by Haley Herbert
art by Hailey Kopp
Trigger warning: This article contains references to childhood trauma and abuse.
Matthew is a ten-year-old child struggling with unresolved mental and physical health issues. They miss class often, have repeated a grade, and do not form many close relationships with other students. At home, Matthew deals with physical abuse from adult caregivers. These facts, rather than just separate facets of Matthew’s life, are likely interconnected. For a long time, studies have focused on understanding cases like Matthew’s, and the way that adverse experiences can contribute to negative behavioral and health outcomes such as troubles in school, interpersonal challenges, and increased risk for mental health problems [1, 2]. Risk factors, or variables associated with increased risk for something, have been heavily explored as they relate to these negative outcomes. An example of these risk factors, adverse childhood experiences (ACEs), are a list of ten commonly agreed-upon and aggregated sources of childhood trauma [3]. These sources include abuse, neglect, parental separation, incarcerated relatives, and mental illness in the home; they are commonly understood as risk factors for a wide variety of adverse outcomes [3]. Understanding the link between these experiences and the negative outcomes they are correlated with might help inform interventions aimed at prevention.
What are Adverse Childhood Experiences and Resiliency?
Resiliency, by its standard definition, is the “ability to recover from or adjust easily to adversity or change” [4]. In the realm of trauma, resilience measures are factors that aid in the ability to adapt to and minimize the negative effects associated with trauma [5]. Children with high resilience measures (i.e., demonstrating persistence and curiosity, tackling problems as a family, and participating in community-level programs) showed fewer mental health outcomes including attention-deficit/hyperactivity disorder (ADHD), behavioral disorders, anxiety, and depression [1]. This suggests that outside of their trauma, these children had certain experiences and access to resources that allowed them to mitigate these effects [1]. Understanding sources of resiliency could illuminate how to develop policy on how to best foster resilience in children who experience ACEs, ultimately minimizing their negative impact.
Neurobiological Differences in ACEs
Those with ACEs often display neurobiological disparities, including differences in activity in the amygdala [6]. The amygdala is a key component in fear response, especially Pavlovian fear conditioning. This is the process in which two stimuli are routinely presented and paired with one another: one that elicits an emotional or physical response and one originally neutral. Eventually, the previously neutral stimulus begins to produce the same response as the non-neutral stimulus [6]. One example of this could be pairing food with the ring of a bell. Although ringing the bell does not originally produce a response, the presence of food causes salivation. After repeated pairing, the bell’s ringing, on its own, would also cause salivation. Children with early-life adversity demonstrate an elevated amygdala response to emotional stimuli compared to children without early-life adversity and are comparatively hyper-responsive to fear-inducing stimuli [2]. This can be incredibly disruptive. For example, if Matthew generalized their fear of the adult caregiver responsible for their abuse to their home, they may never feel safe in that environment, even if that adult caregiver were removed. Alternatively, imagine if this fear was extended to caregivers in general. Matthew might fear and distrust all future caregivers. This inability to distinguish between threat and safety may be responsible for the elevated risk of anxiety found in people with ACEs, since the generalization of fear could be extended to a large variety of contexts [1].
Another neurobiological change found in children with trauma histories includes reduced volume in the hippocampus and amygdala [2]. Together, these brain regions are crucial for determining emotional significance and encoding memories [7]. When an emotion-inducing event occurs, the amygdala and hippocampus work together as a circuit. The amygdala provides important information about the emotional significance of stimuli. Then, the hippocampus processes the event and its emotional significance together in order to encode it as a memory [7]. This teamwork leads to changes in arousal and stress to different stimuli, as a person’s memory of past threats determines their future responses to similar situations [8]. Without a typically functioning amygdala and hippocampus response, a person may overreact or underreact to specific stimuli, since the context in which memories are encoded is not intact.
ACEs have also been linked to changes in a major stress response system in the body: the hypothalamic-pituitary-adrenal (HPA) axis [9]. When a stressor occurs, a region of the brain called the hypothalamus is activated [10]. Following a cascade of reactions, cortisol, a key stress hormone, is released [10]. Child abuse has been found to cause an increase in cortisol production, otherwise known as hypercortisolism [10, 11]. Repeated stressful experiences can cause an increase in HPA activation, resulting in increased levels of stress hormones in the body [9]. One proposed pathway for the HPA axis’ effects on physical health could be caused by hypercortisolism. Sustained stress exposure can suppress the immune system, ultimately rendering the body vulnerable to more illness [2]. Stress hormones, namely glucocorticoids like cortisol, generally have an immunosuppressive function in order to conserve energy in the short term, meaning they may contribute to immune system inhibition and physical health risks following trauma [10]. Another potential avenue for adverse physical health risks following trauma involves changes in telomeres, the protective caps positioned at the end of a person’s chromosomes [12]. Generally, telomeres gradually shorten with age [12]. However, chronic stress can accelerate their shortening, leading to
faster aging and an increased risk for diseases associated with aging [2, 12].
In addition, sustained periods of hypercortisolism can be detrimental to later stress response. To adapt to the extremely high level of stress hormones found in the bloodstream during periods of hypercortisolism, the body receives signals to decrease the release of stress hormones [10]. This causes hypocortisolism, where less cortisol is produced in the body overall [10]. This model suggests that following chronic stress, an individual’s body adapts to the readily available supply of cortisol that existed during these experiences, leading to a decrease in cortisol production later in life [13]. Hypocortisolism can lead to physical health symptoms such as physical weakness, lack of energy, depression, and low blood pressure [14]. Since hypocortisolism is linked to depression, this may correlate with the increased risk of depression found in people with ACEs [1]. This hypocortisolism model for chronic stress has been further supported in our understanding of developmental trauma. When examining two groups for cortisol response levels, one group having early life stress and the other having experienced cumulative but non-early life stress, early life stress better predicted reduced cortisol response than cumulative stress [15]. This suggests that this model might be better suited for those who have experienced developmental trauma or ACEs, since these exposures occur early in life. If we think back to Matthew from the beginning of our story, one can assume that they may have started out with periods of hypercortisolism. Due to the chronic stress created by having an adverse home environment, their body would likely be subjected to stress reactions for prolonged periods of time, continuously signaling the HPA axis to create more and more cortisol. Over time, Matthew’s body would likely adapt to the levels of these hormones by reducing the amount of receptors for stress hormones in the body. This would shift their body into a state of hypocortisolism, which opens them up to a wide variety of health risks.
Behavioral and Health Associations
These neurobiological changes may result in long-term behavioral and physical health consequences. ACEs are associated with a number of negative long-term physical health disparities, including diabetes, cardiovascular issues, and other physical health challenges [1, 3, 16]. In addition, ACEs have been shown to increase risks of mental disorders [1]. Exposure to four or more ACEs has been positively correlated with ADHD, depression, anxiety, and behavioral disorders [1]. Compared to participants with no ACEs, those who reported multiple ACEs were more likely to experience alcohol use disorders, substance use disorders, and suicide attempts and displayed an increased risk of sexually transmitted infections [17]. Just like Matthew, children around the world are experiencing ACEs. They deserve a chance at a life without these physical and mental health risks. As a society, it is our job to find a way to intervene. These outcomes make it clear that finding ways to mitigate the effects of ACEs is critical for reducing physical and mental health disorders in these populations.
Resiliency within the Context of ACEs
Environmental experiences can severely impact outcomes in children with ACEs. Although many ACEs occur inside the home environment, it is possible that in some situations, caregivers may be able to intervene. An example of this could be emotionally sensitive parenting, which has been associated with resilience in children with ACEs [17]. Another example exists within the family system. Families that utilize skills such as discussing problems as a unit, working together to solve them, and staying hopeful have all been associated with reduced levels of mental health outcomes for children with ACEs [1]. Outside of the family, community-level factors have been found to contribute to a child’s resistance against trauma. These factors may be most important for policy, as it may be easier to influence factors outside of the home rather than inside. Access to a trusted adult, residing in a supportive neighborhood, and engagement in community activities are all associated with a reduction in the negative mental health outcomes for children with ACEs [1]. Community-level factors offer an excellent opportunity for intervention because they
allow for direct intervention. If Matthew’s home life was not an identified problem, policy focused on home-life intervention would not be able to intervene. However, even if Mathew’s home life remained an unidentified problem, access to community resources across the board may increase their chances of resiliency. While society as a whole may not be able to directly intervene in the home lives of children, we can spur communities to provide better support systems.
It has been proposed that internal qualities can impact the external experiences and resiliency outcomes of children. One example of these internal characteristics is child temperament [18]. For example, perceived easy child temperament has been associated with more positive interactions with caregivers. This elicitation of positive attention could lead them to gather more adult aid during their maltreatment [18]. However, it is important to note that it is the responsibility of the caregiver to provide high-quality parenting rather than the child to elicit this. Instead, this should be examined as a potential mechanism for individual
differences in resilience for children without strong access to community resources. Other internal resilience factors include qualities of persistence, interest and curiosity in learning new things, and the capacity to regulate emotions [1]. The presence of these qualities are all associated with a reduction in negative mental health outcomes for children with ACEs [1]. Rather than expecting these qualities out of children, interventions could focus on training children in these approaches. For example, rather than placing the blame on Matthew for not already having these qualities, an intervention may be able to train them to find value in persistence or provide psychoeducation on the regulation of emotions. It is important to monitor language when conducting resilience research in order to avoid the victimization of children from these backgrounds. The presence or absence of certain resilience characteristics is not an indicator of who is at “fault” for the outcomes that these children experience. Instead, we should consider these qualities an additive buffer from negative effects that adults may aim to help foster rather than a personal responsibility for these children.
Resiliency as an Intervention
The field of psychology may be able to mitigate the effects of ACEs by promoting resilience measures. Poor childhood health and school absenteeism for children with ACEs has been inversely linked with access to community resilience sources such as the presence of a positive role model or cultural engagement [19]. This means that the more that children are able to access specific resources for support, the less strong the negative effects of ACEs seem to be [19]. This makes the study of resilience factors an excellent source of information on potential interventions. Based on these models, if Matthew were to be given the proper resources, they may be able to demonstrate resilience against their trauma. If we can understand how external and internal factors mitigate the structural, functional, and emotional effects of ACEs, we can understand how to better support children who may not have access to specific resources or train them in internal resilience skills. This research could inform school and community-wide policy.
Ultimately, the goal of this research is to understand the effects of ACEs in order to best design interventions to address them. Imagine if Matthew had clear support from adults outside of the home through strong relationships with teachers or other community members, this support may have eased Matthew’s symptoms, given that research has demonstrated a clear link between access to community resources and later resilience outcomes [1]. If the field of psychology can begin to understand what external resources allow some children to become resilient against their trauma, they can work toward providing these resources to all children. We have been assessing ACEs as risk factors for decades, but it is not always possible to reduce risk in every situation. However, we may be able to mitigate its effects. Policy may have a better chance of increasing a child’s ability to deal with these events through increasing access to resources. Examples of this could be in a school setting, with teachers trained on developing resilience characteristics in children, or mandating smaller class sizes so that children have the ability to develop closer relationships with the teachers they already have. Every child deserves a chance for optimal development, and resilience may be the key to unlocking the ability to foster this for children historically disadvantaged.
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