Adverse Childhood Experiences (ACEs)

Introduction
Welcome to your course on Adverse Childhood Experiences (ACEs).
The purpose of the course is to help you understand:

• what adverse childhood experiences are

• how ACEs may affect children and young people growing up
• trauma and attachment
• potential impact of ACEs in adulthood
• protective factors.

What are adverse childhood experiences?

‘Adverse childhood experiences’ (ACEs) is the term used to describe highly stressful, and potentially traumatic events
or situations that occur during childhood or adolescence. It can be single event, or prolonged threats to, and
breaches of, the young person’s safety, security, trust or bodily integrity*.

What a child experiences is fundamental to their mental health and emotional wellbeing in childhood, adolescence
and adulthood.

For example:

An eight-year-old boy watches his father act aggressively to his mum. He copies these behaviours in school and
frequently gets into trouble. He has difficulty in controlling his own emotions and behaviour.

Being exposed to violence will have a negative impact on his mental and emotional wellbeing which could lead to
low self-esteem and high anxiety levels.

He may feel ashamed of the abuse so try to keep it secret which can lead to isolation and a lack of friends.

Exhibiting aggressive behaviour at the age of eight can be a predictor of later criminal behaviour, arrests,
convictions, traffic offences, spouse abuse and punitive treatment of their own children.

Many people will have experienced ACEs and will have gone on to have stable adult lives. So those working with
children and young people should not use ACEs as a tool for mapping out the child’s destiny. What is important is
that those children and families are offered support and understanding in context to the environment in which they
live.

Direct and indirect

There are ten widely recognised ACEs. These were originally identified in a US study in the 1990’s and they can be
divided into two categories:

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Direct

• physical abuse
• sexual abuse
• verbal abuse
• emotional neglect
• physical neglect.

Indirect

Growing up in a household where there is:

• domestic abuse
• substance misuse
• mental illness
• parental separation
• parental imprisonment.

Other factors

Since the original study it has been recognised there are a wide range of experiences that can have a negative impact
on children. These include:

• bereavement
• experiencing bullying
• poverty
• racism
• neighbourhood violence
• living in a deprived area.

The more a child experiences, the more vulnerable they become.

Trauma and attachment

When a child is exposed to heightened, prolonged and repetitive stress with a lack of nurturing or support from the
parent or guardian they can go into ‘fight, flight or freeze’ mode.

What is fight, flight or freeze mode?

It is the body’s response triggered when we feel at risk. It goes back to our basic evolutionary responses, when to
survive we ran, fought or froze in response to danger.

How do you feel…

When a fire alarm goes off?

Someone shouts at you?
You witness a fight?
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You are asked to do something you are uncomfortable doing?

You probably notice your breathing getting quicker, you may feel light-headed, you may start to sweat. You may feel
anxious and irritable.

The body is in a high state of alert, but in normal circumstances this will go back to normal.

A child stuck in ‘fight, flight or freeze’ mode will find it hard to switch off the primitive brain and is in survival mode
for long periods.

Toxic Stress

Experiencing moderate, short episodes of stress as a child or adolescent helps with normal development.

However, if a child or young person experiences prolonged periods of stress the body doesn’t return to a normal
state and is at a higher state of stress for long periods of time. High levels of stress can affect brain development;
this is called ‘toxic stress’.

The effects of toxic stress

At certain times of our life the brain’s neural pathways are reorganised and then strengthened in response to
experiences or sensory stimulation. This is where the term brain plasticity comes from.

If the brain is constantly exposed to a stressful environment it can affect how the brain develops. Toxic stress
adversely affects physical, social, cognitive and emotional development.

Children who have experienced trauma may be hypervigilant and have difficulty sleeping. They may have a tendency
to act in a way that appears extreme or disproportionate to a situation. These hallmarks will carry on into adulthood.
Toxic stress can also:

• have a negative impact on forming relationships

• adversely affect concentration and learning
• increase the risk of addictive behaviour
• heighten the stress response.

Developmental milestones

A baby’s prenatal brain can be affected by a mother’s stress hormones; these can have a negative impact on the
brain’s ability to make neural connections and strengthen them. This may have a long-term impact on learning,
memory and the ability to process stress and emotions.

• Neglect in infancy can result in language and speech delay.

• Sexual abuse between the ages of three and five years affects emotion, fear and panic responses.
• Toxic stress experienced in adolescence may cause issues with emotional control and social interaction. A
young person may not conform to socially accepted norms and suffer from anxiety and depression.

The more adverse experiences in childhood, the greater the likelihood of developmental delays and later health
problems.

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aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

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Brain development in adolescence

During adolescence the brain is remodelled and developed. Remodelling follows three stages.

• In the early stages of adolescence there is rapid growth of brain matter and the formation of new neural
connections.
• During mid-adolescence neural connections that are not being stimulated will be ‘pruned’ away and lost.
This is where the term ‘use it or lose it’ comes from.
• In the late stages connections that are regularly used become insulated making them more efficient.

How and when this happens will be dependent on age, experiences and hormonal changes. If at this stage a young
person experiences trauma or heightened stress for long periods of time the remodelling may be negatively
affected.

If a young person who experienced trauma and heightened stress as a child is then put into a secure, stable, loving
environment these can begin to be rebuilt and strengthened.

Attachment

Our early experiences in childhood will have a strong impact on our development and behaviour.

Making strong emotional bonds to an individual is a basic part of human nature which begins at birth. Babies are
biologically predisposed to form relationships which make them feel safe and secure. This is the basis of ‘Attachment
Theory’ originally developed by John Bowlby.

If a baby feels threatened the baby will cry out for the caregiver’s attention. The ‘Still Face experiment’ illustrates
how these connections work.

Attachment can be either secure or insecure.

Secure attachments

A child feels loved, safe and secure and their needs are met.

Children and young people who have not grown up in a nurturing, loving environment, who have experienced abuse
or neglect, or whose parents use drugs or alcohol may develop attachment difficulties.

Insecure attachments are divided into:

• Avoidant - These children tend to experience parenting that is hostile, rejecting and controlling. They come
to see themselves as neither loved nor loveable, so find it hard to form close relationships.
• Ambivalent – This type of attachment tends to occur when the caregiver responds inconsistently to the
child’s demands.
• Disorganised – This type of attachment is thought to be caused by frightening parental behaviour and
trauma. A child may be unsure of what to expect from people around them. This form of attachment is
generally experienced by a child who has suffered abuse.

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aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

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Scenario

You have known Milo for the past year as his support worker. Since he was eight-years-old Milo has been in several
different foster placements. You have recently got a new job which means you will no longer be able to work with
him.

How do you think Milo will respond to this news?

Milo starts to get angry; he tells you he doesn’t like you and he never has. Everything you have done together has
been a complete waste of time and he never wants to see you again. Milo feels let down and by reacting in this way
he feels he can control the situation. He feels that you are another person that has walked out on him.

Children who are placed into care, have been separated from their parents or who have been moved several times in
foster/residential placements are at a high risk of attachment disorder.

Someone with attachment disorder may:

• struggle with eye contact

• seek affection from strangers
• be unable to show affection to their parents or caregivers
• have difficulty controlling their own behaviours
• have difficulty expressing and dealing with emotions
• be unable to trust people
• will often find it difficult to trust any professionals who are trying to support them.

Impact of ACEs in adulthood

Several studies have shown that the more ACEs a child experiences the more likely they are to suffer from poor
physical and mental health in adulthood and developing health-harming behaviours.

The pyramid below shows the impact that ACEs can have throughout a person’s life.

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aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

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Almost half the people in England and Wales have experienced one ACE as a child. One in ten have experienced four
or more ACEs. Several studies have shown if a person has experienced four or more ACEs compared to someone
with no ACEs, they are more likely to experience poor health and wellbeing in adulthood.

The type, number of ACEs and the length of time they were experienced may have a negative impact on a child or
young person that can last throughout their life.

The following shows the percentage of different ACEs experienced by adults in Wales. Prevalence levels will vary
dependant on the cohort studied.

• 23% had suffered verbal abuse

• 17% physical abuse
• 10% sexual abuse
• 20% had experienced parental separation
• 16% domestic violence
• 14% household mental illness
• 14% household alcohol abuse
• 5% household drug use*.

Social and wellbeing impact

An individual who has experienced four or more ACEs is:

4 x more likely to binge drink
6 x more likely to smoke
6 x more likely to have had sex under 16-years-old
11 x more likely to smoke cannabis
14 x more likely to be involved in violence
16 x more likely to have used heroin
20 x more likely to have been in prison

They are also more likely to have:

• a poor diet
• a predisposition to criminality
• lower life aspiration
• reduced educational success
• reduced employability
• relationship problems.

Mental health

As we previously discussed, the presence of ACEs increases the chances of people experiencing poor mental health,
having low self-esteem, depression, anxiety and greater risk of suicide attempts.
The World Health Organization estimate that 30% of adult mental illness in 21 countries could be attributed to
physical abuse in childhood or other adverse childhood experiences.

Whilst Tes Global Ltd have made every effort to ensure that the courses and their content have been devised and written by leading experts who have ensured that they reflect best practice in all
aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

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Compared to people with no ACEs, those with four or more ACEs are more likely to have difficulty in:

• relaxing
• thinking clearly
• being able to deal with problems
• making up their own mind about things
• feeling optimistic about the future
• feeling useful.

Physical health in adulthood

In one study eight out of ten adults were shown to have been diagnosed with a major disease if they had
experienced four or more ACEs.

Those that have experienced ACEs are at greater risk of developing:

• cancer
• heart disease
• stroke
• arthritis
• liver disease
• asthma
• obesity.

Early death is also an indicator of previous ACEs.

The importance of breaking the cycle

Raising awareness and understanding ACEs is important so those working with children, young people and adults can
begin to spot the signs and break the cycle.

The co-founder of the original ACE study Dr. Robert Anda said;
“What is predictable is preventable.”

Protective factors

Most parents living in a poor social environment will provide a loving and nurturing upbringing for their child with no
ill effects. A child who experiences their parents separating or bereavement in the family can also feel supported
throughout this time without major detriment to them.

For a child to grow and develop they need:

• positive early attachment experiences

• a significant adult with whom they have a positive relationship whilst growing up
• positive relationships in the wider family and community
• to be listened to
• positive self-image and self-esteem

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aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

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 • to have the skills to develop resilience
• to be encouraged in self-regulation of emotions
• the opportunity to learn and develop.

Other protective factors include:

• safe relationships with peers

• supportive family members e.g. a grandparent
• access to a supportive community
• access to early intervention from services.

What children and young people need

A child or young person that suffers a traumatic event may not be able or want to tell you what they are feeling.

When a child experiences a traumatic event, their voice can often be lost in adults making all the decisions for them.
They may feel and exhibit a range of emotions including, for example, fear, sadness, anger, guilt, shame and have no
control of what is happening. Children may believe wrongly that they have caused bad things to happen.
To help support a child or young person you can:

• listen to them and keep them informed

• provide a safe space for them to talk about their feelings
• where appropriate, give them choices so they feel in control
• encourage them to self-regulate; for example, encouraging helpful ways to reduce anxiety
• offer support that is non-judgemental
• set clear boundaries
• answer their questions honestly
• look for meaning behind behaviour changes
• be sensitive to key dates; for example, birthdays
• be sensitive to key events or triggers
• respond appropriately to a child’s feelings of anger or guilt.

By doing this you will make the child or young person more able to cope, thus developing their resilience.

The importance of listening

Being able to listen will help you understand a child’s perspective and offer them appropriate support.

Why is listening to children and young people important?

• It helps in mutual understanding

• It helps to protect children
• It leads to better decision making and outcomes
• It promotes respect
• It helps build resilience

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aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

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How to develop your listening skills

• Create a safe space

• Listen patiently
• Be comfortable with silence
• Do not interrupt
• Be empathic
• Always remain calm
• Facial expressions, body and arm posture will tell a lot about whether you are listening
• Respond calmly with open questions or reflections to check you have understood
• Do not be judgmental

Active listening is a skill and may take time to learn but it will help create a connection and understanding between
yourself and the person you are supporting.

What is resilience?

Resilience is the ability to live and develop in a positive way and succeed despite stress and adversity that could
result in negative outcomes. It is the ability to maintain positive wellbeing.

Being resilient will protect a person’s emotional and physical wellbeing.

A child or young person whose resilience is growing will:

• have good self-esteem

• have the ability to act on initiative
• trust people
• believe in themselves and not give up easily
• believe in who they are.

Building resilience

To help build resilience among children you could:

• ensure you show, by your words and actions, that you value and respect them
• provide them with a safe space to communicate with a trusted adult
• remind the child it’s okay to ask for support
• ensure the child has access to the help they need
• provide the child with a good education
• ensure the child is safe.

Whilst Tes Global Ltd have made every effort to ensure that the courses and their content have been devised and written by leading experts who have ensured that they reflect best practice in all
aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

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To help parents:

• explain to the parent that building resilience in a child is important

• help parents to build skills in positive parenting
• encourage them that asking for support is a good thing
• encourage them to use the support network around them, such as grand parents
• provide parents with access to support networks in the area.

When working with parents it is a good idea to meet them somewhere safe and non-threatening; it may be good to
ask parents and children where they would like to meet.

You should follow your organisations policy when meeting parents and children off site.

Preventing ACEs
Preventing ACEs in future generations could reduce the levels of:

• smoking
• binge-drinking
• cannabis use
• someone becoming a victim or perpetrator of violence
• a person going to prison
• having a poor diet
• having early sex
• experiencing unintended teenage pregnancy.

Being ACE aware

The more we learn about ACEs the more we realise what we can do to support the children and families that have
experience them.

What can you do?

• Work in a contextual way by taking wider issues into consideration

• Try to understand the child’s needs and offer appropriate support
• Work with agencies/charities
• Listen
• Include the family and child in decision making as appropriate so they feel empowered
• Encourage self-care

Whilst Tes Global Ltd have made every effort to ensure that the courses and their content have been devised and written by leading experts who have ensured that they reflect best practice in all
aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

No part of this material may be reproduced or utilised in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system
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When working with vulnerable children and families it is important to:

• remember that working with children and families is complex and that children don’t fit neatly into
categories
• take advice from professionals around you, recognising your own professional boundaries e.g. social
workers, child psychologists and teachers
• recognise that studying ACEs and working with abused children can trigger difficult feelings in yourself
• recognise the impact of the work on your own emotions and seek professional help if needed
• get high quality supervision for your work to help you work safely
• share any concerns you might have with your line manager or supervisor
• refer children if you suspect abuse or neglect in line with local procedures.

Summary
This concludes your course on ‘Adverse Childhood Experiences’. Not everyone who has been exposed to ACEs will
have negative outcomes, but understanding ACEs and the impact they may have on a child or adult will help support
the work and relationships you have with children, young people and families. By identifying and addressing any
concerns early and working in partnership with others, ACEs can be reduced in future generations.

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undertake the questions.

Whilst Tes Global Ltd have made every effort to ensure that the courses and their content have been devised and written by leading experts who have ensured that they reflect best practice in all
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representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

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