Adverse childhood experiences (ACEs) are negative and potentially traumatic events and experiences that occur during childhood.1 In 1998, the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente published a study that investigated impacts of childhood abuse and neglect on later life and health. The study took place from 1995 to 1997, where 17,000 Health Maintenance Organization members from Southern California underwent physical examinations as well as surveys on their childhood experiences and current behaviors and health status. Respondents were provided with questionnaires that included questions about the first 18 years of their lives. As a result of the study, ten adverse childhood experiences were identified in three categories:2
Physical: A parent or guardian living in your home pushed, grabbed, slapped, hit, or threw something at you so that you had marks or were injured
Emotional: A parent or guardian living in your home swore at you, insulted you, belittled you, or behaved in a way that made you afraid you would be physically hurt
Sexual: An adult, relative, family friend, stranger, or parent touched you in a sexual way, made you touch them in a sexual way, or attempted to have sexual intercourse with you
Physical: A parent or guardian did not take care of your physical needs, did not protect you, did not take you to the doctor when necessary, did not ensure you had enough to eat, or was too inebriated to take care of you
Emotional: A family member made you feel unimportant and unloved and you didn’t feel like your parents or family were looking out for you or each other. Family was not a source of strength or support. You felt isolated and alone as a child
Mental Illness: A member of your household struggled with mental illness and/or attempted suicide or died by suicide
Mother Treated Violently: Your mother was physically abused: pushed, grabbed, slapped, kicked, bitten, hit, threatened with a weapon or more
Divorce: Your parents separated or were divorced
Incarcerated Relative: A member of your household went to prison
Substance Abuse: A member of your household suffered from substance abuse
Additional ACEs which were not included in the initial list of ten include community and environmental experiences such as racism, bullying, and community violence as well as homelessness, surviving an accident, witnessing your mother abuse your father (abuse can occur both ways in a relationship), involvement in the foster care system or juvenile justice system and more.3
The ACE questionnaire is available online and includes a list of ten questions about the ten adverse childhood experiences. Each ACE counts for one point out of ten, and the higher number of ACEs you had, the more likely you are to experience negative health outcomes later in life. It is important to note that the ten ACEs that were identified during this study are not comprehensive, and there are numerous other types of childhood trauma you may have experienced, which would also increase the likelihood of experiencing health problems as an adult.4
Now add up your “Yes” answers: _ This is your ACE Score.”4
Adverse childhood experiences are quite common. According to the CDC, approximately 61% of adults from 25 different states reported experiencing at least one type of ACE, and 1 in 6 reported experiencing four or more types of ACEs.1 The result of this? A large number of avoidable health conditions.
Up to 1.9 million cases of heart disease and 21 million cases of depression were found to be linked to ACEs and therefore could have been potentially avoided by preventing ACEs and toxic stress.1
Having negative or traumatic childhood experiences can result in toxic stress which can negatively impact our health in many ways. While some forms of stress are healthy and allow us to tackle smaller challenges in our daily life, such as public speaking or starting a new job, toxic stress occurs when the stress is more intense, lasts for longer periods of time, and when we don’t have adequate support in place to deal with stress.3
When toxic stress is not addressed and treated, it can result in long-term behavioral issues, health complications, and diseases that are caused by ACEs.3 The more ACEs a child experiences, the more likely they are to suffer negatively in adulthood. One of the major ways in which ACEs present problems later in life is the result of substance abuse. Substances, whether they be alcohol or illicit drugs such as heroin or cocaine, are frequently used as coping strategies for stress and mental health issues. They might make you feel better temporarily, but in the long-term can lead to dependence and substance abuse disorders.
Constant activation of the body’s stress response system can negatively impact the brain’s vital systems. Toxic stress on the brain’s stress pathway can lead to anxiety, depression, impaired learning, and memory.3
Toxic stress also impacts emotional processing and regulation in the brain, leading to hypervigilance and reduced attention control.3 Toxic stress can decrease your ability to experience joy, and lead to difficulties in brain connectivity in not knowing how to respond to situations appropriately.3
Unfortunately, toxic stress can also impact our ability to deal with and respond to stress, meaning that the more frequently we experience toxic stress, the less likely we are able to cope with it in a healthy way.
As children grow older, the experience of childhood trauma, emotional trauma, psychological trauma, and constant toxic stress can lead to health problems and behavioral issues. This is due to the effects that toxic stress can have on epigenetics. Epigenetics is the study of changes in our gene expression, or in other words, which genes are used or not used.3
Toxic stress can change the way that our genes work, causing problems later in life and altering the way that our bodies respond to stress, which can be passed down from one generation to the next through our genes.3 This is why in recent years, researchers have come to understand that childhood, emotional and psychological trauma can be hereditary, and the trauma our ancestors may have experienced can carry down into younger generations.
The CDC-Kaiser study found that adults with an ACE score of 4 or more were at much higher risk for behavioral, physical, and mental health issues later in life.3
These issues include:
Conditions associated with ACEs, such as living in an under-resourced or racially segregated neighborhood, frequently moving, and experiencing food insecurity can also lead to toxic stress.
Trauma refers to the experience of serious adversity or terror or the emotional or psychological response to that experience.5 In other words, trauma is one of the major responses to ACEs and a response to repeated toxic stress. For that reason, trauma-informed care is important when treating both children and adults with ACEs. Much like toxic stress, trauma can change the way that your brain functions and the way that it responds to stress.
Having an ACE does not automatically mean that a child will experience toxic stress or suffer from negative health outcomes later in life. The way that children react to ACEs plays a large role in its effects later in life. A key to helping children work through adverse conditions is to help them to build resiliency.3
Competence: help children to understand their skills
Confidence: help children to have a belief in their own abilities
Connection: help children become connected with other people, their schools and communities to build a support system
Character: help children to understand the difference between right and wrong and promote strong morals and values
Contribution: allow children an opportunity to help others out in order to understand that helping feels good and that asking for help is okay
Coping: help children develop healthy coping strategies to deal with stress and difficult experiences to reduce the chances that children turn to dangerous or quick fixes to deal with stress, such as drug or alcohol use
Control: allow children the opportunity to make their own decisions so that they feel in control of themselves and their lives and are able to take control when handling difficult situations
Communicate: help children to communicate and express their emotions and make them feel empowered by being open with how they feel
There are many other ways to help children build resiliency and to help them deal with ACEs. This work is not only to be done by parents, but by teachers, by the healthcare system, and by local communities.
When we empower our children, we give them a better chance of being strong, resilient, and healthy adults. When children are not raised to be resilient, they are more likely to experience toxic stress which can lead to substance abuse problems later in life.
While the above strategies are helpful in terms of building resilience in our children and equipping them with the necessary skills to tackle adversity, for many adults, the harm is already done and more intensive treatments may be needed to treat ACEs, trauma, and the potential substance abuse disorders that can stem from ACEs.
Treatment options include:
Individuals who have experienced numerous ACEs are likely to suffer from PTSD. It is important that professionals in social work, medicine, and education who work with people who have ACEs interact with patients through a trauma-informed lens.5 This means placing the individual and their experience at the forefront of care. It would start with addressing the experience and working towards the health issue in question.
Inpatient treatment refers to patients who live in a facility and receive 24-hour medical care. This could include the administration of medications used for the treatment of substance use disorders as well as individual or group counseling sessions and/or other treatment sessions that might focus on coping strategies, methods for success in the workplace, family relationships, and more.
Outpatient treatment refers to treatment that individuals receive when they live at home and visit a hospital or medical center to receive medication or counseling. Outpatient treatment is an excellent option for individuals who want to maintain the stability of their home life, while still receiving treatment.
Individual counseling group counseling that occurs in inpatient or outpatient settings.
The most popular 12-Step program is Alcoholics Anonymous, but there are also 12-step programs available for substance use disorders. 12-Step programs help to build a sense of community among individuals going through similar experiences. It helps to not feel alone and to be held accountable by peers.
Aside from professional medical intervention and counseling, there are also numerous in-person and virtual support groups where people who have had similar life experiences can get together and talk about their experiences and feelings. This can help you to feel validated and to realize that you are not alone in your experiences.