Adverse Childhood Experiences and Their Life-Long Impact

By Ami Rokach and Shauna Clayton

Adverse Childhood Experiences and Their Life-Long Impact explores how these experiences influence cognitive, behavioral and social experiences in adulthood. The book conceptualizes the types of violence, abuse, neglect, and/or trauma that factor into ACEs. It also explores the psychopathological outcomes of ACEs among children, including neurodevelopmental and psychosocial mechanisms. By drawing on cross-cultural perspectives, the authors provide insight into the variations between the adversity and trauma children experience. Sections also cover preventive measures, risk factors and various forms of interventional treatment, making this book a core read for psychologists, physicians, social workers, educators and researchers in the field.

• Provides a comprehensive framework for understanding adverse childhood experiences
• Reviews the link between ACE and homelessness, substance abuse, and physical and/or sexual violence in adulthood
• Highlights key components of cross-cultural perceptions on child abuse and neglect, including differences of gender
• Explores options for prevention and intervention for those who experience adverse childhood experiences

• Language: English
• Publisher: Academic Press
• Release date: Aug 8, 2023
• ISBN: 9780323900676

Ami Rokach

Ami Rokach, Ph.D. A clinical psychologist, a member of the psychology dept. at York university in Toronto, and a researcher who has researched and published extensively on loneliness, intimate partner violence, sexuality and sexual abuse, bullying and victimization, the homeless, drug abuse, and criminality. Ami worked at the Ontario Correctional Inst. for 28 years with ‘garden variety’ criminals, sex offenders, and violent, abusive and dangerous criminals, all – or most – of whom experienced ACEs, and continue to inflict it on their children. Additionally, in his private practice, Ami treats people who have undergone ACE and traumatic upheavals in their childhood.

Book preview

Adverse Childhood Experiences and Their Life-Long Impact

Ami Rokach

Psychology Department, York University, Toronto, ON, Canada

Shauna Clayton

York University, Toronto, ON, Canada

Table of Contents

Cover image

Title page

Copyright

Dedication

Prologue: The criticalness of disentangling adverse childhood experiences

Chapter 1. Introduction

Adverse childhood experiences

Chapter 2. Child maltreatment – cross culturally

A case study

Child maltreatment cross-culturally

Global prevalence of maltreatment

Chapter 3. What causes adverse childhood experiences (ACEs)?

Case study

Poverty

Homelessness

Parents who suffered abuse as children

Medical child abuse

Child disability

Intimate partner violence

The impact of war

Chapter 4. Physical child abuse

Case study

Child abuse defined

Causes of child abuse

Interactional variables

Environmental/life stress variables

Social/cultural/economic variables

Assessing risk for physical abuse

Poisoning the child

When the abused child dies

Related illnesses

Behavioral indications of abused children

The tasks parents have not learned

Adolescents abused by parents

Abusive siblings

Bullying and peer violence

Chapter 5. Child sexual abuse

Case study

A need for a unified child sexual abuse definition

Child sexual abuse globally

Abuse characteristics

The profile of the abused child

The traumatic effect of sexual abuse

Effects of sexual abuse

The progression of sexual abuse

Intrafamilial CSA dynamic

The perpetrator

Intrafamilial abuse

Extrafamilial sexual abuse

The effect of CSA on men

CSA and later revictimization

CSA and further victimization

Maternal and child CSA history: intergenerational transmission

Online child sexual abuse

Institutional sexual abuse of children

Child sexual abuse disclosures: what facilitates it and what is an obstacle

CSA disclosure and parental reaction

Barriers to disclosure of CSA

Protective factors

Treatment of sexual abuse

Sexual abuse and prevention in developing countries

Chapter 6. Medical child abuse

From—case description

Prevalence of medical abuse

Common neurological manifestations

Circumstances that may warrant a diagnosis of MCA

Characteristics of the perpetrator

The perpetrators

The motivation of the perpetrator

The internet and MCA

What are the most recommended treatment options?

Treatment outcome

Safety plan and plan for reunification

Individual therapy for other family members or friends

Who are FD patients?

Factors involved in diagnosing FD

Chapter 7. Emotional maltreatment: abuse is not just physical

Emotional maltreatment and resilience

Active and passive emotional abuse

Child emotional abuse

Defining psychological and emotional maltreatment

Active and passive emotional abuse

Emotional abuse, anxiety, and the brain

Emotional abuse, self-esteem, and loneliness

Emotional abuse as a consequence of domestic violence

Misconceptions about child emotional abuse in domestically violent homes

Consequences of emotional abuse

Childhood emotional maltreatment and problematic social media use

The effect of emotional abuse on romantic relationships

The effect of childhood emotional abuse on stress reactivity

Mother's maltreatment in childhood and the effect on her kids

Emotional maltreatment and resilience

Emotional abuse and social support network

Chapter 8. Bullying

Case study

Bullying at school

Socioecological framework for bullying

Prevalence of bullying

Categories of bullying

Cyberbullying

Consequences of bullying

Chapter 9. The various ways of child neglect

Prevalence

What is child neglect?

Forms of child neglect

Child neglect globally

Neglect cross culturally

Intergenerational child abuse and neglect

Family profiles of child neglect

Causes of child neglect

The neglecting parents

The neglected child

Consequences of neglect

Preventing child neglect

Protecting children from neglect

Chapter 10. Children exposed to ACE: The trauma and its aftermath

ACE and household dysfunction

Developmental consequences of child maltreatment trauma

Toxic stress and trauma

Trauma in childhood and psychopathology

Child abuse and how it affects executive functions

Physiological response to the stress and trauma of abuse

Trauma and hyperarousability

ACE, trauma, and later adverse outcomes

Neurological and hormonal consequences of traumatic child abuse

Intergenerational transmission of trauma

Consequences of traumatic sexualization

Trauma, ACE, and early sexual initiation

ACE, trauma, and asthma

Childhood trauma and auditory hallucinations

ACE, trauma, and eating disorders

Childhood trauma and suicidality

Child abuse in residential care settings

Chapter 11. Implications and outcomes of ACEs

Case study

The ACE pyramid

Sexual intimacy difficulties

Child abuse and its effect on adult couple functioning

ACEs and psychosocial well-being

ACEs and personality disorder

Effects of trauma on child brain development

Epigenetics and the effects of trauma on the body

Cognitive effects

Long term effects

Chapter 12. ACEs throughout the lifespan

Case study

Consequences of ACEs

Chapter 13. ACE and its implication over the lifespan

Global life course health consequences of ACE

A review of ACE over the last 100 years

Quality of life of maltreated children

ACE and emotional inhibition

Consequences of emotional abuse

Emotional abuse and depression in adulthood

Causes and consequences of child neglect

ACE and health consequences

Clinical consequences of child abuse

Childhood maltreatment and adult mental disorders

Psychosocial consequences of ACE

Psychological, economic, and physical health consequences of specific child abuse

ACE and personality development

How does childhood maltreatment contribute to mood disorders?

Psychiatric consequences of child maltreatment

ACE and dissociation

ACE and depression in later life

Multiple ACEs and the effects on health

Mother's ACE and its effects

ACE and maternal anxiety

Mothers' ACE and helplessness toward their children

Mother's ACE and children's behavior

ACE, attachment anxiety, and somatic symptoms

ACE and aggression in young adulthood

ACE and sexual offending in adulthood

Childhood maltreatment and intimate partner violence

Effects of child sexual abuse

Chapter 14. The effects of ACE on intimate relationships

Disorganized attachment, ACE and its effect on adult relationships

ACE & romantic relations

ACE & adult intimate relations

ACE & adult love relationships

Long term effects of abuse on relationships

The effect of neglect on romantic relationships

ACE & interpersonal relations in adulthood

ACE & adult intimate relationships of women

ACE & relating to family in adulthood

ACE and sexual victimization in adulthood

Parenting after ACE

Navigating parenthood following CSA

Chapter 15. How did the pandemic affect child maltreatment

Media reports about the effects of COVID-19

COVID & family violence

Economic downturn & child abuse

Risks to children during Covid-19 pandemic

How COVID affects children and their families

COVID & the traumatized

COVID & loneliness

Social isolation

About COVID-19, isolation, and family violence

COVID and its emotional ramifications

COVID & accumulated child abuse

COVID & physical child abuse (PCA)

Healthcare providers' stress during COVID

What can schools do to minimize child abuse?

Chapter 16. Resilience: what it is, and how to develop it

Intro to resilience and definition

Resilience

Resilience of those who underwent CSA

Research on resilience

Factors influencing resilience

Differential prediction of resilience

Genetics and neuroimaging of maltreated children

CSA and resilience in male victims

Enhancing resilience in adult women

Resilience of African sexually abused women

Resilience in physically abused children

Influence of parenting on psychiatric resilience of CSA victims

CSA and resilience in women

Caregivers' effect on children's resilience

Posttraumatic growth of survivors of CSA

Developing resilience

Resilience of CSA victims

Chapter 17. Treating physical abuse and neglect

Case study

Intervention

Pharmacological intervention

Culturally sensitive intervention

Epilogue, or what now?

Index

Copyright

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Dedication

Dedicated to the two most beloved people in my life: Benny & Natalie. With love, compassion, and a deep feeling of gratitude. A.R.

Dedicated to my dear friend E.S., whose perseverance and resilience inspired the idea for this book, and to all the people who are healing from childhood wounds. S.C.

You are not the darkness you endured. You are the light that refused to surrender. – John Mark Green

Prologue: The criticalness of disentangling adverse childhood experiences

I think this man is suffering from memories.

Sigmund Freud

Freud was onto something when he observed and noted the distinct connection between present suffering and past experiences. It is not a unique phenomenon that the experiences and interactions we encounter throughout life's journey accumulate and become embedded within who we are. Positive or negative, our early life experiences have a profound impact on shaping the life course.

Here is Robert's (not his real name) story:

In reflecting on his life, Robert, a professor with a Ph.D. in Criminology, recalled the hardships he faced growing up and recognized two teachers to whom he credits his success. Robert grew up in a single-parent household with two other siblings. His mother was gone for most of his life, appearing now and then, but mainly was absent due to an issue with substance use. His father did not drink or do drugs but was angry at the time and did not cope well with stress. They struggled financially, and Robert's father was often emotionally and verbally abusive and, on occasion, physically abusive. In hindsight, Robert attributes his father's behavior to stress but shared that it was difficult to bear as a child. Alongside enduring challenges at home, Robert was bullied throughout most of his elementary years at school. By the time he got to high school, he had developed severe anxiety and found it difficult to socialize with others, despite no longer being bullied. His mental health had worsened, and he was finding it increasingly difficult to get out of bed in the morning and function at school. Robert's marks were poor and near-failing some courses, such as gym class, because he found it challenging to show up. Rather than eat lunch with the other students at lunchtime, he would isolate himself in the library to look busy. Meanwhile, he could not concentrate and often ended up sitting and doing nothing. Robert shared that many of his teachers treated him as if he were a bad student. They saw a teenager showing up late to school, or not at all, and not completing the course work. Because he found it difficult to speak to others, he seemed aloof and felt it difficult for others to understand him or his behavior. A few months into grade 10, Robert recalls one teacher in particular who would ultimately influence his life's trajectory. The teacher, observing Robert's behavior, approached him 1 day in the library to check in and see how he was doing. It seemed she saw beyond his academic struggles and recognized that there must have been a deeper issue. Robert shared that this was the only teacher who could work with him one-on-one. Eventually, Robert felt comfortable enough to share what was happening to him at home and with the teacher, and he agreed to meet every week to check in so that Robert could have a safe space to talk.

In retrospect, Robert said he only realized the impact of those weekly check-in meetings once he was older. At the time, they seemed useless, but he continued with them. He credits those meetings and the teacher's kindness in approaching him about what might be going on to his motivation to finish high school, which ultimately led to his acceptance into university.

Fast forward 3 years, and Robert struggled again with anxiety at school. During the first 2 years of his undergraduate degree, he was able to avoid socializing and classes that required presentations. In this third year, courses became more intimate in size and required group discussions and presentations as part of the criteria for passing the course. Robert shared that his anxiety from school largely conflicted with his goals and a strong desire to complete his degree and pursue graduate school. He was increasingly becoming disheartened and began to suffer from depression as well as anxiety. Robert expressed that during his time as an undergraduate student, he suffered terribly from feelings of self-hatred and  low self-esteem because he felt he was not living up to the standards he set for himself and would never be able to accomplish his goals. One day during his third year, he approached a professor after class to discuss participation marks and an assignment that required a presentation. He begged the professor to allow him to write his thoughts on the course material through email for participation and write a paper instead of doing the presentation. The professor agreed, so that is how Robert completed the course; however, his weekly participation emails turned into thought-provoking conversations about research and theory related to the course material. His professor was impressed by Robert's ideas and said he was saddened that Robert did not feel confident enough to speak up in class or share his knowledge with others. Through his professor's encouragement, Robert began to speak up a little bit more each class. Once the course was complete, the professor and Robert remained in touch and continued their discussions, and the professor continued to encourage Robert's academic growth. By the time Robert had graduated with his undergraduate degree, he had been accepted into graduate school under the supervision of the same professor who had mentored him a couple of years earlier. By his standards, Robert had overcome some profound struggles and succeeded.

Robert, now a professor himself, said that he often thinks back on his life and wonders the course his life would have taken had he not encountered those two teachers whom each took the time to build a relationship with him and encourage him to thrive. He shared that he often thinks about the abuse he endured, how little he felt about himself, and how two strangers somehow found a way to believe in him and help him overcome his adversity.

Robert is not alone in the abuse he endured as a child. There are children all over the world who will suffer either physical, emotional, and/or sexual violence at any given moment. They may also or only be exposed to some form of violence in their household or community. Further, like Robert, they may be exposed to a parent who has been incarcerated or struggles with substance use. Or all of the above. The continuous occurrences of child violence have perpetuated an endemic issue of suffering among those who endure it. However, the issue of child violence and maltreatment is more complicated than the experiences alone. As this book will detail, early adverse experiences create a cascade of subsequent effects that can institute further harm and suffering if left unmitigated. The adverse childhood experience (ACE) conceptual framework provides insight into the deleterious consequences of trauma and stress on child development. Past and emerging research on the topic has underscored the distinct biological and psychological disruptions and irregularities that may be observed among children who have been exposed to ACEs. For instance, neural structural irregularities as a result of prolonged exposure to toxic stress may disrupt cognitive, behavioral, and socioemotional functioning. The disruptive pattern of ACEs on biopsychosocial development may then impede healthy adaptation and present the child with challenges in navigating their early years in a way that promotes healthy development and well-being. Beyond the short-term impact, we may also observe harmful long-term consequences in ACE victims well into adulthood. It is critical to disentangle ACEs to provide insight into implications on human behavior and functioning. For instance, in looking at the issue of problematic behavior in adults, such as violence that leads to incarceration or health risk behaviors that lead to cardiovascular illnesses, it may not be overtly apparent that what is being observed is potentially stemming from the transmission of trauma or adversity and maladaptive coping across time. Robert's story provides an overview of how protective factors, such as a trusted adult, can buffer against early adverse experiences and their impact on life outcomes. On the other hand, Robert's mother and father provide examples of how unhealthy coping with stressors or adversity can negatively harm individual and family well-being. Disentangling ACEs to highlight the link between exposure and behavior is critical in adopting an understanding of how to break intergenerational cycles of abuse and trauma and instill resilience among those overcoming barriers. Thus, this book aims to shed light on the issue of child maltreatment and its encompassing effects on child development. We closely examine adverse childhood experiences and trauma, including definitions and contextual variations, risk factors, neurodevelopmental and psychopathological implications, intervention, and resilience.

Chapter 1: Introduction

Abstract

The present chapter provides an overview of Adverse Childhood Experiences (ACEs). The history of its conceptual framework is discussed, including historical perspectives on child maltreatment. Consequences of ACEs are also outlined, along with an introduction into the biopsychological effects, including toxic stress and trauma.

Keywords

Adverse childhood experiences; Child abuse; Maltreatment; Toxic stress; Trauma

The present chapter provides an overview of Adverse Childhood Experiences (ACEs). The history of its conceptual framework is discussed, including historical perspectives on child maltreatment. Consequences of ACEs are also outlined, along with an introduction into the biopsychological effects, including toxic stress and trauma.

Inhuman Treatment of a Little Waif, a New York Times article published on April 10th, 1874, was written about a 10-year-old girl named Mary Ellen McCormack (not her real name) who was orphaned and then adopted by a couple in Manhattan, New York (Markel, 2009). Soon after the adoption, the child's adoptive father passed away, leaving Mary Ellen in the care of her adoptive mother, who inflicted severe physical and psychological abuse on her. It was not until community members, who saw marks on the little girl, intervened that the case was brought to court, and the adoptive mother was trialed for what she had done. Mary Ellen testified the following in court against her adoptive mother:

I have now on my head two black-and-blue marks which were made by Mamma with the whip and a cut on the left side of my forehead which was made by a pair of scissors in Mamma’s hand; she struck me with the scissors and cut me. … I never dared speak to anybody, because if I did, I would get whipped.

New York Times, Markel, H. (2009). The child who put a face on abuse. New York Times, 15, D5.

Mary Ellen's adoptive mother was ultimately convicted of assault and battery (Markel, 2009). This case was ground-breaking within the justice system at the time and set the stage for future laws and the development of protective agencies that began to advocate for children's rights. Mary Ellen's case inspired the creation of the New York Society for the Prevention of Cruelty to Children in December 1874, which was believed to be the first agency in the world that worked to protect children against harm (Joav Merrick et al., 2017). Interestingly, at the time of the New York Times publication, there had not been any laws in place to protect children like Mary Ellen against caregivers who abused them. There were more laws to protect animals than to protect children during that period (Markel, 2009).

Since the case of Mary Ellen, many more cases of children who have suffered from abuse at the hands of caregivers have emerged. This has prompted more and more countries to buckle down on combating abuse and advocating for children's rights. For example, following New York's path to providing protection for children, Toronto established its first Children's Aid Society in 1891 (Family & Children's Services, 2022). Over the 19th century, and as various agencies worked to acknowledge and bring more understanding to the issue of children's rights, children were increasingly viewed less as property and were provided with better protection.

Besides regulatory bodies that work to protect children from maltreatment, research on the topic has also made headway in facilitating an understanding of what might constitute child maltreatment and its relentless ability to create stress and trauma within an individual that could potentially remain with them for a lifetime. This chapter will outline the complex nature of child maltreatment, the underlying processes involved in how abuse is internalized, and the long-term effects that may permeate adulthood.

Adverse childhood experiences

Over the years, research has increasingly demonstrated a clear causal link between health risk behaviors and the onset of various physical ailments and diseases, many of which contribute to the decline of quality of life or even the onset of early death (Felitti et al., 1998). While being diagnosed with cardiovascular disease, for example, is unlikely to elicit reflections on early childhood experiences at first glance, more and more research indicates a link between early life experiences, future lifestyle choices, and poor health outcomes later in life. It is critical, then, that public health and medical professionals advocate for more awareness of the consequences of early childhood trauma and its association with poor lifestyle choices. For instance, many people have a general understanding of the effects that continuous consumption of fast food over time can have on health. We know, for example, that there is a link between this kind of consumption and its potential contribution to high levels of cholesterol and heart disease, among other cardiometabolic outcomes (Bahadoran et al., 2015). In another example seen in Canada, cigarette smokers are reminded of the many health consequences that smoking may lead to due to a mandatory law requiring cigarette manufacturers to place health warning labels on their packages (Government of Canada, 2019). With increased health-promoting advertisements and public health advocates spreading awareness of how detrimental certain lifestyle choices can be to our physical and mental health, why do some people struggle to make healthier choices? Further, and beyond physical health concerns, why do some people commit crimes, misuse substances, struggle to provide love and nurturance as a parent to their child, or maintain healthy relationships? The answers to these questions are not straightforward. Based on decades worth of research on child trauma and abuse, we now understand the biological and psychological implications that these early negative experiences have on shaping who victims may become. The residual effects of these negative early experiences can have a long-lasting impact on social interactions, relationships, and capacity for coping. Thus, the answers to questions about negative outcomes in adulthood, such as health risk behaviors, are a part of a complex integrative process involving both biological and environmental factors. Unresolved trauma and pain makes up a hidden epidemic that is largely associated with the social determinants of health and well-being across the lifespan. We now know that childhood adversity and trauma are not only an experience that children endure but make for a public health crisis involving physical and mental health and generational implications if left unmitigated.

Child maltreatment is not a new topic. Researchers have long studied the effects of child maltreatment on mental health; however, it was not until researchers started noticing some commonalities among people with physical health problems that it became clear how early experiences can be all-encompassing. Child maltreatment generally refers to the neglect or abuse that a child experiences. Maltreatment can be perpetrated by a stranger or an adult the child knows well, such as a parent. It was not until the 1990s that maltreatment was conceptualized as more than abuse but as a framework for understanding how early childhood experiences can disrupt healthy development and shape outcomes in adulthood. In the early 1990s, Dr. Vincent Felitti, a physician in the United States, conducted a study to examine the relationship between an individual's life events and obesity. The participants recruited for this study had entered a weight management program. They were compared to a control group of nonobese adults through interviews to assess childhood experiences that might have correlated with weight outcomes in adulthood (Asmundson & Afifi, 2019; Felitti, 1993). Dr. Felitti (1993) found that the participants who had struggled with obesity indicated a higher prevalence of sexual and physical abuse in their childhood and the loss of a parent compared to nonobese participants. The main takeaway from this research appeared to be the differences in experiences of abuse between obese and nonobese individuals, which highlighted the likelihood of food consumption being a coping mechanism for what overweight individuals had suffered in their childhoods.

The study on early childhood experiences and obesity by Dr. Felitti (1993) sparked further interest in how early adversity and trauma stemming from maltreatment affect outcomes in adulthood. Intrigued by the connection, the Center for Disease Control and Prevention (CDC) and Kaiser Permanente in San Diego, California, launched what has been widely referred to as a landmark study within the field of child psychology and public health (Petruccelli et al., 2019).

The study was conducted between 1995 and 1997 in two separate waves involving approximately 17,000 participants (Asmundson & Afifi, 2019). After visiting the Kaiser Permanente's Department of Preventative Medicine in San Diego, California, participants were recruited for an overall health assessment and were sent a family history questionnaire.

Wave one assessed seven categories of adverse childhood experiences (ACEs), and wave two assessed the same seven categories and added two types of neglect.

Accordingly, the categories of ACEs include three forms of abuse: psychological, physical, and sexual, and four forms of household dysfunction: substance use, marital violence, mental illness, and/or incarceration, and two more categories, which were added after the initial wave in the study: parent separation, and emotional or physical neglect (Lacey & Minnis, 2020).

The study's results indicated that the most common occurrences of early childhood adversity appeared to be exposure to neglect, witnessing domestic violence and related household stressors, and abuse (Felitti et al., 1998). According to the investigators, the study showed that approximately two-thirds of the respondents reported an event that fell within at least one category of adversity, and about 40% reported experiencing an event that fell within two or more types of adversity. The study further said that one in six men and one in four women indicated that they had experienced childhood sexual abuse, which, for both sexes, appeared to be linked to depression, substance use, or marital problems in adulthood. Both men and women were equally vulnerable to childhood sexual abuse and adverse outcomes in later life (Felitti et al., 1998). The study also reported evidence of a dose-response relationship between the negative experience in childhood. The investigators further recorded that those adults who had experienced four or more categories had a 4-12-fold increase in smoking, poor self-related health, 50 or more sexual partners, and some form of a sexually transmitted disease. There was also a 1.4–1.6-fold increase in physical inactivity or obesity (Felitti et al., 1998). And the researchers further reported also appeared to be an increased risk of various diseases, including cancer, chronic lung disease, or liver disease, about exposure to multiple categories of adversity.

The ACEs study provided clear evidence linking early childhood trauma to prolonged health-related consequences into adulthood. As discussed throughout the rest of this chapter, the path from exposure to maltreatment and negative outcomes is not simplistic. Rather, the trajectory includes a variety of complexities that factor into how development is shaped.

For instance, the result of these effects includes disruption to a variety of physical and psychological systems. The dysregulation from these negative experiences can impair daily functioning and contribute to poor lifestyle choices, diseases, and the early onset of death. As Asmundson and Afifi (2019) suggest, more research is required on the subject matter to fully understand how duration, intensity, and frequency factor into how adversity is experienced and becomes translated through lifestyle choices in adulthood. As we now understand, it is not simply the lifestyle choices of adults that contribute to the risk of health concerns. There may be underlying causes stemming from residual suffering of traumatic experiences that stay with the individual through critical periods of development and remain unresolved that play a role. Without support or intervention, child adversity and trauma can have a widespread impact across the lifespan, contributing to maladaptive coping mechanisms to compensate for psychological and physical disturbances that result from these experiences. The processes involved in adverse childhood experiences are complex. Not everyone who experiences ACEs will grow up to make unhealthy choices and have adverse outcomes in adulthood. Some key indicators that might inform how the trauma process unfolds regarding ACEs include the individual's stress response and capacity for resilience.

Toxic stress

Stress is a normal part of the human experience. The human body is designed in such a way that our bodies produce a physiological response to alert us to challenges, or perhaps danger, in our environment (Woodcock, 2022). Stress triggers our fight-or-flight response, which activates specific reactions to perceived threats that, from an evolutionary perspective, are intended to help our body adapt and survive. These responses can include a fast heart rate or increased breathing rate. Overall, stress is designed to be a proactive response intended to facilitate our ability to navigate circumstances that deviate from what our brain may consider safe or normal. While stress is a standard biological indicator that lets us know that we must work harder, continuous activation of the stress response system can lead to unhealthy and potentially harmful consequences. For instance, studies have shown that ongoing exposure to stressors can disrupt brain circuitry and dysregulate our stress response system (Hornor, 2015). This type of disruption makes physiological changes that have the potential to disrupt functioning, which can also negatively affect physical health (Aristizabala et al., 2020). To maintain emotional stability and prevent long-term physical health-related consequences from prolonged exposure to stress, the brain must be able to regulate hormones and neurotransmission, a process referred to as homeostasis. An inability to achieve homeostasis can result in lifelong challenges that affect the aging process, inflicting problems such as inflammation and deficits in metabolism (Pomatto et al., 2019). Prolonged exposure to stress has also been linked to negative impacts on the circulatory system including hypertension and coronary artery disease, for example (Esch et al., 2002).

The stress response starts with the activation of the sympathetic nervous system and hypothalamic-pituitary-adrenal (HPA) axis, which involves the production and secretion of hormones that provoke behavioral and psychological changes (Hall et al., 2012). These biological changes promote our capacity to endure the environment's demands (Miller & O'Callaghan, 2002), allowing us to adapt and overcome the encounter. Once input from the stressor is perceived, corticotropin-releasing hormone and arginine vasopressin are activated within the hypothalamus, which triggers the activation of the pituitary gland and the release of the adrenocorticotropin hormone (Beurel & Nemeroff, 2014). The cascade of stress-induced hormone secretion ends when the adrenal cortex stimulation has occurred, triggering the release of glucocorticoids, such as cortisol (Tarullo & Gunnar, 2006). Continuous exposure to stress can create heightened responses throughout parts of the brain involved in the stress and fear response. The accumulation of stressful events and their effects on the body can have a devastating and long-lasting impact on mental health and physical well-being (Cohen et al., 2019).

Not all stress is destructive or damaging. Our ability determines the extent of stress and its subsequent effects on a person, or inability, to cope with the stressor and to alleviate the biological response back to baseline. Studies have shown a link between adversity, altered activity of the HPA axis, and subsequent negative psychological and physical impacts (Joos et al., 2019). The stress response and its effects involve various factors, including duration, intensity, timing, and the context in which the stressful situation is happening (Center of the Developing Child Harvard University, 2022). For example, when a child is being abused, the amygdala, a brain structure involved in a person's fear response, might increase in size as an adaptive response to the threatening environment to increase the chance of survival (Garner & Yogman, 2021). However, continual exposure to stressful situations that elicit this kind of change in neural structure is harmful over time and creates dysregulation (Garner & Yogman, 2021). Survival mode should be temporary and level off once the threat is no longer imminent.

Suppose a person is constantly in a state of stress, with their brain activating accordingly. In that case, changes in neural structures may become permanent and facilitate extremely heightened reactions to situations that would not typically elicit a stress response. Perhaps this may explain situations where there is a differentiation between views of a given situation. When people have suffered extensive stress, they will likely become more vulnerable to perceiving the world around them through a stress-induced lens, leaving them on high alert for threats. Though the environment can impact how the brain is impacted by stressors, there is also a genetic component. Research suggests that exposure to ACEs can dysregulate physiological mechanisms such as the expression of genes, neurological structures, the immune response, and endocrine functioning (Ortiz et al., 2022). Thus, stressors may elicit genetic predispositions, responses solely based on the environment, or may ignite an interaction between both genes and the environment.

One major contributing factor in mitigating the effects of stress and promoting a sense of calmness includes stability and safety in a person's relationships (Garner & Yogman, 2021). This is important because it teaches children how to cope and regulate their responses, ensuring they have a buffer from the stressor and feel secure in the given situation. Safe, stable, and nurturing relationships support children in acquiring the social and emotional skills needed to thrive and be resilient (Garner & Shonkoff, 2012; Garner & Yogman, 2021). In circumstances where stress is under control, future encounters down the road may be met with a healthy and proactive response, which can teach the child that life itself is not stressful and challenges can be overcome. This type of protection buffers against stress and encourages resilience.

Ultimately, stress is a subjective experience that can include immense pressure, frustration, or even anger. As people are shaped by a combination of their experiences and predispositions, stress can affect learning and behavioral, emotional, and social functioning. Stress can be short-lived as well, as we learn to navigate challenges that we are facing and understand adaptive coping mechanisms to mitigate its effects on our mood or emotional state. Stress does have benefits, such as alerting us to imminent threats, but it can become problematic based on the intensity and prolonged exposure, which can negatively impact human functioning (Russell & Lightman, 2019).

Stress is a common human experience, however, there are varying degrees to which it is experienced and to which it impacts biopsychological functioning—i.e., not everyone will suffer from long term effects (Ryan et al., 2016). For instance, positive stress is a short-lived physiological response to a nonthreatening event, such as planning a fun event. The experiences described here are typically infrequent, and the psychological and physical effects are generally mild and safe (Franke, 2014). A person experiencing some form of positive stress may have one or more supportive persons they can rely on to help mitigate the pressure while moving toward experiencing the event. Since positive stress is short-lived, once the event is over, the person's emotions and physiological response is stabilized as the response returns to baseline (Dhabhar, 2014). Adopting healthy coping responses to positive stressors will mitigate against negative consequences of stress and potentially improve mental health (Algorani & Gupta, 2022). Reactions to positive stress experiences may instill an ability to recover from the experience and subsequent effects and provide motivation to conquer similar situations, such as meeting new people (Franke, 2014). Handling positive stress as a child could have benefits as the child may develop tools to approach more challenging situations healthily with the security of their support system and resilience. Under a more intense experience with stress, compared to positive stress, tolerable stress is a response to potentially traumatic, major life events such as a divorce or the death of a family member (Garner, 2013). Under circumstances where an event that has the potential to shape the outcome of our lives occurs, protective factors are critical in reducing the chances of the stress response being prolonged over time. Should the effects from the event become extensive and lengthened over time, the stress response would no longer be tolerable. Under these circumstances, support from another person, such as an adult relationship, can contribute to adaptive coping in stressful situations (Armstrong et al., 2005). An example of social support can be healthy family functioning in which family members can discuss problems and rely on one another openly. Essential components of positive and tolerable stress include external support to buffer against adverse reactions to the stressor. Support is fundamental in activating coping with ACEs and mitigating long-term physiological harm (Friedberg & Malefakis, 2022). With protective factors providing a sense of security and stability, these tolerable stressors are manageable and can enable healthy coping over one's life.

Toxic stress results from continuous exposure to traumatic experiences (Hornor, 2015). While occasional stress is expected, stress can become dangerous when the encounter is constant and intense. Chronic activation of our stress response system dysregulates the body's ability to return to baseline and leads to continual exposure to stress-related hormones and neurotransmitters. This can be especially dangerous in early life during critical periods of development if there is no buffering protection from a parent. For example, ongoing adversity or trauma may contribute considerably to the onset of toxic stress and lead the path to health risk behaviors and to disease (Bucci et al., 2016) The frequency and the damaging effects of toxic stress change the brain so that there is a subsequent risk of developing psychological and physical health concerns (Joos et al., 2019).

Franke (2014) suggests that the consequences of toxic stress may not be known until adulthood and can manifest into poor stress management. Resilience measures one's capacity to overcome adversity and positively adapt to life's circumstances, including the maintenance of mental health (Hermann et al., 2011). The development of resilience may be based on early experiences and outcomes and support systems that have helped the child overcome challenges. Therefore, adversity may not always elicit a toxic stress response that leads to poor health outcomes later in life. This may be attributed to resilience, which is a necessary buffer while navigating stressful situations. Without resilience, unhealthy lifestyles that facilitate the onset of various mental illnesses, such as depression or anxiety, and can have determinantal consequences on physical health, such as obesity and cardiovascular disease (Bonnet et al., 2005). A typical stress response includes acknowledging the stressor, the brain's reaction to it, and then returning to baseline once the stressor is removed, however, research has indicated that maltreated children present with irregularities in cortisol levels and HPA-axis activity (Tarullo & Gunnar, 2006). While enduring tolerable stress, the circumstances are predictable, and the body and brain can recover if the child is protected and the stressor is removed; however, toxic stress will occur when the body cannot recover, and there is no protective buffering and risk factors persist (Shanks & Robinson, 2013). Children with parents with substance abuse or mental illness may also predispose their children to toxic stress due to their inability to cope with stress. This can likely be attributed to the parent's failure to model healthy behavior, a critical part of healthy development during periods when the child is learning about the world around them. Modeling healthy ways to acknowledge and cope with stress will instill future healthy coping responses in the long term once the child is no longer dependent on their caregiver. This process facilitates resilience and the capacity to adapt to stressors and overcome adversity.

Not everyone who experiences intense, or frequent adverse or stressful conditions will suffer negative consequences later in life. Coupled with, or in place of a supportive buffer such as a parent, some helpful approaches to assisting children in overcoming the effects of stress include psychological therapies such as cognitive behavioral therapy (Xian-Yu et al., 2022) and mindfulness-based practices such as yoga (Racco & Vis, 2015). A study conducted by Beltran et al. (2016) found evidence linking positive outcomes between trauma exposure among a sample of boys and treatment that incorporated both yoga and therapy. Research has further suggested that yoga-based mindfulness for children as young as preschool may help to regulate emotions and behavior (Razza et al., 2020). Creating collaborative taskforces in especially vulnerable neighbourhoods, such as those with high incarceration or drug rates, would also be beneficial. One example can be seen in Philadelphia, Pennsylvania which was once rated the fifth largest city and home to some of the poorest neighbourhoods, involving high rates of child abuse, incarceration, community violence, and food insecurity (Pachter et al., 2017). Accordingly, the city used the ACE framework to create the Philadelphia ACE Task Force to help identify individuals and organizations within health care, social services, and public service fields to see if they would be interested in assisting with the development of a trauma-informed approach to combating stress and adversity (Pachter et al., 2017). This example highlights how working at the community level is just as important as intervening at the family level in identifying, assessing, and working with children subjected to adversity and stress. Since we know that stress, especially among children, can be translated through poor coping mechanisms such as behavioral or social problems, it is critical that professionals at various institutional levels, such as educational and health levels, be equipped with the framework and tools required to identify at-risk children.

In a 2016 study focusing on food insecurity, Knowles et al. investigated parents' perspectives on the impact of toxic stress on children's mental health. In their research, they surveyed and interviewed 51 parents of children aged four and under to understand how parents reporting marginal, low, and very low levels of food security explain the relationship between trade-offs associated with the lack of food and how this affects parents' mental health and well-being. The study highlighted adversity in the form of food insecurity and how this experience can transpire into toxic stress. Poorer communities, where food insecurity is expected, will likely be less equipped with the resources to provide parents with the tools to help their children. These parents are dealing with their stress and anxiety; thus, it becomes a vicious cycle. This highlights the necessity of a targeted approach to especially vulnerable communities to promote awareness and identification processes to work with children subjected to food insecurity and long-term consequences.

It is estimated that 50% of the population is exposed to adversity (Andersen, 2015; McLaughlin, 2016; Waite & Ryan, 2019). However, this does not mean that 50% of the population is at risk for toxic stress and developing long-term health concerns. The likelihood of adverse effects from adversity exposure depends on many factors, including how the person is supported and how their brain develops due to the support and ability to overcome the stress. Under circumstances where a child cannot cope with toxic stress due to adversity, the child may remain traumatized, perpetuating further struggles with mental and physical well-being.

What is trauma?

Trauma is the pathological consequence of prolonged stress and adversity. Originating from the Ancient Greek language, the word itself means to wound or damage (Winders et al., 2020). Trauma results from exposure to highly stressful events that negatively impact a person's ability to cope (Giller, 1999). Another source has suggested that the word trauma means to penetrate, coming from the Ancient Greek word diatitreno (Soutis, 2006). Adversity falls along a broad spectrum of individual experiences, many of which may elicit differences in reactions and the onset of stress and trauma. Trauma research has struggled to define what trauma is precisely. This is mainly attributed to the fact that it is more of an experience than a single instance (Enlow et al., 2013; Huang et al., 2014; Winders et al., 2020). The challenge is operationalizing trauma in a way that does not present ordinary stresses as pathological (Haslam, 2016; Weathers & Keane, 2007).

Trauma is something that every adult has likely encountered at least once in their life. Still, it is estimated that only 7% of adults will continue to meet the criteria for posttraumatic stress disorder (PTSD) across their lifespan (Harvard Medical School, 2007; Winders et al., 2020). 8%–15% of adults will experience symptoms of PTSD (Benjet et al., 2016; Bistricky et al., 2017; Kilpatrick et al., 2013; Winders et al., 2020), whereas the rest do not produce any symptoms (Kessler et al., 2005; Schnurr et al., 2002; Winders, 2020).

Childhood trauma is the consequence of adverse, potentially damaging occurrences that fall on a wide spectrum of subjective experiences, including maltreatment such as physical and emotional abuse (Morgan & Fisher, 2007; Reininghaus et al., 2016). Exposure to trauma in childhood can make individuals more sensitive to subsequent adversity through enhanced stress sensitivity and threat anticipation (Howes & Murray, 2014). For example, research has shown that individuals exposed to physical and sexual abuse in childhood reported intense adverse emotional reactions to daily life stress (Glaser et al., 2006). Similar results have been found in responses in individuals with depression (Wichers et al., 2009) and enduring psychotic disorder (Lardinois et al., 2011; Reininghaus et al., 2016).

The residual effects of prolonged exposure to stressful situations and subsequent neurobiological changes are associated with the fear and stress response systems. For instance, as the brain receives incoming stimuli from the environment, it determines vital information regarding the context in which the stimuli are being perceived (e.g., who and what). This information is translated through the prefrontal cortex to make sense of the interaction and understand what is occurring (Cross et al., 2017). Prolonged exposure to adversity may, therefore, heighten the physiological stress response and create structural changes over time that elicit future inappropriate reactions to situations. Individuals who have endured these changes may be on heightened alert for incoming threats, even in typically nonthreatening cases. The hippocampus, prefrontal cortex, and amygdala are critical neural regions that function together and can be impacted to create these types of inappropriate responses (Acheson et al., 2012; Cross et al., 2017). Under circumstances where a trauma response is projected onto a situation that does not require this type of response, an individual likely has not learned to cope with previous traumatic encounters. This alteration to biological and psychological processes can dysregulate emotions and facilitate the onset of trauma-related disorders (Cross et al., 2017). This can inhibit the ability to navigate future stressors healthily and impacts an individual's ability to develop resilience.

Type one trauma is described as acute and straightforward, perhaps an act of God, where the incident is triggered at random (Brunzell et al., 2016; Waite & Ryan, 2019). An example of this could be a car accident. Under circumstances of type one trauma, the likelihood of any stigma attached to the victim who has undergone other, less random forms of trauma is more minor.

In contrast, type two trauma is more complex than type one. Whereas type one trauma can be attributed to an act of nature, type two trauma is often inflicted by another human (Waite & Ryan, 2019). Accordingly, type two trauma typically starts in childhood and is premeditated, deliberate, and continuous (Kira, 2001). An example of this could be sexual assault by a caregiver, which may elicit an researchers have referred to as betrayal trauma. First described by Jennifer Freyd (1996), betrayal trauma is the violation of trust between the perpetrator and the individual dependent on them for their survival. Type two trauma can also be inflicted by someone the victim does not know, which can still create long-lasting damage and suffering to the person's mental and physical well-being.

While both types of trauma have the potential to be painful, the main difference between type one and type two trauma is the person's relationship with the perpetrator. For example, the effects of a car accident may linger and be damaging, but the fact that the incident was likely unintended might factor into how people cope. If the victim were targeted, this would likely play a role in the long-term consequences as the person seeks to come to terms with what has happened to them.

Intergenerational trauma

Intergenerational trauma refers to the cycle of trauma inflicted on families, transmitted across generations of individuals. When a parent or caregiver suffers from unresolved trauma, it can be transferred to their children through various interactional patterns (Hesse & Main, 2000; Isobel et al., 2019). Transmission of intergenerational trauma is discrete in that it may not be an exact replication of the source of trauma but could be a result of a reaction or a vulnerability (Isobel et al., 2019). Intergenerational trauma observed within a child may not be a direct result of a parent but can in fact be a greater part of the child's family and perhaps linked to a grandparent, for example. This phenomenon has been observed in Holocaust survivors whose children and grandchildren have suffered effects of PTSD (Krippner & Barrett, 2019). Intergenerational trauma provides a framework for understanding the effects of past trauma and its subsequent effects on familial interactions. It further speaks to the oppressive effects of trauma on marginalized populations who may not have adequate access to resources to mitigate sociocultural disadvantages (Rides at the Door & Trautman, 2019).

The complexity of the trauma experience and its effects depend upon a myriad of factors embedded within the circumstances under which the trauma occurred, including the duration, intensity, and cycle of the trauma. Thus, when a child is maltreated, the event may be traumatic, but whether it affects the child long-term depends on these factors and how the child learns to adapt and move forward. The trajectory of trauma is essential in determining the path that the life course will take. Winders et al. (2020) suggest that a critical question in trauma research is why some people are more likely to suffer long-lasting effects of a traumatic experience than others who appear to be resilient and remain asymptomatic. Accordingly, Winders et al. (2020) further reported that the variables involved in the onset of posttraumatic stress disorder (PTSD) can include the type and timing of the trauma in the individual's lifecycle and its predictable and controllable nature. The authors further discuss how personality, education, personality strengths and other pretrauma factors, such as social support, can impact outcomes.

It appears that children are among the most vulnerable population to trauma, which may result from the distribution of power in society (Waite & Ryan, 2019). Compared to adults, children have less authority and decision-making capabilities. Further to this point, racial minorities in the United States are especially vulnerable to trauma due to structural inequalities and the disproportionate experience of adversity, which permeates the individual, family, and community levels (Waite & Ryan, 2019). The risks associated with childhood trauma are substantial and contribute to the onset of mood disorders such as depression and anxiety (Jansen et al., 2016). A study by Kuzminskaite et al. (2020) in the Netherlands highlighted the prevalence of current or remitted depressive or anxiety disorders among individuals who indicated having gone through childhood trauma. Their study further showed a partial explanation for choices in adulthood that result in poor health outcomes as a likely result of dysregulation stemming from childhood.

Trauma is more than an individual problem; it is a psychosocial, medical, and public policy problem (Bellis et al., 2014). The experience of trauma is internal; however, its effects can be externalized through the person's behavior and interactions with the world around them. Addressing trauma at a public level is critical in providing individual support and integration into society when a traumatic event has been experienced. When children experience trauma, it may not be immediately evident that something negative has occurred. During critical stages in neural development, children have less of a capacity to express what has happened to them than most healthy adults. Moreover, during development, children are modeling behavior from the adults closest to them and internalizing experiences in a way where they can make sense of the world around them. Under circumstances where a child is being maltreated and unable to explain or perhaps even understand what has happened to them, their behavior may become problematic. Further, studies have shown that children maltreated have a diminished capacity to do well in school, negatively affecting academic outcomes. For instance, a study by Ryan et al. (2018) found that child maltreatment was associated with low scores on standardized math and reading tests. Children suffering from ACEs may also fall victim to bullying or perhaps be the perpetrator of bullying, discussed in a later chapter.

The family and ACEs

Family, a societal construct, represents a group of people who dwell together and are often related, adopted, or have joined as a family by choice (Halliday et al., 2014; Zinn et al., 2011).

A large part of the child-learning process is embedded within the family, where children are first exposed to various life experiences from the basics, such as language, to problem-solving and the embodiment of values. The family unit also teaches life skills and the standard for regulating emotions and interpersonal development, like socialization. A child's first social group is typically their family, which will model how relationships are made and sustained over time. Children learn primarily through observation in their early years and learn to implement what they see as they navigate relationships and encounters external to the family unit, such as at school or, later in life, at work. According to family systems theory, the psychopathology of an individual can stem largely from a disturbed family unit (Kerig, 2019). In other words, when dysfunction is present within the family unit, there may be a more substantial likelihood of adverse outcomes for children.

Family provides the framework for the social, psychological, and biological development of its members (Epstein et al., 1978). According to the McMaster Family Functioning Model (Epstein et al., 1978) family's functioning relies on an incorporation of its capacity for problem solving, communicating, family roles (i.e., repetitive behaviors of each member to fulfill a role), affective responsiveness and involvement, and behavior control (how situations are handled, socializing behavior and the meeting and expressing psychobiological needs). For a family to function in a healthy and positive way, it is important for it to embody values that incorporate characteristics that facilitate adaptive coping. One study showed that family functioning could lessen the impact of adverse childhood experiences on adolescent health and well-being outcomes (Balistreri & Alvira-Hammond, 2016). Simple routines such as eating together as a family and discussing each other's day with a vested interest may help buffer against daily stress and provide a sense of security.

Children rely on their families, particularly their parents, to provide the necessities of life, including shelter, clothing, food, and emotional security. The family should be a safe environment where a child learns to express themselves fully. Consistency and structure are essential in enabling a child to develop. The family plays a significant role in helping a child regulate their emotions and behavior (Fosco & Grych, 2013).

John Bowlby and Mary Ainsworth dedicated many years of their career to studying the importance of early childhood bonding and attachment toward their caregiver. They theorized that if children cannot feel secure or safe with their caregiver, they will not be able to form a healthy attachment (Bowlby & Ainsworth, 2013), which will permeate future relationships into adulthood. When a child is maltreated, healthy bonding with a caregiver will not be possible. Attachment disorder creates an inability to bond with others and is often displayed via destructive behaviors, cruelty to others, constant lying and poor impulse control (Crosson-Tower, 2013; Levy & Orlans, 1998). This is likely attributed to a deep distrust formed when the child is maltreated and does not feel safe. When an attachment is created, the child learns a lesson on trust, reliability, and security. Therefore, the family is vital in providing the framework for bonding and attachment.

As with the case of Mary Ellen, discussed at the beginning of this chapter, the presence or continuation of child maltreatment can depend heavily on societal beliefs around the issue. While society gives parents automatic authority to control and make decisions for a child, the standards upon which parental decisions are deemed healthy rely primarily on customs within a given community. Beyond the family unit, there are overarching assumptions about fundamental human rights in many countries, such as Canada and the United States. For instance, children are expected to have access to education, food, shelter, and medical care. While these are the rights that many societies have imposed, under circumstances where a child is suffering adversity because of a caregiver, there are sometimes barriers to what the child can access without the help of a parent. This poses a question as to who, if not the parent, enforces standard care for children when a parent is unwilling or incapable of making healthy choices for their child? Further to this point, if a child is being abused behind closed doors and cannot effectively communicate what is happening to them, how can society intervene? In the case of Mary Ellen, community members only noticed the abuse once it had gone too far and the marks on the child's body were severe. Rules and regulations have evolved significantly since the 19th century. We now understand that ACEs and childhood trauma are more than isolated incidents that may occur; instead, they are all-encompassing, damaging, and potentially life-threatening if left undetected and untreated. The issue of race is also a factor when considering adversity and trauma. For instance, there may be higher rates of risk factors associated with adversity in communities of color (Shonkoff et al., 2021; Williams, 2018). For example, according to Shonkoff et al. (2021), black children are three times more likely to lose their mother by the age of 10 compared to white children. Racial minority communities are also more prone to financial strain, which can exacerbate stress and the effects of adversity, such as depression (Russell et al., 2018). The social disadvantages worsen the physiological and mental impact of these experiences, highlighting the importance of identifying and intervening within at-risk communities. Artiga and Ubri (2017) describe immigrants as at a greater risk of developing feelings of uncertainty and fear, which can create adverse health outcomes and interfere with development. Accordingly, this may result in heightened stress as challenges across social and environmental domains increase (Artiga & Ubri, 2017).

Understanding ACEs as an epidemic speaks to the multidisciplinary nature of its discourse, involving professionals across a broad spectrum of domains, including physicians such as pediatricians, teachers, government agencies, and mental health clinicians. Beyond the family unit, a trauma-informed approach must be adopted at various institutional levels to identify differences in the needs of children better. Suppose a child is unable to communicate regarding the abuse or neglect. In that case, they may suffer, and the effects could lead to problematic behavior, such as peer victimization, impede academic success, and perpetuate further challenges and disruptions to adult functioning