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Adverse Childhood Experiences: Why It Is Not So Simple to “Just Get Over It”

Published on May 15, 2023

The Lion on the Other Side

Imagine you are a child standing in front of a closed door, hand on the doorknob, palms sweating, heart racing, shakily breathing. You must go through that door, but you are afraid of what waits on the other side. It is a lion. The lion may be asleep, and you might be able to safely tiptoe past it. Or the lion may be waiting to pounce, and you may or may not escape unscathed. But you don’t just have to pass through it once. You live with the lion – every day.

Adverse Childhood Experiences and Toxic Stress

The lion is an adverse childhood experience, or ACE. While an original Kaiser and Centers for Disease Control and Prevention (CDC) study on adverse childhood experiences looked at 10 ACEs related to family dysfunction, abuse and neglect, we also recognize that ACEs come in many other forms, such as food or housing insecurity, experiencing economic hardship, the child welfare system, human trafficking, war or any other threat to personal safety. When you face threats that are chronic, prolonged or severe – particularly when you don’t have a support system or buffer – you begin to experience toxic stress. This degree of stress makes it difficult to carry out everyday tasks. The near constant threat can create a baseline of fear, anxiety and dread from living with the unpredictable. When will there be more food in the pantry? Will we have to sleep in the car again? Will I get beaten for spilling the milk? Am I going to be molested again tonight? It is a roll of the dice every time, living on edge, never knowing what to expect when that door opens.

The Impact of Toxic Stress on Our Bodies

Toxic stress places one in a constant state of “fight or flight” – rapid heartbeat, fast breathing, tense muscles. These changes lead to chronically elevated levels of adrenaline and cortisol (a major stress hormone). This can lead to changes such as elevated blood sugar levels, high blood pressure, increased cholesterol and weakening of the immune system. Toxic stress also leads to structural changes in the areas of the brain associated with fear response, impulse control and executive (higher level) function.

How Toxic Stress Affects Mental Health

So what happens to the feelings and emotions we experience when we are faced with toxic stress? They can be manifested by externalizing or internalizing behaviors. Externalizing behaviors are those in which an individual’s psychological and emotional state is expressed outwardly through behaviors toward others and the physical environment. These outward emotions can be expressed as physical violence, aggression, defiance, theft and bullying. Internalizing behaviors are those in which negative emotions are directed inward toward oneself, and can include feelings of sadness, loneliness, guilt, fearfulness or nervousness. Internalized feelings can show up as withdrawal, disordered eating, self-cutting and other unexplained physical symptoms such as headaches, fatigue, stomach, or chest pain.

Toxic Stress and Health are Dose Dependent

The greater number of ACEs one experiences, the higher the likelihood one will develop one more chronic disease as an adult. These chronic diseases, linked with toxic stress in childhood, are also known as ACE-associated health conditions. For example, an individual who has experienced four or more ACEs is more than two times as likely to develop cardiovascular disease, and more than three times as likely to develop chronic obstructive pulmonary disease (COPD) compared to someone who did not experience any ACEs.

The toll on mental health and emotional well-being is even greater. Consider these facts:

  • Children and adolescents under age 17 years who have experienced 4 or more ACEs are 3.9 times more likely to have depression, 5 times more likely to have ADHD and more than 6 times as likely to use alcohol before age 14.
  • Adults who experience 4 or more ACEs are 3.7 times more likely to experience anxiety, 4.7 times more likely to have depression, 5.2 times more likely to use any illicit drug, nearly 7 times more likely to use alcohol, 10.5 times more likely to have suicidal thoughts and 37.5 times more likely to attempt suicide.
  • People with 6 or more ACEs have a life expectancy, on average, of 20 years less than someone who did not experience ACEs.

ACEs and Toxic Stress Know No Boundaries

The Kaiser/CDC study found more than 60% of individuals had experienced at least one of the original 10 ACEs. No one is immune. Individuals from all races, ethnicities, educational and income levels can experience ACEs. And these experiences are even more prevalent in women, communities of color and marginalized populations due to inherent biases and structural racism. If you or a loved one has experienced ACEs, know you are not alone. And while the statistics may seem bleak, there is hope.

The Power of Building Resilience

While ACEs and other forms of toxic stress in childhood can have a profound impact on long-term physical and emotional health, it is possible to fight back. How so? First, it is important to understand that no one is defined by how many ACEs one has encountered. ACEs are only a part of what might determine a person’s future and are not a guarantee of being doomed. Second, we must learn to build resilience – the ability to bounce back – and teach it to our children. It is the antidote to the toxin, the cushion that protects us and our children when we experience toxic stress.  

To find out your own ACE score, complete the revised Adverse Childhood Experiences Questionnaire for adults, available through Talk with your doctor, have your child screened, and reach out for assistance. For more information on ACEs and toxic stress, self-care resources, how to build resilience, and for provider training, visit

Partnering to Address ACEs in Our Communities

Valley Children’s Healthcare is pleased to partner with Central California Alliance for Health and ACE Overcomers as a PRACTICE grant team. Additional grant partners in Merced County include Merced County Office of Education, First 5 Merced County, United Way of Merced County, and the California Consortium for Prevention and Intervention. Together, we are committed to strengthening partnerships, building services, and expanding the workforce to screen for and address ACES and toxic stress. Our work is made possible by the California Department of Public Health ACEs Aware Initiative.


About the Author

Dr. Carmela Sosa-Unguez is a primary care physician and director of Valley Children's Guilds Center for Community Health. She has practiced pediatrics in both the urban and rural health settings and has focused on children with special healthcare needs and pediatric mental health. Since joining the organization in 2012, Dr. Sosa-Unguez has held a variety of leadership roles, including Associate Program Director of the Valley Children’s Pediatric Residency Program and Medical Director of Valley Children’s Primary Care. Currently, as director of Valley Children’s Guilds Center for Community Health, Dr. Sosa-Unguez works with community partners to improve the health of kids outside of the hospital walls. With her knowledge and expertise, she works to combat the social determinants that impact the overall well-being of kids throughout the Central Valley.