Dr Cecilia Okorochukwu, Dr Rexford Obeng

One of the hardest parts of Paediatrics is caring for children who have experienced traumatic or stressful events, which can have long-lasting effects on their physical and mental health. Some examples of these events (which we call Adverse Childhood Experiences – ACEs) include abuse, neglect, or an unstable home environment. Research has shown that around 1 in 6 adults has experienced four or more ACEs.

This article is going to explore ACEs and what we can to do help mitigate their effects, with an aid memoire of SET-AIMS: supervision, early intervention, training, affinity, interdisciplinary collaboration, maintaining professional development and strengthening community support.

 Types of Adverse Childhood Experiences 

1. Abuse: Physical, emotional, or sexual abuse inflicted by parents, caregivers, or other authority figures. This can have devastating effects on a child’s sense of safety and self-worth. 

2. Neglect: Failure to provide for a child’s basic needs, including food, shelter, supervision, education and emotional support. This can lead to feelings of abandonment and insecurity.

3. Household Dysfunction and family experiences: Exposure to household dysfunction such as substance abuse, mental illness in parents, domestic violence, or incarceration of a family member can create an unstable and chaotic environment for a child.

How do ACEs affect health?

There is strong evidence that ACEs contribute to chronic health problems in adulthood. Some of the health conditions that have been linked to ACEs are heart disease, obesity, diabetes, and even a shortened lifespan. Chronic stress experienced during childhood can lead to dysregulation of the body’s stress response system, which has long-term health consequences.

Impact on physical health

• Cancer: People who have experienced four or more ACEs are at increased risk of developing cancer – this is probably because the stress and trauma from adverse experiences can affect the immune system and its ability to recognise cancer cells.
• Heart Disease: ACEs are linked to an increased risk of heart disease. When the stress response systems are chronically activated, this affects cardiovascular health.
• Diabetes: Exposure to ACEs is associated with a higher incidence of diabetes. Chronic stress impacts insulin regulation, which makes diabetes more of a risk.
• Health Risk Behaviors: People who have been affected by ACEs might smoke, use drugs or eat unhealthily – these behaviours may have begun as coping strategies to deal with the stress of ACEs, and they can further exacerbate chronic diseases.

Mental health effects

Mental health disorders like depression, anxiety, Post-traumatic stress disorder (PTSD), and substance abuse are more common in those with history of ACEs. Traumatic experiences in childhood can also shape brain development, emotional regulation and disrupt coping mechanisms and increase vulnerability to mental health disorders.

Social and behavioral problems

Children exposed to ACEs are more likely to engage in risky behaviors such as substance abuse, anti-social behaviour, and early sexual activity. They sometimes struggle with forming healthy relationships and maintaining stable employment. Research indicates that children living in stressful family environments are more likely to employ avoidant emotion-focused strategies and are less likely to engage in problem-focused coping strategies.

Cognitive function

ACEs can impair cognitive development and academic achievement, leading to difficulties in school and lower educational attainment. The chronic stress associated with ACEs can affect attention, memory, and executive functioning skills. Substantial research has demonstrated a positive linear relationship between the number of ACEs and negative outcomes across multiple domains of health functioning.

Case Study

(Fictional patient) – Mark was a 14 year old young man who, for as long as he could remember, noticed that his parents were regularly verbally and emotionally abusive to each other. He felt that he grew up in a toxic household and that his emotional needs were grossly neglected. On several occasions, he witnessed his father physically abusing his mother, which caused him enormous emotional distress. Mark was often left alone at home without proper supervision, leading to feelings of abandonment, low self-esteem, and fear.

As Mark grew older, the effects of his adverse childhood experiences became  more evident. He developed symptoms of anxiety, depression, and post-traumatic stress disorder. Mark struggled with outbursts of anger and also with forming healthy relationships. His physical health also deteriorated, with symptoms of chronic pain and fatigue – his school attendance dropped off and his teachers worried he would leave without and GCSEs.

He had an intensive course of Cognitive Behavioral Therapy (CBT), one to one sessions and help with reintegration into social groups. With this support Mark was gradually able to overcome these impacts, got back into education and and went on to achieve a place in University to study the course of his choice.

How to Break the cycle of ACEs : 7 TOP TIPS (SET- AIMS) 

1. Supervision and Support provision: Children and young people need immense support and supervision to thrive. By offering regular supervision and appropriate interventions, even those who are already affected by the impact of ACEs can be supported to live to their full potential.

2. Early Intervention and prevention: Early identification and intervention are crucial for reducing the impact of ACEs. Access to mental health services, trauma-informed care, and supportive interventions can help children and families cope with the effects of trauma and build resilience. Prevention is also better than cure. Tangible and reasonable efforts must be deliberately made to prevent ACEs, including promoting positive parenting practices, providing support services for families in need and implementing policies to reduce economic and social disparities.

3. Training: Ensuring that healthcare practitioners, educators and guardians receive comprehensive training and education on the impact of ACEs. These include understanding prevalence, recognising signs of trauma, and evidence-based interventions.

4. Affinity and Compassion: Encourage a culture of empathy and compassion, where practitioners and care givers feel valued and supported in their efforts to help individuals affected by ACEs. Encourage active listening and validation of patient’s experiences. 

5. Interdisciplinary Teams collaboration: This can ensure the provision of holistic care and support to patients with ACEs, enabling them to access other professionals or agencies for additional services needed. 

 6. Maintaining Professional Development: Support ongoing professional development for practitioners through training, workshops, conferences and peer learning opportunities. This allows practitioners to stay up to date with best practices and emerging research in trauma-informed care. 

7. Strengthening Community Support: Building strong, supportive communities can buffer the effects of ACEs by providing children and families with access to resources, social connections, and opportunities for positive engagement. This also includes supporting care givers to look after themselves.

Using these seven tips can help healthcare practitioners and caregivers support young people affected by ACEs and provide them with the care, compassion, and resources they need to heal, thrive, and achieve their full potential. 

Final thoughts…

Adverse Childhood Experiences have huge consequences that carry on into adult life and cast a long-term impact on health and well-being. The strong correlation between ACEs and chronic diseases highlights the critical need for early intervention and support systems. By encouraging resilience through care, education, and community support, we can start to address the effects of these early traumas. It is our collective responsibility to ensure that vulnerable young people receive the nurturing and protection they need to thrive. Working to address ACEs with a MDT approach involving individuals, families, communities, and policymakers will promote healthy development and resilience in children. By recognizing the impact of ACEs and implementing strategies to prevent and address trauma, we can create a brighter future for all children. 

As we move forward, let’s hope we can transform our understanding of ACEs into actionable strategies that promote healing, improve outcomes, and prevent the cross-generational trauma.

Authors: Dr Cecilia Okorochukwu ( Paediatric Trainee, London Deneary), Dr Rexford Obeng (Consultant community Paediatrician)

Edited for PaediatricFOAM by subeditors Dr Sarah Walker and Dr Ailsa McIlwane