Adverse childhood experiences (ACE) were first defined by Felliti et al.1 as traumatic experiences occurring to a person prior to age 18 years. These include several categories, such as recurrent physical abuse, recurrent emotional abuse, contact sexual abuse, a household member who abuses drugs or alcohol, a household family member who is incarcerated, a person in the house with mental illness, intermittent partner violence in the home, having one or no parent, parental divorce, and emotional or physical medical neglect.1 More recent research has expanded ACE criteria to include witnessing violence, being discriminated against, living in an unsafe neighborhood, being bullied, and living in foster care.2 An ACE score is calculated be attributing one point for each category of adversity and then totaling the points for the score. The original study by Felliti et al.1 found that ACEs are common, with two-thirds of the population experiencing at least one ACE and approximately one of every eight people experiencing four or more ACEs. Aside from high prevalence, that study also demonstrated a dose-response relationship ACEs have with poor physical and mental health outcomes of many kinds, including chronic obstructive pulmonary disease, stroke, suicidality, and heart disease.1 For instance, compared to a person with a score of 0, a person with an ACE score of 4 or more has 190% more risk of cancer development, 220% more risk of developing ischemic heart disease, and 1,220% more risk of attempting suicide.1 Several more recent studies confirm these findings among all socio-economic groups at the statewide level.3,4 In addition, higher ACE scores are associated with less educational success, higher unemployment, and more poverty.5
More recent research has described the association of a parent's ACE with their offspring's health and developmental outcomes. This growing body of literature has found multiple areas where the association is active. Parents who witness domestic violence as a child have children with poorer health than children whose parents do not witness domestic violence.6 Low birth weight and shorter gestational age are associated with higher maternal ACEs.7 A 2018 study by Le-Scherban et al.,8 which examined parent-child dyads living in Philadelphia, found that for each 1-point increase in parental ACE, the odds of overall poor child health increased by 19%, and specifically the odds of asthma increased by 17%. Parental childhood adversity is especially related to poor development outcomes. Children of parents with an ACE score of 4 or higher have double the odds of hyperactivity and 4.2 times the odds of an emotional disturbance diagnosis than children of parents with no ACEs.9 This relationship is stronger for maternal history than paternal history.9 Others have found that a parental ACE score of 3 or higher leads to children who are 2.2 times more likely to have developmental delay than children of parents with an ACE score of less than 3.10
It is not clear how parental ACEs mediate poor health outcomes for children. Some have speculated that traumatic stress-related biologic changes are transmitted to future generations through epigenetic mechanisms.11 Several other possibilities exist, including exposure to high health-risk behaviors, living in poor conditions, exposure to poor parental physical or mental health, or exposure to drug and alcohol addiction—all of which are more probable in adults with higher ACE scores. Access to health care may be another factor related to the association. Recent research by Eismann et al.12 found that maternal ACE exposure is significantly related to missed well-child visits by age 2 years. A large longitudinal study by Racine et al.13 revealed two distinct yet indirect pathways by which maternal ACEs influenced infant development outcomes at 12 months. One was biological health risk due to higher health risks in pregnancy, and the other was a psychosocial pathway via maternal stress during pregnancy, meaning there were both physiological and environmental factors.13
The concept of toxic stress is important to bring into the discussion of parental ACE and its relationship to child health and development. According to the Harvard Center for the Developing Child,14 the definition is excessive or prolonged activation of stress response systems in the absence of protection from adult caregivers. It is the absence of protection from adult caregivers that is the most important actionable component functionally related to poor child health outcomes. This nurturing protection offered by a parent to a child buffers the child in times of stress, and it is in that protective relationship that child resilience develops.14 Although individual child sensitivity to adversities is important in development of child resilience, a primary focus on of the work we do in pediatrics is the relationship between child and parent.
Parents or caregivers with high ACEs and unresolved toxic stress may present to our practice settings as parents who are chronically late or miss appointments, noncompliant with treatment plans, or lose medications. Struggling with self-regulation, they may be parents who worry excessively or have high anxiety. They may have difficulty in controlling their emotions and temper and may exhibit harsh parenting style. Some may be challenged by an inability to attune their child's physical or emotional needs and respond appropriately. Those parents may struggle with alcohol and drug abuse or may be exhausted beyond what you would expect or appear to be defeated or detached and have difficulty engaging. Although all of these should raise the concern that a parent is struggling, the most common presentation of a parent with a high ACE score and difficulty with parenting may be none of the above; in other words, a parent who seems to be doing just fine.
Fundamental to helping parents who may be struggling with current toxic stress due to high ACEs is a trauma-informed approach.15 This requires curiosity and for providers to ask the question “What happened to you?” instead of “What is wrong with you?” It requires a family-centered and strength-based empathetic approach based on helping develop parental resilience. There is no real validated parental ACE instrument to use in pediatric practice, but some practices have begun to use maternal ACE surveys as a part of routine health care to identify children who may be at risk and offer support.12 The key here is not to think of this as a diagnostic screen but as a way to get more information about that parent or caregiver and help him or her. The American Academy of Pediatrics has an online trauma tool kit for use in primary care.16 This tool kit has a multitude of resources and materials that may be beneficial in helping families.
- Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245–258. https://doi.org/10.1016/S0749-3797(98)00017-8 PMID: doi:10.1016/S0749-3797(98)00017-8 [CrossRef]9635069
- Cronholm PF, Forke CM, Wade R, et al. Adverse childhood experiences: expanding the concept of adversity. Am J Prev Med. 2015;49(3):354–361. https://doi.org/10.1016/j.amepre.2015.02.001 PMID: doi:10.1016/j.amepre.2015.02.001 [CrossRef]26296440
- Centers for Disease Control and Prevention. Adverse childhood experiences reported by adults--five states, 2009. MMWR Morb Mortal Wkly Rep. 2010;59(49):1609–1613. PMID:21160456
- Gilbert LK, Breiding MJ, Merrick MT, et al. Childhood adversity and adult chronic disease: an update from ten states and the District of Columbia, 2010. Am J Prev Med. 2015;48(3):345–349. doi:10.1016/j.amepre.2014.09.006 [CrossRef]
- Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):174–186. https://doi.org/10.1007/s00406-005-0624-4 PMID: doi:10.1007/s00406-005-0624-4 [CrossRef]
- Forke CM, Catallozzi M, Localio AR, Grisso JA, Wiebe DJ, Fein JA. Intergenerational effects of witnessing domestic violence: health of the witnesses and their children. Prev Med Rep. 2019;15:100942. https://doi.org/10.1016/j.pmedr.2019.100942 PMID: doi:10.1016/j.pmedr.2019.100942 [CrossRef]31321205
- McDonnell CG, Valentino K. Intergenerational effects of childhood trauma: evaluating pathways among maternal ACEs, perinatal depressive symptoms, and infant outcomes. Child Maltreat. 2016;21(4):317–326. https://doi.org/10.1177/1077559516659556 PMID: doi:10.1177/1077559516659556 [CrossRef]27457410
- Le-Scherban F. Wang, Boyle-Steed K, Pachter LM. Intergenerational associations of parent adverse childhood experiences and child health outcomes. Pediatrics. 2018;141(6):e20174274. https://doi.org/10.1542/peds.2017-4274 PMID: doi:10.1542/peds.2017-4274 [CrossRef]29784755
- Schickedanz A, Halfon N, Sastry N, Chung PJ. Parents adverse childhood experiences and their children's behavioral health problems. Pediatrics. 2018;142(2):e20180023. https://doi.org/10.1542/peds.2018-0023 PMID: doi:10.1542/peds.2018-0023 [CrossRef]29987168
- Folger AT, Eismann EA, Stephenson NB, et al. Parental adverse experiences and offspring development at 2 years of age. Pediatrics. 2018;141(4):e20172826. https://doi.org/10.1542/peds.2017-2826 PMID: doi:10.1542/peds.2017-2826 [CrossRef]29563236
- Bowers ME, Yehuda R. Intergenerational transmission of stress in humans. Neuropsychopharmacology. 2016;41(1):232–244. doi:10.1038/npp.2015.247 [CrossRef]
- Eismann EA, Folger AT, Stephenson NB, et al. Parental adverse childhood experiences and pediatric healthcare use by 2 years of age. J Pediatr. 2019;211:146–151. https://doi.org/10.1016/j.jpeds.2019.04.025 PMID: doi:10.1016/j.jpeds.2019.04.025 [CrossRef]31079855
- Racine N, Plamondon A, Madigan S, McDonald S, Tough S. Maternal adverse childhood experiences and infant development. Pediatrics. 2018;141(4):e20172495. https://doi.org/10.1542/peds.2017-2495 PMID: doi:10.1542/peds.2017-2495 [CrossRef]29559588
- Harvard Center on the Developing Child. https://developingchild.harvard.edu/science/key-concepts/toxic-stress/. Accessed November 18, 2019.
- Marsac ML, Kassam-Adams N, Hildenbrand AK, et al. Implementing a trauma-informed approach in pediatric health care networks. JAMA Pediatr. 2016;170(1):70–77. https://doi.org/10.1001/jamapediatrics.2015.2206 PMID: doi:10.1001/jamapediatrics.2015.2206 [CrossRef]
- American Academy of Pediatrics. Trauma guide. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Trauma-Guide.aspx. Accessed October 19, 2019.