The Impact Of Adverse Childhood Events (ACEs)

Adverse Childhood Events

What Are Adverse Childhood Events (ACEs)?

Studies are increasingly identifying that our early life experiences are important when it comes to our health throughout life.

Individuals who have adverse childhood events tend to have more physical and mental health problems as adults than do those who do not have ACEs and ultimately greater premature mortality.

Adverse childhood events include: harms that affect children directly (e.g abuse and neglect) and indirectly through their living environments (eg, parental conflict, substance abuse, or mental illness).

What Are The 10 ACES’s?

The CDC-Kaiser study categorised ACE’s as follows:

  • Physical abuse
  • Emotional abuse
  • Sexual abuse
  • Physical neglect
  • Emotional neglect

And household dysfunction including:

  • Mental illness
  • Mother treated violently
  • Divorce
  • Incarcerated relative
  • Substance abuse

What Is My ACE Score?

Click here for a quick questionnaire you can complete.

What Health Problems Are Associated With Adverse Childhood Events?

The first major ACE 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 their risks of health-harming behaviours (eg, smoking or sexual risk taking) and both infectious and non-communicable diseases (NCDs).

Supported by international work to standardise measurement of ACEs and their effects on health, these findings have since been replicated in studies from low-income and middle-income, and high-income countries.

To have multiple adverse childhood events is a major risk factor for many health conditions. The outcomes most strongly associated with multiple adverse childhood events represent adverse childhood events risks for the next generation (eg, violence, mental illness, and substance use).

Research has found that individuals with at least four adverse childhood events were at increased risk of all outcomes examined. Associations were weak or modest for physical inactivity, overweight or obesity, and diabetes, moderate for smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease, strong for sexual risk taking, mental ill health, and problematic alcohol use, and strongest for problematic drug use and interpersonal and self-directed violence.

How Do ACEs Cause Poor Health?

Studies are increasingly establishing how childhood exposure to chronic stress leads to changes in development of nervous, endocrine, and immune systems, resulting in impaired cognitive, social, and emotional functioning and increased allostatic load (chronic wear and tear that we all accumulate over our lives).

Thus, individuals who have ACEs can be more susceptible to disease development through both differences in physiological development and adoption and persistence of health-damaging behaviours.

Research has also explored the role of epigenetics when it comes to explaining how adverse childhood events increase our likelihood of disease later in life.

Epigenetics refers to how our genes are being expressed. Let’s look at three studies that have explored epigenetics, and specifically methylation, and ACE outcomes.

In one study the researchers aimed to investigate the association between childhood adversity and BDNF promoter methylation in adults aged 65 years and over. (source). Brain-derived neurotropic factor (BDNF) is a neurotransmitter involved in learning and memory, and altered BDNF promoter methylation measured in peripheral tissue has been found with early-life stress. However, whether such methylation differences remain stable into later life, is unknown.

They concluded that the evidence does not support a long-term association between adverse childhood events and BDNF methylation in older age. A really important point however that the authors made was that further large prospective studies are needed, which do not target specific genes, but consider DNA methylation across the genome (source). After all, we have quite a few genes!

Another study looked at DNA methylation in the glucocorticoid receptor gene (NR3C1) and the oestrogen receptor gene (ERα). The glucocorticoid receptor gene  has been associated with both the type and strength of early life adversity with subsequent effects on adrenal gland functioning (glucocorticoids include cortisol).

Animal studies have demonstrated changes in DNA methylation in the oestrogen receptor gene (ERα) as a result of early life adversity. (source)

In this study the authors found that early life adversity does not seem to result in NR3C1 hyper-methylation in midlife and older age. However it is the first study in humans to suggest that childhood adversity might epigenetically modify the ERα gene. (source)

In the third and final study looking at methylation the authors examined the association of experiences of trauma with epigenome-wide DNA methylation among African American mothers and their children aged 3-5 years. They identified no DNA methylation sites significantly associated with potentially traumatic experience scores in mothers. However one site on the ENOX1 gene was methylome-wide-significant in children.This protein-coding gene is associated with mental illness, including unipolar depression, bipolar, and schizophrenia. (source)

It seems the jury is still out on methylation.

Protecting Our Children From Adverse Childhood Events

There is ample evidence supporting system-wide implementation of prevention and treatment even though research on mechanisms needs to and will continue to offer additional insights. (source)

The research discusses primary, secondary and tertiary prevention.

Primary Prevention

This can be towards the entire population by targeting factors such as poverty, income inequality, and low education. While this offers promise for reducing adverse childhood events exposure, it requires stable funding and political will. Am I cynical or do you not see this happening either? While these kinds of approaches are outside the daily activities of health professionals there is always lobbying for change.

Alternative primary prevention approaches include teaching resiliency skills that mitigate risk for adverse health outcomes in youth or by providing courses in sex education and drug awareness that can decrease youths’ engagement in risky behaviours.

Secondary prevention

Secondary preventing requires screening and identification of at risk groups. The concern with this, which is discussed in the research, is the fact that it unfortunately lead to discrimination or can benefit some population subgroups more than others.

A key focus of secondary prevention is the support and training of parents to minimise abuse and neglect.

Another approach to secondary prevention is to address long-term outcomes for children who develop behavior problems as a result of adverse childhood events.

Tertiary Prevention

Tertiary prevention is when individuals already affected by a disease (e.g. anxiety) are treated to restore health.

This could include everything from psychotherapy and/or psychopharmacological intervention, but also physical activity, nutrition along with all the things we talk about in this field – community, purpose, meaning, and healthy living.

Then there is other research that puts forward several protective factors, such as mother-child relations, parental health, community engagement, mindfulness practice, and recently (2020) a paper put forward the potential of regular nature engagement as a possible additional protective factor.

The 7C Model of Resilience can be helpful to consider here too:

Competence – Building their understanding of their skills.
Confidence – Helping kids grow a true belief in their own abilities.
Connection – Connecting children with other people, schools and communities to further build their support system.
Character – Helping them comprehend a clear sense of right and wrong, and teaching them moral values.
Contribution – Offering children a chance to contribute to the well-being of others. They learn that giving service feels good and then feel more confident to ask others for help as well.
Coping – Discovering a variety of healthy coping strategies to prevent children from dangerous “quick fixes” to stress.
Control – Teaching children to make decisions on their own so they can experience a sense of control.

Learn More About Resilience

You may like to check out the section of my blog dedicated to cultivating resilience here.


  1. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis: click here.
  2. Accumulation of adverse childhood events and overweight in children: A systematic review and meta-analysis: click here.
  3. The Role of Mindfulness in Reducing the Adverse Effects of Childhood Stress and Trauma: click here.
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