MED-NERD
Adverse Childhood Experiences (ACEs)
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Outline:
- Introduction
- Incidence
- Mechanism
- Risk factors
- Structural and functional changes of the brain
- Prevention
- References
Introduction:
Adverse childhood experiences (ACEs) are defined as traumatic life events causing severe stress and prolonged negative consequences both physically and mentally.
According to the centers for disease control and prevention (CDC), ACEs are defined as harmful exposure negatively affecting physical, mental health, social, economic future of an individual from birth till the age of 17 years.
Examples of ACEs include:
-Physical, verbal, sexual, emotional abuse.
-Physical, psychological neglect
-Parental mental illness, witnessing suicidal experience, parent or other family member being in prison
-Alcohol or drug abuse
-Domestic violence, intimate partner violence, divorce and separation
Others affecting child health:
-Disaster, war, hunger, homelessness, economic problems
-Disabilities, being a victim of bullying or discrimination
-Unsafe environment surrounding a child
Childhood trauma and ACEs may cause serious mental disorders such as schizophrenia and major depression, chronic health problems, educational problems, work problems, and increased risk of substance use later in life.
Unfortunately, some healthcare providers and professionals may not be educated and do not have knowledge about childhood trauma and ACEs. Following some programs and tips, ACEs may be prevented.
Incidence:
In 2016, the National Survey of Children’s Health estimate showed about 46% of children in the U.S. ranging from 0 to 17 years experienced at least one ACE, about 29.9% of children between 12-17 years experienced at least two or more ACEs. A recent study showed that more than 60% of adults in the U.S. experienced at least one ACE and about 25% of adults experienced three or more ACEs.
A meta-analysis of 880 articles showed 23.5% of individuals experienced one ACE, 18.7% experienced moee than one ACE in Europe. About 41.1% of individuals having illicit drugs in North America, and 34.1% in Europe had the highest risk of ACEs. Moreover, 30% of cases had anxiety, 40% had depression due to ACEs.
Surveys globally and from Europe showed high rates of abuse : 22.9% physical, 9.6% sexual, 29.1% emotional. Regarding neglect the results were: 18.4% emotional, 16.3% physical without mentioning the unreported cases.
ACEs increase the costs of family, society, community, and economy with hundreds of billions of dollars. Annually, almost US$ 748 billion estimated as the total cost due to ACEs in North America, US$581 billion in Europe. Individuals experienced more than one ACEs caused over 75% of the cost. Annual savings of $56 billion may be achieved with 10% reduction in ACEs in North America.
Mechanism:
The mechanism of ACEs may be due to cognitive and social-emotional developmental problems or modified gene expression associated with the extreme stress or toxic experience of ACEs.
Psychological and psychosocial mechanisms:
May cause the mental disorders following ACEs such as exaggerated response and attention toward threatening stimuli. This is associated with functional changes in brain regions ( e.g., amygdala, anterior cingulate cortex [ACC], hippocampus). In addition to functional changes, ACEs may cause structural changes in the volumes of different brain regions. The severity of neural symptoms is explained with dose-dependent effect theory which describes cumulative effect of the number, and other studies including the type and timing of ACE regarding the severity of neural, mental, and somatic alterations.
Risk factors:
According to the CDC, the risk factors of experiencing ACEs can be classified into:
Individual and Family Risk Factors:
-Children with special needs (e.g., disabilities, physical and mental illnesses)
-Improper communication and negative conflict between parents or caregivers and the children.
-Children with no or few friends may have aggressive behaviour
-Families with single parent, with low income, or with low level of education
-Family stress, economic stress
-Drug abuse or neglect in families
-Using improper and extreme methods of punishment
-Families accepting violence and aggression
-Isolated families from community such as neighbors and friends
-Early engagement in sexual activity
Community Risk Factors:
-High rates of violence, crime, poverty, unemployment, llow levels of education and economy
-Access to drugs, alcohol, weapons
-Few activites for youth in community
-Food insecurities in families and unstable housing
-Environmental and social problems
Structural and Functional changes of the brain:
Studies have shown a relation between ACEs and brain changes in certain regions such as hippocampus, amygdala, and Anterior cingulate cortex (ACC). These regions are specifically affected may be due to the presence of high density of glucorticoid receptors, atrophy of dendrites, suppression of neurogenesis. Moreover, it was proved to be associated with modifications in emotion regulation and stress sensitivity.
Structural changes of the brain in ACEs:
-Reduced volume of the hippocampus after ACEs, but recent studies have shown that this becomes less evident when controlling for gender. Some studies showed greater reduction of hippocampus in males than females due to the protective effect of estrogen in females.
-In the amygdala, ACEs increase the volume of amygdala as stress stimulates arborization of dendrites on pyramidal cells that have glucocorticoid receptors in the amygdala. The effect of ACEs on amygdala volume is still controversial. Some studies showed increased amygdala volume in case of: children of depressed mothers, and children reared in institutions probably due to early exposure to emotional or physical neglect. On the other hand, some studies showed reduced amygdala volume as in: substance abuse , Dissociative Identity Disorder, and adults after ACEs with Bipolar depression may be due to exposure to severe abuse.
-Multiple studies showed decreased volume and thickness of ACC.
Effects of ACEs on sensory system:
Experiencing ACEs is associated with sensory system changes that is responsible for perception of trauma.
-Arcuate fasciculus: May be affected by parental verbal abuse.
-Inferior longitudinal fasciculus: It is a region interconnecting limbic and visual systems, may be affected by witnessing domestic violence.
-Visual cortex and right lingual gyrus gray matter: Show reduced volume in young adults who witnessed domestic violence in their childhood.
-Cortex: Increased in thickness in women who experienced maltreatment in their childhood.
-Somatosensory genital field: Showed thinning in children exposed to sexual abuse.
- Brain regions associated with self-awareness and self-evaluation: Showed thinning in women experienced emotional abuse.
-The hippocampal volume: Highly affected in individuals from 3 to 5 years experienced sexual abuse.
Functional changes in the brain that were found in neuro-imaging include:
-Hyperactivity in amygdala due to emotional stimuli in case of childhood maltreatment. Hyperactivity results in high risk of dysfunctional behaviors, mood disorder, anxiety disorder, Bipolar depression, and post-traumatic stress disorder (PTSD).
-Hyperactivity in anterior insula mainly due to emotional stimuli and results in PTSD, social anxiety, and specific phobia.
Prevention:
Screening:
Identification, screening, tracking, and whether early detection trauma may improve the outcomes of ACEs are still not clear. However, learning about life conditions affecting the health of children is one of the routines taking place in high-quality patient-clinician conversations and these conversations are part of “surveillance” for ACEs which allows providing proper support. Early detection of ACEs can help to reverse the hypothalamic-pituitary axis disturbances related to ACEs. The American Academy of Pediatrics (AAP) has established a guidance for screening ACEs by which clinicians are recommended to detect the risk factors of mental and developmental disorders for all children and families in healthcare. The APP guidance includes asking open-ended questions for surveillance of ACEs (e.g, “Since the last time I saw you/your child, has anything really scary or upsetting happened to you/your child or anyone in the family?”). Lack of specificity and relatively shallow evidence base are some of the challenges confronting the implementation of APP strategy.
Challenges:
ACEs may be indirectly assessed by clinicians for example, pediatricians inquiring about ACEs for maternal depression, but toxic experiences such as domestic violence, parental alcohol/drug use, and a member of family in jail are less mentioned.
Some of the challenges facing clinicians: lack of time, lack of training, lack of confidence in discussing trauma, lack of referral resources, lacking evidence of single-outcome or cut-points for “toxicity”, lack of interventions that may not be available at healthcare systems, what type of interventions to use, which treatment to provide, controversy about the worthiness of intervention for ACEs, lacking systems for referral of mental health disorders.
Programs:
Prevention of ACEs can be achieved through early detection and implementation of some programs that may reduce the risks of individuals who experience ACEs, including:
-Head Start and/or preschool programs
-Parenting programs (e.g. Circles of Security)
-The Nurse-Family Partnership
Self support (Questionnaire):
Screening of ACEs and toxic stress experienced in childhood or youth can be done through multiple self-support measures (e.g., the Structured Trauma-Related Experiences and Symptoms Screen, the Childhood Trauma Questionnaire, the Juvenile Victimization Questionnaire (JVQ), the Center for Youth Wellness Adverse Childhood Experiences Questionnaires (CYW-ACEQ), and the Trauma Symptom Checklist for Children (TSCC)).
Some of these questionnaires are specific to post-traumatic stress disorder while others have more wide use. The Traumatic Events Screening Inventory for Children (TESI-C) and the Survey of Well-Being in Young Children (SWYC) can be used to screen emotional-behavioral symptoms.
Protective factors:
The presence of protective factors may also improve the outcomes of ACEs and protect children from the toxic effects of ACEs, including:
-Internal protective factors (e.g., self-regulation or resilience)
-External protective factors (e.g., strong community connection, having a supportive relationship with a caregiver). This may improve critical thinking, critical consciousness, autonomy, sense of purpose, and problem-solving skills of children.
-Having a caregiver with steady employment.
-Caregivers getting involved into parental monitoring and supervision.
-Getting involved into positive activities and enforcement of the role of school.
-Having access to mental health services, economic and financial help.
References:
(1)Sherfinski HT, Condit PE, Williams Al-Kharusy SS, Moreno MA. Adverse Childhood Experiences: Perceptions, Practices, and Possibilities. WMJ. 2021 Oct;120(3):209-217.
https://pubmed.ncbi.nlm.nih.gov/34710303/
(2)Giotakos O. Neurobiology of emotional trauma. Psychiatriki. 2020 Apr-Jun;31(2):162-171.
https://pubmed.ncbi.nlm.nih.gov/32840220/
(3)Bellis MA, Hughes K, Ford K, Ramos Rodriguez G, Sethi D, Passmore J. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. Lancet Public Health. 2019 Oct;4(10):e517-e528. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098477/#!po=9.28571
(4)Adverse Childhood Experiences, centers for disease control and prevention (CDC).
https://www.cdc.gov/violenceprevention/aces/index.html
(5)Herzog JI, Schmahl C. Adverse Childhood Experiences and the Consequences on Neurobiological, Psychosocial, and Somatic Conditions Across the Lifespan. Front Psychiatry. 2018 Sep 4;9:420.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6131660/
(6)Adverse Childhood Experiences (ACEs) and Attachment, Manchester university NHS foundation.
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