“There is no greater agony than bearing an untold story inside you.”
Maya Angelou

Growing up in a home with physical abuse, emotional neglect, mental illness, alcohol use, or drug use are some examples of childhood adversities. The seminal work of Dr. Vincent Felitti and colleagues asked over 17,000 adults to answer questions about adverse childhood experiences — or ACEs — and current health [1]. Results were shocking: More ACEs led to poorer health in adulthood and early death.

It is important to understand that ACEs do not directly cause poor outcomes; there are likely many mediating mechanisms such as maladaptive coping, unhealthy interpersonal relationships, negative health behaviors, dysfunctional thinking styles, and insecure attachments that contribute to these outcomes. In addition to prevention efforts, these are all potential areas in which therapists can intervene to mitigate the long-term effects of adversity.

The political climate in North America has perhaps brought childhood adversity to the forefront in the media (e.g., family separation in the United States, residential schools in Canada), and has likely created an atmosphere laced with fear and danger in disclosing past traumas. In light of this, it is perhaps an opportune time to reflect on ACEs and remind ourselves as therapists of our role to care for clients responsibly and in a safe, and trauma-informed way.

ACEs and Beyond

Although researchers, clinicians, and children’s rights activists have long known that difficult experiences in childhood can have long-term detrimental effects, the ACEs study was the first to present this idea through the lens of medicine and public policy. Understandably then, the ACEs study quickly gained popularity and was the springboard for the ever-growing ACEs research we see today. Felitti and colleagues created a 10-item questionnaire — for each ACE endorsed, an individual gains 1 point on the 10-point scale [1]. The ACEs questionnaire includes the following 10 items:

  1. Physical abuse
  2. Emotional abuse
  3. Sexual abuse
  4. Physical neglect
  5. Emotional neglect
  6. Parental separation or divorce
  7. Living in a home with violence, particularly toward a mother figure
  8. Living in a home with a problem drinker or someone who uses illicit drugs
  9. Living in a home with mental illness
  10. Having a household member go to prison

It is important to consider ACEs beyond the original 10 items included in the questionnaire. Other ACEs to consider include bullying, discrimination, losing a parent, poverty, unstable housing, spanking, war, family separation — the list goes on.

Since the publication of Felitti’s influential work in 1998, many other research groups have demonstrated a dose-response relationship between the number of ACEs and negative physical and psychological sequelae in adulthood. That is, the higher the number of ACEs, the higher the risk of negative outcomes in adulthood.

Graded dose-response associations have been found between ACEs and many physical health conditions in adulthood, such as: ischemic heart disease, cancer, skeletal fractures, liver disease, chronic lung disease, chronic obstructive pulmonary disorder, frequent headaches, recurrent syncope, bowel disease, chronic fatigue syndrome, pelvic pain, fibromyalgia, and obesity.

Difficult experiences in childhood are also robustly related to negative psychological outcomes throughout life, such as depression, anxiety, bipolar disorder, eating disorders, food addiction, substance abuse, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, learning disorders, and suicidal behavior.

ACEs are Common and Disproportional

ACEs are common and have been described as the largest unaddressed public health threat of our time. In the largest US study to date, approximately 62% of adults have experienced one ACE, and 25% endorsed three or more ACEs [2]. At first glance, this may not sound surprising given the high divorce rates in North America; however, a closer look reveals that emotional abuse is the most prevalent ACE (34.42%), followed by approximately equal proportions of parental separation or divorce (27.63%) and household substance abuse (27.56%) [2]. Research on ACEs in Canada lags behind. In a 2012 national survey, 32% of adults reported experiencing physical abuse, sexual abuse, or exposure to intimate partner violence before the age of 16 [3].

Inequalities in stress and adverse social and environmental conditions exist. Higher ACE exposure has been reported by individuals who identify as Black, Hispanic, or multi-racial; individuals with less than a high school education; those who are unemployed, unable to work, or have low income; those with a self-identified disability; and individuals who identify as gay, lesbian, or bisexual. Not coincidentally, this parallels health disparities that exist among minority groups. In Canada, although formal ACEs data are lacking, it is by no means a stretch to speculate that Indigenous peoples, including First Nations, Métis, and Inuit, experience similar disparities in ACE exposure. A look into Canada’s recent history and the current lack of provision of health care and basic necessities to many Indigenous communities highlights the dismal state of affairs.

ACEs are Biologically and Socially Embedded

ACEs get under the skin. Research suggests that ACEs change physiology across body systems [4]. In the face of long-term stress, the allostatic systems (nervous, endocrine, and immune systems) are over-loaded and become less stable, less adaptable, and weaker [4]. This is one possible way that ACEs increase physical and psychological vulnerability. In tandem, ACEs can affect health through social cascades.

What do childhood adversities have in common? Stress. More specifically, toxic stress. Now, stress is not necessarily a bad thing. Part of healthy development is learning how to cope with stress and adversity. In response to physical or psychological threat, the body releases hormones which activate the sympathetic nervous system. This results in an increased heart rate, blood pressure, and release of stress hormones, such as cortisol. The stress response system can have three effects on the body: (1) Positive: stress has a positive effect on the body; (2) Tolerable: tolerable effect on the body; and (3) Toxic: toxic effect on the body. It is therefore important to consider the intensity, frequency, and duration of ACEs, as well as other contextual factors such as the presence of any supportive adult relationships.

Positive response to stress: In response to minor or positive stress (e.g., the first day of daycare) and in the context of secure attachment relationships or other supportive relationships with adults, a child’s stress response is brief and quickly returns to baseline. This characterizes a positive and normal stress response that is necessary for healthy development and adaptive behavior.

Tolerable response to stress: In response to more severe or longer-lasting adversities, such as the death of a loved one, the body’s sympathetic nervous system is activated to a greater degree. Provided that the stressor is time-limited and that the child has access to supportive adults, physiological effects return to baseline and any negative effects are thwarted.

Toxic response to stress: In response to extreme, frequent, and/or prolonged exposure to adversity, such as abuse or neglect, and in the absence of supportive adult relationships, the prolonged activation of the stress response system can have damaging effects on the body.

What about Resilience?

Although the long-term impact of ACEs is well-documented, someone’s ACE score does not necessarily set the stage for future problems. As described above, secure attachment relationships or supportive relationships with adults can have a buffering effect on the impact of stress. Compared to children with insecure attachment styles, children with secure relationships with adults have a more softened stress response; that is, when exposed to a threat, they resolve the challenge without producing excessive stress hormones [5]. When working with clients who have experienced early adversity, it is helpful to remember that some clients will be more susceptible to stress than others.

ACEs in the Therapy Room

The notion of difficult experiences in childhood potentially leading to problematic behaviors later in life is not a new concept, particularly to those practicing psychotherapy. The robustness of the association between ACEs and physical/psychiatric vulnerability are notable and have led to a movement in the US for screening for ACEs in health care. There is debate in the literature about widespread screening for ACEs, and rightfully so; unrestricted screening is not likely to be beneficial without effective interventions in place to support individuals in need [6].

In the context of psychotherapy, most (hopefully all) mental health practitioners assess for past trauma in the clinical interview. The usefulness of asking about past trauma, and in particular ACEs, extends beyond differential diagnosis. Apart from someone’s raw ACE score, an individual’s subjective experience of adversity can provide insight into their current struggles, can reveal their potential resilience, and can be helpful in case formulation and treatment planning.

In the absence of a thorough history at the outset of therapy, or perhaps a delay in disclosing childhood adversities on the client’s part, ACEs can creep into a session at a later date, at which point the case formulation and treatment plan should be revisited to ensure treatment progresses in a trauma-responsive way.

ACEs can enter into the therapy room in the form of countertransference, or a history of personal ACEs from the therapist’s perspective. Remaining mindful of these processes and seeking appropriate supervision and/or psychotherapy is an equally important way of caring for clients responsibly.

This article was originally published on January 2, 2019.


[1] Freudenberger, H. J. (1975). The staff burn-out syndrome in alternative institutions. Psychotherapy: Theory, Research and Practice, 12, 73-82.

[2] Merrick, M. T., Ford, D. C., Ports, K. A., & Guinn, A. S. (2018). Prevalence of adverse childhood experiences from the 2011-2014 Behavioral Risk Factor Surveillance System in 23 states. JAMA Pediatrics, published online Sept 17, 2018.

[3] Afifi, T. O., MacMillan, H. L., Boyle, M., Taillieu, T., Cheung, K., & Sareen, J. (2014). Child abuse and mental disorders in Canada. Canadian Medical Association Journal, 186, E324-E332.

[4] Danese, A., & McEwen, B. S. (2012). Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiology & Behavior, 106, 29-39.

[5] National Scientific Council on the Developing Child. (2005/2014). Excessive stress disrupts the architecture of the developing brain: Working Paper 3.

[6] Finkelhor, D. (2017). Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse & Neglect, http://dx.doi.org/10.1016/j.chiabu.2017.07.016.

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