ACREs I (Adverse Childhood Relationship Experiences): The Most Underestimated Risk Factor for Chronic Illness aka Invisible ACEs

If you’ve heard of adverse childhood experiences (ACEs) and have a low score (such as 1 or “zero ACEs”), you may still suspect that trauma has somehow affected your health but feel like your doctors and the research are missing something important.

Or you may have a high ACE score and feel that it was the emotional abuse or neglect that was the hardest.

In other words, you recognize that your childhood was difficult – you got yelled at a lot, or had to be a pleaser to keep things running smoothly in your family, or you learned that being quiet and invisible was the best way to get by, or you lost a parent and lived with a family that never really recovered from this or some other trauma.

This post introduces huge and unrecognized impact of one of the ACEs known as emotional neglect. I refer to these as adverse childhood relationship experiences (ACREs). This post will help you assess links between ACREs and chronic illness. It also shares the science.

Life may feel like a slog. Your body may be incredibly sensitive to treatment (even tiny doses make you worse or don’t work or stop working after a while). You may have PTSD, complex PTSD or a chronic illness (or all three) and feel that it relates to trauma but have nothing that validates your hunch.

Adverse childhood relationship experiences (ACREs) draw from the science that recognizes how these kinds of difficult relationships influence the nervous system, epigenetics and health.

ACREs refers to emotional neglect and abuse i childhood. Experiences such as not feeling seen, having had no one to turn to with difficult feelings when you were a child, having had little sense of connection with others in your family, having not felt safe or protected or loved even though there was no abuse or violence (or if there was violence or abuse), having been treated as though you were invisible or the problem or weak or stupid. And more.

Adverse childhood relationship experiences increase risk for chronic illness, PTSD and complex PTSD. ACREs represent what are also known as attachment wounds, developmental trauma, complex trauma and otherwise difficult early events that children experience when their parents are unable to be nurturing, supportive, kind and gentle, and to repair the inevitable mistakes that happen.

I have created the term “ACREs” as a construct that links to the well-studied science of adverse childhood experiences (ACEs). ACEs have shown us that 10 kinds of trauma influence risk for chronic health conditions in children and adults – losing a parent such as from divorce, separation or death; physical, emotional and sexual abuse; physical or emotional neglect; having a parent with a mental illness or who abuses substances; witnessing violence in your home; having had a household member who’s gone to jail (which, like other ACEs, is usually related to yet other ACEs in the family). ACEs are the tip of the trauma iceberg and show us that other kinds of trauma influence longterm health too.

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Research has demonstrated that ACREs – the RELATIONSHIP factor – can also have important and similar effects as well.

The value of understanding ACEs and ACREs? When we recognize that early adversity is indeed a risk factor for our symptoms, it gives us the context to find new tools for healing. Because reversing symptoms, recovering, improving and even reversing the effects of trauma is possible. It may not be a quick fix, but the effects of trauma are more common than we’ve though – and  not as solid or permanent.

In addition, there are positive experiences that make us more resilient in childhood as well as in adulthood. I’ll share some of that encouraging research below, including the single question that one family physician discovered that helps identify risk vs resilience.

Even more good news? Being sick, having a chronic illness. living with mysterious or difficult-to-diagnose symptoms, having PTSD or complex PTSD – is not in your head. It is not your fault. It’s in our nervous systems and immune systems, in our cell danger responses and more.

What we’re learning is that ACREs are “invisible ACEs.”

And there is a link between ACREs and chronic illness and other chronic symptoms.

ACREs are among the hardest types of adversity to recognize. This is because the families we grow up in feel normal to us. It’s all we’ve known. They feel like they were normal even when they have been especially difficult. Because children tend to think it’s their fault when things aren’t going right in their environments or in their families. Or when their parents are stressed or anxious or upset.

Since starting to look into the research 20 years ago as well as working to heal from my own chronic illness during this time period, I’ve come to believe that ACREs are among the single most underestimated source of risk for chronic illness and other chronic health conditions.

Here’s what you need to know so you can begin to work with your symptoms in new ways. So you can know you’re not to blame. So you can know that feeling anxious, depressed or sick is not a personality flaw. So you can share the science with family, friends, colleagues – and especially with health care professionals. Because ACREs – and their effects – are real.

Children are Designed to Learn Safety From Parents

“Secure Attachment”

Children are designed to “attach” to their parents, who are themselves also “designed” to nurture their little ones and to help them feel safe and loved. A child’s experience of “secure attachment” creates a sense of belonging and connection. A sense that all is right in the world.

When we – and our nervous systems and immune systems and other organ systems – feel safe and protected, we learn that we can reach for what we want in the world. We learn that our needs are important, and will get met. We develop a deep sense that the world is a safe enough place and that we can defend ourselves or ask for and get help when we need it. We learn that we are special and have something to contribute. We grow a sense deep at our core that we are worthy and lovable. We bring these core beliefs to other relationships later in our lives.

A person who has positive expectations of both self and other is secure. Secure attachment is associated with an internalized [learned] sense of being worthy of care, of being effective in eliciting care when required, and a sense of personal efficacy in dealing with most stressors independently. Secure individuals are described as adaptable, capable, trusting, and understanding.” ⁽¹⁾Maunder RG, Hunter JH. Attachment and psychosomatic medicine: developmental contributions to stress and disease. Psychosom Med. 2001;63:556-67. p. 558, Abstract

Secure attachment happens when there is enough awareness and support in a family. When parents have enough support  themselves to be nurturing and to see and treat their children as the deeply intelligent and precious beings that they actually are.

The science of attachment is teaching us that when children do not have a deep enough sense of safety when they are growing up, or when they do not have an adult on whom they can truly rely, it affects their nervous systems. It influences their sensitivity to stress. It also increases their risk of developing a chronic illness or other chronic health condition.

“Insecure attachment”

Insecure attachment is “characterized by ‘only sometimes’ type of caregiving, [in which] babies learn that the world and their ability to have an impact on it is basically inconsistent – sometimes things happen, sometimes they don’t – sometimes all their needs are met, and sometimes only some of them are.

Infants learn that others are not dependable or consistent. They often also do not learn or understand emotions – their own or others’ (cited from this blog).

As has been identified in the adverse childhood experiences (ACEs) research first conducted by Felitti and Anda in 1998, and as described in this post on ACEs using the example of Mason from the movie “Boyhood”, insecure attachment is common.

The fact that it is common, however, does not make it “normal.”

The fact that ACREs and insecure attachment is common does not mean it has not effects.

Insecure attachment reflects the impact of parents’ own subtle and unrecognized experiences of trauma and the relationships they have had with their own parents.

Things that happen to us can make it difficult for us to attune to our children and to their needs for connection and protection. Parents don’t choose to misattune or subtly fail to nurture their kids. As a society we have yet to recognize how life experiences can profoundly interfere with our built-in longings and desire to do so.

For those with chronic illness, it can make all the difference to know that it’s not our fault and that there are ways of healing. It can make all the difference to know about the science so we don’t have to wait for medical professionals and other health care providers to learn about the research.

Adults with subtly dismissive parenting styles may love and care for their children but respond to fear and grief, excitement or self expression by avoidance and silence, by giving advice, denying, attacking, minimizing or invalidating feelings.

These styles of parenting are often perceived as benevolent, especially when compared to overt abuse.

But these characteristics of parenting have an impact on a child’s developing sense of self as well as on physical and emotional health. Just like the 10 types of more overt trauma known as ACEs (adverse childhood experiences) do.

Lack of support for the expression and resolution of emotions and connection is a significant factor in ACREs – they are invisible ACEs.

ACREs and Chronic Illness

Emotional and Psychological Health

When parents are less available and nurturing, children develop nervous systems that are more sensitive to stress and less able to feel safe and trusting in the world. This is a way in which our cells, physiologies and physical bodies develop subtle (or overt) perceptions of threat.

We’ve long thought that individuals who develop PTSD have done so because of a single event that happened before the symptoms – the car accident, war, abuse and other events. Rachel Yehuda, PhD. is a professor of psychiatry and neuroscientist at Mount Sinai and one of the most well known researchers in the field of trauma. Yehuda and others have found that individuals who develop PTSD have also had adverse events in childhood. In addition, a great history of adversity is associated with greater severity and a younger age of onset ⁽²⁾Yehuda, R., & Seckl, J. (2011, Dec). Minireview: Stress-related psychiatric disorders with low cortisol levels: a metabolic hypothesis [Review]. Endocrinology, 152(12), 4496-4503..  The same is seen with chronic illnesses of all kinds.

Kids with insecure attachment also develop learned beliefs. Beliefs such as a sense that who they are is not important or acceptable. They may learn to be silent and to ignore their feelings. Or have trouble recognizing what they believe and feel and want, unless it involves feelings their parents can tolerate ⁽³⁾Mate, G. (2003). When the Body says No: Understanding the stress-disease connection. Hoboken, NJ, Wiley & Sons.. They may also feel profoundly alone and isolated in the world.

Children with insecure attachment sometimes express their distress by acting out, tuning out or by becoming defiant. Sometimes they become the “good kid” who excels in school, plays by the rules, acts happy and learns to be a people pleaser – all regardless of the cost to themselves.

While these coping strategies can enable children to survive their childhoods and even excel, there are also costs. These costs include physical health as well as emotional health.

Physical Health Consequences of Insecure Attachment

Maunder and Hunter have found that insecure attachment (ACREs) are associated with physical illness in children ⁽⁴⁾Maunder RG, Hunter JH. Attachment and psychosomatic medicine: developmental contributions to stress and disease. Psychosom Med. 2001;63:556-67. Abstract. These include:

• recurrent ear infections,
• asthma,
• cystic fibrosis,
• epilepsy,
• failure to thrive,
• congenital heart disease

They also describe that the ACE studies provide further strong evidence that insecure attachment is a risk factor for chronic physical illness ⁽⁵⁾Maunder, p. 560.

In other words, if you experience ACEs such as physical, emotional or sexual abuse; physical or emotional neglect; witness violence in your household; have a parent with a mental illness or who abuses substances such as alcohol or drugs – it is very likely that your family does not feel safe, supportive or nurturing in a reliable way as well.

These “softer,” harder to measure, and easier to overlook aspects of our earliest relationships – the support and nurturing connection – are very important to our development.

ACREs are therefore an invisible aspect of ACEs that don’t quite get counted or recognized. They do, however, have the same effects on health.

The long-term effects of ACEs include increases in

• all types of cancer
• type 2 diabetes,
• heart and lung diseases,
• autoimmune diseases of all kinds,
• liver disease,
• skeletal fractures
• and more.

Other studies have also found a higher incidence of childhood trauma in chronic fatigue ⁽⁶⁾Heim C, Wagner D, Maloney E, Papanicolaou DA, Solomon L, Jones JF, et al. Early adverse experience and risk for chronic fatigue syndrome: results from a population-based study. Arch Gen Psychiatry. 2006;63(11):1258-66. Abstract. PDF, ⁽⁷⁾Heim C, Nater UM, Maloney E, Boneva R, Jones JF, Reeves WC. Childhood trauma and risk for chronic fatigue syndrome: association with neuroendocrine dysfunction. Arch Gen Psychiatry. 2009;66(1):72-80. PDF and fibromyalgia ⁽⁸⁾Borsini, A., Hepgul, N., Mondelli, V., Chalder, T., & Pariante, C. M. (2013, Oct 7). Childhood stressors in the development of fatigue syndromes: a review of the past 20 years of research. Psychological Medicine, 44(9), 1809-1823. Abstract.

The Absence of Nurturing Has a Larger Impact Than the Presence of ACEs

A 2019 study by Ali Crandall, Ph.D. and colleagues in Utah has found that the absence of positive, nurturing, protective experiences may have a greater impact on health and risk for chronic conditions than the presence of abuse and other ACEs ⁽⁹⁾Crandall, A., Miller, J. R., Cheung, A., Novilla, L. K., Glade, R., Novilla, M. L. B., Magnusson, B. M., Leavitt, B. L., Barnes, M. D., & Hanson, C. L. (2019, Oct). ACEs and counter-ACEs: How positive and negative childhood experiences influence adult health. Child Abuse and Neglect, 96, 104089. Abstract.

This finding has been a shock to many.

It’s a game changer for others who have known, deep down, that something wasn’t right even if it all “seemed” normal when they were kids. Their difficulties maintaining healthy relationships, liking other humans, or trusting people have just not seemed normal. Their challenges in feeling worthy. Their bodies that don’t respond to treatments that seem to work for others.

Anti-ACEs / Counter-ACEs Increase Resilience

Crandall’s research found that positive experiences are protective. So protective, in fact, that they called them “anti-ACEs” or “counter-ACEs” because they reduce the effects of adversity in significant ways.

They found that the kinds of experiences that reduce risk for chronic conditions, painful beliefs and difficult emotions later in life can seem small. They can appear inconsequential given their huge influence. And yet the little things turn out to make a big difference in buffering children from the effects of adversity.

The kinds of things that create, support and increase resilience in children include:

• Having good friends & neighbors
• Beliefs that provide comfort
• Liking school
• Teachers who care
• A caregiver who you feel safe with
• Opportunities to have fun
• Feeling comfortable with yourself
• A predictable home routine like regular meals and bedtimes

What anti-ACEs also mean is that support for parents can also help, especially if parents have their own challenges and histories of trauma. Finding ways to create predictable home routines, for example, can make a big difference.

30 Year Prospective Study: Insecure Attachment Affects Physical Health

Sroufe et al have been conducting a prospective study in Minnesota for 3 decades ⁽¹⁰⁾Sroufe LA, Egeland B, Carlson EA, Collins WA. The Development of the Person: the Minnesota study of risk and adaptation from birth to adulthood. New York: Guilford Press; 2005. They have found that insecure attachment in childhood increases risk for physical illness in adulthood:

… Individuals who were insecurely attached at both [12 months and 18 months] were four times more likely to report physical illnesses [as well as inflammation-related and nonspecific illnesses] at age 32 than those who were continuously secure early in life ⁽¹¹⁾Puig, J, Englund MM, Simpson JA, Collins WA. Predicting Adult Physical Illness From Infant Attachment: A Prospective Longitudinal Study. Health Psychol. 2012, p. 5

Life experiences affect our physical health. It comes back to what I described in an earlier post on epigenetics and why chronic illness may be reversible. This is the discovery that genes do not determine our health. It’s the combination of our genes and life experiences that influence whether genes turn on or off. Adversity and Safety influence gene function through the process of epigenetics and these changes can be reversed. This is the hope that comes from an understanding of trauma.

Multigenerational Influences

Parents tend to raise their children the way they were raised.

This is seen in humans and other mammals, where early maternal care influences epigenetics in the next generation. ⁽¹²⁾Francis RC. Chapter 6: Twigs, Trees and Fruits. Epigenetics: how environment shapes our genes. New York: W. W. Norton & Company; 2012. p. 65-76., ⁽¹³⁾Nathanielsz P. Life in the Womb: the origin of health and disease. Ithaca, NY: Promethean; 1999, ⁽¹⁴⁾Hurley D. Grandma’s experiences leave a mark on your genes: Your ancestors’ lousy childhoods or excellent adventures might change your personality, bequeathing anxiety or resilience by altering the epigenetic expressions of genes in the brain. Discover. 2013 June 11 If one generation grows up feeling unsafe or having little support, this is what they unconsciously role model and reenact with their offspring. Via epigenetics. ⁽¹⁵⁾Weaver IC, Cervoni N, Champagne FA, D’Alessio AC, Sharma S, Seckl JR, et al. Epigenetic programming by maternal behavior. Nat Neurosci. 2004;7(8):847-54. Abstract The effects of parenting are described as “a form of social inheritance mediated by epigenetic processes.” ⁽¹⁶⁾Francis RC. Chapter 6: Twigs, Trees and Fruits. Epigenetics: how environment shapes our genes. New York: W. W. Norton & Company; 2012. p. 65-76, p. 71.

World Wars I and II and The Great Depression were a deeply stressful and often traumatic experience for an entire generation and whole culture. They are examples of events that have had under-appreciated consequences.

Experiences of loss can also make it difficult for a parent to connect to their children. And stress “is a big suppressor of maternal behavior” ⁽¹⁷⁾described by Champagne in this article on epigenetics in Discover. Learn more about how the interruption of bonding around the time of birth can decrease the ability of parents to feel love they are designed to feel for their children and how this is something that happens outside of our control.

The science of Anti-ACEs provides hope for all the parents who are healing their own trauma in order to raise their children in a healthier way and who are striving to actively help their children be more resilient.

In other words, the work we are doing on ourselves to become more aware and to heal helps make the world a better place, starting with the positive effects it has on our loved ones – our children, our family systems and parents, our spouses, our friends and beyond.

Gabor Mate’s One Question: The Resilience Factor

Family physician Gabor Mate has written a book looking at the role of life events in shaping risk for chronic disease. ⁽¹⁸⁾Mate, G. (2003). When the Body says No: Understanding the stress-disease connection. Hoboken, NJ, Wiley & Sons. He interviewed people with a variety of different illnesses for “When the Body Says No,” and presents the research suggesting factors that influence risk of cancer and chronic illnesses including MS, RA, lupus and more – are all similar to one another.

In his book Mate presents a question that represents the underlying effects of ACREs. It helps many people with chronic illness and other chronic symptoms understand why their normalized childhoods may have actually been distressing to the point of affecting their long-term health.

Mate’s question is (p. 128).

When, as a child, you felt sad, upset or angry, was there anyone you could talk to – even when he or she was the one who had triggered your negative emotions?

In a quarter century of clinical practice, including a decade of palliative work, I have never heard anyone with cancer or with any chronic illness or condition say yes to that question.

Many children are conditioned in this manner not because of any intended harm or abuse, but because the parents themselves are too threatened by the anxiety, anger or sadness they sense in their child – or are simply too busy or too harassed themselves to pay attention. “My mother or father needed me to be happy” is the simple formula that trained many a child – later a stressed and depressed or physically ill adult – into lifelong patterns of repression (Mate, When the Body Says No, p 128).

The flip side of this question is that those who have had someone they COULD go to – a teacher, a coach, a neighbour, the school counsellor, a friend’s family – have resilience in their systems. They have something that may have helped prevent the evolution to a chronic illness, or that may have helped delay the onset until they were an older age, or that may have lead to an illness that is less severe or more sensitive and accepting of treatments. It’s a buffer they can build on. This was one of Oprah’s big discoveries when she first learned about ACEs – because she’d had a teacher who had believed in her, and it had made a huge difference in her life.

Breaking the Taboos on ACEs & ACREs

My life’s work is about understanding how life experiences influence risk for chronic physical illness  so that we can recognize new tools that can help us heal and improve and maybe even recover from our chronic illnesses.

Many people with chronic illness have had experiences of poorly recognized, dismissed or overlooked these ACREs that are so often invisible and insidious.

We need to stop blaming, shaming and judging people for having symptoms or chronic illnesses. And for not feeling safe in the world.

We need to break the taboos about sharing difficulties that occur in childhood (the taboos and secrecy around ACEs in our culture are part of the challenge of making changes, as mentioned in a presentation by ACEs researcher Vincent Felitti, MD), ⁽¹⁹⁾Felitti refers to taboos and shame in a book chapter, “Felitti V, Anda R. Lifelong Effects of Child Maltreatment. In: Chadwick DL, Alexander RA, Giardino AP, Esernio-Jenssen DJ, Thackeray D, editors. Chadwick’s Child Maltreatment: Sexual Abuse and Psychological Maltreatment. 4th ed. Saint Louis, MO: STM Learning, Inc; 2014. Understanding ACEs – visible and invisible – can help us do that. It can also help prevent us from transferring the patterns to our children and the blame to parents.

Understanding ACREs Offers Hope: Treatment Approaches for ACREs and Chronic Illness

There is an inspiring set of studies by psychologist Tony Madrid, who found a way to reduce and often cure symptoms of asthma in children by treating their mothers for traumatic events that occurred during the pregnancy, birth and infancy of their child. You can learn about Dr. Madrid’s work at AsthmaBusters. His discoveries have yet to be integrated in other clinics but they are the wave of the future and offer powerful tools for prevention as well as early treatment of chronic illness.

My main focus for ways of working with the effects of ACREs include certain types of psychotherapy like the ones used by Dr. Madrid.

You can get a sense of the power of psychotherapy and other approaches for working with trauma in the more than 2400 comments posted on an ACEsTooHigh blog post “Got your ACE score?” Some commenters have done a lot of psychotherapy over the years and are finding their way through their old traumas; many continue to do psychotherapy and have found it has transformed their lives for the better. Some are just beginning. Some never knew that it was possible to feel better. The responses are courageous, gritty, painful and heart warming.

Some trauma therapists will have experience in working with trauma related to early relationships and there’s a list of different approaches and links on the therapies page. One can also work with a therapist who specializes in issues related to the parent-child relationship. Some work with parents and babies, others with children, adults and families. Here’s a website to help find therapists specializing in this work around the world.

We are starting to see and make changes in working to optimize long-term health in many areas as it relates to trauma.

Friend and colleague Arielle Schwartz, Ph.D, has written a few books on complex PSTD and a guide with exercises for healing the effects of ACREs. You can find it here on amazon.

A number of pediatricians and children’s clinics around the country are learning how to help parents with their own ACEs in ways that feel supportive to them. Working to heal and prevent ACEs also helps prevent and heal ACREs.

Schools are using this information to change how they treat students (here’s one school’s story), and see more on the ACEs too High news site about the latest research and developments in ACEs, developed by journalist Jane Ellen Stevens.

Felitti’s clinic at Kaiser has seen over 450,000 patients since learning of the ACE findings (personal communication with Dr. Felitti winter, 2018 when he updated the figure from 400,000). They have developed ways of asking patients about their ACEs that fit into routine medical care and that make it possible for people to begin to feel seen and heard ⁽²⁰⁾Felitti V, Anda R. Lifelong Effects of Child Maltreatment. In: Chadwick DL, Alexander RA, Giardino AP, Esernio-Jenssen DJ, Thackeray D, editors. Chadwick’s Child Maltreatment: Sexual Abuse and Psychological Maltreatment. 4th ed. Saint Louis, MO: STM Learning, Inc; 2014.

If you are working on a healing journey with chronic illness, keep up your dedication and the strong work. It takes courage to look within and to work with influences from the past. It takes time and patience. It’s also helpful to be reminded that there is no quick fix and that our bodies want our respect as well as our compassion. Go at the pace you need to go. Take the time you need. Keep plugging away. Every seed you plant makes a difference. Every new experience of support and safety helps convey a new and healthy message to your system.

Know that you are not alone – we are a tribe of pioneers here, recognizing the effects of adverse life events and chipping away so that we can leave the world a better place.  We know it’s not our fault. We know it’s real. And we honor the intelligence in our bodies and minds, in our souls and nervous systems – the deep wisdom within that wants to heal. That knows how to heal. That is working with us as best they can to keep guiding us back home to more health, more healing, and to a greater sense of who we are.

Learn More About Attachment Trauma / Complex PTSD and Healing

See the documentary Wrestling Ghosts, on how one family – and a mom in particular – begins to heal

Treating Chronic Illness: 10 Empowering Tools That Will Help You Heal

Related Posts:

ACREs II: How I Overcame Severe Food Intolerances by healing ACREs

ACREs III: My Story and Origins of Flares, Triggers, Shame

#2 Early Trauma and Chronic Illness: Clues from Birth Events; Asthma Recoveries

Adverse Childhood Experiences, “Boyhood”, and Risk for Chronic Illness

Treating Chronic Illness by Repairing the Health of “No” to Heal Invisible Adverse Childhood Events (ACEs)

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