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The Learning Institute

The Learning Institute

Toxic Stress and Adverse Childhood Experiences (ACEs)

Since Felliti et al. (1998) drew attention to the link between adversity in childhood and poor health outcomes, there has been a growing recognition that we need to protect and support children, young people and adults who have experience of Adverse Childhood Experiences (ACEs).

Subsequent research and studies have been driving the move towards trauma informed practice when working with children, young people and adults.  However, putting ACEs into context and understanding that when trauma occurs, it can change the neurobiology of the brain is key to learning how to respond appropriately to children and young people.

This two hour continuing professional development activity aims to raise your awareness of the impact of toxic stress and ACEs.  You can undertake this training as an individual or in pairs/small groups. On completion, there will be opportunities for research and extended learning if this is your area of interest.  

ACEs – A Brief Overview 

Felliti discovered a link between the development of obesity and childhood sexual abuse in 1985 as part of his work in an obesity clinic in Kaiser Permanente’s Department of Preventive Medicine in San Diego.  Subsequent small scale studies led him to believe that there was a link between childhood adversity and health outcomes, so he began a collaborative research study with Anda, a researcher from the Centre for Disease Control and Prevention. In 1998, the ACE study, as it is now known asked 13,494 adult participants about their health history in addition to childhood experiences.  9,508 (70.5%) responded.

Seven categories of adverse childhood experiences were studied:

  • Psychological abuse
  • Physical abuse
  • Sexual abuse
  • Violence against mother
  • Living with household members who were substance abusers
  • Living with household members who were mentally ill or suicidal
  • Living with household members who were ever imprisoned.

The number of categories of these adverse childhood experiences was then compared to measures of adult risk behaviours, health status, and disease.  Although, there has always been anecdotal evidence to suggest a link between adversity in childhood and poorer outcomes in adulthood, the ACE study was one of the largest pieces of research into this. 

Over half of the respondents reported at least one ACE, and a quarter reported more than or equal to two categories of exposures to adversities in childhood. 

The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. 4 ACEs or more, significantly increased the risk of poor adult outcomes.

 

Study One – ACE Study

This study can be found in the American Journal of Preventative Medicine: 
Felitti, M. D., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A., M., Edwards, V., Koss, M., P. and Marks, J., S. (1998) 'Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study', American Journal of Preventative Medicine, 14 (4), pp. 245-258. https://doi.org/10.1016/S0749-3797(98)00017-8

There have been similar studies undertaken throughout the world, all of which in which show a correlation between the number of adversities and adult outcomes.

It is important to recognise that most of these studies have been carried out within western cultures and that critics suggest more studies need to be undertaken in non-western cultures.  However, research undertaken in Brazil by Soares et al. (2016) does suggest there is an inter-relational link between childhood adversity and poor adult health outcomes.

 

Study Two – ACE Study Critique

This study can be found in the Journal of Child Abuse and Neglect: 
Soares, A., Howe, L., Matijasevich, A., Wehrmeister, F., Menezes, A. and Gonçalves, H. (2016) 'Adverse childhood experiences: Prevalence and related factors in adolescents of a Brazilian birth cohort', Child Abuse and Neglect, 51 (January),  pp. 21-30. https://doi.org/10.1016/j.chiabu.2015.11.017

In the UK, Professor Mark Bellis and colleagues have been researching ACEs since 2013.  In 2014, he undertook some research with 2028 adults aged 18-69 years who lived in Wales.   They provided anonymous information on their exposure to ACEs before the age of 18 years and their health and lifestyles as adults.  The study achieved a compliance rate of 49.1% and the sample was designed to be representative of the general population in Wales.    Data was collected in participants’ places of residence using an established questionnaire incorporating the short ACE tool developed by the US Centre for Disease Control and Prevention and based on the work by Felitti et al (1998).

The findings from this, and a subsequent study undertaken in England corroborated the original ACE study.  Adversity in childhood leaves a mark.

Image showing ACEs

The UK studies have identified parental substance misuse, prison sentences of the caregiver(s), divorce and separation, childhood sexual abuse, neglect, physical abuse, emotional abuse, suicidal death and domestic abuse as ACEs.

The original study in 1998 by Felliti et al. put suicide and mental health of the caregivers under one umbrella.  There is now recognition that parental mental health is an independent ACE.

Neglect was also not included in the original ACE study.

A picture of a pencilThis list is not exhaustive.  Make notes and consider any other adversities that might impact on children and young people?

 

Did you consider?

  • Bullying (including cyberbullying)
  • Sudden and/or serious medical condition
  • Chaos or dysfunction in the house
  • Bereavement
  • Separation from a parent or caregiver (e.g. service personnel)
  • Stress caused by poverty
  • Accidents
  • Violence at home, school or the surrounding community
  • War/Terrorism
  • Constant moves within education or house

There is growing recognition that social inequalities alongside ACEs play a key role in outcomes for children and adults.  However, educational attainment is linked more to ACEs than income. 

A picture of a pencilWatch this video from the Welsh Public Health Network.  What are the key messages within this clip?

Video from: https://www.youtube.com/watch?v=YiMjTzCnbNQ

 

 

 

ACE Studies and their Findings 

The life course of ACEs

Pyramid showing the affect ACEs can have over a life course

 

 

 

 

 

 

 

 

 

 

 

 

 

Whilst Kelly-Irving and Delpiere (2019) point out that many ACE studies are retrospective and depend on adults recalling their experiences of adversity in childhood which may be unreliable, the studies have produced some compelling evidence that ACEs can…:

  • Underpin poor educational attainment, health-harming behaviours and anti-social and criminal behaviour in adolescence, and in later life the development of premature ill health and death.
  • People who experience ACEs as children are more likely to raise their own children in households where ACEs are more common. 
  • Cycles of childhood adversity can become intergenerational locking families into poor health and anti-social behaviour.  Recognition and prevention of childhood adversity is key to reducing the impact on children now and for future generations. Bellis et al. (2015)
  • A child with ACEs is more likely to develop a disrupted nervous system and disturbed hormal and immune development. This may lead to emotional and learning difficulties and they could go onto adopt health harming behaviours and engage in criminal activity. They are also more likely to develop a non communicable disease (one that isn’t passed from one person to another). So, for example, there is a higher risk of a child with ACES developing heart disease. There is also an increased risk of disability, social problems and low productivity.
  • Felitti et al (1998) suggests that the more ACEs suffered, the higher the risk is of dying prematurely.

 

Four or more ACEs

A person with four ACEs or more is...:

Adapted from Bellis et al. 2015
Picture of wine glass 4 x more likely to be a high risk drinker.
Picture of woman with a pram 6 x more likely to have had or caused a teenage pregnancy.
 Picture of a clenched fist 15 x more likely to have committed violence within the past 12 months.
Picture of a syringe 16 x more likely to have used crack cocaine or heroin.
Picture of handcuffs 20 x more likely to have been incarcerated.

Furthermore, findings from a survey conducted by Bellis et al. in 2015 of 7,414 young people between the ages of 18 to 29 suggests that 30% (2,224) had hit someone in the last 12 months, as opposed to 3% (222) with no ACEs.

 

A Note of Caution

Whilst some institutions are regularly screening for ACEs, Finkelhor (2018) cautions against screening for ACEs without evidenced based interventions.

This article can be found in the Journal of Child Abuse and Neglect: 
Finkelhor, D. (2018) 'Screening for adverse childhood experiences (ACEs): Cautions and suggestions', Child Abuse and Neglect, 85 (November), pp.174-179. https://doi.org/10.1016/j.chiabu.2017.07.016

 

Epigenetics and Intergenerational ACEs

Some research suggests that the trauma of ACEs may be passed on within the genetic code leading to intergenerational ACEs. 

Environmental factors can alter how our genes operate, particularly when we are young and some research suggests that this can be passed onto the next generation (Lehrner and Yehuda, 2018).

This is a complicated area of research, but it does suggest that life events can trigger biochemical messages that change the structure of the gene.  This can, in turn, be passed onto the next generation.

Additional reading on this topic can be found here:

Lehrner, A. and Yehuda, R., (2018) 'Cultural trauma and epigenetic inheritance', Cultural Development and Psychopathology, 30 (5), pp. 1763-1777. doi: 10.1017/S0954579418001153.

Van der Kolk, B. (2014) The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma. London: Penguin Random House.

Toxic Stress 

Image showing stress levels - positive, tolerable and toxic
Adapted from Centre on the Developing Child, Harvard University (2020)

Not all stress is bad.  The body needs a certain amount of stress response to function normally.  However, high levels of stress over long periods of time can lead to poor health outcomes for children and adults.

Toxic stress impacts the developing brain as the body is producing a range of physiological reactions to prepare for threat.

 

 

The Developing Brain

Image of brain MRI
Adapted from Childhood Domestic Violence Association (2020)

A Structural MRI Study of Human Brain Development from Birth to 2 Years undertaken by Knickmeyer et al. (2008), suggests that the brain is 80% of its adult volume by the age of 2.  If a brain is being subjected to stressful situations in development, it makes sense to suggest that it will be adversely affected.

 

More information on the study undertaken by Knickmeyer et al. can be found in the Journal of Neuroscience:
Knickmeyer, R. C.,  Gouttard, S., Kang, C., Evans, C., Wilber, K.,  Smith, K., Hamer,  R. M., Lin, W., Gerig, G., Gilmore, J. H. (2008). A Structural MRI Study of Human Brain Development from Birth to 2 Years, Journal of Neuroscience 28 (47) 1217612182; https://doi.org/10.1523/JNEUROSCI.3479-08.2008 

 

Image of pencilWatch this video from the Center on the Developing Child at Harvard University.  What are some of the key messages within the clip?

Video available at: https://www.youtube.com/watch?v=rVwFkcOZHJw

 

 

This short video clip reminds us how adversity can impact upon the developing brain.  When the body and brain is overloaded with stressful situations, the stress response system becomes maladapted. Children are more likely to establish a fixed allostatic load which can lead to anxiety, aggression and/or dissociation. 

 

Blue and white picture of head and brain

 

Adversity leaves a mark on children.  Research suggests that the developing mind and body is impacted by childhood adversity (Van der kolk 2014).

 

Van der Kolk (2014) began working with veterans of the Vietnam war in the late 1970’s and discovered a link between trauma suffered in war and post traumatic stress disorder.  He began to develop his ideas and research into the field of trauma and the relationship between the mind, brain and body both for children and adults.  His research suggests that trauma impacts the brain and it is stored as an experience that can affect the way we think, feel and behave which in turn can result in negative outcomes without positive interventions.  As more research is undertaken in this field, the link to trauma and toxic stress has become clearer.  Mcgarvey (2019) suggests that behaviours, life experiences and outcomes are profoundly impacted by the stress hormone cortisol.  This hormone floods through the body when we are in fight or flight mode, but becomes maladapted when individuals are exposed to long term adversities or there are not enough protective factors to negate its impact.

 

Additional reading on this topic can be found here:

McGarvey, D. (2017) Poverty Safari: Understanding the Anger of Britain's Underclass. Edinburgh: Luath Press.

Van der Kolk, B. (2014) The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma. London: Penguin Random House.

Polyvagal Theory

Watch this video of Dr. Stephen Porges discussing Polyvagal Theory.  What are some of the key messages within the clip?

Video available at: https://www.youtube.com/watch?v=ec3AUMDjtKQ

 

 

As Porges points out in the video, the response to stress is involuntary and can be triggered by a variety of situations. 

Children and young people may not understand what is triggering their behaviour, but according to Porges (2017) physical and neurological responses to stress are linked. Understanding this is crucial to enable us, as professionals, to build relationships with children.

It is therefore important we control our own anxieties and keep in mind our non-verbal cues. 

Allowing the child to feel safe by monitoring our environment but also our body language, facial expressions and tone to help children to feel relaxed, and at ease.

Health Warning – You may find the following sound clip distressing.

Picture of a pencilListen to this recording of a 999 Call.  Whilst listening, consider the toxic stress that this child might be subjected to.

 

The situation that unfolded within the sound clip was clearly distressing for this child.  It may be that other adults in his life never found out about this incident, as most research suggests that children do not disclose abuse (NSPCC 2013).  Children in these situations may never tell another adult, but present in school as distressed or with behaviour issues. However, Allnock and Miller (2013) suggest that over 80% of children do try to tell someone they are suffering abuse, but they are either not believed or the help they receive is inadequate.

Being vigilant and building relationships with children and young people so that they feel safe and secure is a key protective factor.

Zubin and Spring (1977) have suggested that our ‘stress/vulnerability threshold’ is fluid, is determined by situation, and by the presence of ‘adverse’ and ‘protective’ factors.

If so, then part of our job as professionals is to try to inhibit adversity and promote protective factors. 

The aim of this session has been to put ACEs and toxic stress into context.

If this has sparked your curiosity, we hope that you will continue your professional development and undertake further research with us. 

Post Session Task
 

Before the next session, please complete the post session task.

References and Additional Reading
 

Allnock, D. and Miller, P. (2013) No one noticed, no one heard: a study of disclosures of childhood abuse. Available at: https://learning.nspcc.org.uk/research-resources/2013/no-one-noticed-no-one-heard (Accessed: 5 January 2020)

American Academy of Pedeatrics (2020) The Resilience Project: We can stop toxic stress. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Clinical-Assessment-Tools.aspx (Accessed 5 January 2020)

Atkinson, M. (2013) "What we say we need": A report looking at the basic items, opportunities and aspirations that are important to children and young people. Available at: https://www.childrenscommissioner.gov.uk/publication/what-we-say-we-need/ (Accessed: 6 January 2020)

Bellis, M. A., Hughes, K., Leckenby, N., Perkins, C. and Lowey, H. (2014) 'National Household Survey of adverse childhood experiences and their relationship with resilience to health-harming behaviours in England', BMC Medicine. 12, 72. Available at: https://doi.org/10.1186/1741-7015-12-72 (Accessed 06 December 2019)

Bellis, M. A., Ashton, K., Hughes, K., Ford, K., Bishop, J., and Paranjothy, S. (2015) Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population. Available at: http://www.wales.nhs.uk/sitesplus/documents/888/ACE%20
Chronic%20Disease%20report%20%289%29%20%282%29.pdf
 (Accessed: 6 January 2020)

Burke, N. J., Hellman, J. L., Scott, B. J., Weems, C. F. and Carrion, V. C. (2011) 'The Impact of Adverse Childhood Experiences on an Urban Paediatric Population', Child Abuse and Neglect, 35 (6), pp. 408-413 Available at: https://doi.org/10.1016/j.chiabu.2011.02.006 (Accessed: 3 June 2020)

Center on the Developing Child at Harvard University (2020) Toxic Stress. Available at: https://developingchild.harvard.edu/science/key-concepts/toxic-stress/ (Accessed: 3 June 2020)

Center on the Developing Child at Harvard University (2011) Toxic Stress Derails Healthy Development. 30 September. Available at: https://www.youtube.com/watch?v=rVwFkcOZHJw (Accessed: 3 December 2019)

Childhood Domestic Violence Association (2020) Major Childhood Adversities Trigger Toxic Stress That Can Derail the Life of a Child; A Caring Adult Can Be the Antidot. Available at: https://cdv.org/2019/06/major-childhood-adversities-trigger-toxic-stress-that-can-derail-the-life-of-a-child-a-caring-adult-can-be-the-antidote/ (Accessed: 2 June 2020).

Felitti, M. D., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A., M., Edwards, V., Koss, M., P. and Marks, J., S., (1998) 'Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study', American Journal of Preventative Medicine, 14 (4), pp. 245-258.  Available at https://doi.org/10.1016/S0749-3797(98)00017-8 (Accessed: 14 June 2019)

Finkelhor, D. (2018) 'Screening for adverse childhood experiences (ACEs): Cautions and suggestions', Child Abuse and Neglect, 85 (November), pp. 174-179. Available at: https://doi.org/10.1016/j.chiabu.2017.07.016 (Accessed: 11 January 2020)

Haw, C., Hawton, K., Houston, K. and Townsend, E. (2001) 'Psychiatric and personality disorders in deliberate self-harm patients', British Journal of Psychiatry, 178, pp. 48–54. Available at: https://doi.org/10.1192/bjp.178.1.48 (Accessed: 11 January 2020)

Hughes, D., A Simple Guide for Raising Your Troubled Child Available at: https://beaconhouse.org.uk/inspiration/dan-hughes-24-ss/ (Accessed on 14.06.19)

Hughes, H., Ford, K., Davies, A., Homolova, A. and Bellis, M. (2018) Sources of resilience and their moderating relationships with harms from adverse childhood experiences. Available at: https://www.wales.nhs.uk/sitesplus/documents/888/ACE%20&%20Resilience%20Report%20(Eng_final2).pdf (Accessed: 1 June 2020) 

Kahneman, D. (2011) Thinking, Fast and Slow. New York: Farrar, Straus and Giroux.

Kelly-Irving, M. and Delpiere, C. (2019) 'A Critique of the Adverse Childhood Experiences Framework in Epidemiology and Public Health: Uses and Misuses' Social Policy & Society, 18 (3) pp. 445-456. Available at: https://doi.org/10.1017/S1474746419000101 (Accessed: 4 June 2020)

Knickmeyer, R., Gouttard, S., Kang, C., Evans, C., Wilber, K., Smith, K., Hamer, R., Lin, W., Gerig, G. and Gilmore, J. (2008) 'A Structural MRI Study of Human Brain Development from Birth to 2 Years', Journal of Neuroscience, 28 (47), pp. 12176-12182. Available at: https://doi.org/10.1523/JNEUROSCI.3479-08.2008 (Accessed: 16 January 2019)

Lehrner, A. and Yehuda, R., (2018) 'Cultural trauma and epigenetic inheritance', Cultural Development and Psychopathology, 30 (5), pp. 1763-1777. doi: 10.1017/S0954579418001153.

Lloyd, S. (2016) Improving Sensory Processing in Traumatised Children: Practical Ideas to Help your Child’s Movement, Coordination and Body Awareness. London: Jessica Kingsley.

Longfield, A. (2018) Children’s mental health briefing: A briefing by the Office of the Children’s Commissioner for England. Available at: https://www.childrenscommissioner.gov.uk/
publication/childrens-mental-health-briefing/
 (Accessed: 4 June 2020)

McGarvey, D. (2017) Poverty Safari: Understanding the Anger of Britain's Underclass. Edinburgh: Luath Press.

Ortega, R., Elipe, P., Mora-Merchan, J., Luisa Genta, M., Brighi, A., Guarini, A., Smith, P. K., Thompson, F. and Tippett, N. (2012) 'The Emotional Impact of Bullying and Cyberbullying on Victims: A European Cross‐National Study', Journal of Aggressive Behaviour, 38 (5), pp. 335-427. doi: 10.1002/ab.21440

Penna, S. (2019) The Disguise of Trauma. Available at: https://rockpool.life/wp-content/uploads/2019/10/The-Disguise-of-Trauma-1.pdf (Accessed 03.12.19).

Porges, S. W., (2017), The Pocket Guide to the Polyvagal Theory: The Transformative Power of Feeling Safe (Norton Series on Interpersonal Neurobiology), London: W.W. Norton and Company Limited.

PsychAlive (2018) Dr Stephen Porges: What is the Polyvagal Theory? 23 April. Available at: https://www.youtube.com/watch?v=ec3AUMDjtKQ (Accessed 3 December 2019)

Public Health Network Cymru (2017) Adverse Childhood Experiences (ACEs) Wales. 13 November. Available at: https://www.youtube.com/watch?v=YiMjTzCnbNQ (Accessed: 3 December 2019)

Soares, A., Howe, L., Matijasevich, A., Wehrmeister, F., Menezes, A. and Gonçalves, H. (2016) 'Adverse childhood experiences: Prevalence and related factors in adolescents of a Brazilian birth cohort', Child Abuse and Neglect, 51 (January),  pp. 21-30. https://doi.org/10.1016/j.chiabu.2015.11.017 (Accessed: 14 January 2020)

Spratt, T., McGavock, L. (2014) 'Prevalence of Adverse Childhood Experiences in a University Population', Journal of Abnormal Psychology, 86 (2), pp.103-126.

Van der Kolk, B. (2014) The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma. London: Penguin Random House.

Zubin, J. and Spring, B. (1977) 'Vulnerability: A new view of schizophrenia', Journal of Abnormal Psychology, 86 (2), pp.103-126.