Adverse Childhood Experiences

Adverse Childhood Experiences (or ACEs, for short) are no new thing, but only in recent decades have we come to realise the scope of their impact on children and the adults they become. ACEs can broadly be defined as traumatic events occurring before age eighteen. What counts as an ACE is open for interpretation, with the official domains liable to change.

The history of ACEs

To start thinking about ACEs and what they mean for us, we have to go back to 1995 when Kaiser Permanente (a massive non-profit healthcare organisation in the US) started giving detailed questionnaires to patients who came in for medical exams on their experiences in childhood. These questionnaires covered a range of topics spanning eight different domains of adversity. The team then compared these ACE scores with each patient’s medical history. Naturally, it can seem obvious to us now that abuse and trauma in childhood can affect your health and well-being quite significantly, but what was surprising at the time was not just that these events had an impact but how much of an impact these adverse childhood events had.

The ACE Domains

It would be useful to know these ACEs before we examine their impact in depth, but this becomes a bit tricky as new domains of adversity are always added. We’ll start with the original eight before adding the ‘newer’ ones.

Abuse

• Physical
• Sexual
• Emotional

Household dysfunction

• Mental illness
• Incarceration
• Divorce
• Interpersonal violence
• Substance abuse

The same study then went on to add two categories of neglect.

Neglect

• Emotional
• Physical

A subsequent study, ‘The Philadelphia ACE Study’, in 2015, identified that community factors were routinely neglected from research and so added in five community domains. These are often referred to as the expanded ACEs.

Community

• Racism
• Bullying
• Living in foster care
• Neighbourhood safety
• Community violence

Many different questionnaires now exist to try and elicit the ACEs that individuals have experienced, but not all encompass the same domains.

The impact of ACEs

Now that we know the 15 ACEs and that they are linked with poor health and well-being, let’s get into the nitty-gritty.

The researchers were taken aback by their findings in the original Kaiser-Permanente study (which mainly represented a white upper-middle-class demographic). Two-thirds of patients had experienced at least one ACE, and one in eight had an ACE score of over four. This is shocking, but they discovered a staggering dose-response model when they compared these results with medical histories. The more adverse experiences one faces as a child, the worse they fare across almost every measure. Higher rates of obesity, addiction, depression, and smoking seem almost intuitive, but heart disease, cancer, and liver disease were also higher, even after factoring in confounding measures. Could there be an element of causation as well as correlation? Could adversity itself be making people ill?

It’s difficult to discuss the effect of ACEs on health as practically every health condition is inextricably linked to these experiences. I will mention some commonly reported statistics as a starting point.

ACEs are also highly linked with rates of obesity, unemployment, and health risk behaviours such as smoking, drinking, and drug use. To list all of the known impacts of ACEs would be to write a rather large textbook, so I encourage you to research your field of practice.

The physiology

We don’t know the full mechanism of how ACEs cause all these effects, but one major player seems to be the HPA axis.

To give a brief overview, the HPA axis (or the hypothalamic-pituitary-adrenal axis) is activated during stress. This leads to the release of stress hormones and glucocorticoids, which in turn switch on various defence responses in the body (think raised heart rate, dry mouth, clammy skin for the obvious; raised glucose and raised inflammatory markers for the less so). This wouldn’t prove an issue if we were still back in our prehistoric days when stressors were extreme and temporary. Still, nowadays, we are exposed to the chronic stress of the modern world, and our HPA axis is not equipped to handle this (inefficient at best, devastating at worst). Overloading our HPA axis isn’t uncommon today, but just because it’s normal doesn’t mean it’s right, and this can have significant consequences, especially if this chronic stress arises in childhood.

In his book ‘How Children Succeed,’ Paul Tough compares this HPA axis to a firehouse, where every time a child experiences a stressful event, their fire alarm sounds. This, in isolation, isn’t bad, but when it keeps happening, firefighters kick the doors in and blast the hose. The lifelong damage doesn’t come from the fire but from the body’s attempt to protect itself from it.

The controversy over ACEs

The measurement and use of ACEs can seem pretty straightforward, but significant controversy surrounds them. It is a hotly debated topic, and many groups have tried to adapt and adjust the measure to improve its viability as a scoring system.

The argument is that ACEs are a crude measure of adversity, particularly the original eight. There are a huge amount of adverse experiences a child may face that aren’t covered even under the expanded ACE domains. Plus, there is no differentiation between the frequency and intensity of events within the same category. This means a child who may have lived through an amicable divorce at the age of two would have the same ACE score as a child whose parents had a very hostile divorce when they were age twelve.

Additionally, certain factors have been shown to dramatically reduce the effect of childhood adversity on health and well-being. So, while we may know that four or more ACEs will have significant repercussions on a population level, we have limited ability to predict the effects on an individual basis. This isn’t to say that population-based predictions aren’t valuable. Still, when working with children one-on-one, we can’t guess how these experiences will manifest themselves.

Another frequently mentioned argument is that these scores are often based on adults reflecting on their childhoods. This can leave room for memories to change shape and be forgotten, potentially leading to inaccurate measures. In addition, the ACE scores don’t account for any coexisting disability or additional needs groups.

However, the ACE score was never intended to be used individually; it was intended to highlight the links between childhood adversity and lifelong healthcare outcomes and thus provide a measure of risk. It can be a useful clinical tool, especially when starting conversations, but it’s important to know its limitations when used with patients.

So, what can we do about it?

Adverse childhood experiences are not uncommon and highlight the importance of safeguarding in a paediatric setting. However, safeguarding and prevention only have so much reach, and we don’t always know how to help a child who has already experienced adversity.

Fostering a strong sense of resilience within children is the major way to help them better overcome adversity. Three primary factors play into the development of resilience: relationships with caring adults, agency and self-efficacy, and emotional and self-regulation. It’s worth remembering that prevention is always better than cure, and just because there are children who have been strong in the face of adversity doesn’t mean that they should have had to be.

Let’s turn our attention to resilience

What does it mean for a child to be resilient? And why is that so important? When considering ACEs, the next step is to start thinking about what we can do to reduce the risks that adversity imposes and how resilience plays a monumental role.

What is resilience, and why is it important?

Resilience can be quite hard to define, but the consensus is that it means you can bounce back during tough times. Everyone has varying levels of resilience. Everyone responds to life’s challenges differently. A resilient person may thrive in times of stress or uncertainty, whereas someone on the opposite end of the spectrum may struggle to cope.

‘Tough times’ cover a range of scenarios, from exam deadlines and moving house to some of the more hard-hitting ACEs. This is where the importance of resilience comes into play. Recovering from adversity means a child will be more capable, empowered, and protected from developing mental health issues, as they can grow with these challenges rather than shy away from them. They will be more confident in their ability to manage stressors and be more willing to tackle things head-on, which can make a huge difference in their lives, present and future.

Let’s imagine two adolescents who live in abject poverty in an area with high crime rates and are now completing their national exams – we’ll call them Anne and Beth.

Anne struggles to keep up with her schoolwork, and her teachers remark that she becomes very anxious whenever a test comes.

Despite her life circumstances, Beth is doing well at school, has a good group of friends, and seems to thrive under exam pressure.

Beth is more resilient than Anne by the very definition of the word and will likely be more confident and self-assured going forward. But why? Is this just an inborn trait, or can we help foster resilience?

What makes a resilient child?

Many factors contribute to resilience, but they can be divided into three main categories: relationships with caring adults, agency and self-efficacy, and emotional and self-regulation. Knowing these factors, alongside a child’s circumstances, may help us make a more accurate prediction of how they will fare in the future.

Relationships with caring adults

One of the most important contributors to resilience is a child’s relationship with the adults in their life. Negative outcomes associated with adversity can be mitigated or even avoided, provided that the adults in a child’s life are responsive to their needs and provide a safe space for them.

A 2022 study by Partington et al. showed that children living in families classed as thriving in the early lockdown months of the coronavirus pandemic went on to have significantly better mental well-being as the pandemic evolved. The opposite effect was seen with families that didn’t reach this thriving benchmark; these children had poorer mental and emotional health. This is just one example of the many studies looking at the relationship between good relationships and resilience.

A further example of this can be illustrated through allostatic load, which refers to the cumulative burden of chronic stress and life events. It allows us to measure the actual effects of adversity by measuring cortisol, adrenaline, and HbA1c. One study at Cornell measured allostatic load in a cohort of children and assessed the relationship between these biological results and life circumstances. The more adversity those children had faced, the higher their allostatic load, but this was with one very important exception. If the adults in a child’s life (mother in the case of this study) were particularly attentive, this correlation ceased to exist – the difficulties a child may have faced no longer resulted in poorer health outcomes. Some might think this would boil down to some incredibly involved parents who have plenty of time and money to support their child (and hats off to them). Still, the research shows that standard good-quality parenting is enough to make a significant difference in a child’s future.

This doesn’t just apply to a child’s parents and any guardian, teacher, or adult with whom the child is in frequent contact. Supporting the adults in a child’s life to be attentive and caring is one of the most significant things you can do to promote good health outcomes.

Returning to Anne and Beth and their respective relationships, Anne lives at home with both of her parents, but they tend to keep to themselves, letting Anne take care of herself. She has to do her own cooking and is reluctant to ask her parents for help whenever she needs it as she doesn’t want to bother them.

Beth, however, lives with her mum, who she considers her best friend. She relies on her for support and knows that she will always be there to help her no matter what.  As a result, Beth is more willing to take risks and is more confident, as she knows she will always have a strong support network, contributing significantly to her resilience. Anne gets very anxious and shies away from new situations as she must navigate them alone.

Agency and self-efficacy

Another major factor in developing a resilient child is agency. Agency, put simply, is the feeling of control over your actions and their consequences—the feeling of being in the driving seat when it comes to your life. Self-efficacy, the belief that you can accomplish what you set out to do, coexists with agency. This is especially important in a healthcare setting where children often feel exceptionally out of control as they aren’t always invited to make their own healthcare decisions.

The value of agency in healthcare settings was highlighted in research undertaken in 2019 by Krockow et al. They suggested that shared decision-making improves patient confidence, increases patient happiness, and protects against future psychosocial problems. Agency allows children to feel responsible and trusted. This develops their belief in self-efficacy and their own capability and, in turn, improves their ability to cope with life’s stressors. Naturally, there are many situations where it is hard to involve children in their health decisions, but any involvement can significantly impact how well they cope.

Improving agency doesn’t just hold value in the healthcare environment. There are significant benefits across all domains of life. A study into children in care, published in 2017 by Berridge, found that children classed as self-reliant were more successful in their schooling than those who were stressed or disengaged. By participating in discussions surrounding their care, children could feel more in control with increased purposefulness and resilience. Self-reliance here means that the child can rely on themselves and make their own decisions without needing support. It’s important to remember that support is still incredibly important and can’t be ignored because it isn’t an absolute ‘need’.

A child who believes in their capability will do extraordinary things for their self-worth and resilience. By trusting themselves to cope with difficulties, they give themselves the power to do so and will recover from adversity much quicker than less self-assured children.

Revisiting our case study, Beth is very confident and self-assured. When she sets out to do something, she will not stop until it’s done, and despite her life circumstances, she decides to focus on the things she can control.

Anne, however, doesn’t have the confidence Beth does, isn’t so sure of her own ability, and doubts herself. This means Anne feels out of control in her own life and doesn’t feel like she can do as well as Beth, so she becomes very resigned and complacent.

Emotional – and self-regulation

Self-regulation, the ability to manage emotions and behaviours, is the third fundamental component of resilience and is often regarded as one of the cornerstones of child development.

This ability to control our feelings is part of our executive function and covers our more difficult thought processes. A study conducted by Neuenschwander et al. reported that young children with greater executive functioning abilities managed the transition into formal schooling considerably more successfully than those who weren’t as well equipped, highlighting the improved ability of those children to cope in adverse situations. It was also shown that increases in self-regulatory ability enabled students to stay focused despite distractions, fatigue, and lack of drive, directly influencing the grades students would go on to achieve. Perhaps this highly suggests a positive correlation between higher executive functioning, self-regulation, and increased academic resilience.

On top of that, a more directly-linked study by Ogelman and Önder in 2019 demonstrated increased resilience scores in 5–6-year-old children. The children’s emotional regulation strategies could be used to predict their resilience levels, with children who were more adept at self-regulation consistently scoring higher.

The vast amount of supporting evidence clearly shows a definitive association between a child’s ability to regulate emotions and their ability to bounce back from adversity. The psychology behind this link is thought to be that increased levels of self-control lead to the development of vital coping skills, the cornerstone of a resilient mindset.

Circling back to Anne and Beth, Anne struggles to cope with her emotions and hasn’t quite learnt how to self-soothe in times of stress. As a result, she has started to have panic attacks, and her school teachers have suspected she is depressed.

Beth, however, whilst she does have the occasional low mood, copes well and knows how to take care of herself when her mood dips. Because of this, Beth feels in no danger of ‘spiralling’ as soon as she feels low and trusts in herself to get through hard times.

What can we do with this information?

Now that we know what resilience is, why it’s important, and what it’s made of, we can start to consider how we can use this information as healthcare professionals.

The first useful thing to do is to have a think for yourself. ‘What has stood out for you and your practice? What could you change to promote resilience in a child? Which of the three main resilience factors are the children you’re working with lacking?’ There’s no one-size-fits-all advice, as every practitioner and every child is different.

To think more generally, we can take away some key messages from each of the big three. In regards to supporting good relationships between a child and caring adults, remember that adults need support, too, and take the time to refresh your knowledge on what you can offer them. At the same time, however, don’t forget that whilst a child is under your care, YOU are the caring adult, so make sure you prove it to them.

To promote a strong sense of agency and self-efficacy, ensure that you involve children in their healthcare decisions as much as physically possible. This doesn’t (necessarily) mean letting the child make all of the decisions, but at least letting them have their say and be given a platform to voice their opinions. Explain what’s happening to them, at the very least, which is all too easy to forget on a busy shift.

The most difficult aspects of promoting resilience are emotional and self-regulation, but they are doable. Children in hospital and healthcare environments naturally experience many big and unfamiliar emotions, so supporting them through those emotions is a must. See what support your local services can offer, try to set aside the time to talk through what they’re feeling in a space where they can ask questions, and practise emotional co-regulation.

Incorporating at least one new action into your practice can make a huge difference for a child and help them recover from any adversity life may throw their way. However, adversity is best avoided, and this is where we rely on our principles of safeguarding. It’s lovely to help a child overcome trauma, but it’s so much better to prevent it.

Our Case Study

Throughout this article, we’ve discussed Anne, Beth, and their respective lives. There is just a made-up story, but for many children, it is reality. Instead of theorising about how miserable Anne’s life could become due to her circumstances, it’s more beneficial to think about how changes made to her day-to-day could improve her quality of life.

Imagine that the teacher who suspected Anne might be depressed then went on to talk to her and refer her to a local counselling service. Anne may have developed a trusting relationship with her teacher and counsellor, giving her the confidence and support to venture out. They may have also talked with her parents, who may have been shocked and thought that Anne was happy to take care of herself, and as a result, made sure they devoted more time to making sure she was happy and healthy. Counselling may have taught Anne valuable coping mechanisms and enabled her to work through her emotions. At the same time, extra school support may have given her increased self-assuredness and a heightened sense of control.
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All of this is to stress that these changes won’t happen on their own. They require action, which we as healthcare professionals, are particularly well-suited to give. We need to be better equipped to help the children we see to help themselves.

Recommended Reading

The original 1998 Adverse Childhood Experience Study – Felitti et al. (Study)

How Children Succeed – Paul Tough (Book)

How childhood trauma affects health across a lifetime – Dr Nadine Burke Harris (TED Talk)

Selected references

Berridge, D. (2017) ‘The Education of Children in Care: Agency and Resilience’, Children and Youth Services Review, 77, pp: 86-93. doi: https://doi.org/10.1016/j.childyouth.2017.04.004

Evans, G. et al. (2007) ‘Cumulative risk, maternal responsiveness, and allostatic load among young adolescents’, Development Psychology, 43(2), pp: 341-51. doi: https://doi.org/10.1037/0012-1649.43.2.341

Krockow, E., Riviere, E. and Frosch, C. (2019) ‘Improving Shared Health Decision Making for Children and Adolescents with Chronic Illness: A Narrative Literature Review’, Patient Education and Counselling, 102(4), pp: 623-30. doi: https://doi.org/10.1016/j.pec.2018.11.017

Neuenschwander, R. et al. (2012)‘How do Different Aspects of Self-Regulation Predict Successful Adaptation to School?’, Journal of Experimental Child Psychology, 113(3), pp: 353-71. doi:https://doi.org/10.1016/j.jecp.2012.07.004

Ogelman, H. and Önder, A. (2019) ‘Emotional Regulation Strategies of 5-6-year-old Children and their Levels of Resiliency’, Early Child Development and Care, 191(2), pp: 221-29. doi: https://doi.org/10.1080/03004430.2019.1613650

Partington, L., Mashash, M. and Hastings, P.D. (2022) ‘Family Thriving During COVID-19 and the Benefits for Children’s Well-Being’, Frontiers in Psychology, 13. doi: https://doi.org/10.3389/fpsyg.2022.879195