What are adverse childhood experiences (ACEs)?

On this page:

What are the most common ACEs?
How do ACEs affect health and functioning?
How do relationships help?
How can professionals help?
What about organisations and policy makers?

Children are born with the potential to do great things – for themselves, their family and their community. But adverse childhood experiences (ACEs) can get in the way of children’s potential, by impacting their relationships, sense of self and perceptions of the world around them.

ACEs are very stressful events or circumstances that may occur during childhood. They can have significant effects on infants’ and children’s physical health, mental health, development and social functioning. Without support, children’s health and wellbeing can continue to be impacted by ACEs during adolescence and into adulthood.

Childhood adversity is more common than you might think. In their seminal study – which coined the term ‘ACEs’ – Vincent Felitti and colleagues found almost two-thirds of participants had experienced at least one adverse experience as a child (Felitti et al., 1998). While the results of Australia’s first dedicated ACEs survey are yet to be published, separate studies have found high rates of individual ACEs in Australian communities (Scott, Price-Robertson, Bromfield, Vassallo & Rosier, 2017).

Social inequalities such as unemployment, food insecurity, homelessness, financial hardship, and racism place greater stress on families and increase the likelihood of childhood adversities occurring. This explains why the rate of adversity is higher among vulnerable populations, such as Aboriginal and Torres Strait Islanders (Zubrick et al., 2005), juvenile offenders (Baglivio et al., 2014), and children involved in welfare services (Kerker et al., 2015).

ACEs are now considered a critical public health challenge (Sara & Lappin, 2017), which impact not only an individual’s physical and mental health outcomes over a lifetime, but their ability to contribute meaningfully to society. But poor outcomes are not inevitable. If we intervene early – with strategies to strengthen children’s resilience and relationships, and policies to better support families experiencing hardship – we can not only reduce the impact of childhood adversity, but even prevent it from occurring in the first place.

What are the most common ACEs?

The most widely recognised and researched ACEs relate to abuse, neglect, and household adversities, such as parental substance use or family and domestic violence (Felitti et al., 1998). Data on the prevalence of different ACEs in Australia is limited (Lamont et al., 2014), but it’s estimated rates may rise as a result of the coronavirus (COVID-19) pandemic, which has seen the number of families experiencing financial hardship, social isolation, housing stress and mental health difficulties increase (Australian Institute of Health and Welfare, 2021; Bryant, Oo, & Damian, 2020).

Social inequalities place greater stress on families and increase the likelihood of childhood adversities occurring.

How do ACEs affect health and functioning?

Adverse childhood experiences may last for months, even years. Exposure to stressful experiences over a long period of time can trigger a ‘toxic stress’ response, flooding the body with the stress hormone cortisol (Shonkoff, Boyce, & McEwen, 2009). These ongoing, abnormal levels of cortisol disrupt the healthy development and functioning of the brain. They limit children’s ability to develop a sense of trust and safety in the world around them, which in turn makes it harder for them to form and maintain healthy relationships, develop resilience and build a positive sense of self.

Toxic stress can impact the parts of the brain responsible for self-regulation, reward-seeking, executive function and threat perception (National Scientific Council on the Developing Child, 2005/2014), leading to developmental delays, lower educational attainment, and trouble with social and emotional adjustment. The more ACEs a person experiences, the more toxic stress they’re exposed to, and the greater their chances of developing a range of physical and mental health disorders in adulthood (Allen & Donkin, 2015; Choi, DiNitto, Marti & Choi, 2017; McLaughlin, Koenen, Bromet & Karam, 2017). This in turn can make it harder for individuals to do well in school, get a job that pays a liveable wage, and achieve financial, housing and social stability – especially if they also experience racism, ableism or other forms of discrimination.

How do relationships help?

One of the most important protective factors in a child’s life is a safe, caring and supportive relationship with someone they trust (National Scientific Council on the Developing Child, 2015). We know that even just one positive, caring relationship can act as a buffer against the effects of toxic stress and substantially improve a child’s recovery from stressful life events (Crouch, Radcliff, Strompolis, & Srivastav, 2019).

No matter the kind of adversity a child or young person experiences, having someone in their lives who makes them feel safe and protected – a parent, sibling, relative, teacher, neighbour or coach – helps support their mental health and resilience. Adults who have overcome significant adversity as children say that having an emotionally supportive person in their life, who saw them as unique and interesting and who supported their ideas and dreams, was vital. In cases of child sexual assault, having someone the child knows they can talk to and who will believe them is critical for their recovery.

In the following clip (1 min 9 sec), Carol Ronken, Director of Research for Bravehearts, talks about the importance of always believing children who disclose sexual abuse.

Even just one positive, caring relationship can substantially improve a child’s recovery from stressful life events.

How can professionals help?

The first step to addressing ACEs is understanding the family’s unique circumstances. However, when asking about adversity, it’s important to contextualise your questions, rather than simply tallying up an ACEs score. A trauma-informed approach can aid your understanding of the ‘whole child’ – their internal and external worlds, current and past experiences, risk and protective factors – and enable you to determine the best support strategies, without needing your client to disclose the specific ACEs they’ve experienced. Providing parents with information about ACEs will also help you to have open, honest conversations with them about their experiences, without fear of judgement.

In the podcast excerpt below (1 min 11 sec), Dr Nicola Palfrey, former Director of the Australian Child & Adolescent Trauma, Loss & Grief Network, unpacks why an understanding of ACEs is key to working in a trauma-informed way.

An intergenerational lens is also important when working with families experiencing adversity. It invites parents to think about their own childhood: what they learned from their parents or other adults in their lives, and how these learnings have influenced their own parenting decisions. It allows the parent to come to terms with their childhood experiences of adversity, consider their preferences for their relationship with their own children, and to plan for positive outcomes. It also invites both children and parents to reflect on the parent-child relationship, and how the parent’s own challenges or experiences of adversity may be interrupting this relationship.

As a practitioner, you can help parents to explore their strengths, know-how and parenting skills, and the ways they can build on these to interrupt intergenerational cycles of disadvantage.

In the following video (44 sec), Gill Munro, a social worker and Practice Development Officer at Emerging Minds, shares how an intergenerational approach can help your work with both children and parents.

In addition, the most effective prevention and early intervention strategies against ACEs focus on (Marie-Mitchell & Kostolansky, 2019; Centre on the Developing Child, 2015; Traub & Boynton-Jarrett, 2017):

promoting children’s resilience
building and strengthening safe, supportive adult-child relationships
building children’s sense of self-efficacy
providing children with opportunities to improve their adaptive and self-regulatory skills
strengthening children’s connections with their spiritual and cultural traditions; and
educating families on the impacts of ACEs and how they can be reduced.

Parenting programs, such as the Positive Parenting Program (Triple P) and Tuning into Kids, along with home visiting programs have been shown to improve children’s social, emotional and behavioural outcomes and adults’ parenting practices (Sahle et al., 2020).

What about organisations and policy makers?

Social, environmental, family and personal circumstances can overburden parents, making it hard for them to provide the best care and support for their family. This in turn impacts the parent-child relationship, which is key to building resilience and buffering children from the impacts of adversity. To prevent ACEs, we need policies that lighten the load on families.

For example, poverty has been found to strongly predict most types of childhood maltreatment, even after controlling for parental education, occupation, unemployment and housing (Doidge et al., 2017). The type of neighbourhood an individual lives in, and their ability to access affordable services may also determine their chances of experiencing adversity (Coulton, Korbin, & Su, 1999; Duncan, Ludwig, & Magnuson, 2007). Policies to reduce socio-economic disadvantage must be at the centre of any plans to target and reduce childhood adversity within the community.

Internationally, screening tools have been key to early identification of children at risk of/experiencing adversity. While Victoria and the ACT have incorporated ACEs questions into their kindergarten health checks, Australia has lacked a uniform approach to collecting and monitoring data on childhood adversity; and much of the existing literature around ACEs uses data from overseas populations.

The Australian Child Maltreatment Study (ACMS) is the first survey to explore the prevalence of ACEs in Australia, along with the co-occurrence of five different types of child maltreatment: physical, sexual and emotional abuse; neglect; and exposure to family and domestic violence (ACMS, 2021). The study aims to measure both physical and mental health outcomes, identifying the burden of disease in order to assess the economic cost of ACEs and inform practice and policy decisions. Data collection was completed in October 2021, and the final report will be available in 2023.

If we intervene early, we can not only reduce the impact of childhood adversity, but even prevent it from occurring in the first place.

Research consistently shows that prevention and early intervention strategies targeting ACEs reduce the risk of mental health disorders in adulthood (Bellis et al., 2019; Kessler et al., 2010; Jones, Merrick, & Houry, 2019; Jorm & Mulder, 2018). What is often missed, however, is the societal and economic benefits of reducing childhood adversity – how supporting a child to grow into a healthy, resilient adult enables them to contribute to their community in a positive, meaningful way. This is what we should keep in mind when working with children and parents: by reducing or removing a child’s risks of experiencing adversity, we improve the outcomes for everyone.

Resources

Toolkit: Adverse childhood experiences (ACEs) Online course: Intergenerational mental health Online course: Supporting children who have experienced trauma Fact sheet (for parents): ACEs and children’s wellbeing Fact sheet (for parents): ACEs and resilience Practice paper: Complex trauma through a trauma-informed lens Practice paper: Supporting children who have been sexually abused Podcast: What are adverse childhood experiences? Podcast: Responding to the challenge of child sexual abuse

References

Allen, M. & Donkin, A. (2015). The impact of adverse experiences in the home on the health of children and young people, and inequalities in prevalence and effects. London: UCL Institute of Health Equity.

Australian Child Maltreatment Study. (2021, April). Comprehensive study of child maltreatment in Australia launches. Brisbane: Queensland University of Technology.

Australian Institute of Health and Welfare. (2021, May). Child protection (snapshot). Canberra: AIHW.

Baglivio, M. T., Epps, N., Swartz, K., Sayedul Huq, M., Sheer, A., & Hardt, M. S. (2014). The prevalence of adverse childhood experiences (ACE) in the lives of juvenile offenders. Journal of Juvenile Justice, 3(2).

Bellis, M. A., Hughes, K., Ford, K., Ramos Rodriguez, G., Sethi, D., & Passmore, J. (2019). Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: A systematic review and meta-analysis. The Lancet Public Health, 4, e517-e528.

Bryant, D. J., Oo, M., & Damian, A. J. (2020). The rise of adverse childhood experiences during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12(1), S193–S194.

Centre on the Developing Child. (2015, March). Key concepts: Resilience. Cambridge: Harvard University.

Choi, N. G., DiNitto, D. M., Marti, C. N., & Choi, B. Y. (2017). Association of adverse childhood experiences with lifetime mental and substance use disorders among men and women aged 50+ years. International Psychogeriatrics, 29(3), 359–372.

Crouch, E., Radcliff, E., Strompolis, M., & Srivastav, A. (2019). Safe, stable, and nurtured: Protective factors against poor physical and mental health outcomes following exposure to Adverse Childhood Experiences (ACEs). Journal of Child and Adolescent Trauma, 12, 165–173.

Coulton, C. J., Korbin, J. E., & Su, M. (1999). Neighborhoods and child maltreatment: A multi-level study. Child Abuse and Neglect, 23(11), 1019–1040.

Doidge, J. C., Higgins, D. J., Delfabbro, P., Edwards, B., Vassallo, S., Toumbourou, J. W., & Segal, L. (2017). Economic predictors of child maltreatment in an Australian population-based birth cohort. Children and Youth Services Review, 72, 14–25.

Duncan, G. J., Ludwig, J., & Magnuson, K. A. (2007). Reducing poverty through preschool interventions. Future of Children, 17(2), 143–160.

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Jorm, A. F. & Mulder, R. T. (2018). Prevention of mental disorders requires action on adverse childhood experiences. Australian & New Zealand Journal of Psychiatry, 52, 316-319.

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Marie-Mitchell, A. & Kostolansky, R. (2019). A systematic review of trials to improve child outcomes associated with adverse childhood experiences. American Journal of Preventive Medicine, 56(5), 756–764.

McLaughlin, K. A., Koenen, K. C., Bromet, E. J., & Karam, E. G. (2017). Childhood adversities and post-traumatic stress disorder: evidence for stress sensitisation in the World Mental Health Surveys. The British Journal of Psychiatry, 211(5), 280–288.

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National Scientific Council on the Developing Child. (2015). Supportive relationships and active skill-building strengthen the foundations of resilience (Working paper No. 13). Cambridge: Harvard University.

Sahle, B., Reavley, N., Morgan, A., Yap, M., Reupert, A., Loftus, H., & Jorm, A. (2020). Communication brief: Summary of interventions to prevent adverse childhood experiences and reduce their negative impact on children’s mental health: An evidence-based review. Melbourne: Centre of Research Excellence in Childhood Adversity and Mental Health.

Sara, G. & Lappin, J. (2017). Childhood trauma: Psychiatry’s greatest public health challenge? The Lancet Public Health, 2, e300–e301.

Scott, D., Price-Robertson, R., Bromfield, L., Vassallo, S., & Rosier, K. (2017). The prevalence of child abuse and neglect. (CFCA resource sheet). Melbourne: The Australian Institute of Family Studies.

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Traub, F., & Boynton-Jarrett, R. (2017). Modifiable resilience factors to childhood adversity for clinical pediatric practice. Pediatrics, 139(5), e20162569.

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