What are Adverse Childhood Experiences (ACEs) and Positive Childhood Experiences (PCEs), and how do they impact health outcomes?

Adverse Childhood Experiences (ACEs) and Positive Childhood Experiences (PCEs): Definitions and Health Impact

What are ACEs?

Adverse Childhood Experiences (ACEs) are traumatic events occurring before age 18 that encompass ten specific categories within three broad domains: abuse (physical, emotional, sexual), neglect (physical, emotional), and household dysfunction (caregiver substance abuse, caregiver mental illness, caregiver divorce/separation, caregiver incarceration, domestic violence). 1

• This framework was established to characterize and quantify the effects of childhood adversity across different settings and populations 1
• ACEs are highly interrelated rather than occurring independently—two-thirds of individuals report at least one ACE, and 81-98% of those with one ACE experience at least one additional ACE 2
• The presence of one ACE significantly increases the odds of having additional ACEs by 2 to 17.7 times (median: 2.8 times) 2

What are PCEs?

Positive Childhood Experiences (PCEs) are supportive relationships and experiences that buffer against adversity and proactively build foundational social and emotional skills leading to resilience. 1

• PCEs include safe, stable, and nurturing relationships (SSNRs) that not only buffer adversity when it occurs but also build resilience for future challenges 1
• The promotion of relational health through PCEs needs to become an integral component of pediatric care and a primary objective for pediatric research and advocacy 1

Health Outcomes Associated with ACEs

Dose-Dependent Relationship with Morbidity and Mortality

Higher ACE scores demonstrate dose-dependent relationships with leading causes of adult morbidity and mortality, including cardiovascular disease, lung disease, liver disease, mental illness, and cancer. 1

• Each additional ACE increases risk in a graded manner—the higher the ACE score (1 point per category experienced), the higher the risk for adverse outcomes 1
• Well-established associations between ACEs and poor health outcomes decades later highlight the biological mechanisms by which adversity "gets under the skin" to negatively impact life-course trajectories 1

Behavioral Health Consequences

• ACEs are associated with unhealthy behaviors including tobacco use, alcohol and substance misuse, risky sexual behaviors, and obesity 1
• Justice-involved youth report particularly high rates of ACEs, placing them at greater need for behavioral health intervention and at greater risk for continued justice involvement 1
• ACEs are associated with increased psychiatric symptoms, mental health problems, lower self-control, higher aggression and impulsivity, and increased risk for suicidal ideation and attempts 1

Biological Mechanisms of Toxic Stress

Toxic stress responses—in which the physiologic stress response to adversity is large, chronic, and unmitigated by social-emotional buffers—represent the key mechanism linking ACEs to poor health outcomes. 1

• Toxic stress responses alter multiple interacting systems: genomic function, brain structure and connectivity, metabolism, neuroendocrine-immune function, the inflammatory cascade, and the microbiome 1
• These stress-induced alterations influence the adoption of maladaptive coping behaviors decades later 1
• Validated biomarkers of physiologic stress responses have transformational potential as measures of experienced adversity and responsiveness to interventions 1

Prevalence Across Populations

Age-Related Impact

• ACEs affect health outcomes throughout the lifespan, from childhood through adulthood 1
• The effects manifest differently across developmental stages, with immediate impacts on behavioral health in youth and chronic disease manifestations in adults 1
• Justice-involved youth demonstrate particularly high prevalence of ACEs, with significant associations between ACEs and delinquency, psychiatric outcomes, substance use, and academic outcomes 1

Special Populations at Higher Risk

• Youth who experienced human trafficking are at particularly high risk for experiencing more ACEs 1
• Youth arrested for sex-trafficking violations, who are disproportionately female and Black youth, experience higher levels of every type of ACE 1
• Youth who committed sexual offenses experienced more ACEs than youth who committed non-sexual offenses 1

Clinical Implications and Intervention Evidence

Current Evidence Gaps

The strongest evidence for intervention effectiveness is for cognitive-behavioral therapy for people exposed to abuse, while findings for other interventions—including psychological therapies, parent training, and broader support interventions—remain inconclusive despite some positive results. 3

• Most intervention approaches focus on mitigating individual psychological harms and do not address the social pathways which may mediate the negative impacts of ACEs 3
• Many negative impacts of ACEs (on health behaviors, social relationships, and life circumstances) have not been widely addressed by intervention studies 3
• There are no intervention studies specifically examining ACEs among justice-involved youth, despite 38% of existing studies being longitudinal/prospective analyses 1

Trauma-Informed Care Framework

The four R's approach—realize, recognize, respond, and resist re-traumatization—provides guidance for pediatric providers implementing trauma-informed care. 4

• Realize how ACEs affect health across the lifespan 4
• Recognize pediatric clinical symptom presentation and implement screening protocols for ACEs 4
• Respond with evidence-based care while avoiding re-traumatization of patients 4
• Universal ACEs screening in healthcare settings serves as a surveillance tool to inform and guide medical practice and policy for delivering trauma-informed care 5

Public Health Perspective

• Childhood trauma represents a current public health crisis in the U.S. and worldwide 5
• ACEs are common, interrelated, and contribute to multiple adverse social, behavioral, and health outcomes throughout the lifespan 5
• Policy makers have launched initiatives such as California's ACEs screening program for publicly-insured youth, recognizing the broad and profound impact of ACEs 1

Why Study ACEs and PCEs from a Health Promotion Perspective

Studying ACEs and PCEs from a health promotion perspective is beneficial because toxic stress explains how society's most intractable problems—disparities in health, education, and economic stability—are rooted in shared biology but divergent experiences and opportunities. 1

• Prevention of childhood toxic stress responses and support for optimal development across the lifespan requires promotion of relational health as an integral component of pediatric care 1
• Understanding both adversity (ACEs) and protective factors (PCEs) allows for comprehensive approaches that not only prevent harm but also proactively build resilience 1
• The elemental nature of relational health needs to be reflected in training, research, practice, and advocacy to address the root causes of health disparities 1