Each year during Stress Awareness Month, we publish a series of articles about stress: what it is, why we experience it, and what we can do about it. We also offer statistics on the prevalence of stress in our communities and advice on how to handle stress that becomes chronic, toxic, or dangerous to our health and wellbeing.

Our first article defined and discussed chronic stress. In that article, we talked about the difference between typical daily stress and chronic stress, then described the short- and long- term physical and emotional consequences of chronic stress.

Our second article discussed three types of stress identified by the experts at the Harvard Center on the Developing Child: positive stress, tolerable stress, and toxic stress. In that article, we focused on toxic stress. We talked about the negative physical and emotional consequences of toxic stress and introduced the idea that those consequences can be mitigated – or avoided altogether – when responsible, caring adults are present to help children process stressful experiences.

This third article in our series addresses the most dangerous type of childhood stress we know about. It’s a type of stress is so damaging that health professionals created a new category of stress to discuss and address it. Think of it as extreme, toxic stress. Events that fall into this category have a name you may have heard: adverse childhood experiences (ACEs).

The ACE Study

In 1998, the Centers for Disease Control (CDC) and Kaiser Permanente Health Systems launched a study on the effect of adverse childhood experiences on long-term physical, mental, social, and emotional health. Known as the ACE Study, this paper marked the beginning of an approach to mental and emotional healthcare practices now commonly called trauma-informed care.

According to the ACE Study, adverse childhood experiences include:

• Physical, emotional or sexual abuse
• Physical or emotional neglect
• Domestic violence
• Living with a parent or caregiver with a substance use or mental health disorder, or living with an individual who was incarcerated or sentenced to be incarcerated

Over the next fifteen years, the original research team published a series of articles that demonstrate the long-term consequences of adverse childhood experiences. The data show that when individuals experience four or more ACEs, they’re likely to experience:

• Problems in brain development
• Disruptions in social, cognitive, and emotional function
• Impaired risk-assessment and impulse control
• Chronic illness, disease, and disability

This work changed healthcare as we know it – and that’s not an exaggeration. But the change was not instantaneous. It took two more large studies – and almost twenty years – for the mainstream medical establishment to recognize the role ACEs play in overall health and wellbeing.

The Philadelphia Study

In 2014, Dr. Roy Wade of the Children’s Hospital of Philadelphia published a paper called “Adverse Childhood Experiences of Low-Income Urban Youth.” He began his research when he realized he worked with children every day who experience extremely adverse events that were not recognized by healthcare practitioners as adverse childhood experiences. He also knew the young adults he worked with suffered from chronic health conditions that could be explained by ACEs – if their early experience were recategorized as adverse.

Therefore, Dr. Wade, in collaboration with the Institute for Safe Families, decided to analyze the childhood experiences of individuals from low-income, urban areas, and compare them to their long-term health outcomes. What he and his team found did not surprise him at all. He knew his patients’ early experiences had negative impacts on their physical and emotional health – but he did not expect his data to be as conclusive as it was.

His study expanded the list of childhood experiences now recognized as adverse to include:

• Experiencing racism and/or bullying
• Living in foster homes
• Living in an unsafe neighborhood
• Witnessing violence
• Experiencing economic hardship

This was a big step in trauma-informed care.

The biggest step, however, was still to come.

The CDC Report

In 2019, a landmark report published by the CDC cleared up any doubt over the long-term effects of ACEs on health and wellbeing. Although before 2019, the link between ACEs, chronic disease, and mental illness had been clearly established by scores of peer-reviewed scientific papers, the CDC report quantified the long-term health consequences of ACEs and estimated the extent to which chronic disease could be reduced if ACEs were eliminated.

CDC researchers found that exposure to ACEs is connected to five of the leading causes of death in the U.S. These are:

• Cancer
• Diabetes
• Heart disease
• Suicide
• Drug Overdose

Researchers estimated that preventing ACEs from occurring could reduce:

• Heart disease by 12.6%
• Depression by 44.1%
• Obesity and overweight by 1.7%

Those are significant numbers. Taken together, they represent millions of people. They imply that we, as a society, can improve our overall health and wellbeing by paying more attention to the health, welfare, and day-to-day safety of our children.

ACEs, Trauma-Informed Care, and Children

The same day the CDC published their report, the Journal of the American Medical Association published a paper called “Identifying and Preventing Adverse Childhood Experiences: Implications for Clinical Practice.” The paper outlined a set of guidelines for clinicians concerned about how to best support patients they suspect have experienced childhood adversity.

The guidelines specifically advocate that health professionals adopt a trauma-informed perspective in all clinical situations. They advise clinicians to:

• Prevent ACEs by educating parents and caregivers
• Incorporate trauma-informed care into primary care
• Understand how trauma affects health
• Screen for ACEs and trauma in all clinical settings
• Use culturally sensitive assessments to screen for ACEs
• Promote resilience
• Promote protective factors such as emotional literacy and psychological coping skills
• Address physical issues through the lens of trauma-informed care and with an awareness of ACEs
• Address mental health issues through the lens of trauma-informed care and with an awareness of ACEs
• Provide linkage – i.e. referrals – to mental health support for issues related to trauma or ACEs

That’s what the leading health experts in the nation advise clinicians to do for their patients. It all makes perfect sense and will help improve the lives of anyone who experiences childhood adversity. As mental health clinicians who specialize in treating adolescents with mental health and/or substance use disorders, we embrace the trauma-informed approach to clinical care – and we offer the same advice to parents, teachers, and anyone who works with teenagers.

We know it’s what they need, and we know it’s the best way to help them.

What You Can Do

We’ll simplify this advice, however, and suggest a shift in perspective that may be new to some. Here’s what we think: in any situation involving a child or teenager, consider the possibility that early adversity and trauma may play a role. We understand that’s a broad statement, but we mean it. This goes for behavioral issues, academic issues, social issues, and family issues, too. If a child or teen has problems, take a trauma-informed, ACE-aware approach. What teen survivors of trauma and adversity need most is to be heard, recognized, valued, and supported by responsible, caring adults. They need unconditional love. First from their families, and second, from anyone in a position to offer it. With this approach, we can help our children and teens overcome adversity and live full, productive lives.