Adverse Childhood Experiences (ACEs) are major, compounding risk factors for physical and mental disorders among children and adults. Research has pointed to the need for strategies relieving and preventing trauma. Interventions for trauma, labeled as trauma informed care (TIC), requires observation of resiliency against trauma as well as its negative impacts on health. Catching trauma early in children remains a public health crisis. This article discusses trauma informed care in light of the prevalence and nature of ACEs (i.e., traumatic toxic stress, childhood adversity).
Childhood Adversity: Definition and Scope
Childhood adversity can be described as stressful events or circumstances that are outside of a child’s control, which compounded can be detrimental to his/her physiological and psychological (i.e., cognitive and behavioral functioning).
The most common ACEs fall under childhood abuse, child neglect, household dysfunction, poverty, and peer relational issues (i.e., bullying, lack of friends). However, shocking events such as witnessing the death of a loved one as well as moving frequently are also among many other ACEs. Measuring the behavioral and emotional responses to ACEs in real-time can be helpful in gaining a more comprehensive understanding of their later, longer-lasting effects in adulthood.
Traumatic Toxic Stress: How ACEs affect Neurological Functioning
Health professionals are becoming increasingly aware of the impact social and environmental experiences have on health.
Physiological/Positive Stress, Tolerable Stress, & Traumatic Toxic Stress
Stressors that activate a normal fight/flight response in a child that ultimately helps with personal growth can be described as positive/physiological stressors. More shocking stressors that can be overcome with appropriate parental nurture is tolerable stress. Chronic stressors without a support system can lead to traumatic toxic stress (TTS).
Response to stress involves two systems, the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS). Activation of the HPA axis ultimately results in the release of cortisol, epinephrine, and norepinephrine from the adrenal cortex, which affects many organ systems (i.e., cardiovascular via increasing heart rate). The body must go back to equilibrium at some point, so there is a negative (or counteracting) response in which the levels of cortisol return to baseline when the stressor is deemed gone. In TTS, however, the HPA axis remains activated, wreaking havoc on the body (especially the immune system) with the short term outcome of abnormally high levels of cortisol and the long term of abnormally low levels (or a lack) of cortisol.
Neurologic Remodeling in the Context of TTS
Dysregulation of the HPA axis via TTS has profound impacts on the brain with vulnerability heightened during childhood/adolescence (C/A). TTS results in epigenetic changes with regard to how the body responds to stress. These changes can occur by DNA methylation and histone acetylation that change gene expression. Some of these changes can be reworked during C/A, but others will be rooted throughout the lifetime with the possibility of being passed onto offspring. The hippocampus, amygdala, and prefrontal cortex are particularly affected by HPA axis dysregulation.
The hippocampus is involved in forming new memories and learning. It goes through much change throughout adolescence when learning and memory formation proliferates. TTS suppresses hippocampal neuronal proliferation, leading to long-lasting impairments in memory and learning formation. The amygdala, part of the limbic system, and responsible for the perception of emotions such as fear is activated during stressful events. TTS can lead to over-proliferation of neurons in the amygdala, resulting in more impulsive behaviors (as a reaction to stress). The prefrontal cortex, implicated in impulse control and future planning, will be underdeveloped as a consequence of TTS.
TTS transforms normal physiological responses to stress by regional brain alterations, resulting in hypersensitivity in which neutral events are experienced as shocking and life-threatening.
Epidemiology of Childhood Adversity
Epidemiologic studies on ACEs are relatively new, the original study being conducted in 1998. The population prevalence of having at least one ACEs falls between 55-64%%. A study surveying 42,272 children from nine Balkan countries found the prevalence to fall between 65-83%%. Studies have shown that ACEs likely co-occur and that the prevalence of having four or more ACEs is a staggering 15%%.
Impact of Childhood Adversity and TTS on Health
Studies on ACEs have revealed the need to shift focus from the effects of individual kinds of childhood mistreatment to those of compounded ACEs on children and adults. The negative outcomes of ACEs can be broadly divided into (1) risky behaviors (2) leading causes of death and other long-standing health problems (3) poor mental health and (4) other consequences.
Health Risk Behaviors
There is a dose-response relationship between the number of ACEs and risky behaviors. Four or more ACEs increases the rate of IV illicit substance abuse (11.3 times), severe obesity (1.6 times), sexual intercourse with more than 50 partners (3.2 times), and alcoholism (7.4 times). The adoption of these risky behaviors are likely in response to (and cope with) trauma, referred to as a “trauma organized” lifestyle. Circumstances of limited healthcare with a “trauma organized” lifestyle from neurological alterations mediated by TTS are thought to result in an increased risk of illness and death.
Leading Causes of Death and Other Chronic Diseases
Childhood trauma and four or more ACEs, in particular, can lead to autoimmune diseases (from HPA axis dysregulation), heart disease, lung cancer, stroke, and other problems such as obesity and insomnia.
There is extensive evidence surrounding the relationship between the aggregate number of ACEs and mental health difficulties. Learning and behavioral problems among children are in relation to the cumulative number of ACEs. ACEs have severe implications for the mental health of adults with four or more ACEs increasing the risk of depression and suicide attempts by 4.5x and 12.2-15.3x, respectively. Those who have suffered from multiple childhood traumas and consequent emotional dysregulation may develop PTSD with dissociation and automatic hyperreactivity. This can make traditional treatments especially difficult as PTSD dissociation comes with immense difficulty in establishing relationships as a result of emotional under-engagement.
Approaches to Reducing the Burden of ACEs
A complex interaction between the individual, family, and community exists in ACEs, so prevention interventions and policies can follow the general public health approach, involving primary, secondary, and tertiary preventions. Primary preventions would involve preventing ACEs so future generations of children do not experience them. Secondary preventions would involve immediate efforts after an ACE to mitigate the short- and long-term effects of it on the child. Tertiary prevention would involve treating and reducing the severity of the long-term consequences of ACEs. Psychological first aid (PFA), parent-child interaction therapy (PCIT), child-parent psychotherapy (CPP), and CBT have been shown to be effective interventions for ACEs.
Trauma Informed Care
Trauma Informed Care (TIC) is meant to be a multilevel approach to change the way organizations view and approach trauma, treating children in an informed manner to primarily avoid re-traumatization.
The SAMHSA promotes the use of six broad principles for TIC:
1. Making sure clients feel physically and emotionally safe.
2. Organizations should be transparent and trust staff and clients.
3. Peer support is an essential resource for TIC.
4. Adverse experiences can be healed by every member of a trauma-informed organization.
5. Approaches that are client-focused and empower clients are important.
6. Efforts should be culturally-informed (i.e., gender and historical).
There is emerging evidence on the effectiveness of TIC in improving health-care delivery. Trauma-informed organizations must be sure to properly screen for trauma and operate in tandem with the above principles to appropriately and effectively treat clientele.