Published: July, 2018

Adverse Childhood Experiences

We now understand that exposure to stressful or traumatic experiences may increase the amount of stress hormones that a child's body makes and this can increase their risk for health and developmental poblems.

The first major ACE (Adverse Childhood Experience) study examined relations between the number of ACEs reported by more than 17,000 individuals in the USA and their health as adults. It found that the more ACE types that individuals reported, the greater the risks of their health-harming behaviours (eg smoking, sexual risk taking) and both infectious and non- communicable disease. Felitti VJ, Anda RF, Nordenberg D, et al. relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults.Am J Previous Med 1998; 14:245-58 Almost two thirds of participants reported having at least one ACE and 12% reported having four or more. A dose- response relationship was revealed between the number of ACEs experienced by an individual and negative health outcomes, such that with increasing numbers of ACEs the odds or reporting an illness or health risk also increased.

Specifically persons with an ACE score of 4 or more carried a 1.6x greater odds of reporting diabetes in adulthood compared with adults with a score of zero., 1.6 x likelihood of severe obesity and 2.2 x likelihood of Ischaemic Heart Disease.

Toxic stress occurs with strong, frequent or prolonged adversity. It is characterisd by disruption of brain architecture and other organ systems. Toxic stress can be buffered by the child having a relationship with a responsive (empathic /emotion coaching relationship style) adult. Toxic stress is associated with poor impulse control and difficulty with emotion regulation.

Children experiencing ACEs of 4 or more carry a higher risk of developing diabetes/ Ischaemic Heart Disease/ severe obesity AND they are likely to have difficuty planning and managing their lives.

The theory put forward by Center on the Developing Child, Harvard University and The Youth Wellness Center in San Francisco is that some of the effects of toxic stress can be buffered by responsive relationships and the earlier in childhood that the exposure to the toxic stress is reduced and buffering begins, the better the outcomes.

This seminal study has since been replicated and expanded upon globally and in August 2017 The Lancet published a paper funded by Public Health Wales and produced by The College of Health and Behavioural Sciences, Bangor University, Wales (Professor K Hughes , Professor M A Bellis eg al). In this international systematic review and meta analysis risk estimates for individuals (age 18 or more) with at least four ACEs were compared with those with none. 

The conclusion drawn by the Welsh team is that having four or more ACEs is a major risk factor for many helath conditions. The outcomes most strongly associated with multiple ACEs in their study represent ACE risks for the next generation (eg violence, mental illness and substance use). 

A comment about the paper by Stuart A Kinner and Rohan Borschmann of Melbourne University, Australia  again in the The Lancet summarises the research as showing that exposure to at least four ACEs was associated with increased odds of poor mental, physical and sexual health; harmful substance use ; violence ( perpetration and victimisation); and physical inactivity. The association between multiple ACE exposures and subsequent suicide attempts gave an odds ration of 30:14 but the association between ACE exposure and self harm was not assessed. In addition the study showed a consistent association between exposure to at least four ACEs and poor health outcomes irrespective of the particular combination of ACEs pointing toward a causal pathway defined by cumulative exposure to stress, trauma and adversity rather than the specific effects of exposure to particular individual adversities. 

The dose dependent relationship between ACE exposure and poor health outcomes is not as clear in the Welsh meta analysis as in the original work by Felitti and Anda.  This reflects how the data was colllected - specifically the heterogeneity in construction of the exposure variable In the Welsh study.

The two articles in the Lancet are attached to this page as is a small Welsh study which pre dated the meta analysis. 

EHCAP is applying the learning from these studies and from institutions such as Center on Child Development, Harvard and The Youth Wellness Centre in San Francisco within Youth Wellness Pods . We are attempting to identify what works or doesn’t work for particular subgroups and to enable collisions of expertise by collaborating across differing groups and services. 

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