Adverse childhood experiences (ACEs represent the challenging and often traumatic events that shape the lives of children before they reach the age of 18 years (Bryant & VanGraafeiland, 2020; Gilgoff et al., 2019; Purewal et al., 2016). Overwhelming evidence shows the potentially damaging impact of ACEs on development, future health, well-being and social outcomes (Leitch, 2017). ACEs can be divided into four main categories: (a) child abuse (emotional/ physical/ sexual abuse); (b) child neglect (emotional/ physical neglect); (c) household dysfunction (witnessing domestic violence, caregiver with mental or serious physical illness, caregiver with substance abuse problems, incarcerated caregiver, loss of a caregiver, separation/divorce, unemployed caregiver; hardship); and (d) community stressors (foster care, bullying, unsafe neighbourhood, racism) (Bryant & VanGraafeiland, 2020; Gilgoff et al., 2019; Larkin et al., 2012).
Childhood exposure to ACEs is a global problem with far-reaching impacts on short-term and long-term health and well-being as well as development (Jewkes et al., 2010; Larkin et al., 20212). ACE exposure is widespread with ninety percent of all children, irrespective of race, economic background or location, exposed to at least one ACE (Bryant & VanGraafeiland, 2020; Gilgoff et al., 2019; Purewal et al., 2016). Although the impact of trauma and adversity is wide-ranging and enduring, it is often not recognised or addressed (Gregorowski & Seedat, 2013). Due to the enormous costs associated with ACE exposure, identifying and addressing ACEs have become highly pertinent issues (Bryant & VanGraafeiland, 2020; Larkin et al., 2012). Early ACE detection to mitigate the impact of previous ACE exposures together with preventing or minimising future adversity can help foster positive long-term development, health and well-being (Oh et al., 2018). It can also help offset the enormous ACE-mediated social and healthcare costs (Cameron et al., 2018).
Although there is a dearth of research specifically focused on ACEs in South Africa, substantial evidence exists to support the notion that most South Africans are exposed to disproportionately high levels of multiple ACEs that significantly impact their development, health and well-being (Anda et al., 2010; Eagle, 2015; Jewkes et al., 2010; Manyema & Richter, 2019; Williams et al., 2007). These impacts are further confounded by a lack of safety nets, and interventions to manage and offset these impacts, alongside pervasive social inequalities (Eagle, 2015; Srivastav et al., 2020). Jewkes and colleagues (2010) found that South Africans experience high levels of physical abuse (92%), emotional abuse (56%), emotional neglect (41%) and sexual abuse (28%) before the age of 18. A clear association between HIV infection rates and ACEs as well as mental illness (depression, suicidality) and substance and alcohol abuse have been demonstrated in the South African population (Jewkes et al., 2010).
ACEs are precursors or common pathways to developmental delays, poor mental and physical health, social problems, and reduced scholastic and career achievement (Anda et al., 2010; Bryant & VanGraafeiland, 2020; Larkin et al., 2012; Negriff, 2020). ACEs are interrelated and often co-occur (Larkin et al., 2012). They have a cumulative or dose-dependent effect on human development, health, and well-being; in other words, the more ACEs a person experiences, the greater the impact on their health and well-being (Larkin et al., 2012; Purewal et al., 2016). Exposure to ACEs during sensitive developmental periods in childhood and adolescence is particularly harmful due to increased vulnerability and a higher likelihood of lasting impacts during these stages (Gilgoff et al., 2020). This highlights the importance of early detection and intervention, as well as identifying the best windows of opportunities for interventions to be maximally effective (Dorn et al., 2019; Gilgoff et al., 2020; Wekerle et al., 2007).
The impairments associated with ACEs can result in unhealthy ways of relating to others, a proclivity for risk-taking behaviours and the adoption of poor health behaviours (smoking, alcohol/substance abuse, poor sleeping habits, obesity, risky sexual behaviour, low consumption of fruit/vegetables), and poor decision-making (criminal/violent behaviour, learning difficulties, bullying, delinquency) (Anda et al., 2010; Crandall et al., 2019; Liu et al., 2021; Nebraska Department of Health and Human Services, n.d; Wekerle et al., 2007). ACEs thus increase the risk for poor general health, mental illness (autism, ADHD, depression, PTSD, anxiety, suicidality, ODD), common chronic diseases (heart disease, stroke, diabetes, lung diseases like asthma and COPD, arthritis, headaches), and autoimmune diseases (Crandall et al., 2019; Nebraska Department of Health and Human Services, n.d.; Purewal et al., 2016). In addition, ACEs contribute to poor quality of life, premature death, and poor life outcomes such as incarceration, poor scholastic attainment, low productivity and unemployment.
Persistent ACEs are accompanied by chronic activation of the hypothalamic-pituitary-adrenal axis leading to a dysregulated stress response called the toxic stress response (Harris, 2020). This leads to sub-optimal social, cognitive and emotional development making individuals more vulnerable to psychological problems, behavioural difficulties, a poor ability to relate to others, poor coping mechanisms and a negative core identity (Cameron et al., 2018; Gregorowski & Seedat, 2013; Lubit et al., 2003). ACE exposure also impairs the development of the ability to regulate, together with the ability to identify and express emotions in appropriate ways (Gregorowski & Seedat, 2013; Lubit et al., 2003). Emotional dysregulation is characterised by intense or inappropriate emotional responses to situations and has been identified as an important factor in the development of psychological problems (American Psychological Association, n.d.-a; Gregorowski & Seedat, 2013).
Protective factors or counter-ACEs exist that act as a buffer against the potential negative effects of ACEs and include strong parent-child relationships, social support, supportive communities, and resilience (Bryant & VanGraafeiland, 2020; Crandall et al., 2019; Gilgoff et al., 2019). Marginalised and vulnerable communities often lack these protective buffers and other resources to offset the effects of ACEs (Larkin et al., 2012). Repeated ACE exposure in the absence of protective buffers leads to toxic stress that changes brain structure and functioning at a neurobiological level with impacts on brain development, learning, and mental and physical health (Anda et al., 2010; Bryant & VanGraafeiland, 2020; Larkin et al., 2012). According to many authors like Crandall and colleagues (2019), the most important lesson is that although decreasing ACE exposure might be important in improving community health and well-being, increasing protective factors in communities- especially communities with high levels of childhood adversity- may be even more critical. In this way, health problems as a result of childhood adversity will be reduced whilst well-being will be increased simultaneously (Crandall et al., 2019).
Addressing ACEs
Optimally addressing ACEs should ideally entail a comprehensive approach that would include ACE screening, psychoeducation, lifestyle education (healthy diet, exercise, alcohol/substance use), relaxation techniques, mindfulness and resilience training, coping skills, relational skills, and cognitive behavioural therapy techniques (Cameron et al., 2018; Harris, 2020; Lubit et al., 2003). Targeting the impaired emotion regulation capacity and coping mechanisms of individuals has been shown to diminish the long-term consequences of ACEs along with alleviating the current influence of ACEs and stressors (Cameron et al., 2018).
Targeting the impaired emotion regulation capacity and coping mechanisms of individuals has been shown to diminish the long-term consequences of ACEs along with alleviating the current influence of ACEs and stressors (Cameron et al., 2018). Emotion regulation, resilience and coping skills can be learned and improved whereas most ACEs are not easily malleable (Cameron et al., 2018). Interventions that provide psycho-educational and skills training activities can improve emotional functioning and resilience and ultimately result in improved long-term physical health and well-being (Cameron et al., 2018).
Resilience is not just the ability to withstand difficulties but also the ability to flourish in good times and in various different situations and settings (Anda, 2024; Crandall et al., 2019). Resilience is proven to buffer against the effects of ACEs (Anda, 2024). Although some people are innately more resilient than others, resilience can be fostered through “positive experiences, supportive environments and the caring intervention of others” (Anda, 2024). Resilience is thus dynamic and ever-changing (Crandall et al., 2024). Strong attachment relationships and healthy, supportive family environments have also been shown to have a significant influence on helping individuals overcome the potential impact of ACEs (Scully et al., 2019). According to the Center on the Developing Child at Harvard University (n.d.), “fostering strong, responsive relationships between children and caregivers, and helping adults and children build core life skills, can help to buffer a child from the effects of toxic stress”.
Even from a neuroscience perspective, there are clear brain scans that show how neglect or abuse impact brain development. There is a famous story about the Nicolae Cesseascue, who ruled Romania between 1965 to 1989.
He wanted to increase the population in order to increase financial status of the country by banning birth control and other forms of contraception. He also rewarded those women financially who had more than 4 children. So what happened? The children we given up for adoption into state facilities and the facilities, where they used to have a care ratio of 3:1 was not 20:1.
Children at age of 4 sitting with bottles propped up on the back of the cots as there was no time for transitioning onto solids (which fosters Sensory integration) with more nutritional consumptions. Looking out of a window and not being able to play and run around, laugh and explore.
We can also understand that the requirements placed on the caregivers reaches burdensome levels and places Chronic stress on them which could possibly also fall onto the children in various ways, constant crying, lack of attention, connection, support and love.
With a lack of parental/carer interaction, there is a lack of neural network development. The vital links across the network of the brain are not developed
With high stress, high levels of cortisol are generated that can cause brain cells to die and reduce the connections between the cells in certain areas of the brain, harming the vital brain circuits.
The result—an anxious, violent, impulsive, emotionally unattached child.
It should be noted that past and present traumas have the same emotional and cerebral effects; although the latter are not produced in the amygdala, the center of emotional control, as would be expected, but in the Anterior Cingulate Cortex
Responsible for regulating decision making, empathy and emotions. So here we have the inability to be compassionate towards themselves and others; says Candice Lambert, Neuroscience counsellor at Wellness Dialogue Group.
Universal, cost-effective interventions are especially important for countries like South Africa with a lack of resources (Gregorowski & Seedat, 2013). Schools are ideally positioned as the locale for this type of intervention (Mendelson et al., 2020). Teachers are also suitable candidates and can be trained to provide basic interventions that can make a significant impact on the effect ACEs have on their learner cohorts (Ford & Russo, 2006). Teachers can forge long-term and trusting relationships with both their students and their students’ parents (Harris et al., 2017; Oh et al., 2018). Additionally, positive teacher-student relationships can act as a buffer against the effects of trauma and contribute to the resilience of their students (Nadat & Jacobs, 2021). Teachers are also good at detecting signs of trauma in their students because they can observe their daily activities and interactions over time (Lubit et al., 2003). Furthermore, teachers often become powerful role models to their students and can model self-regulation and other useful skills, often in subtle ways (Ford & Russo, 2006). Utilising school resources for prevention and intervention programmes can help integrate these interventions into everyday teaching practices (Mendelson et al., 2020).
In Conclusion
Adverse Childhood Experiences (ACEs) have far-reaching impacts on long-term human development, health, and well-being (Harris, 2020). This understanding should guide our actions (Finkelhor, 2018). ACE screening and interventions are essential investments in improving community health and well-being (Purewal et al., 2016). Furthermore, focusing on fostering protective factors against ACEs offers a practical way to mitigate their extensive impact on health, well-being, and development (Crandall, 2019). By addressing childhood adversity, we can change the long-term trajectory of individuals, communities, and countries mired in the negative consequences of ACEs (Gilgoff et al., 2020). In the words of Robert Anda, ACEs do NOT need to be destiny and do NOT need to dictate the life stories of those who have experienced early adversity and trauma (Anda, 2024).
References
Anda, R. F., Butchart, A., Felitti, V. J., & Brown, D. W. (2010). Building a framework for global surveillance of the public health implications of adverse childhood experiences. American journal of preventive medicine, 39(1), 93-98. https://doi.org/10.1016/j.amepre.2010.03.015
Anda, R. (2024). What’s Cooking Here and Why. Community Resilience Cookbook. Retrieved November 6, 2024, from https://communityresiliencecookbook.org/whats-cooking-here-and-why/
Bryant, C., & VanGraafeiland, B. (2020). Screening for adverse childhood experiences in primary care: a quality improvement project. Journal of Pediatric Health Care, 34(2), 122-127. https://doi.org/10.1016/j.pedhc.2019.09.001
Cameron, L. D., Carroll, P., & Hamilton, W. K. (2018). Evaluation of an intervention promoting emotion regulation skills for adults with persisting distress due to adverse childhood experiences. Child Abuse & Neglect, 79, 423-433. https://doi.org/10.1016/j.chiabu.2018.03.002
Crandall, A., Miller, J. R., Cheung, A., Novilla, L. K., Glade, R., Novilla, M. L. B., … & Hanson, C. L. (2019). ACEs and counter-ACEs: How positive and negative childhood experiences influence adult health. Child Abuse & Neglect, 96, 104089. https://doi.org/10.1016/j.chiabu.2019.104089
Dorn, L. D., Hostinar, C. E., Susman, E. J., & Pervanidou, P. (2019). Conceptualizing puberty as a window of opportunity for impacting health and well‐being across the life span. Journal of Research on Adolescence, 29(1), 155-176. https://doi.org/10.1111/jora.12431
Eagle, G. (2015). Crime, fear and continuous traumatic stress in South Africa: What place social cohesion?. Psychology in Society, (49), 83-98. http://dx.doi.org/10.17159/2309-8708/2015/n49a7
Finkelhor, D. (2018). Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child abuse & neglect, 85, 174-179. https://doi.org/10.1016/j.chiabu.2017.07.016
Ford, J. D., & Russo, E. (2006). Trauma-focused, present-centered, emotional self-regulation approach to integrated treatment for posttraumatic stress and addiction: Trauma adaptive recovery group education and therapy (TARGET). American journal of psychotherapy, 60(4), 335-355. https://doi.org/10.1016/j.chiabu.2018.03.002
Gilgoff, R., Singh, L., Koita, K., Gentile, B., & Marques, S. S. (2020). Adverse childhood experiences, outcomes, and interventions. Pediatric Clinics, 67(2), 259-273. https://doi.org/10.1016/j.pcl.2019.12.001
Gregorowski, C., & Seedat, S. (2013). Addressing childhood trauma in a developmental context. Journal of Child & Adolescent Mental Health, 25(2), 105-118. https://doi.org/10.2989/17280583.2013.795154
Harris, N. B. (2020). Screening for adverse childhood experiences. JAMA, 324(17), 1788-1789. https://doi.org/10.1001/jama.2020.16452
Harvard University (n.d.). ACEs and Toxic Stress: Frequently Asked Questions. Center on the Developing Child. Retrieved November 6, 2024, from https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/
Jewkes, R. K., Dunkle, K., Nduna, M., Jama, P. N., & Puren, A. (2010). Associations between childhood adversity and depression, substance abuse and HIV and HSV2 incident infections in rural South African youth. Child abuse & neglect, 34(11), 833-841. https://doi.org/10.1016/j.chiabu.2010.05.002
Larkin, H., Shields, J. J., & Anda, R. F. (2012). The health and social consequences of adverse childhood experiences (ACE) across the lifespan: An introduction to prevention and intervention in the community. Journal of Prevention & Intervention in the Community, 40(4), 263-270. https://doi.org/10.1080/10852352.2012.707439
Leitch, L. (2017). Action steps using ACEs and trauma-informed care: a resilience model. Health & justice, 5(1), 1-10. https://doi.org/10.1186/s40352-017-0050-5
Lubit, R., Rovine, D., Defrancisci, L., & Eth, S. (2003). Impact of trauma on children. Journal of Psychiatric Practice®, 9(2), 128-138. https://journals.lww.com/practicalpsychiatry/Abstract/2003/03000/Impact_of_Trauma_on_Children.4.aspx
Liu, S. R., Grimes, K. E., Creedon, T. B., Pathak, P. R., DiBona, L. A., & Hagan, G. N. (2021). Pediatric ACES assessment within a collaborative practice model: Implications for health equity. American Journal of Orthopsychiatry. https://doi.org/10.1037/ort0000536
Manyema, M., & Richter, L. M. (2019). Adverse childhood experiences: prevalence and associated factors among South African young adults. Heliyon, 5(12), e03003. https://doi.org/10.1016/j.heliyon.2019.e03003
Mendelson, T., Clary, L. K., Sibinga, E., Tandon, D., Musci, R., Mmari, K., Salkever, D., Stuart, E. A., & Ialongo, N. (2020). A randomized controlled trial of a trauma-informed school prevention program for urban youth: Rationale, design, and methods. Contemporary clinical trials, 90, 105895. https://doi.org/10.1016/j.cct.2019.105895
Nadat, Y., & Jacobs, S. (2021). Elements that contribute to resilience in young women from a high-risk community. Social Work, 57(1), 87-100. http://dx.doi.org/10.15270/52-2-908
Nebraska Department of Health and Human Services. (n.d.). Adverse Childhood Experiences (ACE) Pyramid. Retrieved March 29, 2022, from https://www.unmc.edu/bhecn/_documents/ace-handout-ne-specific.pdf
Negriff, S. (2020). ACEs are not equal: Examining the relative impact of household dysfunction versus childhood maltreatment on mental health in adolescence. Social Science & Medicine, 245, 112696. https://doi.org/10.1016/j.socscimed.2019.112696
Oh, D. L., Jerman, P., Silvério Marques, S., Koita, K., Purewal Boparai, S. K., Burke Harris, N., & Bucci, M. (2018). Systematic review of pediatric health outcomes associated with childhood adversity. BMC pediatrics, 18(1), 1-19. 10.1186/s12887-018-1037-7
Purewal, S. K., Bucci, M., Gutiérrez Wang, L., Koita, K., Silvério Marques, S., Oh, D., & Burke Harris, N. (2016). Screening for adverse childhood experiences (ACEs) in an integrated pediatric care model. Zero to three, 37(1), 10-17. http://dk-media.s3.amazonaws.com/media/1lq96/downloads/299688/2016-01-ztt-journal-s.pdf#page=12
Scully, C., McLaughlin, J., & Fitzgerald, A. (2019). The relationship between adverse childhood experiences, family functioning, and mental health problems among children and adolescents: A systematic review. Journal of Family Therapy, 42(2), 291-316. https://doi.org/10.1111/1467-6427.12263
Srivastav, A., Strompolis, M., Moseley, A., & Daniels, K. (2020). The empower action model: A framework for preventing adverse childhood experiences by promoting health, equity, and well-being across the life span. Health Promotion Practice, 21(4), 525-534. https://doi.org/10.1177/1524839919889355
Wekerle, C., Waechter, R. L., Leung, E., & Leonard, M. (2007). Adolescence: A window of opportunity for positive change in mental health. First Peoples Child & Family Review: A Journal on Innovation and Best Practices in Aboriginal Child Welfare Administration, Research, Policy & Practice, 3(2), 8-16.
Williams, S. L., Williams, D. R., Stein, D. J., Seedat, S., Jackson, P. B., & Moomal, H. (2007). Multiple traumatic events and psychological distress: the South Africa stress and health study. Journal of traumatic stress, 20(5), 845-855. https://doi.org/10.1002/jts.20252
Written by Jandi Newall – Medical Doctor and Researcher at Wellness Dialogue Group
