Understanding ACEs


Adverse Childhood Experiences refer to potentially traumatic events experienced in childhood. Also known as ACE’s, these experiences may be responsible for a broad range of health complications in adulthood.

Trauma manifests itself in the body as toxic stress.[1] The body can handle stress for short periods but not for prolonged periods. When a person has experienced trauma, abnormally large amounts of stress chemicals are released into the body.

As per the nature of trauma, defined by SAMHSA as anything that overwhelms a person and continues to disrupt their life after the event[2], these stress chemicals eventually take a significant toll on the health of both the body and the mind.

All of the following are considered adverse childhood experiences:

  • Physical, emotional, or sexual abuse (single incident or repeated)
  • Bullying by another child or sibling
  • Homelessness
  • Exposure to domestic violence
  • Exposure to mental illness in the home
  • Exposure to substance misuse in the home
  • Neglect
  • Parental divorce
  • Incarceration of a family member
  • Discrimination (racism/sexism/ableism)
  • Exposure to violence in the community

Trauma elicits a threat response in all mammals, including humans. While mammals will respond to threat with fight/flight or freeze[3], as humans, we tend more to dissociate.[4]

Our ‘thinking mind’ goes offline, and survival becomes a priority. This serves the initial purpose of helping us to survive, but the thinking mind needs to come back online if we are to be healthy and functional. When a child has been traumatised, they get stuck in their threat response.

As a result, the child will be on constant lookout for more threat. This continues into adulthood and can have a negative impact on our:

  • Intra and interpersonal relationships
  • Physical health
  • Mental health
  • Behavioural health

Childhood trauma can hinder our ability to trust and relate to others openly. The threat we experienced in childhood has not been resolved, so we are still reacting to it. Triggers, such as people, places, smells, and traumatic memories, can hit us at any time and send us back into a trauma response. We might find ourselves lashing out at others, shutting down emotionally, or experiencing significant distress for no apparent reason.


What Is the ACE Study?

The term ‘adverse childhood experiences’ originated in 1995 in the groundbreaking CDC-Kaiser Permanente ACE Questionnaire.[5] Researchers in California, USA, conducted the study by surveying approximately 17,000 individuals. The questionnaire asked participants a series of ten questions about their early childhood experiences. The questions centred around various forms of adversity in the home, such as emotional abuse, physical or sexual abuse, neglect or abandonment, and household dysfunction.

The data collected from the study revealed two key findings, all of which would go on to inform our understanding of childhood trauma and how it relates to our overall health and well-being.

The study found that:

  • More than 2 in 3 people have experienced at least one ACE, and almost 1 in 4 people have experienced three or more ACEs.
  • There is a strong correlation between the number of ACEs experienced and poor health outcomes later in life, including diabetes, heart disease, depression, and substance abuse.


The Impact of Adverse Childhood Experiences

Adverse childhood experiences jeopardise a child’s neurodevelopment.[6] As such, they face emotional, social, and cognitive impairment. This can lead to the adoption of health-risk behaviours, such as substance misuse, self-harm, disordered eating, and violence. These health-risk behaviours have a negative impact on one’s life potential. They also increase one’s risk of disease, disability, and social problems. Ultimately, ACEs can lead to early death.[7]

Unresolved trauma manifests in adulthood in a myriad of ways. One of the most damaging ways in which it manifests is through substance misuse, a significant health-risk behaviour. The emotions, thoughts, and memories associated with one’s trauma can be distressing. They can cause feelings in the body and thoughts that a person cannot accept or integrate into their lives. As such, the person may turn to substances to cope. Among those who struggle with substance abuse, a significant majority have self-reported childhood trauma.[8]

Substance abuse and trauma are closely linked. Once a person begins to use substances to cope with their distressing, traumatic memories, they are at high risk of developing dependence and later addiction to the substance. Addiction itself is traumatic. When addiction and unresolved trauma co-occur, they exacerbate each other and complicate treatment.[9]


ACEs and Toxic Stress

The term ‘toxic stress’ refers to the impact of prolonged stress on a child’s neural development, as well as the development of their immune and cardiovascular systems.[10] Suppose a child experiences multiple ACEs over time. In that case, the body experiences an excessive stress response that wears away at their physical and mental health.

A simple metaphor for understanding toxic stress is to liken it to revving an engine for days or weeks at a time. The engine is designed to work for short periods. Excessive revving, or, in terms of the body’s stress response system, ‘activation’, jeopardises the engine’s health and functionality.

Toxic stress can impact a child in any of the following ways:

  • Reduced stress tolerance
  • Difficulty making and maintaining friendships
  • Increased release of stress hormones, which weakens the immune system
  • Poor learning and memory
  • Health complications
  • Reduced ability to engage in school and home responsibilities

Children who have multiple ACEs face an increased risk of the following as they grow into adolescence and adulthood.

  • Adolescent pregnancy
  • Substance abuse (Illicit drugs, prescription medication, alcohol)
  • Depression
  • Heart disease
  • Obesity
  • Domestic violence/intimate partner violence
  • Liver disease
  • Sexually transmitted disease/infection (STD/STI)
  • Smoking
  • Self-harm
  • Suicide


How to Lessen the Impact of ACEs

The most effective method of lessening the impact of ACEs is to take preventative measures against them. Prevention is the most effective cure. The Centers for Disease Control and Prevention (CDC), who had been partners in the original 1995 ACE study, have created a valuable resource that outlines how we can effectively tackle the issue of ACE prevalence. The resource, entitled Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence, explores how we can reduce the prevalence of impact of ACEs.

According to the CDC, we can reduce ACE prevalence by[11]:

  • Improving accessibility to economic support for families
  • Public education and awareness about ACEs and their impact
  • Promoting norms against violence
  • Providing high-quality childcare
  • Teaching valuable life skills – healthy relationships, social-emotional learning, parenting skills and family approaches
  • Mentoring and after-school programs
  • Psychological intervention – treatment, behavioural health interventions, family-based treatment for substance use disorder (SUD)


Treatment for ACEs

Targeted, trauma-informed care and treatment can help to mitigate the effects of ACEs on individuals.[12] Trauma-informed care is not a specific treatment but rather an approach to treatment. Healthcare providers are sensitive to and knowledgeable of the impact of trauma and clients’ sensitivity to triggers. Trauma-informed care considers a client’s trauma history. It aims to provide high-quality, appropriate care without re-traumatising the client in the process.

Trauma-informed approaches to treatment that can benefit those suffering the impact of multiple ACEs include:

  • Trauma-focused Cognitive Behavioural Therapy (TF-CBT)
  • Eye Movement Desensitisation and Reprocessing (EMDR)
  • Somatic Experiencing (SE)
  • Family-based SUD treatment
  • Sensorimotor Psychotherapy
  • Experiential therapies (art, yoga, dance, meditation)

Experiential therapies such as yoga, mediation, dance/movement, drama therapy, and arts-based therapies are all used effectively in trauma treatment and help clients overcome their trauma symptoms.

Trauma, especially trauma that occurred in childhood, is a complex condition to treat. Fortunately, tremendous advances have been made in the area of trauma treatment in recent decades. The field has moved away from a strictly psychotherapeutic, narrative approach to trauma and toward a holistic approach., where all aspects of a client’s life are considered in treatment.

 If you have a client, or know of someone who is struggling to heal from psychological trauma, reach out to us at Khiron Clinics. We believe that we can improve therapeutic outcomes and avoid misdiagnosis by providing an effective residential program and out-patient therapies addressing underlying psychological trauma. Allow us to help you find the path to realistic, long-lasting recovery. For information, call us today. UK: 020 3811 2575 (24 hours). USA: (866) 801 6184 (24 hours).


[1] Yaribeygi, Habib et al. “The impact of stress on body function: A review.” EXCLI journal vol. 16 1057-1072. 21 Jul. 2017, doi:10.17179/excli2017-480

[2] Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

[3] Roelofs, Karin. “Freeze for action: neurobiological mechanisms in animal and human freezing.” Philosophical transactions of the Royal Society of London. Series B, Biological sciences vol. 372,1718 (2017): 20160206. doi:10.1098/rstb.2016.0206

[4] Schmidt, Norman B et al. “Exploring human freeze responses to a threat stressor.” Journal of behavior therapy and experimental psychiatry vol. 39,3 (2008): 292-304. doi:10.1016/j.jbtep.2007.08.002

[5] Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M. and Marks, J., 1998. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine, 14(4), pp.245-258.

[6] McLaughlin, Katie A et al. “Childhood adversity and neural development: deprivation and threat as distinct dimensions of early experience.” Neuroscience and biobehavioral reviews vol. 47 (2014): 578-91. doi:10.1016/j.neubiorev.2014.10.012

[7] Centers for Disease Control and Prevention (2019). Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

[8] Khoury, L., Tang, Y., Bradley, B., Cubells, J. and Ressler, K., 2010. Substance use, childhood traumatic experience, and Posttraumatic Stress Disorder in an urban civilian population. Depression and Anxiety, 27(12), pp.1077-1086.

[9] McCauley, Jenna L et al. “Posttraumatic Stress Disorder and Co-Occurring Substance Use Disorders: Advances in Assessment and Treatment.” Clinical psychology : a publication of the Division of Clinical Psychology of the American Psychological Association vol. 19,3 (2012): 10.1111/cpsp.12006. doi:10.1111/cpsp.12006

[10] Franke, Hillary A. “Toxic Stress: Effects, Prevention and Treatment.” Children (Basel, Switzerland) vol. 1,3 390-402. 3 Nov. 2014, doi:10.3390/children1030390

[11] Centers for Disease Control and Prevention (2019). Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

[12] Menschner, C. and Maul, A., 2016. Key Ingredients for Successful Trauma-Informed Care Implementation. [ebook] Center for Health Care Strategies. Available at: <https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf> [Accessed 24 March 2021].