Adverse Childhood Experiences & Complex Trauma
What are Adverse Childhood Experiences (ACEs)?
Understanding ACES
Adverse Childhood Experiences (ACEs) are stressful and potentially traumatic events that occur during childhood and adolescence (ages 0 to 18). These experiences can have profound and lasting effects on a child's development, health, and wellbeing throughout their life.
Types of ACEs
ACEs fall into several categories:
- Witnessed or experienced abuse and neglect (e.g., physical, sexual or emotional abuse, neglect)
- Household difficulties (e.g., family violence, substance abuse by family members, mental health difficulties in the family, separation of a family unit by divorce, incarceration of a family member
- Community and environmental factors (e.g., exposure to community violence, discrimination or racism, poverty or homelessness)
The Reality of ACEs
ACEs are unfortunately common. According to the 2016 Singapore Mental Health Study, which interviewed nearly 4,500 Singaporeans across all ages, 63.9% reported experiencing at least one ACE in their lifetime. The most common ACE was physical or emotional abuse or neglect, followed by familial and household difficulties.
Why ACEs Matter
ACEs are concerning because:
- The more ACEs a person experiences, the higher their risk for difficulties later in life (This is also known as a dose-response relationship)
- Without proper support and intervention ACEs can affect physical health, mental health and daily functioning.
However, it is important to also understand that:
- The presence of protective factors (like caring adults and trauma-informed environments) can reduce the impact of ACEs
What Happens when ACEs are prolonged?
When exposure to ACEs is prolonged and occur particularly within a child's familial or caregiving context, it can have long-term consequences to the child's development. This is what we call complex trauma.
Understanding Complex Trauma
Complex trauma is different from other types of trauma because it often:
- Happens during critical periods of a child's development
- Involves people who should be protecting or nurturing the child
- Disrupts the child's ability to form safe, trusting relationships
Prolonged and chronic trauma creates ongoing stress that changes how a child's brain and body develop. This can lead to difficulties that look like other conditions such as Attention Deficit and Hyperactivity Disorder (ADHD), autism, or behavioural disorders. There are seven domains of impairment that children exposed to such environments can be impacted in:
- Attachment and Relationships
- Physical Health: Body and Brain
- Emotional Responses
- Behaviour
- Cognition: Thinking and Learning
- Dissociation
- Self-concept
Attachment and Relationships
Early caregiving relationships are important because they provide the very first context within which children learn about themselves, their emotions, and their relationship with others. Through these early bonds, children develop a sense of safety in the world and an understanding of their own worth as a person. Children who have healthy attachment patterns with their caregivers tend to have greater capacity to develop effective self-soothing, communication, and relationship skills.
When these early relationships are unstable and unpredictable, a child’s ability to develop emotionally and form healthy attachments is affected. They may have trouble understanding their own emotions and managing them. They face difficulties developing communication skills needed to resolve conflict and interact effectively with others. Some children may be overly trusting, whilst others become deeply distrustful of everyone. They may also find it challenging to recognise that their words and actions can affect how other people feel, making social interactions difficult. These make it problematic for them in developing healthy and stable relationships with family members, romantic partners, friends, as well as authority figures.
Physical Health: Body and Brain
The development of the brain is incredibly sensitive to the environment a child grows up in. When children experience ongoing trauma, it affects their development in several ways:
Brain Development Changes: When children grow up in constantly frightening or stressful environments, their brain development is impacted. The brain prioritises survival, activating the fear centre of the brain (amygdala) more frequently, while connections between other parts of the brain like the areas responsible for learning, memory, and emotional control (the prefrontal cortex and hippocampus) may be reduced. This means these children often:
- React more strongly to perceived threats
- Have difficulty learning new information when stressed
- Struggle with problem-solving and planning ahead
- Find it hard to adjust their behaviour to different situations
Stress Response System: Normally, when we face stress, our bodies release stress hormones to help us cope, then return to normal once the danger passes. For children with complex trauma histories, this system becomes stuck in "high alert" mode. Their bodies produce stress hormones constantly, which:
- Weakens their immune system, making them more prone to illness
- Disrupts sleep patterns
- Affects their ability to concentrate and learn
- Can lead to chronic health problems later in life
Body Awareness Issues: Many children with complex trauma struggle with understanding their body's signals. They might:
- Be hypersensitive to sounds, lights, or touch
- Have little awareness of pain or internal sensations
- Experience unexplained pains and aches (e.g., headaches or stomach aches)
Emotional Responses
Children with complex trauma face unique challenges in understanding, expressing and managing their emotions. These difficulties may present as internalised behaviours such as isolating themselves from others, suppressing their emotions or inappropriately blaming themselves for the difficulties they are experiencing. Others may externalise these feelings and act out, be more physically aggressive, become defiant and engage in risky behaviours. Difficulties regulating emotions put children at risk of developing mental health difficulties such as depression, anxiety and issues with anger management later in life.
Additionally, they may also react strongly or intensely to cues in the environment that remind them of traumatic events and have difficulty calming down when affected by the reminder. As their trauma events are often interpersonal in nature, even slightly stressful interactions (e.g., disagreeing with someone, someone being angry at them) may trigger extreme emotional responses in them.
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 daydreaming, 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 ingang fights.
To find out more about how a child’s behaviour may be affected because of prolonged trauma, navigate to the “Adverse Childhood Events and the Impact on Children” Tab under Trauma-Informed Care in Healthcare.
Cognition: Thinking and Learning
In view of the impact of prolonged trauma on the brain, children with trauma histories are at risk for language delays, reduced problem solving, planning and organisation skills. They may struggle with attention because their brains are constantly scanning for potential threats. Even in safe environments like classrooms, they may be distracted by their internal reactions to trauma reminders, making it difficult to pay attention to lessons or complete tasks.
Trauma can also affect both working memory (holding information in mind temporarily) and long-term memory formation. Hence, children may have trouble remembering instructions, learning new concepts or recalling information.
Dissociation
Dissociation is the brain’s way of protecting an individual during overwhelming experiences. When a child cannot physically escape a traumatic situation, their mind creates an escape route by disconnecting from the experience. This is often not a conscious response to the traumatic event. Dissociation may be described by children and youth as a sense of 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.
For children who experience repeated trauma, dissociation can become a learned response. They may tend to dissociate more easily not just when reminded about traumatic events, but also in response to everyday stressors and they feel emotionally overwhelmed. This can affect their ability to be fully present in their daily activities and in life, which creates gaps in memory and a fractured sense of time, making it hard for children to remember events or understand the sequence of what happened. As a result, their development in many other areas is affected, such as in learning, emotional regulation, social interactions, as well as in their ability to make sound judgments or plans to achieve their goals.
Self-Concept
A child’s sense of who they are develops through their early relationships. When these relationships are unpredictable or harmful, it can affect how children see themselves and their future.
Children with complex trauma often develop what researchers call “negative working models”, or deeply held belief such as:=
- I am unlovable or bad
- I can’t trust others to care for me
- I am helpless
Unfortunately, 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. Such beliefs can also lead to choices that put children at further risk such as:
- Accepting unhealthy relationships because they feel they do not deserve better
- Engaging in risky behaviours because they do not think they are worth protecting
- Avoiding opportunities for growth because they expect to fail
The Path Forward
While the effects of complex trauma can be serious and long-lasting, it is important to know that healing is possible. The healing journey begins when caring adults reach out to build healthy relationships with a child by:
- Providing stable, safe and nurturing relationships
- Recognising signs that a child may be impacted by events in the past
- Practicing trauma-informed practices in schools, healthcare and community settings
- Connecting the child to evidence-based therapeutic support and interventions with trained professionals to support development, emotional or mental health needs
References
Hughes, K., Bellis, M. A., Hardcastle, K. A., Sethi, D., Butchart, A., Mikton, C. & Dunne, M. P. (2017). The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. The Lancet Public Health, 2(8), e356-e366.
Sar, V. (2011). Developmental trauma, complex PTSD, and the current proposal of DSM-5. European Journal of Psychotraumatology, 2(1), 5622.
Stover, C. S., & Keeshin, B. (2018). Research domain criteria and the study of trauma in children: Implications for assessment and treatment research. Clinical psychology review, 64, 77–86. https://doi.org/10.1016/j.cpr.2016.11.002
Subramaniam, M., Abdin, E., Seow, E., Vaingankar, J. A., Shafie, S., Shahwan, S., Lim, M., Fung, D., James, L., Verma, S. & Chong, S. A. (2020). Prevalence, socio-demographic correlates and associations of adverse childhood experiences with mental illnesses: results from the Singapore mental health study. Child abuse & neglect, 103, 104447.
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
Get it on Google Play