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Childhood Health Risks: Notes & Sources


Adverse Childhood Experiences (ACEs) “… are broadly defined as incidents during childhood that harm social, cognitive, and emotional functioning. Frequent or prolonged exposure to such events creates toxic stress that damages the architecture of the developing brain” (Iowa Family Child and Policy Center, 2012).  The Washington State Family Policy Council asserted thatthe cumulative stresses of ACEs are the most powerful determinant of the public's health and the strongest common driver of mental, physical and behavioral health costs.”

Confidence interval (also called "error bar") is the range of values that includes the true value 95% of the time. If the confidence intervals of two groups do not overlap, the difference between groups is statistically significant (meaning that chance or random variation is unlikely to explain the difference).            

Frequent mental distress is defined as experiencing stress, depression, or emotional problems for 14 or more of the previous 30 days. 

King County regions: The geographic boundaries of the four King County sub-regions (North, Seattle, East, and South) are defined by the aggregation of ZIP codes adults for adults and by the aggregation of school districts for teens.

Race/Ethnicity: Federal standards mandate that race and ethnicity (Hispanic origin) are distinct concepts requiring 2 separate questions when collecting data from an individual. "Hispanic origin" is meant to capture the heritage, nationality group, lineage, or country of birth of an individual (or his/her parents) before arriving in the United States. Persons of Hispanic ethnicity can be of any race. Communities Count's terms for racial/ethnic groups are derived from those used by the U.S Census Bureau in 2010.

  • Communities Count terms:  Hispanic, Non-Hispanic, White Non-Hispanic, Black, American Indian/Alaska Native (AIAN), Asian, Native Hawaiian/Pacific Islander (NHPI), White, and Multiple Race (Multiple). Persons of Hispanic ethnicity can be of any race and are included in other racial categories. Racial/ethnic groups are sometimes combined when sample sizes are too small for valid statistical comparisons of more discrete groups. 
  • 2010 Census terms: Hispanic or Latino, Not Hispanic or Latino, White alone (Not Hispanic or Latino),  Black or African American, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, White, Some Other Race, and Two or More Races.

Risk and protective factors:  Broadly, risk factors are conditions that increase the likelihood of future negative outcomes and protective factors are conditions that counter or buffer the effects of risk factors, promoting resilience and decreasing the likelihood of negative outcomes. For the analysis of the Healthy Youth Survey (HYS) of 8th, 10th, and 12th graders presented here, “risk and protective factors” refer to a specific set of attitudes, beliefs, and elements of the social environment that predict adolescent problem behaviors such as violence, delinquency, and the use of alcohol, tobacco, or drugs.  As with adverse childhood experiences, the probability of negative outcomes goes up as the number of risk factors increases and goes down as protective factors increase. 

  • Examples of risk factors from the 2010 HYS:
    • Feeling disengaged from one’s neighborhood, and feeling that activities in the neighborhood are irrelevant to one’s life.
    • Perceiving that alcohol and other drugs are readily available.
    • Failing academically (whether or not the failure is linked to a student’s abilities).
    • Feeling that school is irrelevant to one’s life.
    • Not perceiving that use of alcohol, tobacco, or drugs could be risky.
    • Hanging out with peers who reinforce the above feelings, perceptions, and behaviors.
    • Examples from protective factors in the 2010 HYS:
      • Feeling that one has opportunities to participate meaningfully in community and school activities such as sports teams, school government, extracurricular activities, and service clubs.
      • Feeling that one’s contributions at school are recognized and rewarded.
      • Having social skills and positive relationships with peers.
      • Believing in right and wrong.


Adverse childhood experiences are also associated with youth mental health problems and substance abuse.  Using state administrative data for Medicaid-enrolled youth age 12 to 17, Washington State researchers found that the risk of mental health problems and substance abuse increased with the number of adverse childhood experiences. Perhaps more importantly, they found that risk levels varied considerably by type of experience, with child abuse or neglect increasing risk much more than other factors (Lucenko et al., 2012).

Data have been averaged over 3 years to enable comparisons across groups that would otherwise be too small for detection of statistically significant results.

Interventions that strengthen early attachment relationships between parents and children can prevent and reduce the negative consequences of adverse childhood experiences.  The Nurse-Family Partnership, an evidence-based home visitation program available in King County, is an example of this kind of intervention. Other interventions throughout childhood can also reduce the effects of adverse childhood experiences.  See Paul Tough book (cited below) for more information.   

Statistical Significance: Unless otherwise noted, any difference mentioned in the text is statistically significant (unlikely to have occurred by chance).

Data Sources

Adverse childhood experience (ACE), obesity, smoking, excessive drinking, health status, and cardiovascular health data come from the 2009-2011 Washington State Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a random telephone interview survey of non-institutionalized adults ages 18 and older that has been conducted in King County every year since 1987. Starting in 2003, the BRFSS was administered in English and Spanish. For adverse childhood experiences, respondents were asked a series of 11 questions requesting that they think back to the time before they were 18 years old.  One question was asked for each ACE category except sexual abuse (3 questions) and substance-abusing household member (2 questions). ACEs may be underreported, as the BRFSS relies on self-report and does not include people in hospitals or institutions, groups that may have experienced ACEs disproportionately. The limitations of an English-and-Spanish-only telephone survey include the following: a) people who do not have a land line telephone or who do not speak English or Spanish are excluded, and b) people who have less education and lower incomes are underrepresented. For additional information on the Washington State BRFSS, see:  For more detailed information about the 11 questions about adverse childhood experiences, see:

Comparative adverse childhood experience data from 5 states were collected in a pilot study that used the 2009 ACE module of the Behavioral Risk Factor Surveillance System (BRFSS) and analyzed by the Centers for Disease Control and Prevention. The 5 states were Arkansas, Louisiana, New Mexico, Tennessee, and Washington.  For more information, see

King County data on adolescent risk and protective factors come from the Washington State Healthy Youth Survey (HYS), a survey of public school students in grades 6, 8, 10, and 12 that is conducted every 2 years.  Many King County schools participate in the HYS, but not all schools participate in all survey years. Risk and protective factor scores are computed on the basis of answers to more than 100 questions about conditions and experiences in the community, at school, with family, and with peers. A limitation of the risk and protective factor data is that the questions have not been asked in a consistent way over the years, making it difficult to track changes over time and student cohorts. For example, some of the questions used to compute the risk and protective data found in 2008 Communities Count report were not asked in the 2010 survey. More information is available at the websites below:

Other Sources

Adverse childhood experiences, stress, and impaired brain development:

City Health Profiles provide demographic and health information for 25 geographic areas in King County – mostly large cities (e.g., Seattle, Bellevue), groups of small cities (Bothell/Woodinville), or combinations of cities with nearby unincorporated areas (e.g., Renton/Fairwood). Each report has seven sections:
  • Demographics
  • General health status
  • Leading causes of death
  • Health risk factors and chronic diseases
  • Injury and violence-related mortality
  • Maternal and infant health
  • Access to care and preventive services

School District Health Profiles provide demographic and health information for several school districts in King County.  The profiles were developed by Public Health-Seattle and King County in collaboration with school districts for the purpose of informing school policy-makers and administrators, health and wellness planners, and the public about student health indicators at the district level. The data come from the Healthy Youth Survey, which is administered every 2 years to students in grades 6, 8, 10, and 12.  Each profile report has 6 sections: 

  • Demographics of survey respondents
  • Obesity, physical activity, and dietary behaviors
  • Mental health
  • Personal safety and violence
  • Alcohol, tobacco, and other drug use and second-hand smoke exposure
  • 3 additional indicators, selected by each district (examples: adults to turn to for help when feeling sad or hopeless; family skipped meals in past 12 months due to finances; bullied in the past 30 days because of face, ethnicity, or national origin)

Definition of adverse childhood experiences:

Definitions of risk and protective factors:

Interventions to counter the effects of adverse childhood experiences:

  • Tough, Paul.  How children succeed: Grit, curiosity, and the hidden power of character (2012). New York: Houghton Mifflin Harcourt Publishing Company. Good review of research and effective interventions to counter ACEs are found in Chapter 1.  The programs detailed in the rest of the book may also counteract the effects of ACEs. 
  • Nurse-Family Partnership, an evidence-based home visitation program, pairs registered nurses with at-risk, 1st-time mothers to help them through pregnancy and the first 2 years of their babies’ lives.  For an overview of research results, go to  Long-term benefits of the program (comparing children whose mothers participated in NFP vs. those whose mothers did not participate) have included reductions in child abuse and neglect, lower arrest rates, and reductions in alcohol, tobacco, and drug use.  Information on King County’s Nurse-Family Partnership is available at    
Maps of King County covering a wide range of topics can be accessed at  Maps most immediately relevant to Communities Count are under the headings of Community data & demographics, Public health, and Environment & natural resources, but other maps should be useful as well (farmers markets, transit routes, walking and biking routes, parks, traffic counts, etc.).