systems. In fact, in some countries ACEs are routinely monitored, and additional instruments could be administered through institutions like schools and hospitals;
• linked directly to loss of economic productivity (i.e. GDP), in part because of their tight correlation with negative health outcomes. Some argue that "adverse childhood experiences and rearing may generate a public health burden that could rival or exceed all other root causes." Not surprisingly, estimates of the economic costs of ACEs are remarkable:

https://www.sciencedirect.com/science/article/pii/S2468266721002322

Possible Charitable Investments

How would ACES, as a framework, guide charitable investment? Some researchers have called for greater investment in mental health support for parents, to prevent intergenerational transmission of ACEs. Focusing on parents - and tailoring interventions to mitigate the specific ACEs they may have experienced in youth - could disrupt intergenerational transfer of health problems, while also promoting protective behaviors: https://www.sciencedirect.com/science/article/abs/pii/S0272735821000404

Other researchers have called for the integration of Positive Childhood Experiences (PCEs) into mainstream educational and public health programming. PCEs – like feeling supported by friends, or having an adult who takes interest in your welfare - may mitigate the negative health impacts (and toxic stress/PTSD) caused by ACEs. E.g. https://www.sciencedirect.com/science/article/pii/S0749379722000137,  https://journals.sagepub.com/doi/abs/10.1177/1541204020972487

There is evidence that policy-makers are beginning to pay attention to ACES. For example, California is exploring the design of social services that are savvy to the health burdens caused by ACEs. See this report: https://www.cahmi.org/docs/default-source/resources/roadmap-for-resilience-compressed_1.pdf?sfvrsn=d0ed7f62_0

Risks or weaknesses

What are the risks or weaknesses of the ACES framework? First, there is relatively little rigorous research on the classes of interventions that would be required to prevent ACEs, mitigate ACEs, disrupt intergenerational transfer, and provide positive childhood experiences. There are many candidate interventions, but ACEs have not been used as an intermediate outcome measure in most relevant intervention studies. Second, ACES (i.e. the scale for ACEs) has not yet been validated in every cultural context. 

Conclusion

Overall, there is considerable work to develop and adopt a framework like this, but we wanted to share a brief conceptual model for the role of ACEs in human well-being. Right now, there seems to be a vacuum in our theoretical framing of welfare. We often look to subjective well-being – i.e. people’s internal states – as a proxy for welfare, rather than examining the life experiences that ultimately shape our subjective beliefs, self-concepts, and affective states. 

Questions

• Strength of the correlation between ACEs and negative health outcomes (how good are these measures, actually?)
• How protective are PCEs, in practice? (empirical literature)
• Thinking of social experiences as a set of person-specific transaction logs that we can’t access. But, capturing ACES allows us to express the person’s social history in some abstract form.
• How this is different from (or relates to) social networks – e.g. density, centrality, frequency of engagement (ex: Blumenstock migration & CDRs). We don’t argue that it’s unimportant who you’re connected with, but this is complementary what your experiences might have been.