How can we tackle lifelong health inequalities by addressing childhood stress?
We all know how important our childhood is in establishing the foundations for our future. However, many of us are unaware of how traumatic events can affect our physical health as adults.
In 1995, Kaiser Permanente and the U.S. Centre’s for Disease Control and Prevention (CDC) identified that childhood trauma contributed to 7 of 10 of the leading causes of death in the West. This landmark study looked at over 13,000 adults. They explored the effects of traumatic childhood experiences on health-risk behaviours (like smoking and alcohol use) and disease.
They found that those affected had a 20-year reduction in life expectancy from heart disease, lung disease and cancer. The term ‘Adverse Childhood Experiences’ (AKA ACEs) was created to describe events that these scientists thought were important in determining future health. These include abuse, neglect and household dysfunction occurring in childhood:
Over half of the participants reported at least one ACE. 1/8thhad experienced 4 or more ACEs. Even more worrying, was the additive effect of these ACEs. Those with 4 or more ACEs had an increased risk of heart disease, depression and suicide attempts compared to those reporting no ACEs.
How ACEs affect physical and mental health from birth to death
ACEs don’t have to be experienced during a person’s life. There may be historical trauma experienced by a child’s ancestors (for example racism, genocide and other systemic oppression). In addition to this, the society which the child is born into also has an impact on their development. Children from the most deprived backgrounds are at the greatest risk of experiencing ACEs. The effects last into their adult life and lead to greater disease and disability.
Since this study was published, over two decades ago, a lot of research has gone into how our bodies respond to these traumatic events. ACEs have been shown to contribute to our social, emotional and cognitive well-being. Areas of our brains which are responsible for impulse control and higher functioning are damaged by ACEs. These areas help inhibit risky behaviours which can harm our health. ACEs caused people to adopt more of these behaviours (e.g. illicit drug use and smoking), inevitably leading to chronic physical illness and early death.
However, experts also found that those who had not adopted risk behaviours were still at an increased risk of physical health problems in later life. Why is this? There appears to be a direct stress response in our bodies when we experience ACEs.
How does our stress response work?
Our normal response to danger is regulated by stress hormones. These are released by the
adrenals - a gland that sits on top of your kidneys. This evolutionary response meant that when confronted by a threat (like a predator), humans could respond to the situation by releasing hormones to enhance performance. This is also known as the ‘fight or flight response’.
It’s controlled by the HPA axis (the hypothalamic-pituitary-adrenal axis), which acts as a connection between our brains and adrenals. When you or I perceive ourselves to be in a dangerous situation, our adrenals release adrenaline and other stress hormones to act on various organs.
What happens in children?
When a child experiences traumatic events, this same response is triggered. What’s worse is that If the ACEs keep happening, children are under a state of chronic stress. Their HPA goes into overdrive. High doses of stress not only affect developing brains but leads to a state of inflammation within the body.
There is damage to blood vessels, leading to a higher risk of heart disease and stroke. Stress also weakens our immune system. As the stress response requires so much energy, any energy from food is stored, increasing the risk of obesity.
Hormones are also affected, resulting in changes to the time of puberty. The damage is so pervasive, that it damages processes right down to how DNA codes are read. All these processes continue whilst ACEs are experienced and unsurprisingly have effects on the health in later adulthood.
The long term effects of ACEs on physical wellbeing
So, what’s being done about ACEs?
Despite all of the research behind ACEs, little is communicated with carers, teachers and health-care providers. Many believe that this is due to a failure of countries to appreciate the public health and financial implications of ACEs.
The World Health Organisation recommends that even more data needs to be collected on ACEs. Using this information, health and social care providers can advocate for policies to promote nurturing environments for children.
We love a recent TEDTalk by a paediatrician who works in America, Dr Nadine Burke. Dr Burke was quick to recognise the effect of ACEs in children. She was running a clinic which provided free healthcare to children from one of the most deprived areas of San Francisco.
Dr Burke found that her clinic combated many physical health problems such as asthma and infection. These families often just lacked the financial support needed for their children to be healthy.
Even with her clinic in place, she found that a lot of children were being referred to her with ADHD. In her own consultations, she found that these children didn’t quite fit this clinical picture. After reading about the effects of ACEs, she believed that these children were already presenting with the behavioural damages that ACEs had been linked with. Dr Burke experienced first-hand the negative effects of ACEs and wanted to do something about it.
Dr Burke and her team started the Youth Centre for Wellness, which aims to increase awareness about ACEs and implement tailored and early support. This includes a team of educational psychologists, dieticians and home visitors who are committed to educating parents and schools about the effects of ACEs.
So, what’s happening in the UK? Nationwide, we are lucky to have the ‘Healthy Child’ programme. This service aims to care for families and children, from pregnancy and into the early years of childhood.
We can think of an approach to tackling ACEs as:
1. Preventing them from occurring in the first place,
2. Identifying them when they occur and
3. Helping counter-act the negative effects on a child’s health.
During pregnancy, families who require extra support are identified early. ‘Healthy Start’ is a means-tested scheme which helps improve the health of low-income pregnant women and their families. They provide vouchers for important vitamins needed during pregnancy and breastfeeding and also food vouchers for items such as milk, fresh fruit and vegetables. You can see if you’re available for this service with your GP or midwife.
Regular contact with your midwives and health visitors in the early years also help identify children at risk from adversities. Families can be offered extra support from social workers and carers.
2. Early intervention
Parents with mental health conditions were identified as one of the ACEs. Perinatal mental health teams help manage new or existing mental health conditions during pregnancy and the post-natal period. New mothers can be referred to these services by their midwives, antenatal team or GP.
Families who find they are struggling with their child’s care also have access to services such as ‘Baby Steps’, an educational programme for families with additional needs.
There is also a variety of support available in nurseries. All schools should have anti-bullying campaigns running annually. Some schools have even introduced mindfulness into the primary school curriculum, to help children tackle emotions such as anger and sadness.
Youth offending teams work with young people who have been arrested or taken to court and help them stay away from crime. They run local programmes, help young people and their families at court and stay in touch if a young person is sentenced to custody.
Other services include Care to Learn, which helps young parents (under 20), with childcare costs whilst they continue with their education.
Are ACEs the same for all children?
The original 10 indicators of adversity are not exhaustive. With new trends in technology and migration, we need a more thorough understanding of events which can affect a child’s future health. Children from the poorest countries often find themselves surrounded by civil unrest, are displaced from their homes and experience poverty.
Even with services in the UK and America, there is a disparity in the uptake of support. There is a significant racial and ethnic gap in mental health-seeking behaviours. This is possibly worsened by language barriers and cultural beliefs.
More research is needed to understand other sources of possible trauma and the effect that current interventions have in mediating their effects.
Can positive experiences help shape future health?
Prevention and early intervention shouldn’t be the only way of tackling this problem. We have to consider the effect that positive experiences have in un-doing the damages that ACEs are linked to.
New research shows that every single ‘positive relational experience’ (that is, a bond that the child perceives as kind), is important. It lowers the risk of depression and other mental health conditions in later life.
An example would include teachers at school who takes time to listen to a child’s worries or children who take part in team sports such as football. These were children who had felt protected by an adult (who wasn’t a parent/ carer) or felt a sense of belonging in their local community or school. Individuals who could recall positive experiences along with ACEs fared better than those who couldn’t. In fact, they were 72% less likely to experience the negative consequences of ACEs on their mental health.
So, whilst a lot of is going into addressing ACEs worldwide we believe we should all be encouraging a pro-active response on an individual level. We should be helping raise awareness about the negative consequences of ACE, as people who come into contact with children on a daily basis. Having ways that to counteract ACEs will foster an environment to allow children to flourish and build resilience in the face of adversity.
Purpose Print Summary
1. Our childhood experiences can have a massive impact on both our mental and physical health, called ACEs
2. The stress response our bodies experience increases the risk of conditions such as heart disease, cancer and stroke
3. In the UK, there are various national schemes which aim to prevent and mitigate the effects of ACEs
4. Although a lot more needs to be done to raise awareness about ACEs, we can start from a small scale by trying to increase the number of positive experiences children have when growing up
Written by Madura Nanthakumaran, Purpose Print Team
Real Science Real Evidence
1. Landmark ACE study: Felitti V et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine. 1998;14(4):245-258.
2. Physical effects of ACEs on health: Bellis M, Hughes K, Ford K, Ramos Rodriguez G, Sethi D, Passmore J. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. The Lancet Public Health.2019;4(10):e517-e528.
3. Diagram – lifetime effect of ACEs: ‘The ACE pyramid’ https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/about.html
4. Diagram: ‘Early Adversity has Lasting Impacts’ https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/about.html?CDC_AA_refVal=https%3A//www.cdc.gov/violenceprevention/acestudy/about.html
5. TED talk: Nadine Burke Harris ‘How childhood trauma affects health across a lifetime’ https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_lifetime/up-next?language=en
6. Positive childhood experiences: Bethell C et al. Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample. JAMA Pediatrics. 2019;173(11):e193007.