The initial Adverse Childhood Experiences (ACEs) Study published in 1998 correlated 10 instances of early life adversity to poor adult life outcomes. The instances were physical, emotional, and sexual abuse; physical and emotional neglect; and household dysfunction: growing up in a home with a member incarcerated, a member with mental illness, a member with substance use problems, parental separation, or where there was domestic violence.

Results indicated that ACEs tended to occur in clusters – experiencing one type makes experiencing other types more likely – and that an increase in ACEs correlated with poorer physical, behavioural and social outcomes. How or by what mechanism(s) these findings occur within the individual has not been fully elucidated. Taking an approach that views ACEs and toxic stress as parts of an overall dynamic developmental disruption may shed some clarity on the processes, as it appears that after experiencing a certain threshold of adversity the child’s developmental trajectory is negatively altered.

The foundational base for a growing child’s dynamic developmental life is shaped through meaning-making interactions with its environments and caregivers. Past experiences become the templates through which ongoing present and future interactions are interpreted. These repeated meaning-making processes constantly remodel body structures (such as the developing brain), sculpt or refine the functioning of these structures (i.e. regulatory systems), and influence how the child relates to changes in its internal and external environments. This is especially significant in early childhood when new relationships, functional connections, networks, systems, capacities and capabilities rapidly emerge. Typically, during early life, it is the primary caregivers who form the first extra-uterine interactive environment from which the newborn gains developmental and regulatory directives and perspectives. It is here where nature and nurture begin their ongoing reciprocal interactions.  

One can therefore appreciate how important the quality of early childhood relationships with primary caregivers are for the present and future life of the growing child.

Daily repetitive caregiver and environmental encounters shape the child’s present and future regulatory capacities and capabilities, especially as newer hierarchically defined brain regions fully emerge and mature. These complex structures and their functions are woven into the child’s previously defined interpretive templates and go on to influence further sequential development. Over time, as the child encounters new people and environments, more complex bio-psycho-social realms coalesce and form the basis for the child’s view of him/herself, the world around them, and their place in it. The nature and quality of the child’s experiences can either reinforce or modify previous positive or disruptive meaning-making encounters.  

It is well-known that safe, loving, secure relationships improve both short- and long-term bio-psycho-social outcomes. These relationships that provide positive, predictable, rewarding interactions strengthen the child’s relational ties, buffer the child against major stressors and reinforce the child’s evolving ability to regulate emotions. These factors facilitate complex emotional and cognitive growth and decreased survival-based (fight, flight, freeze) functioning. As a result, the child’s systems orientate towards experiencing positive social engagements and gaining agency in adapting to changes with minor stressful episodes.

A child who is exposed to dysfunctional early relationships and environments is more likely to manifest poor physical, behavioural and social-emotional outcomes. Due to the unsafe nature of these early environments, there is a fracturing of the foundational needs of the child to be protected and nurtured. Its world becomes unsafe and unpredictable, often with no one to relieve its distress. New environments and relationships are to be avoided. The child feels helpless to effect change in its environment and its ability to relate to or reason with others in a healthy manner is compromised. Ongoing bio-psycho-social development is impaired as the child anticipates future adverse experiences. Over time, defensive regulatory systems become hyper-aroused and difficult to down-regulate, resulting in deleterious side effects including chronic illness and even premature death.

For the child whose development has been impaired by past adverse experiences, its hyperacute defensive survival reactions take precedence. As a consequence, the child’s ability to integrate and utilise higher cortical functioning is compromised. For example, the affected child becomes hypervigilant to minor changes in its surroundings, the rigours of school (sitting still, focusing, following directions, relating to others) may become too demanding and difficult, leading to academic underachievement. Many of these children are misdiagnosed with attention deficit disorder and various intellectual disabilities due to a lack of informed approaches to recognising symptoms of childhood adversity. Once labelled, they are often treated in ways that further exacerbate their developmental dysfunctions. If, on the other hand, their challenges are properly recognised and they are placed in environments that promote safety, regulation and healing, the vast majority of them will acquire or regain positive functioning and excel.

Recognising individual ACEs as parts of a cumulative disruptive process that initiates changes in a child’s life will help us understand many of the challenges our children face.

Richard Honigman, FAAP, is a general paediatrician with over 30 years of private practice experience. He attended NYU’s Metropolitan Leadership Program and obtained his MD at SUNY Downstate College of Medicine in 1976. Honigman also holds an Infant-Parent Mental Health Post-Graduate Certificate from the University of Massachusetts – Boston. He is the Chair of the Research and Education team at Reach Within (based in Grenada) and has presented at numerous global conferences in Rome, Bermuda, Antigua, Grenada and elsewhere. A well-regarded expert in trauma-informed care, Dr Honigman advises UNICEF in the Eastern Caribbean Region.