“ACEs” referred to three specific kinds of adversity children faced in the home environment—various forms of physical and emotional abuse, neglect, and household dysfunction. The key findings of dozens of studies using the original ACEs data are: (1) ACEs are quite common, even among a middle-class population: more than two-thirds of the population report experiencing one ACE, and nearly a quarter have experienced three or more. (2) There is a powerful, persistent correlation between the more ACEs experienced and the greater the chance of poor outcomes later in life, including dramatically increased risk of heart disease, diabetes, obesity, depression, substance abuse, smoking, poor academic achievement, time out of work, and early death.
How do ACEs relate to toxic stress?
ACEs research shows the correlation between early adversity and poor outcomes later in life. Toxic stress explains how ACEs ”get under the skin” and trigger biological reactions that lead to those outcomes. In the early 2000s, the National Scientific Council on the Developing Child coined the term “toxic stress” to describe extensive, scientific knowledge about the effects of excessive activation of stress response systems on a child’s developing brain, as well as the immune system, metabolic regulatory systems, and cardiovascular system. Experiencing ACEs triggers all of these interacting stress response systems. When a child experiences multiple ACEs over time—especially without supportive relationships with adults to provide buffering protection—the experiences will trigger an excessive and long-lasting stress response, which can have a wear-and-tear effect on the body, like revving a car engine for days or weeks at a time.
Importantly, the Council also expanded its definition of adversity beyond the categories that were the focus of the initial ACE study to include community and systemic causes—such as violence in the child’s community and experiences with racism and chronic poverty—because the body’s stress response does not distinguish between overt threats from inside or outside the home environment, it just recognizes when there is a threat, and goes on high alert.
What is trauma, and how does it connect to ACEs and toxic stress?
While trauma has many definitions, typically in psychology it refers to an experience of serious adversity or terror—or the emotional or psychological response to that experience. Trauma-informed care or services are characterized by an understanding that problematic behaviors may need to be treated as a result of the ACEs or other traumatic experiences someone has had, as opposed to addressing them as simply willful and/or punishable actions.
What can we do to help mitigate the effects of ACEs?
People who have experienced significant adversity (or many ACEs) are not irreparably damaged. There is a spectrum of potential responses to ACEs and their possible chain of developmental harm that can help a person recover from trauma caused by toxic stress.
More ACEs Resources
- Centers for Disease Control and Prevention: More about the original ACEs study and subsequent research.
- ACEs Too High: A site focused on news and research around ACEs.
- Substance Abuse and Mental Health Services Administration: Information on trauma-informed approaches and trauma-specific interventions.
- At the most intensive end of the spectrum are therapeutic interventions, ranging from in-patient treatment to regular sessions with a mental health professional, which are designed specifically to deal with serious trauma.
- Trauma-informed care or practice is less intensive, but affects how practitioners in a range of fields, such as social work, medicine, and education, work with people who have experienced toxic stress, and reflects an awareness of the harm that has occurred and takes that into account. There are also many less-intensive practices that can help individuals reduce the effects of stress—from meditation and breathing exercises, to physical exercise and social supports.
- ACEs-based screening and referral is an increasingly common approach, in which individuals are given an ACE score based on a brief survey of their own personal history of ACEs. This can indicate a general, non-specific sense of increased risk based on population-level probabilities, but it cannot predict accurately how any one individual will fare. In other words, a high ACE score can serve as a rough first screener to identify people who may benefit from services, but it cannot tell you what specifically you are at risk for, nor what to do about it.
- The ideal approach to ACEs is one that prevents the need for all levels of services: by reducing the sources of stress in people’s lives, whether basic needs like food, housing, and diapers, or more entrenched sources of stress, like substance abuse, mental illness, violent relationships, community crime, discrimination, or poverty. Supporting responsive relationships with a parent or caregiver can also help to buffer a child from the effects of stress, and helping children and adults build their core life skills—such as planning, focus, and self-control—can strengthen the building blocks of resilience. These three principles—reducing stress, building responsive relationships, and strengthening life skills—are the best way to prevent the long-term effects of ACEs.
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“ACEs” stands for “Adverse Childhood Experiences.” These experiences can include things like physical and emotional abuse, neglect, caregiver mental illness, and household violence.
The more ACEs a child experiences, the more likely he or she is to suffer from things like heart disease and diabetes, poor academic achievement, and substance abuse later in life.
Toxic Stress Explains How ACEs “Get Under the Skin.”
Experiencing many ACEs, as well as things like racism and community violence, without supportive adults, can cause what’s known as toxic stress. This excessive activation of the stress response system can lead to long-lasting wear-and-tear on the body and brain.
The effect would be similar to revving a car engine for days or weeks at a time.
We Can Reduce the Effects of ACEs and Toxic Stress.
For those who have experienced ACEs, there are a range of possible responses that can help, including therapeutic sessions with mental health professionals, meditation, physical exercise, spending time in nature, and many others.
The ideal approach, however, is to prevent the need for these responses by reducing the sources of stress in people’s lives. This can happen by helping to meet their basic needs or providing other services.
Likewise, fostering strong, responsive relationships between children and their caregivers, and helping children and adults build core life skills, can help to buffer a child from the effects of toxic stress.
ACEs affect people at all income and social levels, and can have serious, costly impact across the lifespan. No one who’s experienced significant adversity (or many ACEs) is irreparably damaged, though we need to acknowledge trauma’s effects on their lives. By reducing families’ sources of stress, providing children and adults with responsive relationships, and strengthening the core life skills we all need to adapt and thrive, we can prevent and counteract lasting harm.
Seven categories of traumatic circumstances in childhood, included physical and sexual abuse, neglect, incarceration, and whether a patient’s parent suffered from mental illness. They called this a study of Adverse Childhood Experiences or Aces. This is a good graphic explanation of Aces. They found that Aces are very common: 50% of patients reported at least one, and 25% reported at least two. Among the 9,508 patients they screened, those who had experienced four or more categories of childhood exposure to trauma were twice as likely to develop heart disease compared to someone with an Aces score of zero – but other diseases were also more prevalent.
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12 December 2019, The Correspondent, by Irene CASELLI
Image editor Lise Straatsma searched for the old photographs that accompany this piece. These photos show moments from people’s lives. The physical damage – stains, creases and bits missing – changes what is left of the ‘memory’. Photo: Flickr / Simpleinsomnia
It started with a slip of the tongue.
In 1985, Vincent Felitti was running a weight loss clinic in San Diego, California, when he began to notice something strange. The treatment was successful – patients were definitely losing weight – but the physician was perplexed by the high dropout rate. Why would someone who had worked so hard suddenly let it all go?
Felitti was going through a routine set of questions one day, with a patient. Donna, 53 at the time, had lost up to 100lb before rapidly putting them back on. Felitti meant to ask: “How old were you when you first became sexually active?” Instead what came out was: “How much did you weigh when you became sexually active?”
“40lb,” Donna replied.
Felitti thought there was a mistake, so he asked again. That was when Donna revealed she had been sexually abused by her father at the age of four.
Weeks later, the doctor was with a different patient struggling to maintain her weight loss when a similar story came up. She had also been abused and was now sleep-eating.
Felitti started wondering whether he had found a link between sexual abuse and obesity and started routinely asking patients whether they had been abused. To his surprise, the number of positive answers was very high. When he found 186 patients, he asked his colleagues to help do a screening.
Our bodies were made to react quickly to the arrival of predators so we could run. If you’re in a forest and a bear approaches, stress hormones are released into the body. Your heart pumps faster … You get ready to fight that bear or run.
In 1990, he presented his preliminary findings at a national conference on obesity in Atlanta, Georgia, where he was widely criticised. But Felitti’s work caught the attention of the Centers for Disease Control, the leading US national public health institute. Robert Anda, an epidemiologist researching the link between behaviour and cardiovascular disease, was particularly intrigued.
Anda and Felitti drafted a questionnaire they sent the clinic’s patients with questions relating to seven categories of traumatic circumstances in childhood, including physical and sexual abuse, neglect, incarceration, and whether a patient’s parent suffered from mental illness. They called this a study of Adverse Childhood Experiences or Aces. This is a good graphic explanation of Aces. They found that Aces are very common: 50% of patients reported at least one, and 25% reported at least two. Among the 9,508 patients they screened, those who had experienced four or more categories of childhood exposure to trauma were twice as likely to develop heart disease compared to someone with an Aces score of zero – but other diseases were also more prevalent.
The effects of trauma on the body
Felitti and Anda’s study was groundbreaking. It’s the basis for our understanding of the effects of traumatic childhood events.
Think of the case of migrant children separated from their families in the US, or the impact of forest fires, Here is one headline referring to bushfires and trauma.floods, mass shootings, This is another headline using the word trauma in connection to children.or domestic violence. Headlines now use the word trauma all the time, but the focus is often on mental health, with little thought given to the implications for physical health.
In the years following Felitti’s research, a variety of studies have zoomed in on the connection between childhood trauma and diseases.
Over the millennia we have developed the ability to react quickly to perceived danger. If you’re in a forest and a bear approaches, stress hormones are released into the body. Your heart pumps faster, your airways open up to let more air through, your pupils dilate. You get ready to fight that bear or run.
“But what happens when you can’t experience safety in your cave because the bear is living in the cave with you?” asks California’s surgeon general Nadine Burke Harris, a paediatrician advocating for Aces screening. Exposure to hardship can change the way our stress hormones react and push our bodies into being in fight-or-flight mode all the time.
When those experiences affect us constantly from childhood, we’re later incapable of regulating our reactions to everyday life. It’s similar to post-traumatic stress disorder that soldiers get when they return home from war.
Katherine Ehrlich, assistant professor in psychology at the University of Georgia, says: “The body seems to keep score. Adverse experiences are linked to changes in physiological systems, including neuroendocrine and immune systems, and these changes may have implications for long-term physical health.”
Aces don’t just have biological effects. They can actually be transmitted from one generation to another. It is an up-and-coming branch of neuroscience called epigenetics.This piece in the Guardian is a good introduction to the concept of epigenetics.
The limitations of Aces research
The sample group for Felitti and Anda’s initial research was almost exclusively middle class, which has led some researchers to criticise the range of questions This study provides a critical look at the concept of adversity used in the initial study.and the categorisation of adversity (poverty, racism or bullying were not identified as adverse conditions).
Along the same lines, there is little relevant research beyond the US and Europe, This study goes into this.which is a similar problem because the wording and range of questions used to understand this complex issue reflect a cultural bias – a result of the location of the original research.
While the need for a more robust questionnaire has been addressed, and different versions For example, the World Health Organization has this international version of the questionnaire.have been drafted, existing research on the relationship between childhood adversity and biological changes in the body remains nonetheless valid.
Most researchers also can’t wait 30 years for results of poor health outcomes, so most assessments rely on questions about childhood. And of course reporting on our past can be tricky because memory can play tricks on us, Read my earlier piece on recalling childhood memories.but this does impact the validity of research based only on memory.
Another limitation is that the changes being measured as a result of Aces are often very small. “It is fair to call the research very suggestive, but developing,” says Stephen Boos, a paediatrician focusing on child abuse.
From theory to practice
So what can we do about Aces? How is this research applied to our everyday lives? Should paediatricians screen with the Aces questionnaire – and is that the best way they could help patients?
The medical community has given a fair amount of pushback. There have been fears of racial and socio-economic profiling associated with universal screenings.
But advocates say that Aces happen everywhere.
Burke Harris writes: “When you bring it down to the level of cells, the level of biological mechanisms, then it is about all of us. We are all equally susceptible and equally in need of help when adversity strikes. And that is what a lot of folks don’t want to hear. Some want to stand back and pretend that this is just a poor-person problem.”
But Aces do not just affect poorer people, as Felitti and Anda’s study showed.
“Affluence is certainly not a protective factor against all harm,” says Ehrlich. “Children – even children from wealthy families – can be at risk for exposure to adversity.”
When it comes to everyday medical practice, the idea of Aces is quite hard to implement. For example, what do you do as a doctor if you find out that a child you are examining has been abused? In the absence of protocol, doctors enter a grey area where they may have to report the abuse to protective services and may not be able to do so in a sensitive way.
Boos says: “Physicians are a bit leery of screening for something, and then having nothing to do to affirmatively respond to it. This may not be a fully valid concern, but it is a natural one, particularly if you are on a time crunch.”
Burke Harris got around this problem in her own clinic by putting in place a multidisciplinary team, which included a psychologist to provide support to those who reported Aces. Her team also changed the questionnaire, adding extra factors (such as bullying and racism) and also asking patients and their carers to provide an overall score without answering yes or no to each question. This way, patients are not revealing which adverse conditions they went through and so may be less likely to hide this information.
So, can Aces be reversed?
Scientists call the presence of Aces that are unremitting and not countered by a supportive adult and a safe home “toxic stress”. This is a good explainer of toxic stress.High levels of toxic stress is probably what determines the biological changes that are so worrisome. But the impact of Aces depends on how well a child is buffered by their environment and their carers.
Action taken in the early years of life both counteracts adversity in those early years and develops resilience This video by the Center on the Developing Child at Harvard University explains how resilience develops early on.in children that will protect them from later adversity.
Robert Sege and Charlyn Harper Browne have written about the “health outcomes of positive experiences” or Hope, which also works with a scoring system similar to Aces.
The underlying idea is that a Hope score can decrease the impact of an Aces score, and that by building Hope factors in families we can actively mitigate Aces.
“Emphasising the importance of children and families building on their strengths and doing positive things together is something that paediatricians can do, and would enjoy doing to counter Aces,” Boos explains. “This sort of counselling can benefit all families and is easily incorporated into any paediatric practice.”
The buffer becomes hugely important, not just to attenuate stress hormones but also to alleviate the associated major health issues and prevent conditions being passed from one generation to another.
Healthy traits can also be transmitted genetically. So the question is: could we potentially make everyone healthier if we ask the right questions from the start?
Thanks to member of The Correspondent, Stephen Boos, for providing insightful material, giving valuable feedback, and fact-checking the article.Shared 286 times12 December 2019Part of collections For those caring for children, Dealing with trauma, First 1,000 days
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