If we were to think closely about our lives – and were we blessed with the non-judgmental self-awareness that is so essential – we might find that at the root of our every behavioural and internal dysfunction, there is something that happened to us as children. The trauma of our early lives leaves indelible imprints on us. Indeed, the trauma of our everyday lives affect us more than we know. 


How exactly does early childhood trauma (right from the prenatal stages) impact our adult lives? Since the 1940s, child psychologists like Donald Winnicott and Alice Miller (‘80s), have been firm about the relationship between early childhood trauma and negative adult outcomes. Winnicott posited, for example, that unless the mother is able (gently, kindly, firmly) to shatter the illusion of her early oneness with the infant (“good enough mothering”), the infant will have trouble with intimate relationships throughout his or her unconscious life. Similarly, Alice Miller said that if parents are (however unconsciously) emotional unavailable to children, such that the latter’s views of reality are negated or confused, the child will grow up to have depressive tendencies. However, mainstream Western medicine had no scientific evidence of this link between trauma and adult outcomes until about two decades ago.


Between 1995 and 1997, the Centre for Disease Control of the United States surveyed over 14,000 patient volunteers of the healthcare organization Kaiser Permanente (of these, over 9000 participated in the survey). The study aimed to discover a connection, if any, between childhood trauma (defined as ‘Adverse Childhood Experiences’) and adult outcomes in terms of health, wealth and well-being. Through questionnaires, participants disclosed information regarding their childhoods, which was measured against the ACE scale, and study findings stated that over 2/3rd of the participants reported experiencing at least one ACE, and were also at high vulnerability for health-risk behaviours, etc.


In this section, we will look at the ACE Study in detail.


For the purposes of the ACE Study, Adverse Childhood Experiences were defined in clear terms. All experiences referred to the participant’s first 18 years of life. According to the definition, ACE is one or a combination of three things: Abuse, Neglect and Household Challenges.

  • The Abuse category was further divided into emotional, physical and sexual abuse:

    • Emotional abuse involves insults, foul language, and fear for personal safety to the child from an adult caregiver (parent, step-parent or any other adult).

    • Physical abuse involves a level of physical violence (pushing, hitting, slapping, grabbing, throwing) against the child by an adult caregiver that results in injury or marks. 

    • Sexual abuse involves an adult (familiar or stranger, at least 5 years older than the child) touching or fondling a child’s body in a sexual manner, or making the child do the same to the adult, or any type of sexual intercourse (attempted or committed).

  • The Neglect category was further divided into emotional and physical neglect, but reverse-defined to simplify the questionnaires:

    • Emotional neglect is (reversely) when someone in the child’s family made him or her feel loved, special and important, and provided strength and support through close family ties. 

    • Physical neglect is (reversely) when the child had someone to take care of him or her materially, and during times of illness; or (directly) the child did not have enough to eat, had to wear dirty clothes, and the parents were constantly abusing substances.

  • The Household Challenges category was divided to reflect family dysfunction:

    • Physical violence and/or the threat of severe violence against the mother or maternal figure by the father, stepfather or the mother’s boyfriend.

    • Substance abuse in the household, where a family member was an alcoholic or used street drugs.

    • Mental illness among one or more family members, or an attempted (or otherwise) suicide in the family.

    • Parental separation or divorce

    • Incarceration of a household member, either current or past

These metrics were worked into the ACE Study questionnaires, and administered to men and women separately (though the questions were similar). The analysis permitted the Study to discover the widespread presence of ACEs. Subsequent studies explored the correlations and connections between ACEs and adult outcomes.

Risk Factors

The ACE Study sought to correlate the presence of childhood traumas to the manifestation of certain parameters for adult outcomes. Broadly, these outcomes were as follows:

  • Disease risk factors and incidence

  • Quality of life

  • Healthcare utilization

  • Mortality

Adult Outcomes

These included physical and psychological outcomes – and focused significantly on self-rated health as well: 

  • Smoking or other substance abuse (including alcohol, drugs, and parenteral drug abuse)

  • History of heart attacks or strokes, including ischemic heart disease

  • Chronic obstructive lung disease and chronic bronchitis

  • Hypertension or diabetes, hepatitis or jaundice

  • Cancer

  • COPD, including emphysema

  • Fractures, representative of the risk of unintentional injuries

  • Problems with regard to marital status or family, or jobs

  • Severe obesity and physical inactivity

  • Depressed moods or suicide attempts

  • History of a high number of sexual partners (>50)

  • History of sexually transmitted diseases

In particular, questions regarding self-rated health, such as “Do you consider your physical health to be excellent, very good, good, fair, or poor?”, were considered strongly predictive of mortality (or early death). These outcomes were then analysed (using SAS and logistic regression) against the reported presence of ACEs among study participants.


The ACE Study found a definitive correlation between the experiences of childhood trauma and adverse adult outcomes for physical and psychological health. In turn, these affect quality of life, capabilities (“real opportunities to do and be what [they] have reason to value”), and finally, longevity. 


Upon analysis of the data, the ACE Study found that there is a significant dose-response relationship between the number of ACEs experienced and the following disease conditions: ischemic heart disease, cancer, chronic bronchitis or emphysema, history of hepatitis or jaundice, skeletal fractures, and poor self-rated health. 


Alarmingly, the ACE Study found that when compared to people who had experienced no ACEs, those who reported exposure to 4 or more categories of ACEs had a 4- to 12-fold increase in health risks for alcoholism, drug abuse, depression, and suicide attempts; a 2- to 4-fold increase in smoking, poor self-rated health, >50 sexual partners, and sexually transmitted diseases; and a 1.4- to 1.6-fold increase in physical inactivity and severe obesity. ACEs may also affect adult attitudes towards “health and healthcare, sensitivity to internal sensations [introspective awareness], or physiologic functioning in brain centers and neurotransmitter systems”.


Since ACEs have neuroregulatory impacts, resulting in the creation of neurotransmitter pathways prone to vulnerabilities, exposure to ACEs also has a significant impact on the formation of health-risk behaviours. For instance, nicotine, having “beneficial psychoactive effects in terms of regulating affect [emotions]”, finds greater probability of use amongst those who are depressed. Extrapolating, people exposed to ACEs are more prone to drug use to regulate their moods. This, the Study posits, may provide “biobehavioural” explanations for the links between ACEs and adult health-risk behaviours. Such behaviours contribute crucially to the manifestation of physical diseases in adult life. Given the propensity of Western medicine to treat diseases symptomatically, the root causes of disease (which may be found in ACEs) are ignored.

The ACE Pyramid explains diagrammatically the relationship between ACEs (starting with transgenerational trauma) and adverse adult outcomes, including early mortality. Further information about disrupted neurodevelopment and social, emotional and cognitive impairment may be found in Section IV – Understanding the Biology of ACEs.

As such, exposure to one or more ACEs actively increases the chances of health-risk behaviours and early death, as well as a host of diseases.


While the ACE Study does not go into detail on solutions, it does offer broad suggestions for the prevention and reversal of ACEs and their impact. In general, the Study sets down strategies for the “prevention of the occurrence of ACEs, preventing the adoption of health-risk behaviors as responses to ACEs, and, finally, helping change the health-risk behaviors and ameliorating the disease burden among adults whose health problems may represent a long-term consequence of ACEs”.


i) Prevention of ACEs

Prevention of ACEs is a difficult and intricate process, requiring the presence of attuned primary caregivers as well as early identification of disease processes. These refer to both primary and secondary prevention methods.


Primary Prevention

Primary prevention refers to a situation where ACEs do not occur at all. This is clearly difficult, since family dysfunction and transgenerational trauma are very common. Ultimately, large-scale individual, familial and societal changes are required to erase ACEs entirely, such that all children grow up in healthy environments where their needs (both spoken and unspoken) are met. The ACE Study suggests early home visitation as a method to reduce the widespread presence of ACEs.


Another method referred to by the ACE Study is the Commonwealth Fund’s Healthy Steps at 15 programme. The programme introduced changes to pediatric care (from birth to age 3), including early intervention by specialists in the “developmental and psychosocial dimensions of both childhood and parenthood”. This was achieved through the development of close relationships between specialists and families through regular office visits, home visits and telephonic advice for parents in a managed care setting. Transforming early caregiving approaches by “talking and sharing books, cuddling, smiling, and otherwise responding to and interacting with infants and toddlers” has shown that there is a profound effect on “emotional development, learning abilities, and the way the child functions in later life”.


Secondary Prevention

Secondary prevention of the effects of ACEs includes identifying those at risk (or high risk), providing an early, holistic diagnosis, and subsequently delivering treatment. It requires, importantly, increased awareness of the impact of ACEs in an adult’s life. This includes not only the awareness of general or absolute dysfunctionality, but also a clear and effective understanding of the coping mechanisms and behaviours that were adopted in early childhood (and continuing to the present day) to dissociate or cope with ACEs.


The ACE Study offers suggestions for some strategies that can help with secondary prevention through early diagnoses and treatments. These include “increased communication between and among those involved in family practice, internal medicine, nursing, social work, pediatrics, emergency medicine, and preventive medicine and public health”.


ii) Preventing the adoption of health-risk behaviours

Secondary prevention is critical in preventing adults who have been exposed to ACEs from adopting health-risk behaviours. As we saw earlier, the experience of ACEs may lead to mistrustful and confused attitudes towards health and healthcare. High levels of exposure to ACEs result in anxiety, anger and depression in children. Psychological coping mechanisms and neurochemistry affected by ACEs make such adults (or adolescents) vulnerable to health-risk behaviours. In particular, when such health-risk behaviours are adopted as coping devices, they “tend to be used chronically”.


Preventing the adoption of health-risk behaviours begins with the recognition that such behaviours are used as coping mechanisms. For instance, diagnosable Attention Deficit Hyperactive Disorder (ADHD) is the result of a childhood coping mechanism, viz. dissociation from an environment that is detrimental, confusing or overwhelming to the child. Depression (and often, its mate, grandiosity) may be an outcome of the emotional unavailability of parents (who are often under intense psychosocial stress) – a parental inability to ‘see’ or mirror the child as he or she is, and not as the parents would like them to be. 


In essence, awareness is the first step to preventing health-risk behaviours. While such awareness is fundamentally an ACE-affected adult’s task, enlightened practitioners of medicine and psychology (both psychiatry and psychotherapy) may assist in this process. As Dr. Epstein says, bringing such behaviours (and crucially, remembering the “forgotten aspects of childhood experience”) into one’s field of awareness itself alters one’s attitude toward them, and is the first step towards change and healing.


iii) Reversing health-risk behaviours and disease burdens


"As children develop, their brains 'mirror' their parent’s brain. In other words, the parent’s own growth and development, or lack of those, impact the child’s brain."

~ Dan Siegel


Tertiary care of adults suffering the consequence of ACEs is a difficult process, and as yet, requires further study and practice. However, certain methods may assist in this. These methods are discussed in detail in Section III (Recognising Your Own ACEs), but we provide a conceptual basis here.


Children, as Dr Gabor Maté says, take everything personally. They experience parental emotions and responsiveness (or lack thereof) as personal episodes, and it is partly this ‘mirroring’ that results in exposure to ACEs. However, Dr Alice Miller, noted German child psychologist and Nobel Prize nominee, posits that the presence of Enlightened Witnesses is valuable in reversing risk behaviours and other repercussions. By Enlightened Witnesses, Dr Miller refers to those adults who are uncompromising and unafraid “to stand up for children assertively and protect them from adults’ abuse of power”.


In managed care or therapeutic settings, an Enlightened Witness (who may, under normal circumstances, be a psychotherapist or any other trained professional) can allow an ACE-impacted adult to relive his or her childhood trauma and lead the healing process. Through various methods, including role-playing and inner child excavation, the affected adult may resolve childhood trauma in safe and protected spaces. Witnesses can elicit and help resolve emotional responses and coping mechanisms that were repressed, choicelessly, in childhood. 

For children whose childhoods were mired in trauma (or indeed, grazed by trauma), their authentic, empathetic and attached selves are lost or hidden. The reintegration of the child’s self, by an ACE-affected adult who has the desire, ability and support to do so, is a long and non-linear process that involves acknowledging and assimilating the trauma and mourning the loss of a healthy, loving childhood. Such a reintegrated adult can then develop empathy and compassion, and then perhaps, become Enlightened Witnesses for others.