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Adverse Childhood Experiences

Research, Effects, and Tools for Change

Wolfe, Jace PhD; Smith, Joanna MS; Stowe, Darcy MS, CCC-SLP, LSLS Cert. AVT; Elder, Tamara MS, CCC-SLP, LSLS Cert

doi: 10.1097/01.HJ.0000582460.24645.02

From left: Dr. Wolfe is an adjunct assistant professor at the University of Oklahoma Health Sciences Center and Salus University and the director of audiology at Oklahoma City's Hearts for Hearing, where Ms. Smith is a founder and the executive director. Ms. Stowe is the director of listening and spoken language at Hearts for Hearing. She is a speech-language pathologist and a certified Listening and Spoken Language Specialist (Cert AVT). Ms. Elder is a speech-language pathologist and a certified listening and spoken language specialist (Cert AVT) who is the director of pediatric care at Hearts for Hearing.

A few years ago, the audiologists and speech-language pathologists at Hearts for Hearing became concerned about the lack of progress in some pediatric patients with hearing loss despite the fact that most were identified at birth, fit with appropriate amplification early, and enrolled in timely intervention. This concern led us to embark on a yearlong partnership with an infant mental health professional (see Hearing Journal. 2015;68[12]:19).1 Through this partnership, we learned about the importance of attachment between infants and caregivers. Notably, we learned about the power of a parent's adverse childhood experiences (ACEs) and how these can cause significant disturbances in the attachment relationship between the parent and child. This, in turn, may place a baby at risk for impairments in development and social-emotion functioning that have life-long effects.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

Since the first ACEs research was published about 20 years ago, new technologies, ways of thinking, and interdisciplinary partnerships have emerged that revealed key answers to an age-old debate: nature vs. nurture. ACEs research has given us a new understanding of how adversity becomes intergenerationally embedded and how resilience can create striking improvements in people's lives. To better understand the impact of ACEs knowledge in improving the outcomes of children with hearing loss, check out these key takeaways from our application and training in the area of adverse childhood experiences.2

1. Where it all began. The original ACE study began in an obesity clinic in San Diego in 1985. For over five years, Vincent J. Felitti, MD, the chief of Kaiser Permanente's revolutionary department of preventive medicine, had been mystified as to why half of his patients who needed to lose 200 to 600 pounds would drop out after one year in the program. He interviewed approximately 200 patients who dropped out of the obesity clinic's program. He saw the emergence of patterns, including childhood sexual abuse and other childhood events that affected the patients’ health as adults.3 To date, over 50 peer-reviewed articles on the ACE study have been published.1

2. The ACEs questionnaire. The ACEs questionnaire, developed from Filetti's initial interviews, has been widely used in related studies that aim to shed light on the long-term impact of ACEs in adults. The questionnaire is 10 yes-or-no questions related to 10 types of preventable experiences that occur within the first 18 years of a person's life. These questions include five categories of household dysfunction, three categories of abuse, and two categories of neglect.3-5

3. Accumulation of ACEs. Between 1995 and 1997, Robert Anda, MD, a medical epidemiologist with the Centers for Disease Control and Prevention (CDC), partnered with Filetti to initiate a large research study of more than 17,000 participants who were followed for over 15 years.6 According to Jane Ellen Stevens, the founder and editor of, this was the “largest, most important public health study you never heard of.”7 This was the first time that researchers looked at the effects of several types of trauma rather than the consequences of just one. One significant conclusion was the accumulation of ACEs categories, which showed that the higher the number of categories reported by an individual, the greater this population's risk for mental, physical, behavioral, and productivity challenges in adulthood.5,6

4. ACEs are more common than we know. ACEs are common in all socioeconomic groups. About 67 percent of the study participants experienced one or more types of ACEs; of these, over 25 percent had three or more, and over five percent experienced six or more ACE types. ACEs tend to cluster—where there is one category, there are likely others. Of the ACE study participants who experienced one ACE category, 87 percent experienced others and over 50 percent experienced four or more.3

5. ACEs have long-lasting effects. ACEs have a dose-response relationship with many health problems. As researchers followed participants over time, they discovered that a person's cumulative ACEs score has a strong, graded relationship with numerous health, social, and behavioral problems throughout their lifespan, including substance use disorders. Furthermore, many problems related to ACEs tend to be comorbid.4 An ACEs score of greater than four is considered to be the tipping point for prediction of future problems.6

6. ACEs affect brain development. Human brain development is sequential, beginning in utero and by the time of birth, necessary capabilities for survival are in place, including regulation of internal functions and the ability to suck and swallow. The brain's size and function are shaped by experiences during childhood.3 “The stress of severe and chronic childhood trauma–such as being regularly hit, constantly belittled, watching your father often hit your mother–releases hormones that physically damage a child's developing brain.”8 Fight, flight, or freeze hormones flood when a person or child is in danger. These same hormones become toxic when they are turned on for too long for example, with frequent or prolonged ACEs.7,9

The development of executive function extends well into the second decade of life, and can also be negatively affected by ACEs. Imagine how this plays out with a young mother whose child is diagnosed with hearing loss, and this mother has consistent difficulties with problem-solving, attending appointments, and advocating for her child.

7. Relationships heal. The parents of babies and children with hearing loss are the most powerful people for reducing ACE scores, and have the most potential for changing the trajectory of the public's health in the next generation. It requires a skilled specialist in ACEs to be able to talk with parents about how their ACE histories may be affecting their lives and influencing their parenting.7,10

8. Shift your perspective. As clinicians, we shouldn't ask, “What's wrong with you?” Instead, we should ask, “What happened to you?” The ability of a person to recognize responses to a stressful situation and knowing his or her ACEs score is the first step. When we avoid talking about ACEs, we may inadvertently be sending a message that people should be ashamed of their childhood experiences.2

Provide opportunities to validate the family experiences of our patients and their families. The validation does not mean agreement, but a way of being present for patients and their family members. Validation is listening 100 percent, providing accurate reflection of what you heard, articulating what a person might be feeling or sensing, and practicing radical genuineness. This suggests that you are meeting patients and their families as equals and that you believe they can solve any issue involving their young child with hearing loss.

Commit to and engage with a reflective practice. The ability to reflect on one's actions helps engage in a process of continuous learning. It's also a way of studying our experiences to improve the way we work with families.11-13

9. Where do we turn? If you find yourself concerned about ACEs in the child or family you're working with, refer them as soon as possible to a licensed clinical social worker (LCSW) who is trained in helping individuals with ACEs develop resilience. Be intentional in developing relationships with providers in your area who are familiar with providing intervention for children and families with a history of ACEs. Keep in mind that we are responsible for helping break the cycle of ACEs and contributing to resilience.2

10. Be the change. Maya Angelou said it best: “Do the best you can until you know better. Then when you know better, do better.” Challenge yourself professionally to gain training in ACEs. Challenge your team to contribute to resiliency in any way possible. Cultivate relationships with related professionals to positively affect the outcomes for children with hearing loss. Assess the impact that your personal ACEs may have on your audiology practice. Reach out and speak up for the most vulnerable.

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1. Wolfe, J., Smith, J., Elder, T., & Roberts, E. (2015). The Powerful Influence of Infant Mental Health on Hearing Loss. The Hearing Journal, 68(12), 19. doi:10.1097/01.hj.0000475867.05465.82.
2. NEUROSCIENCE EPIGENETICS ADVERSE CHILDHOOD EXPERIENCES RESILIENCE (NEAR) Toolkit: Addressing ACEs in Home Visiting by Asking, Listening and Accepting Version 2 | January 2016 Prepared by Region X ACE Planning Team.
3. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V.,… Marks, J. S. (1998, May). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Retrieved from
5. Stevens, J. E. (2015, June 03). The Adverse Childhood Experiences Study-the largest, most important public health study you never heard of-began in an obesity clinic. Retrieved from study-you-never-heard-of-began-in-an-obesity-clinic/
6. Adverse Childhood Experiences Study: Child Abuse and Public Health. (n.d.). Retrieved from
7. What Are ACEs? And How Do They Relate to Toxic Stress? (n.d.). Retrieved from
8. Davies, D. (2011). Child development a practitioners guide. New York, NY: Guilford.
9. Adverse Childhood Experiences too High? Educating Yorkshire in ACEs awareness. (n.d.). Retrieved from
10. Siegel, D. J. (2013, December 26). Parenting from the Inside Out: How a Deeper Self-Understanding Can Help You Raise Children Who Thrive: 10th Anniversary Edition. Retrieved from
11. Hanft, B. E., Rush, D. D., & Shelden, M. L. (2004). Coaching families and colleagues in early childhood. Baltimore: P.H. Brookes Pub.
12. Heffron, M. C., & Murch, T. (2010). Reflective supervision and leadership in infant and early childhood programs. Washington, DC: Zero to Three.
13. Nuzzo, Chiara. 2006, 10 Questions to Foster Your Journey Towards Self Reflection, Philadelphia.
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