What is an Adverse Childhood Experience?

An adverse childhood experience (ACE) is a potentially traumatic event that occurs in childhood (from birth to 17 years old) that can have a lasting, negative impact on a child’s health as they develop into adulthood. These experiences include physical, emotional, and sexual abuse, parental divorce, incarceration of a family member, exposure to an addicted or mentally ill family member, and exposure to domestic violence, as well as economic hardship[1]. Individuals tend to differ in the severity of their response to ACE, with factors such as the nature, frequency and seriousness of the traumatic event, prior history of trauma, and available family and community supports all affecting the response[2].

How do Adverse Childhood Experiences affect people?

Effects of ACEs include disruption of early brain development and nervous and immune system functioning. Adopted behaviours as a result of adverse childhood experiences can lead to behavioural and health issues such as alcoholism and other substance use disorders, depression, eating disorders, unsafe sex, heart disease, obesity, and other chronic illnesses[3].

In order to determine whether or not a person has been affected by an ACE, practitioners administer an ACE questionnaire based on a 1985 study of adverse childhood experiences led by Dr.Vincent J. Felitti, who noticed a high dropout rate in his obesity clinic in California despite the fact his patients were successfully losing weight. After reviewing his patients’ backgrounds he observed that many of those he was treating had a history of adverse childhood experiences such as physical and sexual abuse[4]. Felitti questioned if obesity was, for some people, a result of a coping mechanism in dealing with adverse childhood experiences. It was found that obesity was in fact a common attempt at protecting oneself from further abuse and that patients in Felitti’s clinic had dropped out as a result of anxiety surrounding their weight loss.

Benjamin Fry, psychotherapist, author, founder of Khiron Clinics and past iCAAD London speaker, suggests in his book The Invisible Lion that when we experience a threatening situation, in this case childhood physical or sexual abuse, our nervous systems respond by fight or flight, or freeze[5]. When the nervous system freezes, the energy from the response gets stored in the body until it is discharged. Discharge is not possible until the initial cause of the response has been addressed and dealt with. Consciously or unconsciously, the nervous system seeks to return to the initial event. If obesity is a coping mechanism against further incidences of abuse, then weight loss may hint to the nervous system that the coping mechanism is no longer valid and it will return to square one, dealing with the threat. This would explain the resurgence of anxiety in patients who managed to successfully lose weight.

Felitti’s study led to the development of the ACE study, a large study in the US by the Center for Disease Prevention and Control (CDC) and US care consortium Kaiser Permanente, in which 17,000 individuals were assessed by physical examination and the ACE questionnaire to identify the effects of their traumatic childhood experiences on their physical and mental well being in adult life. The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations into cases of child abuse and neglect as well as household challenges and later-life health and well-being[6].

The ACE Questionnaire is comprised of ten sections that address family dysfunction; physical, sexual and emotional abuse and neglect by parents or caregivers; peer violence; witnessing community violence, and exposure to collective violence[7]. The questionnaire assists researchers and healthcare professionals in identifying cases of abuse and neglect in childhood, as well as exposure to family dysfunction such as substance use issues, violence, and incarceration.

The following are some sample questions from the questionnaire[8]:

  • Did a parent or other adult in the household often push, grab, slap, or throw something at you?
  • Was a household member depressed or mentally ill or did a household member attempt suicide?
  • Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?

Findings from the study showed that of the 17,000 participants, 40% had been exposed to two or more of the different categories of question, and 12.5% reported exposure to at least four[9], indicating that incidence of adverse childhood experiences was much more common than previously understood.

A high score in the questionnaire, one of six or more out of ten, highlights the effect of ACEs on mortality rate, as an individual with this score may have a reduced life expectancy of up to 20 years[10].

The use of this questionnaire can help professionals assess the health risks of affected individuals, and help individuals themselves in becoming more aware of potential health issues. It can be applied in clinical settings to help clinicians in investigating the root cause of trauma in patients experiencing drug and alcohol problems, mental health conditions, chronic health conditions, and domestic violence.

ACE Prevention

According to Felitti, the impact of a successful approach in preventing adverse childhood experiences ‘might be as great as that of a major vaccine[11].’ The CDC proposes a number of preventative measures to reduce the frequency of ACEs. These include strengthening economic supports for vulnerable families, promoting social norms that serve to protect against adversity and violence via the use of public education campaigns, ensuring a strong start for children by home visitation and high quality child care, teaching skills like social-emotional learning and how to have healthy relationships, mentoring and after school programs to connect young people to caring adults, and intervention where necessary to address and lessen immediate and long term harms[12].