Adverse childhood experiences are different than child trauma, and it’s critical to understand why (


Cissy's note: As more of us are learning about and sharing information on ACEs, more of us are reading and seeing questions, criticism, commentary, and guidance about if, when, where, how, and who should (or shouldn't) be asking, screening, talking about, using ACEs terminology and framing and how it confuses or expands the more clinical, medical, and traditional concepts of what traumatic stress is and how it's best responded to. I have my own opinions, of course, which is why I joined this movement almost five years ago. I don't agree with everything in this brief but love being a social network where we share, learn, try to understand what others are thinking, feeling - especially when it challenges some of our own beliefs, as well as when it resonates deeply. 

Please find two paragraphs from a policy brief written by Jessica Dym Bartlett and Vanessa Sacks which was published on Child Trends blog yesterday. 

Legislators, caregivers, and the media increasingly recognize that childhood adversity poses risks to individual health and well-being. The original Adverse Childhood Experiences (ACEs) Study has helped raise public awareness about this critical public health issue. However, as the use of ACEs questionnaires for identifying potentially harmful childhood experiences has gained popularity, it is important to understand how ACEs differ from other commonly used terms, including childhood adversity, trauma, and toxic stress.

Childhood adversity is a broad term that refers to a wide range of circumstances or events that pose a serious threat to a child’s physical or psychological well-being. Common examples of childhood adversity include child abuse and neglect, domestic violence, bullying, serious accidents or injuries, discrimination, extreme poverty, and community violence. Research shows that such experiences can have serious consequences, especially when they occur early in life, are chronic and/or severe, or accumulate over time. For example, the effects of childhood adversity can become biologically embedded during sensitive periods of development and lead to lifelong physical and mental health problems. However, adversity does not predestine children to poor outcomes, and most children are able to recover when they have the right supports—particularly the consistent presence of a warm, sensitive caregiver.

To read all seven paragraphs of this blog post, go to the Child Trends site. 

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Great commentary!  My two cents is about the blog author's warning to be careful about pathologizing and overtreating children who don't need it... with the understanding that they want to include more than the original ten,  I still can't imagine that promoting resilience or even referring the child for therapy is harmful... 

To me, ACEs science leads to positive psychology and the promotion of all the things related to resilience leads to a thriving flourishing life - something every parent wants for themselves and their child.  In a world where we are more depressed and more suicidal than ever before, we need the concepts of resiliency in all of our lives.  Resiliency is a protective factor and ACEs is about prevention, not diagnosis and pathology. 

Cissy, thanks for your long and thorough comment. I was about to comment and address all the points you made, and now I don't have to!

Over on, our companion news site for the general public, in the section "Got Your ACE Score", people have left more than 2,000 comments. Many, many of them are along the lines of "I have a high ACE score, did all the things I was supposed to do -- got a PhD, had an important job and successful career, raised a family, and I'm miserable, have lots of medical issues, and now I finally understand why."

Another piece of research that came to mind in your challenge of the "one caring adult" issue is a study that looked at economically successful African Americans and ID'd the toll that racism had on their physical health. You can have all the "one caring adults" in the world, and still suffer the effects of ACEs, especially those that require systems change.

And the whole issue of the emphasis on functioning v. health impact...I think the emphasis on functioning comes from what drives schools to embrace this ACEs science...they of course want students to be in their thinking brains, rather than survival brain to be able to learn. Of course, if they're in their thinking brains instead of survival brain during the school day, that helps them, but if they go home to live in a toxic environment, their short- and long-term health is compromised, as is their ability to have healthy relationships.

I remember Sue Delucci, one of the early pioneers in integrating ACEs science & resilience in a crisis nursery in Kennewick, WA, saying that what spoke to her about the ACE Study was the tiny kids' future health; she didn't want them growing up to have heart attacks in their 50s. She made a small, but significant dent there: She got the return rate of kids down to zero by changing the environment in the nursery, taking a different approach with the kids, and training foster parents and biological parents about ACEs science & research. It was a small dent, because when she left, the nursery went back to its old ways — we have SUCH a long way to go on developing consistent leadership in this ACEs movement — but it was significant, because she developed a course that was widely used in the state.

Lara Kain (ACEs Connection Staff) posted:

Thank you for sharing this! I am glad they are bringing up the conversation. I always address this concept when training on ACEs or Trauma-Responsive Schools. Without introducing the differences it is easy for people learning these concepts to use trauma and ACEs as synonyms. I'd be curious to hear what parts don't resonate for you, I am always learning from your insight! 

I love describing each of the terms which are often used interchangeably (toxic stress, trauma, ACEs, and childhood adversity) - to understand why people respond to and resonate with (or not) some more than others. 

We all certainly have our personal and professional preferences.

This part, I like and it doesn't resonate with me. 

"However, adversity does not predestine children to poor outcomes, and most children are able to recover when they have the right supports—particularly the consistent presence of a warm, sensitive caregiver." 

Here's what I mean.

I agree that adversity in childhood isn't destiny and doesn't mean children, and adults can't and don't recover and thrive. We often do. But if and when we do, and even in the absence of symptoms, the ACE study does show us that there are impacts even if only higher risks. And higher risks, for earlier mortality, on average, of almost two decades, ain't nothing.

Even when functioning well, there are impacts to how people do physically, financially, socially, and I think that's been important for people to learn so that we aren't always looking at functioning, in the moment, as the measure. That's important, from a clinician or provider perspective, to prioritize, but that's not the same as optimal wellness and health and understanding that there can be impacts in the absence of specific problems to address one at a time. 

Also, while I of course know the resource about having a trusted and caring person in the life (in the personal life, a relative, coach, neighbor) is robust, the idea that any and all trauma can be remedied by one caring person - though of course that love, caring, and one person can be incredible support and buffering, and that it eradicates all the health risks associated with high ACEs, also isn't something we can say yet. I'd love more research on this though, those with high ACE scores of 6 or more who are living happy, healthy, and well into old age and what was mediating, protective, best. Lots of us are waiting for that gold!

But even so, the opposite of adversity isn't resilience or even relation buffering, it's lack of adversity, the presence of the advantages of safety, at home and in the community and in systems."

If we focus on "right responses," and "right supports," we keep the conversation about treatment, fixes, responses and that's needed. However, that's a small part that gets a lot of focus. When resilience talk when it doesn't include accounting for how resources are and aren't distributed among populations, as well as how trauma, ACEs, toxic and traumatic stress are - it can feel like an elevated way of blaming people for not functioning better after trauma, like others can and do. I worry about that.

So, I don't disagree with the specifying and clarifying the words, especially for how clinical and medical people use them, which isn't the only way they can and are used. But it's important to know.

I have a fundamental disagreement with keeping talk about ACEs, trauma, traumatic and toxic stress so firmly grounded in the clinical and medical model without acknowledging that it generally hasn't been effective for people with ACEs, who also happen to be, disproportionately represented in largest numbers as those also poor, who are people of color, and female, from the LBGTQ community, and who have been diagnosed with a disability. How many intersectional issues are addressed in typical resilience talk or traditional trauma treatments. How often do we learn about social determinants of health or other issues other than our individual responses to individual history?

For me, not nearly enough. We're not showing up to school or to work or to life with the same ACEs, traumas, stresses, or the same resources, privileges, or advantages. None of this is destiny but there are also some trends, at a population level that we can notice, and impacts and bias. 

Also, this part doesn't resonate, for me. " Gaining a full picture of a child can avoid overtreatment of children who have been exposed to ACEs but are functioning well." It implies that poor functioning is the way to measure if trauma has impacted people and that functioning well is the same as wellness (and like many of us who over reat, or over work, or who have more socially acceptable coping techniques know, that's not the same as great health)... While functioning is one way to measure how a person is doing it's not a full picture and particularly if one isn't employed and has physical or emotional symptoms and ailments that make functioning more challenging. I'm not sure I'd say that person is doing worse, but maybe less able to cover the impact.

Finally, it also doesn't address how poor any of our treatments, to date have been for individuals, families, and communities who have experienced trauma, toxic stress, trauma, traumatic stress, and childhood adversity (in various combinations). The medical treatment model for trauma came out of an understanding of post-traumatic stress as relates to veterans, and like the resilience model, had the frame of people need to "bounce back" to where they once were, before trauma. That frame worked, when trauma is an event, but for those for whom trauma is an environment, where there was no "there" to bounce back to, necessarily, things looked different. For a long time, that never included an understanding of complex and developmental trauma and still, it often overlooks generational, historical, and trauma caused by systems. 

Whew, that is a long answer. My gut response is about as long as this original brief so it's hit some buttons. And it's not all in response to this one policy brief, which I think is really well-written and articulates a lot of what I've heard a lot of lately (and I've met one of the co-authors twice and she's all over it all and you'd love her work).

It's more that I'm five years into this movement and reflecting a lot of late. It's more a general frustration with what brought me to the movement that hasn't moved more, and it's how much of the framing and conversations remain based in medical and clinical models and language that I don't always connect with emotionally, and personally, as a mom and a survivor. For me, the neutrality of ACEs, the language of describing events that happened, not symptoms of a diagnosis in a person, not labels of a condition in a person, still pushes my buttons and is something I wish had changed more by now.

I know the authors writing this also want more focus to be on wider social issues and that I appreciate. It's just figuring out how to get there when trauma is still talked about in the medical/clinical ways is what I'm less sure of. 

I hope you aren't sorry you asked me what didn't resonate, because WOW, I've not written this much in a while. 

I learn so much from you, Lara, so I'd love to hear your thoughts and more about what DOES resonate with you and what you talk about in workshops and think about before and after! Now that I've written, I realize I've been stewing, for a while, about some things. So thanks for inviting me to share my feelings and opinions. 


Thank you for sharing this! I am glad they are bringing up the conversation. I always address this concept when training on ACEs or Trauma-Responsive Schools. Without introducing the differences it is easy for people learning these concepts to use trauma and ACEs as synonyms. I'd be curious to hear what parts don't resonate for you, I am always learning from your insight!