Adverse Childhood Experiences & Complex Trauma
Adverse childhood experiences (ACEs) are stressful and potentially traumatic events that occur in childhood (0 to 18 years old). These include witnessing or experiencing abuse, neglect, and other forms of family or household difficulty (e.g. family violence, separation of family unit by divorce, incarceration or grief, family member with substance use or mental health difficulties).
According to the 2016 Singapore Mental Health Study, which interviewed nearly 4500 Singaporeans across all ages, 63.9%, reported experiencing at least one ACE in their lifetime – the most common ACE being physical/emotional abuse or neglect, followed by familial/household difficulties. These figures are concerning because ACEs can have long-lasting negative impact on a child’s well-being. These include impact on their:
- Physical health (e.g. weaker immunity system, susceptibility to diseases)
- Mental health (e.g. depression, obsessive-compulsive disorder, alcohol abuse, suicidality)
- Daily functioning (e.g. poorer academic or vocational performance)
As such, it is important for us to recognise the crucial role that adults play in preventing ACEs from occurring in their homes and communities, by establishing safe, stable, and nurturing relationships and environments for their children. If a child has been exposed to any ACE(s), it is critical to ensure they receive timely and adequate support.
Complex Trauma
When exposure to ACEs are prolonged, and occur particularly within a child’s familial or caregiving context, it can have devastating consequences to the child’s development. There are seven primary domains of impairment that children exposed to such environments can be impacted in:
- Attachment and Relationships
- Physical Health - Body and Brain
- Emotional Response
- Experiencing Dissociation
- Behaviour
- Cognition - Thinking and Learning
- Self-concept and Future Orientation
When this happens, a child can be understood as having experienced complex trauma. The effects of complex trauma are wide-ranging, long-lasting, and put children at risk of further trauma exposure (e.g. victimisation, unintentionally placing self in risky situations), interpersonal difficulties, poor academic performance, addictions, and chronic medical illnesses. As the areas of child development affected by prolonged experience of ACEs are interlinked, treatment progress tends to be slower, and requires a longer period of time. The table below tells us more about how these domains affect children.
Attachment and Relationships
Early caregiving relationships are important as they provide the very first context within which children learn about themselves, their emotions, and their relationship with others. It is from these relationships that they develop a sense of safety in this world and their value as a person. When these early relationships are unstable and unpredictable, their ability to develop in these areas, and have healthy attachment in relationships, are affected.
They have trouble understanding their own emotions and managing them. They have difficulties developing communication skills to solve problems and interact with others. Some children may be overly trusting, or distrustful towards others. They may also find it challenging to understand that what they say or do may affect how other people feel. These make it problematic for them in developing healthy and stable relationships with significant others, romantic partners, friends, as well as authority figures.
Children who have healthy attachment patterns to their caregivers tend to have greater capacity to develop effective self-soothing, communication, and relationship skills.
Physical Health: Body and Brain
The development of the brain is sensitive to the environment that the child grows up in. Children who grow up in a constantly frightening and highly stressful environment (i.e. maltreatment, family violence), or lacking healthy mental stimulation (i.e. neglect), are subjected to a compromised development of their body’s immune system. Additionally, their body’s stress response may not develop normally and, as a result, are more vulnerable to being easily overwhelmed by stress.
When we experience stress, our bodies release high levels of stress hormones to help us respond to the threat or source of stress accordingly. The stress hormones in our bodies subside once the threat or stress is over. However, for children with complex trauma histories, the stress hormones in their bodies stay at high levels for a prolonged period of time, resulting in “damage” to connections between areas of their brain. This causes their brains to work in a less organized manner, where they are at an increased risk of responding to stress in unhelpful ways (e.g. helplessness, confusion, intense anger outbursts). Whereas a lack of healthy mental stimulation can prevent a child's brain from developing to its full potential.
Children with complex trauma histories may also have frequent complaints of physical pains, such as headaches and stomachaches. Studies have shown that adults with histories of complex childhood trauma suffer more physical conditions and chronic illnesses than adults who do not.
They often struggle with body dysregulation, where they over-respond or under-respond to sensory stimuli. This means that they are either hypersensitive to light, sounds, touch or smell, or they have little to no awareness of pain, touch, or internal physiological sensations. Consequently, they may frequently complain of chronic pain in their body despite no physical causes found for it or feel no pain despite suffering from physical problems because they are unaware of their body’s physical experience.
Emotional Responses
Children with complex trauma often have difficulty identifying, expressing, and managing their emotions. Because of this, they may respond to stress in unhelpful ways to cope. Some children and youth may isolate themselves from others, suppress their emotions or inappropriately blame themselves for the difficulties they are experiencing (i.e. internalised stress reactions). Others may act out, be more physically aggressive, become defiant and engage in risky behaviours (i.e. externalised stress reactions). They would be at a greater risk of developing mental health difficulties such as depression, anxiety, and issues with anger management later in life.
For children and youth with a history of complex trauma, reminders of traumatic events could be everywhere in their environment. Hence, they may react often and intensely – with fear, sadness, anger, or avoidance – and have difficulty calming down when affected by the reminder. Because the traumas are often interpersonal in nature, even slightly stressful interactions may serve as a trauma reminder that can trigger extreme emotional responses in them. However, because difficulties with managing emotions is so pervasive, and they did not get to learn how to calm themselves down whenever they become upset, they are often easily overwhelmed.
Emotional dysregulation can occur even in the absence of relationships, which can cause lifelong difficulties in various areas of their lives if they do not receive the appropriate support and intervention needed to heal from their trauma(s).
Experiencing Dissociation
Dissociation occurs when the brain does not connect our thoughts, feelings, and sensations in a way that is normally expected.
In the context of trauma, children may dissociate as a coping response to the overwhelming and terrifying experience. This is often not a conscious response to the traumatic event. When children or youth experience a devastating or overwhelming event, they may perceive themselves being detached from their bodies, being above or somewhere else in the room watching what is happening to them. Or they may feel as if they are in a dream-like, altered state, where the situation does not feel real or like it was happening to someone else instead of them.
As these children face repeated episodes of trauma, they may tend to dissociate more easily and more often as a defense mechanism, even in response to other stressful life events. This can affect their ability to be fully present in their daily activities and in life, which creates fractures and discontinuity in their sense of time. As a result, their development in many other areas are affected, such as in learning, attention and concentration in school, emotional regulation, social interactions, as well as in their ability to make sound judgments or plans to achieve their goals.
Behaviour
Children with a complex trauma history may be easily triggered or reminded of their trauma. Because they often struggle with emotional regulation and have trouble calming down, their reactions to stress and perceived threat or rejection can be volatile, intense, and appear unpredictable and extreme.
A child who grew up in an environment where they felt powerless or had lived in frequent fear of an abusive authority figure, may react defensively and aggressively in response to perceived blame or attack. Alternatively, they may at other times be very controlled, rigid and unusually compliant with adults or authority figures. Children who dissociate may appear as if they are day dreaming, not paying attention, or “spacing out”.
Other behaviours of children with a history of complex trauma include eating disorders, high-risk behaviours such as substance abuse, self-harm, unsafe sexual practices, or engaging in reckless, dangerous or illegal activities, like stealing, getting involved in gang fights.
Find out more about how a child's behaviour may be affected post-trauma over here!
Cognition: Thinking and Learning
Children with complex trauma backgrounds are at risk for language delays, difficulties with attention, and tend to have poorer problem-solving and abstract reasoning skills. They may have trouble sustaining attention, curiosity, as they may be distracted by their internal reactions to trauma reminders. As a result, they may tend to fair more poorly academically, or at their workplaces.
In cases of neglect, the lack of sensory and emotional stimulation that the child received during early childhood may give rise to some of these issues, resulting in poorer academic or vocational performance later in life.
Self-concept and Future Orientation
A caregiver’s relationship with their child is important in the formation of a child’s self-identity. The reactions of caregivers and close adults around them help form their sense of self-worth and value.
Early experiences of repeated maltreatment or neglect lead a child to think they are helpless, defective, and unlovable. Children who carry this view of themselves are more likely to blame themselves for negative experiences in their life, have a diminished sense of competency, and tend to carry the expectation that others will reject them, making them less willing to reach out, or respond to support from others.
A child or youth who has a complex trauma history may see themselves as “broken” or “damaged”, feel powerless, where their efforts to move forward in life are pointless. They have difficulties feeling hopeful and the world to them may feel like a meaningless place to live in. Because they have learned to live in a “fight-flight-freeze” (survival mode) response, they tend to live in reaction, instead of being able to think about, plan or dream about a possible safe and successful future.
References
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Subramaniam, M., Abdin, E., Vaingankar, J. A., Chang, S., Sambasivam, R., Jeyagurunathan, A., Seow, L. S. E., Van Dam, R., Chow, W. L. & Chong, S. A. (2021). Association of adverse childhood experiences with diabetes in adulthood: results of a cross-sectional epidemiological survey in Singapore. BMJ open, 11(3), e045167.
The National Child Traumatic Stress Network (NCTSN). (2018). Complex Trauma, Effects. https://www.nctsn.org/what-is-child-trauma/trauma-types/complex-trauma/effects
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