How ACEs Affect Health

Childhood adversity increases risk for long-term health and behavioral issues.

Research shows that the adversity we experience as children can affect us into adulthood. Challenges children face in school, life – and ultimately with their health – are often the symptoms of ACEs and toxic stress.

The good news is, the earlier we can identify that a child is experiencing ACEs and toxic stress, the sooner children and families can be connected to the services they need to prevent or heal the effects.

Frequently Asked Questions

  • Adverse Childhood Experiences (AECs)
  • Toxic Stress
  • Care and Prevention
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What is the ACE study and why is it so important?

The Adverse Childhood Experiences Study (ACE Study) was a groundbreaking research study conducted by Kaiser Permanente and the Centers for Disease Control and Prevention (CDC). It was the first large scale study to look at the relationship between ten categories of adversity in childhood and health outcomes in adulthood. Key findings, published in 1998, were:

  • ACEs are incredibly common — two-thirds of study participants had experienced at least one ACE category and one in eight individuals had experienced four or more ACEs.
  • The higher your ACE score, the higher the likelihood of developing long-term health problems like heart disease, stroke, cancer, and diabetes.
What are ACEs and why do they matter?

Adverse Childhood Experiences (ACEs) refer to ten specific categories of exposures grouped into 3 types: abuse, neglect and household dysfunction such as parental substance abuse or mental illness. Exposure without a positive buffer, such as a nurturing parent or caregiver, can lead to a Toxic Stress Response in children, which can, in turn, lead to health problems like asthma, poor growth and frequent infections, as well as learning difficulties and behavioral issues. In the long term, exposure to ACEs can also lead to serious health conditions like heart disease, stroke, and cancer later in life.

What are the 10 ACEs from the ACE Study?

The ACE Study identified ten categories of Adverse Childhood Experiences:

  • Abuse: 1) Physical, 2) emotional, and 3) sexual
  • Neglect: 4) Physical and 5) emotional
  • Household dysfunction: 6) Parental mental illness, 7) incarcerated relative, 8) mother treated violently, and 9) household substance abuse. The category that was previously called “divorce or parental separation” was recently updated to 10) “not being raised by both biological parents.”
What about other types of adversity?

The ten ACE categories identified in the original Kaiser/CDC study Study were associated with long-term health consequences in a population of over 17,000 adults. However, subsequent research has explored the relationship between other childhood adversities and health. Evidence shows that factors such as bullying, community violence, death of a parent or guardian, discrimination, or separation from a caregiver to foster care or migration may also lead to a toxic stress response.

How do childhood experiences affect adulthood?

Research shows that the adversity we experience as a child can affect how our stress response functions, leading to long-term changes in our brains and bodies and leading to health problems as an adult. Experiencing 4 or more ACEs is associated with significantly increased risk for 7 out of 10 leading adult causes of death, including heart disease, stroke, cancer, COPD, diabetes, Alzheimers and suicide.

What is the ACE questionnaire?

An ACE questionnaire consists of a series of questions to identify if you’ve been exposed to Adverse Childhood Experiences (ACEs). The questions and scoring system in an ACE questionnaire are based on the framework of the 1998 Adverse Childhood Experiences Study (ACE Study).

What is an ACE score?

The concept of the ACE score was developed by a team of physicians for the 1998 Adverse Childhood Experiences Study (ACE Study). In the study, each participant was assigned an ACE score by adding up the number of adversities the person had experienced.

What is the ACE pyramid?

The ACE Pyramid is a visual representation of the framework of the 1998 Adverse Childhood Experiences Study (ACE Study) and illustrates how ACEs in childhood could affect a person over a lifetime. The pyramid is built of layers showing the mechanism by which ACEs can influence health and well-being through disrupted neurodevelopment, social, emotional, and cognitive impairment, etc. A limitation of the ACE Pyramid is that it doesn't take into account individuality variability in a person’s response to ACEs.

What is toxic stress?

Stress is a normal and healthy part of development. The toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment, well into the adult years. If left unaddressed, toxic stress can affect growth, learning, behavior, immunity and and even the way DNA is read and transcribed. Kids who are exposed into very high doses of adversity have more than double the lifetime risk of heart disease and cancer and a nearly 20-year difference in life expectancy.

The stress response can be conceptualized into three types:

  • Positive stress response is a normal and essential part of healthy development, characterized by brief increases in heart rate and mild elevations in hormone levels. Some situations that might trigger a positive stress response are the first day with a new caregiver or receiving an injected immunization.
  • Tolerable stress response activates the body’s alert systems to a greater degree as a result of more severe, longer-lasting difficulties, such as the loss of a loved one, a natural disaster, or a frightening injury. If the activation is time-limited and buffered by relationships with adults who help the child adapt, the brain and other organs recover from what might otherwise be damaging effects.
  • Toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity — such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship.
  • Without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment, well into the adult years.
What are some of the signs of toxic stress in children?

The signs of toxic stress are many and varied, as multiple systems in our bodies are affected, including the nervous system, hormonal system and immune system.

One of the most common signs of toxic stress in children is behavioral problems. In young children this can manifest as crying more than usual, becoming extra clingy, regressing to bed wetting or baby talk, or developing new fears. In older children, behavioral symptoms could include learning difficulties, juvenile offending, substance abuse, suicidality, and risky sexual behavior.

It is important to note that although behavioral symptoms are common, some children may not exhibit them. However, that does not mean that their brains and bodies are not been affected by ACEs. Children exposed to ACEs may also exhibit physical health issues like asthma, sleep disturbances, frequent infections, frequent headaches or stomach aches.

Can children overcome tough childhoods and be fine later in life?

Many children can experience adversity but stable and nurturing adult relationships can help protect them from toxic stress. However, science indicates that in the absence of caring, supportive relationships even adults who have survived a difficult childhood and achieved academic, financial or social success later in life often struggle with significant health issues. Children at risk may not exhibit behavioral symptoms but that does not mean their brains and bodies are not being affected by toxic stress. This latency of ACEs and toxic stress affecting adult health has made it difficult to connect the dots – but it is now clear that early identification can have significant health impacts later in life.

How do I care for children facing adversity?

The first step is for parents, caregivers or other adults working closely with children to recognize the child’s exposure to adversity. Research shows that, even under stressful conditions, supportive relationships with caring adults can prevent or mitigate the damaging effects of toxic stress by restoring children's stress response systems. Parents/caregivers also can help guide essential elements of a child’s wellbeing such as sleep, play and nutrition. Lastly, it is important that parents practice self-care so that they provide the support their children need.

Why is parent/caregiver self-care important when it comes to toxic stress?

In order for parents to be a buffer for their child’s stress, they have to have healthy stress management themselves. Self-care is not “selfish” -- rather it is essential for helping parents/caregivers be healthy, stable, caring adults and provide the support kids need.

What is trauma-informed care?

Trauma-informed care is an approach that understands the impact that trauma can have on the body, mind and relationships. This understanding is incorporated into care and treatment, and focuses on improving a person’s overall wellness, versus simply treating the symptoms, such as mental illness. In addition, research has shown that trauma-informed care should also include consideration of the health impacts of adversity.

How can I help my child build resilience?

Resilience is the ability to overcome stress and adversity while maintaining normal psychological and physical functioning. It is the result of a combination of individual characteristics, social and environmental protective factors. Some ways that adults can help children build resilience include being a supportive and positive influence in the child’s life, helping to buffer them from adversity, supporting the development and practice of self-regulation skills, and championing health-promoting activities like regular physical activity, quality sleep, good nutrition and mindfulness.

What can I do to help relieve stress?

There are many things you can do to relieve stress. At the top of the list are the basics: regular sleep, nutrition and exercise. Physical activity not only helps you stay fit, but releases good chemicals in your body that can energize you and lift your moods. Other effective stress-relieving tactics include practicing mindfulness and cultivating healthy relationships and working with a therapist.

Can sleep help my child manage stress?

Establishing good sleep practices supports good overall health. Childhood adversity is associated with changes to the brain, immune system, hormones and DNA regulation. Healthy sleep enhances the effectiveness of connections between brain cells, improves immune functioning, helps the body process and reduce stress hormones and is protective against wear and tear on our DNA. Adequate sleep leads to improved attention, behavior, learning, memory, emotional regulation, quality of life, and mental and physical health. Some healthy sleep habits include establishing a consistent bedtime routine, incorporating physical activity into your day, cutting down on screen time, and creating a cool, quiet, relaxing bedroom environment.

Can exercise help my child manage stress?

Childhood adversity is associated with impaired learning and frequent infections in children. Exercise can improve learning, the immune system, brain development, and reduce stress. Being more physically active can be a family affair, providing an opportunity for families to spend more time together. Determine what activities your child enjoys, model more active behavior yourself, and provide a safe environment for the activities. In addition, provide toys like balls and jump ropes that encourage physical activity, and limit screen time.

Can a good diet help my child manage stress?

Research shows that proper nutrition can help the body’s immune system better manage stress. Childhood adversity is associated with impairments in cognitive and physical development in children. Good nutrition combined with engaged caregiving can mitigate risks for poor cognitive, motor, and social functioning and help children to adapt in times of adversity. Some ways you can encourage your child to eat healthier include:

  • Include fruits and vegetables with each meal (fresh, frozen or canned)
  • Involve your child in healthy meal planning, shopping and cooking
  • Eat breakfast that incorporates fruit and whole grains
  • Eat together as a family as often as possible
  • Drink water with every meal and snack, and before and after physical activity
Can mindfulness help my child manage stress?

Childhood adversity can negatively impact the mind and body. Research shows that mindfulness can help reduce stress hormones and feelings of stress, elevate mood, improve immune function, reduce pain, build resilience, enhance personal relationships, support brain growth and function, sharpen cognition, improve memory, and enhance learning.

Mindfulness is being aware in the present moment. It includes being aware of feelings, thoughts, and how the body feels, without bringing in judgement. You can be mindful in any moment of your life -- while talking on the telephone, playing with your child, washing the dishes, driving home, and exercising.

Mindfulness may be cultivated through proven techniques, like meditation. Meditation may involve finding a quiet place to sit comfortably, noticing how your body feels, paying attention to your breathing, and bringing your mind back to the present moment when it wanders.

When should I consider mental health services for my child?

There may be a time when you will need additional support as a parent/caregiver. Working with healthcare professionals, including your pediatrician and mental health professionals, can be incredibly beneficial. Treatment may help bring greater awareness and understanding of the impact of adversity and trauma on your child and family, strengthen the parent-child relationship, improve individual self-regulation skills and parent-child co-regulation capacities, stabilize behaviors and mood, and ultimately restore levels of functioning in development, daily activities, and adaptive coping.

Many families begin exploring mental health services by discussing concerns with their child’s pediatrician, who may connect them to a mental health professional. When choosing the right professional, it is important that s/he has experience working with children and families, uses trauma-focused evidence-based practices (i.e. treatments supported by research), and is accessible (e.g., easy to get to/located relatively nearby, has office hours that work for your family).

Remember as part of your child’s treatment, the mental health professional will probably ask for your participation and cooperation. Your involvement is extremely important to the recovery of your child and the well-being of your family.

* Links to external websites are provided for convenience of reference only and are not intended as an endorsement by the Center for Youth Wellness (CYW) of the organization or individual operating the host website or a warranty of any type regarding the host website or the information on that site.

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