The document summarizes research on Adverse Childhood Experiences (ACEs), which are potentially traumatic events that occur in childhood (0-17 years) such as abuse, neglect, and household dysfunction. The original ACE Study found that ACEs are common, often occur in clusters, and have strong links to health risks and diseases in adulthood. Individuals with 4 or more ACEs are at greatly increased risk for cancer, heart disease, depression, suicide attempts, drug use, and other negative outcomes. While childhood trauma can disrupt brain development and impact health and behavior, building supportive relationships and teaching coping skills can help mitigate negative impacts and break intergenerational cycles of trauma.

1. ACES FRAMEWORK
CHILDHOOD TRAUMA
Tammi Winchester, MPA
Department of Health & Human Services
Tammi.Winchester@Nebraska.gov
402-670-2408

2. ACES (Adverse Childhood Experiences):
What is it? How it was discovered? What does it mean? What’s the big deal?
Trauma and it’s effects on children
Becoming trauma informed
Objectives

3. What Are ACEs?
Adverse Childhood Experiences
ACEs are experiences in childhood that are unhappy, unpleasant, hurtful.
Sometimes referred to as toxic stress or childhood trauma.
Abuse & trauma suffered in early years of
development result in a far greater likelihood of pre-
psychotic and psychotic symptoms. Perry, B.D.
(1994)

4. Why is This Important?
Because ACEs are:
• Surprisingly common
• Occur in clusters
• The basis for many common public health problems
• Strong predictors of later social functioning, well-being, health risks, disease, and death
• An ACE Score of 4 or more results in having multiple risk factors for these diseases or the
disease themselves.
• An ACE score of 6 or more results in a 20 year decrease in life expectancy.

5. ACES BACKGROUND
• SEVERE AND PERSISTENT EMOTIONAL PROBLEMS
• HEALTH RISK BEHAVIORS
• SERIOUS SOCIAL PROBLEMS
• ADULT DISEASE AND DISABILITY
• HIGH HEALTH AND MENTAL HEALTH CARE COSTS
• POOR LIFE EXPECTANCY
The higher the ACE score, the greater the likelihood of:

6. The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997 Over 17,000 Health Maintenance Organization
members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and
current health status and behaviors.

7. HOW WERE ACES DISCOVERED?
Like any other great discovery of course!

8.
Probably the most important public health study (1985).
Dr. Vincent Felitti, Chief Physician of Kaiser Permanente’s Department of Preventive Medicine in San Diego, CA,
mystified - couldn’t figure out why, the last five years, more than half of the people in his obesity clinic dropped out.
Although people who wanted to shed as little as 30 pounds could participate, the clinic was designed for people who were
100 to 600 pounds overweight.

9. Felitti, recalls asking a female participant when she became sexually active…
– although physicians are given plenty of training in examining body parts, they are given little
support in talking about what patients do with some of those body parts.
“Instead of asking, “How old were you when you were first sexually active,” he asked, “How much did you
weigh when you were first sexually active?’ the woman, answered, ‘Forty pounds.’”
He didn’t understand what he was hearing. He misspoke the question again. She gave the same answer, burst
into tears and added, “It was when I was four years old, with my father.”
Felitti didn’t know at the time, but this was the more important result — the mind-shift, that would
begin spreading far beyond a weight clinic in San Diego. It would provide more understanding about
the lives of hundreds of millions of people around the world who use biochemical coping methods –
such as alcohol, marijuana, food, sex, tobacco, violence, work, methamphetamines, thrill sports – to
escape intense fear, anxiety, depression, anger.

10. Adverse Childhood Experience Categories
Abuse of Child
■ Recurrent Severe Emotional and physical abuse
■ Contact Sexual abuse
Trauma in Child’s Household Environment
■ Substance abuse
■ Parental separation or divorce -
■ Chronically depressed, emotionally disturbed or
suicidal household member
■ Mother treated violently
■ Imprisoned household member
■ Loss of parent – (by death, by suicide, - or by
abandonment)
Neglect of Child
■ Abandonment
■ Child’s basic physical and/or emotional needs
unmet
Impact of Trauma and Health Risk Behaviors to Ease
the Pain Neurobiological Effects of Trauma
■ Disrupted neuro-development
■ Difficulty controlling anger-rage
■ Hallucinations
■ Depression
■ Panic reactions
■ Anxiety
■ Multiple (6+) somatic problems
■ Sleep problems
■ Impaired memory
■ Flashbacks
■ Dissociation
Health Risk Behaviors
■ Smoking
■ Severe obesity, Physical inactivity
■ Suicide attempts
■ Alcoholism
■ Drug abuse
■ 50+ sex partners
■ Repetition of original trauma
■ Self Injury, Eating disorders
■ Perpetrate interpersonal violence
Long-Term Consequences of Unaddressed
Trauma (ACEs) Disease and Disability
■ Ischemic heart disease
■ Cancer
■ Chronic lung disease and emphysema
■ Asthma
■ Liver disease
■ Skeletal fractures
■ Poor self rated health
■ Sexually transmitted disease
■ HIV/AIDS
Serious Social Problems
■ Homelessness
■ Prostitution
■ Delinquency, violence, criminal behavior
■ Inability to sustain employment
■ Re-victimization: rape, DV
■ Compromised ability to parent
■ Intergenerational transmission of abuse
■ Long-term use of health, behavioral health,
correctional and social services

11. ADVERSE CHILDHOOD EXPERIENCES ARE COMMON
• 1 IN 4 EXPOSED TO 2 CATEGORIES OF ACES
• 1 IN 16 WAS EXPOSED TO 4 CATEGORIES
• 22% WERE SEXUALLY ABUSED AS CHILDREN
• 66% OF THE WOMEN EXPERIENCED ABUSE, VIOLENCE OR FAMILY STRIFE IN CHILDHOOD
• MORE THAN 25% GREW UP IN A HOUSEHOLD WITH AN ALCOHOLIC OR DRUG USER
• 25% HAD BEEN BEATEN AS CHILDREN
• 1 IN 6 PEOPLE HAD FOUR OR MORE ACES
• THE HIGHER THE ACE’S – MORE LIKELY THE ADULT WILL HAVE HAD 50+ PARTNERS. BEING AT RISK FOR UNWANTED PREGNANCY,
STI, HIV/AIDS
Of the 17,000 Participants:

12. Compared to people with no ACEs, those with four or more ACEs were:
• 2 X’s more likely to smoke
• 7 X’s more likely to be alcoholics
• 6 X’s more likely to have had sex before age 15
• 2 X’s more likely to have cancer or heart disease
• 12 X’s more likely to have attempted suicide
• Men with 6 or more ACEs: 46 X’s more likely to have injected drugs VS. men with no ACES
WHAT’S THE BIG DEAL?

13. ACE VS IV DRUG USE

14. ✓smoking,
✓severe obesity,
✓physical inactivity,
✓depression,
✓suicide attempt,
✓alcoholism,
✓illicit drug use,
✓injected drug use,
✓50+ sexual partners,
✓history of STD
TOP 10 RISK FACTORS FOR DEATH IN THE USA

15. Learning to cope with stress is an important part of a child’s development.
ACES IMPACT ON BRAIN DEVELOPMENT
Stress & the brain
Excessive & repeated stress:
Neglect, violence
Chaos, unpredictability
Hostility, rejection
Causes disruption of brain architecture:
Impairs cell growth
Interferes with healthy neural circuits

16. Healthy Brain Development
All Daisies!
Kids experiencing trauma
May be overgrown with weeds

17. "Two people can see the same situation and interpret it
very differently based on experience and beliefs. Snow is
fun vs. snow is horrible!"
In any situation, an individual perceives & interprets what is happening, creating a picture, or mental model, of some
aspect of the world.
Mental models are comprised of assumptions, beliefs, & values people hold, sometimes for a lifetime.
The mental models are at the base, as an underpinning to the structures that individuals create. These structures then
generate patterns of change over time as well as the discrete events occur.

18. FLIGHT, FIGHT OR FREEZE HORMONES
Help us accelerate when we’re being chased by a vicious dog, fight
when we’re cornered, or turn to stone and stop breathing to escape
detection by a predator, but they become toxic when they’re turned on
for too long.
(Determined by a group of neuroscientists and pediatricians: Harvard -Martin Teicher, Jack Shonkoff, Rockefeller -Bruce McEwen, child psychiatrist Bruce Perry at the Child Trauma
Academy.

19. FLIGHT, FIGHT OR FREEZE HORMONES
If you’re in a forest & see a bear, efficient fight or flight system instantly floods
your body with adrenaline, cortisol & shuts off the thinking portion of your brain
that would stop to consider other options.” (PEDIATRICIAN- NADINE BURKE)
If a bear threatens a child every single day, his emergency response system is
activated over & over & over again.
Child is always ready to fight or flee from the bear, but the part of his brain – the
prefrontal cortex – that’s called upon to diagram a sentence or do math becomes
stunted, because, in our brains, emergencies – such as fleeing bears – take
precedence over doing math.

20. CHALLENGING BEHAVIORS AND REACTIONS in children:
• Non-compliant or oppositional
• Anxious, worried, tense
• Angry, agitated, or irritable
• Withdrawn or depressed
• Sleepy and tired in class (due to difficulty sleeping, bad dreams, or nightmares)
• Uncomfortable with transitions and routine changes
• Jumpy or easily startled by sudden sounds or movements, such as bells, sirens, doors slamming, changes in lighting,
or unanticipated physical contact
• Self-destructive or self-injurious
• Anticipating rejection and abandonment

21. Untreated ACES Events Only Exacerbate Over Time

22. Biologically: problems with movement & sensation, hypersensitivity to physical contact, difficulty with balance &
coordination.
Physically: stomach problems, fast heart rates, difficulty sleeping, poor sleep, disturbed eating
Socially: relationships can be characterized by boundary problems or distrust. They can have difficulty empathizing with
others. feeling alone, childish”, expecting maltreatment
Intellectually: trouble focusing, completing tasks, understanding their part in what happens to them, leaning difficulties.
underachievement at school
Emotionally: difficulty regulating mood, knowing their feelings, low self esteem, not a clear sense of self, feel angry,
ashamed, low self esteem, anxious, depressed, over or underestimating danger
Behaviorally: poor impulse control, aggression, or becomes passive and fearful, have a heightened awareness of
potential dangers, reckless, aggressive risk taking behavior, (danger of re-vicimization,)
What does it look like?

23. By adolescence, children seek relief through:
• Drinking alcohol
• Smoking tobacco
• Sexual promiscuity
• Using drugs
• Overeating/eating disorders
• Delinquent behavior
Consciously or unconsciously, they use these as solutions to
escape from depression, anxiety, anger, fear and shame.

24. Depressive reactions are quite serious leading to:
• Decline in school/learning or occupational performance
• Social isolation,
• Loss of interest in normal activities,
• Self-medication with alcohol or drugs,
• Acting-out behavior to try to mask their depression, & most seriously, attempts at suicide.
• Difficulties in establishing or maintaining new relationships
What Makes These Reactions Worse?
Posttraumatic Stress Reactions are evoked by trauma reminders (Triggers), continue to encounter places, people, sights,
sounds, smells, & inner feelings remind them of past traumatic experiences, even years afterwards. These reminders bring
on distressing mental images, thoughts, & emotional/physical reactions.

25. The ACE Study opened our eyes to see a “chronic public health disaster ."
Children affected by ACEs appear in all human service systems throughout the lifespan — childhood, adolescence, and adulthood — as
clients with behavioral, learning, social, criminal, and chronic health problems as well as poverty.” Generations of trauma…
Children in the child welfare system almost by definition have suffered trauma, often multiple traumatic events, and 50-75%
exhibit behaviors or symptoms that need mental health treatment.
CHILD WELFARE AND TRAUMA

26. AWARENESS
Traumatic events make it difficult for children to trust. They make it difficult to feel worthy, take initiative & form
relationships.
Children struggling with trauma don’t need another adult to tell them what is wrong with them. What they do
need, what helps them thrive, is an adult who treats them with simple sustained kindness, an adult who can
empathize with the challenges they face moving between home & school.
Meaningful participation gives opportunities to be heard, make choices, have responsibilities, belong, & engage in
problem solving. When we make meaningful contributions to the welfare of others, we improve our own feelings of
self-worth. Helping others strengthens resiliency.

27. A NEW APPROACH
USE A TRAUMA LENS
• SHIFTING FROM WHAT IS WRONG WITH THIS PERSON? TO WHAT HAS THIS PERSON BEEN THROUGH?
• CONNECT CHILDREN TO RESILIENCY ACTIVITIES
• MIND-BODY CONNECTIONS

28. ACES, Often Last a Lifetime, But they don’t have to!
Healing can occur, the cycle can be broken.
The ability of the brain to change its architecture as a result of
experience in different environments & activities.

29. Brain Architecture is experience dependent
Social-emotional buffering makes a big difference.
• Positive Parenting
• Trusted Mentor
• Healthy Attachment
• Social-emotional skills

30. Building Supportive Relationships
It Starts with Modeling
• Asking questions & wondering
• Becoming an active listener
• Pointing out the positive
• Being empathetic
• Someone to turn to
• Teach skills to youth
• Plan activities that focuses on nutrition, exercising or
relaxation techniques
• Help children develop healthy relationships
• Model/teach problem solving skills, planning ahead,
goals

31. Teach the Seven C’s
You didn’t CAUSE it
You can’t CURE it
You can’t CONTROL it
You can help take CARE of yourself
By COMMUNICATING your feelings,
Making health CHOICES, and
CELEBRATING being yourself

32. • Provide consistency & stability in interactions it greatly fosters a sense of safety & predictability by remaining consistent with these
children.
• Help children identify triggers resulting in stress reactions & support their use of coping skills. Children with complex trauma may
perceive themselves as “bad,” “crazy,” or having something “wrong” with them. Assist them in understanding their reactions & their
interpretation of the current event that is triggering the reaction.
• Be concrete in offering suggestions for managing emotions. These children often lack the capacity for self-regulation. They can’t
just “calm down.” They may require assistance with how to calm down. – telling them to calm down often escalates them…
• This will provide children with: opportunities to feel safe & assured, able to identify triggers that set of the fight-flight-freeze
behaviors & improve their abilities to attune themselves to cues from others.
HELPFUL ACTIONS

33. STRENGTH BUILDING
If our society is to prosper in the
future, we will need to make
sure all children have the
opportunity to develop
intellectually, socially &
emotionally.

35. Resources and Videos:
http://www.cdc.gov/ace/index.htm
www.NCTSNet.org
Removed part 1 & 2 –highly recommended!
https://www.youtube.com/watch?v=lOeQUwdAjE0
https://www.youtube.com/watch?v=I1fGmEa6WnY