The Relationship Between ACEs, Trauma-Related Psychopathology and Resilience in Vulnerable Youth: Implications for Screening and Treatment

Abstract

This study examined the impact of ACEs in vulnerable adolescents and assessed whether resilience would have a moderating impact on psychological functioning. Participants included 40 youth, aged 12–17 identified as having experienced family violence and who were referred for treatment at the San Diego Center for Counseling (SD-CC). The relationship between ACEs, trauma-related symptomology, and psychological functioning was examined using results from the Child Posttraumatic Stress Scale (CPSS) and the Personality Assessment Inventory for Adolescents (PAI-A). The Child Youth Resiliency Measure was utilized to assess whether resilience buffered against the impact of ACEs. A positive relationship between the number of reported ACEs and trauma-related symptomology was found. There was a dose dependent response: youth endorsing 4 or more ACEs had significantly more psychopathology and showed less resilience as compared to those scoring below 4. The more resilient the sample, the less symptomatology was found. Regression analysis showed that resilience had a protective influence: as ACE distress increased, those high in resilience reported less somatization or depression. These findings support the use of the ACE measure as a screening tool and underscore the importance of assessing resilience in conjunction.

Adolescence is a time of rapid change and development. In an ideal developmental trajectory, it is a period in which youth broaden their cognitive capacities and abstract reasoning skills, develop a sense of personal values and identity and vocational and life goals, differentiate from family, form connections with peers, and grapple with their emerging sexuality (Erikson 1972). In a less ideal trajectory, adolescence can be a timeframe when high-risk behaviors emerge, such as substance use, unsafe sexual behavior, and self-injurious behavior. It has been well established that enduring adversity in childhood and adolescence has negative implications for adult physical, emotional, and social functioning, and that the impact can be especially deleterious when multiple forms of adversity and maltreatment are present (Felitti et al. 1998). As articulated by Herman (1992) “while the victim of a single acute trauma may say she is ‘not herself’ since the event, the victim of chronic trauma may lose the sense that she has a self” (p. 385). This quote speaks to the potentially compounding effect of experiencing multiple forms of adversity, especially during critical developmental periods that relate to emergent identity.

Adverse Childhood Experiences (ACEs) and Adult Outcomes

Prior to the last twenty years, much of the research regarding the impact of childhood trauma was focused on understanding the sequalae of specific forms of abuse, when, in reality, people are often exposed to co-occurring adverse experiences (Felitti et al. 1998). In their widely cited “ACE” study, Felitti et al. (1998) explored the relationship between the breadth of trauma and the cumulative impact of multiple childhood stressors with later outcomes. A questionnaire assessing 10 types of adverse childhood experiences (ACEs) was administered to 17,000 adults who had presented for standardized medical examination. These 10 ACEs include: emotional, physical or sexual abuse, emotional or physical neglect, and five forms of dysfunction in the home including substance abuse, mental illness, criminal behaviour, domestic violence, or parental separation. Overall, more than half of the respondents reported having endured at least one adverse childhood experience before the age of 18 years, while one out of four reported exposure to two or more ACEs, suggesting that these adverse experiences are not rare occurrences. The presence of multiple ACEs was found to be strongly related to risk factors for mortality and diseases: a graded positive relationship was found between the number of adverse experiences reported in childhood and a wide number of risk factors related to morbidity (e.g., smoking, obesity, depression, substance abuse and sexually transmitted infections), physical illnesses (e.g. heart disease and cancer), and a wide array of mental health problems. When compared with subjects who scored zero on the questionnaire, subjects who experienced four or more categories of ACEs were two and a half times more likely to have contracted a sexually transmitted infection, were twice as likely to smoke cigarettes, twelve times as likely to have attempted suicide, and more than seven times as likely to consider themselves an ‘alcoholic.’

Since the publication of the initial ACE study, numerous follow-up studies on adults have linked ACEs to a variety of high-risk behaviors, poor health outcomes, and psychological difficulties. The latter include eating disorders, substance misuse, suicide attempts, depressed mood, anxiety, and posttraumatic stress disorder symptoms (Flaherty et al. 2013; Johnson et al. 2002; Lansford et al. 2002). Studies on adults support the proposition that experiencing multiple forms of adversity in childhood has the potential to increase the prevalence of trauma symptoms and in its most acute form, posttraumatic stress disorder (Brady and Back 2012; Schalinski et al. 2016; Swopes et al. 2013). While ACEs, might not always be a direct antecedent of psychiatric disorders, there is growing neurobiological research suggesting that childhood maltreatment predisposes certain regions of children’s nervous system—such as those related to stress and the limbic system—to develop in ways that increase the risk of severe psychopathology (Benarous et al. 2017; Keyes et al. 2012; Sala et al. 2014; Teicher et al. 2014).

ACEs, Psychological Functioning in Youth and Complex PTSD

Mirroring the research on adults, research on youth historically focused on examining the impact of singular types of trauma on childhood and adolescent development (Chartier et al. 2010). Critically, fewer studies have examined the impact of cumulative ACEs on adolescent development. Studies that have been done to date indicate that experiencing multiple forms of adversity negatively affects adolescent mental health (Duke et al. 2010; Moore and Ramirez 2016). For example, a study conducted by Bielas et al. (2016), found a strong link between cumulative ACEs and scores on irritability, and predicted depressive disorders, suicidality, post-traumatic stress disorder (PTSD), and anxiety disorders in detained adolescent males. That said, other studies found that relatively low percentage (13%) of youth with multiple ACEs met the diagnostic criteria for PTSD (e.g., Dierkhising et al. 2013).

These findings point to the likelihood that psychological outcomes might not be adequately captured by the DSM-V criteria for PTSD. Based on the mounting evidence that exposure to ongoing trauma during early stages of development presents as distinct from more discreet exposure to trauma, the World Health Organization (2018) has proposed two related diagnoses within the spectrum of trauma and stress-related disorders: posttraumatic stress disorder (PTSD) and complex PTSD (cPTSD). Complex trauma, also known as developmental trauma, is often related to ongoing abuse resulting in issues with attachment, emotional regulation, and identity. It is defined by six clusters of symptoms including: alterations in regulation of affect and impulses, alterations in attention or consciousness, alterations in self-perception, alterations in relations with others, somatization, and alterations in systems of meaning. Complex trauma appears to better capture the impact and symptomatology of these more cumulative adverse childhood experiences (Bailey et al. 2007).

Resilience and Protective Factors

Although there is compelling evidence about the negative impact of ACEs on adult outcomes and some research on the impact of ACEs on youth, fewer studies exist that investigate mitigating factors. Werner (1989) summarized the findings of a longitudinal study that followed a group of participants from birth until their early thirties. Participants who experienced ‘stressful childhoods’ had increased likelihood of adult criminality, tremulous marriages, and financial difficulties. However, the presence of certain protective factors, such as a fulfilling career, supportive personal relationships, and an internal locus of control mitigated the impact of stressful childhood experiences. Collectively identified as resilience, it was found that participates high in these factors were more likely to have grown into content and well-adjusted adults. A number of subsequent studies have supported this initial finding by identifying various other protective factors that mitigate the effect of childhood difficulties in at-risk youths. Being taught problem solving skills, being involved in clubs and social programs (Henley 2010), having a parent with fewer mental health problems (Howell et al. 2010), and having a positive self-perception (Radke-Yarrow and Brown 1993) have all been related to increased resilience. Crouch et al. (2019) has linked this research directed to ACEs by identified that having a safe, stable, and nurturing relationship with an adult greatly mitigated the negative impact of having four or more ACEs in a group of youths.

The ACE as a Screener Among Adolescents

The use of the ACE questionnaire (ACE-Q) among youth needs more attention in the literature. It has been proposed that ACE exposure is a cyclical phenomenon in that children who have parents with high ACEs are at increased risk of ACE exposure (Bellis et al. 2013). It has also been established that having exposure to some types of ACEs increases the risk of exposure to other types (see Burke et al. 2011; Felitti et al. 1998). Although the articles cited differ in their breadth of focus, the authors are fairly unanimous in asserting that early identification and intervention is crucial. Pending the clinical validation of the ACE-Q, the widespread screening of youth is steadily moving towards standardized practice in hopes of shifting health care focus from reactive to preventative interventions (Purewal et al. 2016).

Purpose of the Present Study

This study sought to get a snapshot of the population of youth presenting for treatment, not only to assess the number of ACEs these youth endorsed, but also to grasp the frequency with which these phenomena occurred and the perceived severity of these experiences. This research also sought to examine the relationship between the number, frequency and perceived severity of ACEs on scores of several psychological measures. In keeping with prior research on adults, this research analyzed whether there was a dose dependent response; i.e., whether youth who had 4 or more ACEs would demonstrate significantly greater psychopathology as compared to youth who had less than 4 ACEs. Finally, resilience was assessed to see whether higher resilience scores would moderate the relationship between the number of ACEs and scores on the selected psychological measures.

Method

Participants and Procedure

The SD-CC falls under the auspices of the San Diego Family Justice Center and provides counselling to youth who have been exposed to family violence. This exposure can include having witnessed intimate partner violence and/or having directly incurred some type of abuse. For the purpose of improving services and contributing to outcome research, the SD-CC added a protocol to their intake, including a demographics form, the ACE-Q, the Child PTSD Symptom Scale (CPSS), the Personality Assessment Inventory-Adolescent (PAI-A) and a version of the Child and Youth Resilience Measure (CYRM). For participants to be included, they had to be between the ages of 12–17 years, and at the intake stage of treatment (to eliminate treatment effects) and have the requisite reading ability. Both the youth and guardian were given an information letter about the study and had to provide written informed consent. They were advised that their participation was entirely voluntarily and there would be no penalty should they wish to remove their data from the research database.

Measures

ACE Exposure

The original ACE-Q was administered. The questionnaire is comprised of 10 items a assessing various forms of adversity occurring before the age of 18 years. Items are scored as either absent (“no”) or present (“yes”) with a corresponding score of 0 or 1 respectively, for a possible score of 10. A criticism of the original ACE-Q is that it failed to consider the frequency and severity of the respective ACEs. To address this limitation, non-dichotomous items were expanded to assess the frequency of the ACE; i.e., “If you responded ‘yes’ circle the most accurate response: This happened 1. Yearly; 2. Monthly; 3. Weekly; 4. Daily.” Each item was followed up with a question about the impact or distress caused by each ACE ranging from: “1. Not very upsetting; 2. A little upsetting; 3. Somewhat upsetting; 4. Very upsetting.” The ACE-Q has acceptable psychometric properties. Test re-test reliability for the questionnaire has been good, with kappa coefficients of .66 for emotional abuse; .55 for physical abuse; .69 for sexual abuse; .75 for growing up with household substance abuse; and .77 for growing up witnessing interpersonal violence. The convergent validity of the ACE questionnaire was established by finding high correlations between ACE scores and scores of previous sexual abuse assessment tools (Edwards et al. 2001, as cited in Ritacco and Suffla 2012, p. 7)

Posttraumatic Stress

The Child Post-Traumatic Stress Disorder Symptom Scale (CPSS) is a self-report measure designed to assess PTSD severity in children ages 8 to 18 (Foa et al. 2001). While the CPSS was originally designed to assess PTSD resulting from a singular traumatic event (such as an earthquake), there is precedent in the literature for its use as a screener for complex trauma (Cowles and Davis 2017; Denton et al. 2017). The first 17 items, adapted from the DSM-IV PTSD criteria, assess symptom severity by measuring the number of disturbances experienced in the past two weeks. These items are scored on a 4-point Likert type scale ranging from 0 (not at all) to 3 (5 or more times a week). Final scoring yields a total PTSD severity score, and a severity score for each symptom cluster (re-experiencing, avoidance, and arousal). Preliminary studies yielded acceptable psychometric properties (Foa et al. 2001). Internal consistency was high for the total PTSD score (alpha .89) and related subscales (i.e., re-experiencing (.80), avoidance (.73), and arousal (.70)). Test-retest reliability coefficients were high for total score (.84) and related subscales (i.e., re-experiencing (.85) and arousal (.76), and moderate for avoidance (.63).

Other Psychological Symptomatology

The Personality Assessment Inventory—Adolescent (PAI-A) was used to assess the presence of general psychological symptomatology. The PAI-A was developed for youth ages 12 to 18 and has been used as a screener for pathology and psychological disorders (Meyer et al. 2015). There are 22 non-overlapping scales (4 validity scales to monitor for malingering; 11 clinical scales to detect pathology; 5 treatment consideration scales; and 2 interpersonal scales to measure how individuals approach relationships) and 31 subscales (Turner 2014). The PAI-A uses a four-point Likert-type scale in which the individual indicates if a statement is “False, Not at All True; Slightly True; Mainly True; and Very True” about themselves. Internal consistency alphas for the scales range from .70 for the “Positive Impression” scale to .90 for the “Aggression” scale, with a mean alpha value of .79. Both the clinical and community sample reported seminal alpha values for the 22 scales. Internal consistency values for the subscales were lower, ranging from .47 for the “Anxiety-Related Disorders-Phobias” subscale to .85 for “Anxiety-Related Disorders-Traumatic Stress” subscale, with a mean alpha value of .69. Both the clinical and community sample reported similar alpha values for the 31 subscales. Test-retest reliability coefficients ranged from .65 for the “Positive Impression” scale to .89 for the “Somatic Complains” scale, with a mean alpha coefficient of .78. Coefficients for the subscales ranged from .59 for “Mania-Irritability” to .88 for “Aggression-Physical Aggression” with a subscale mean of .76 (Sandoval 2010, as cited in Spies, Carlson, & Geisinger, 2010).

Resilience

The present study assessed resilience using the Child and Youth Resilience Measure-12 (CYRM). The CYRM is a 12-item self-report instrument designed to assess the “individual, relational, communal, and cultural” (Ungar 2016, p. 2) resources available in a youth’s life which may contribute to resilience. It uses a five-point Likert-type scale and asks respondents to indicate to what extent (from 1= “Not at All” to 5 = “A Lot”) each statement describe them. An example of an item is, “my friends stand by me during difficult times” (Ungar 2016, p. 17). Final resilience score is a sum ranging from 12 to 60. Preliminary studies yielded acceptable psychometric properties (Liebenberg et al. 2013; Ungar and Liebenberg 2011). Researchers conducted three repetitions of Exploratory Factor Analyses in order to shorten the 28-item version of the CYRM. This shortened form “demonstrates sufficient validity to merit its use as a screener for key resilience characteristics among youth” (Liebenberg et al. 2013, p. 135).

Results

IBM SPSS Statistics for Windows, version 25 was used to conduct all analyses. Comparison of demographic and clinical characteristics between groups were assessed using t-tests and Mann-Whitney U-test, as appropriate. Pearson’s correlation was used to investigate the associations between continuous variables. Significance was set at p < 0.05 for all analyses and values are reported as means ± standard deviation (SD).

Participant Demographics

Forty adolescents between the ages of 12–17 years, with a mean age of 14.51 (SD = 1.64) participated in this research. The majority of participants were female (64.1%) and of Hispanic or Latino ancestry (65.8%).

ACEs, CPSS and Resilience Scores: Total Sample and Demographic Differences

Overall, the sample was resilient [M = 49.65 (SD = 7.99), Median = 50.50] and reported, on average, 3.65 ACEs (SD = 1.63). In terms of CPSS categories, most participants (55%) fell in the mild subclinical category, 7.5% fell in the clinically mild category, 15% fell in the moderate category, 7.5% fell in the moderate-severe category and 15% fell in either the severe or extremely severe categories. The mean CPSS score was 17.13 (SD = 11.48). Males (M = 3.36, SD = 1.55) and females (M = 3.92, SD = 1.61) did not differ in the number of reported ACEs (t(37) = 1.06, p = .295). There was also no significant gender differences in resilience scores [males (M = 51.93, SD = 6.71) and females (M = 48.56, SD = 8.61), t(37) = 1.26, p = .215]. There were no gender differences in CPSS categories (Mann-Whitney U test = 195.00, p = .329). The mean rank for males was 17 and the mean rank for females was 20.80. Correlation analysis revealed that there was no significant relationship between age and ACEs (r = .168, p = .305) or between age and resilience scores (r = −.292, p = .067). In addition, age was not significantly related to CPSS category (r = .155, p = .354).

Personality Assessment Inventory—Adolescent (PAI-A)

Figure 1 presents PAI-A results for the sample. Some participants revealed a marked elevation that would indicate the presence of clinical psychopathology; i.e., t-scores 70 and above, reflective elevations higher than 97.7% of the comparison group. The following scales had 17.5% to 22.5% of the sample fall in the clinically significant range: anxiety (cognitive, affective, and physiological), phobias, depression (physiological), resentment, social detachment, and borderline affective features. There were also a number of subscales that, while not clinically significant, did fall in the range (t-scores 60–69 reflecting elevations higher than 84%–97% of the comparison sample) suggesting symptomatology and areas of concern. These scales included: mania, irritability, depression (cognitive), and negative relationships. There were no gender differences on any of the PAI-A subscales.

Fig. 1.

PAI-A results: percentage of elevations that were t-70 and above or between t-60-69 (i.e., clinically significant or areas of concern, respectively)

Relationship among ACE, CPSS, and Resilience

Pearson correlations were conducted to examine the relationship among ACE, CPSS, and resilience total scores for the entire sample. There was a strong, positive relationship between ACE and CPSS scores (r = .52, p = .001), meaning that, as expected, ACEs were associated with higher levels of trauma. There was a moderately negative relationship between CPSS total scores and resilience (r = −.39, p = .014), and the relationship between ACE scores and resilience was trending towards statistical significance (r = .29, p = .067).

Relationship among ACE, CPSS, Resilience Total Scores, and PAI-A Standardized Scores

Correlations were run between ACE total score and each of the PAI-A subscale t-scores. Only one significant relationship was found; i.e., adverse childhood experiences was associated with higher traumatic stress scores (r = .40, p = .014). As would be expected, there were significant correlations between CPSS and several PAI-A subscales. Specifically, strong positive correlations were found between CPSS and Conversion (r = .46, p = .03), Somatization (r = .41, p = .009), Anxiety-cognitive (r = .62, p < .001), Anxiety-affective (r = .45, p = .003), Anxiety-physiological (r = .42, p = .007), Phobias (r = .34, p = .034), traumatic stress (r = .72, p < .001), Depression – cognitive (r = .34, p = .031), Depression – affective (r = .34, p = .034), Depression – physiological (r = .47, p = .002), Mania – irritability (r = .33, p = .04), Social Detachment (r = .52, p = .001), Identity Problems (r = .44, p = .005), and Negative Relationships (r = .33, p = .04).

Moderately strong inverse relationships were found between resilience total scores and a number of the PAI-A subscales. As illustrated in Table 1, resilience was inversely related to Somatization (r = −.51, p = .001), Anxiety-affective (r = −.36, p = .021), Anxiety-physiological (r = −.34, p = .031), Phobias (r = −.41, p = .009), traumatic stress (r = −.48, p = .002), Depression – affective (r = −.55, p < .001), Depression – physiological (r = −.43, p = .005), Mania – irritability (r = −.43, p = .006), Social Detachment (r = −.42, p = .007), Affective Instability (r = −.36, p = .024), Identity Problems (r = −.42, p = .007), Negative Relationships (r = −.46, p = .003), Antisocial Behaviours (r = −.32, p = .046), and Aggressive Attitudes (r = −.39, p = .014).

Table 1.

Dose dependent response: differences between Low (<4) and High (≥4) ACE scores on PAI-A

	ACE scores
	Low		High
	M	SD	M	SD
Somatization	50.07	7.973	59.09	15.313
Anxiety - Cognitive	51.14	9.395	59.45	11.449
Traumatic stress	50.38	8.600	61.27	11.385

ACE: Frequency and Distress Ratings

In addition to assessing the presence of ACE items, ratings on frequency of ACE occurrence and the perceived distress caused by each ACE was measured. As displayed in Table 2, there appears to be some variability in terms of the frequency and perceived level of distress for each item. Almost all participants who indicated “yes” to item 2 “Parent or other adult in the household push, grab, slap, or throw something at you, hit you so hard” or item 3 “Adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way” ranked these experiences to have been very distressing. Distress levels were summed across the 10 ACE items to create a composite ACE distress measure.

Table 2.

Frequency of ACEs and distress ratings

ACE item	Not very (%) n	A little (%) n	Somewhat (%) n	Very (%) n
1. Parent or another adult in the household swear at you, insult you, put you down, or humiliate you	17.6 (3)	17.6 (3)	17.6 (3)	47.1 (8)
2. Parent or another adult in the household push, grab, slap, or throw something at you, hit you so hard	–	–	–	100 (7)
3. Adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way	12.5 (1)	–	–	87.5 (7)
4. Often feel that no one in your family loved you or thought you were important or special	11.1 (1)	–	22.2 (2)	66.7 (6)
5. Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?	–	100 (2)	–	–
6. Parents ever separated or divorced	32.1 (9)	3.6 (1)	25 (7)	39.3 (11)
7. Mother or stepmother often pushed, grabbed, slapped, or had something thrown at her	2.5 (1)	18.2 (2)	30.8 (4)	61.5 (8)
8. Live with anyone who was a problem drinker or alcoholic or who used street drugs	18.2 (2)	18.2 (2)	27.3 (3)	36.4 (4)
9. Household member depressed or mentally ill or did a household member attempt suicide	9.1 (1)	18.2 (2)	45.5 (5)	27.3 (3)
10. Household member go to prison	25 (3)	16.7 (2)	33.3 (4)	25 (3)

The Impact of Ace Distress and Resilience as a Moderator

Correlations were computed between the composite ACE distress measure and CPSS and CYRM scales. There was a moderate, inverse relationship between ACE distress and CYRM scale (r = −.35, p = .035) and a strong relationship between ACE distress and CPSS (r = .56, p < .001). ACE distress scores correlated with a number of PAI-A standardized scores. Moderate positive correlations were found between ACE distress and Conversion (r = .33, p = .049), Anxiety - Affective (r = .38, p = .019), and Traumatic Stress (r = .38, p = .021). The interaction between depression-affective score on the PAI and ACE distress was modulated by CYRM score (Resiliency) on regression analysis: Interaction −0.1007 (± 0.0350 std. error, p = 0.0071). The interaction between somatization on the PAI and ACE distress was also modulated by CYRM score (Resiliency) on regression analysis: Interaction −0.0697 (± 0.0342 std. error, p = 0.05) (see Table 3). Thus, as expected, subjects with strong resiliency had lower levels of psychopathology, despite higher level of ACE’s, suggesting that the factors associated with resiliency provided a buffer against the impact of the ACEs.

Table 3.

Regression analysis: resilience as measured by the CYRM as a moderator of PAI-A scores

	B	Standard error	t	p	95% CI for B
	DV: PAI-A; Depression-Affective (Standardized Score)
ACE distress	−.0957	.2765	−.3462	.7314	−.6582, .4668
Resiliency	−.7607	.2306	−3.2991	.0023	−1.2298, −.2916
Interaction	−.1007	.0350	−2.8733	.0071	−.1720, .0294
	DV: PAI-A; Somatization (Standardized Score)
ACE distress	.0878	.2701	.3251	.7472	−.4618, .6374
Resiliency	−.5237	.2253	−2.3248	.0264	−.9821, −.0654
Interaction	−.0697	.0342	−2.0347	.0500	−.1393, .00001

Discussion

Overall, the trend of the data suggests a positive relationship between the number of ACEs and the presentation of trauma-related psychopathology in youth. While on average, participants reported fewer than 4 ACEs (3.65 ACEs; SD = 1.63), consistent with the adult literature, a dose dependent response existed in that youth who had 4 or more ACEs exhibited more trauma-related symptoms than youth with less than 4 ACEs. Of note, areas associated with complex trauma, such as depression, somatization, anxiety, issues with identity and problems with interpersonal functioning, were moderately to significantly elevated, and a fair number of youths who had higher ACE scores also reported moderate to severe PTSD-related symptoms. While distress and trauma-related symptomology increased with ACE’s, the data also underscore the function of resilience in buffering these outcomes. Resilience, as measured by the CYRM, was inversely related to a number of subscales on the PAI-A, and inversely related to aggregate scores on CPSS; meaning, the more resilient the sample, the less the symptomatology. Specifically, as ACE distress increased, those high on resilience reported less somatization and depression than those low on resilience. The opposite was found for those low in resilience; i.e., as ACE distress increased, those low in resilience reported more depression and somatization. Given the well-documented and grave long-term consequences of having a high number of ACEs, furthering our understanding of resilience and protective factors is critical.

Based on their association with a multitude of physical and mental health problems, ACE’s have been described by Dr. Nadine Burke Harris, the Surgeon General of California, as “one of the most serious, expensive and widespread public health crises of our time.” (Education and Labor Committee 2019, p. 1). Reduction and remediation of ACE-related factors is clearly mandated. Arguably, not only should public health initiatives focus on measuring and reducing the number of ACEs children and youth are exposed to, but also the present investigation contributes to a growing body of research highlighting the importance of both measuring and building resilience to overcome and address the poor outcomes associated with adverse events in childhood. Indeed, some research has already pointed to promising areas where resilience is related to individual characteristics and skills that can be bolstered through learning (Henley 2010). For example, across a range of exposures to ACEs, dispositional mindfulness was associated with fewer health conditions, better health behavior, and better health-related quality of life in adult populations (Whitaker et al. 2014).

Finkelhor (2018) raised important points about the potential limitations of using the ACE-Q as a screener. Among other concerns, he pointed out lack of clear casual connections between ACEs and particular symptoms/treatment targets, he questioned the justification for screening given the scarcity of clinical resources and noted the paucity of evidence-based programming to intervene with multiple forms of trauma (Finkelhor 2018). In speaking to some of these concerns, there is a growing body of research that has pointed to the importance of identifying vulnerable youth and that resilience-building through fostering positive relationships and prosocial outlets can indeed, mitigate the impact of multiple ACE’s (Werner 1989; Crouch et al. 2019). Multiple disciplines are also embarking on important neurobiological research. For example, one investigation examined the role of adverse events in stimulating neurobiological stress responses that can shape neural systems in a way that contributes to ongoing physical and mental health problems. The authors conclude that: “Systematic and developmentally well-timed interventions might have the potential to change developmental trajectories and promote resilience. Moreover, understanding how specific dimensions of early adversity affect underlying stress response systems and how alterations in these systems are related to later psychosocial outcomes might facilitate more precise and targeted interventions” (Fisher et al. 2006, p. 215). That said, further investigation is certainly warranted.

The current research was one such step in trying to measure and understand the psychological impact of adverse childhood experiences on youth, and the mitigating influence of resilience. That said, this study was not without its limitations. The sample size was small and ideally this study could be replicated on a larger scale, with a control group. Also, this research relied heavily on self-report. Future research could employ a multimethod design; e.g., it would be useful for caregivers to be verbally interviewed and also provide ratings of the youth to increase reliability of ACE reporting, observed symptom presentation, and areas of resilience. More generally, there are inherent limitations to research examining the effects of family violence and other ACEs, as these experiences are often private events that go undetected. Even when identified, youth might be reluctant to discuss the full scope of these experience due to a fear of the ramifications of mandatory reporting. Further, there was some attrition from the study and from treatment, which speaks to the possibility of a lack of generalizability of these findings in that that participants who were able to successfully complete the rigorous protocol differed from those who were not. Finally, there is some support in the literature regarding additional factors for concern that fall beyond the scope of the ACE-Q. For example, The Pediatric ACEs and Related Life-events Screener (PEARLS) was validated in a pilot study and includes not only adverse childhood experiences (ACEs) but also other researched determinants of health (Koita et al. 2018). It could be worthwhile for future studies to explore augmenting the extant ACE questionnaire to tap into vulnerabilities uniquely relevant to adolescent development, such as bullying and sexual and physical violence in dating relationships (Pepler et al. 2006).

Despite this study’s limitations, the findings do provide support for the utility of using the ACE-Q as a screener for youth. Adding supplemental questions about frequency of ACEs and associated distress appears to be an important additional step that provides richer data about impact of these adverse experiences. This study also contributes to a growing body of research pointing to heartening findings on the moderating impact of resilience. Accordingly, it is also suggested that assessing resilience in conjunction with ACEs is essential. In so doing, we maximize the possibility of creating targeted, individually tailored, strengths-based treatment that takes inventory of, builds upon, and cultivates additional resources that help mitigate against the impact of ACEs.

Compliance with Ethical Standards

Disclosure of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical Standards and Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation at Humber College and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.