Many people who enter treatment for substance use, depression, anxiety or relationship difficulties have lived through painful experiences earlier in life. Learning about adverse childhood experiences, often called ACEs, can help people understand why certain reactions or coping strategies developed.

The purpose is not to blame the past for every problem or to define someone by a score. The purpose is to replace shame with understanding and to identify skills, relationships and treatments that can support recovery.

What Are Adverse Childhood Experiences?

Adverse childhood experiences are potentially traumatic or highly stressful experiences that occur before age 18.

The original ACE framework focused on experiences such as abuse, neglect and serious problems within the household. Current public health approaches also recognize that adversity can occur in the broader environment, including exposure to violence, instability and other conditions that interfere with a child’s sense of safety, stability and connection.

Common ACE categories include:

• Physical, emotional or sexual abuse
• Physical or emotional neglect
• Growing up with substance use or serious mental health problems in the household
• Domestic violence or other violence in the home
• Parental separation or major household instability
• Having a household member incarcerated

An ACE questionnaire counts categories of exposure. It does not measure how severe an experience was, how long it lasted, what support was available or how a particular person was affected.

Two people with the same ACE score can have very different histories, strengths and needs.

An ACE score should therefore be viewed as one piece of information, not as a diagnosis or prediction.

How Trauma Can Affect the Body and Mind

Children depend on adults and their environment for safety.

When danger, chaos or fear are frequent, the body may spend too much time preparing to survive. Stress hormones and the nervous system are designed to help us respond to emergencies. When stress is intense or prolonged and there is not enough protection or support, this response can become what public health experts often describe as toxic stress.

Toxic stress can affect developing brain systems, the immune system and the body’s stress-response system.

Over time, this can influence:

• Attention
• Learning
• Decision-making
• Emotional regulation
• Sleep
• The ability to calm down after stress
• How a person responds to perceived danger

These effects are not signs of weakness.

Many trauma responses can be understood as adaptations that once helped a person survive an unsafe or unpredictable environment.

For example, a child who learns to constantly watch for danger may become an adult who is highly alert to changes in another person’s mood. Someone who learned that expressing feelings was unsafe may shut down during conflict. Someone who could not depend on others may have difficulty trusting people even when they want close relationships.

In adulthood, trauma may contribute to behaviors such as:

• Avoiding difficult situations
• Becoming overwhelmed during conflict
• Feeling constantly on guard
• Struggling with trust
• Reacting strongly to rejection
• Experiencing emotional numbness
• Having difficulty managing anger, fear or sadness

Childhood trauma is also associated with an increased risk of depression, anxiety, posttraumatic stress symptoms, sleep difficulties and certain chronic health conditions.

However, increased risk does not mean a person will automatically develop these problems.

The Connection Between ACEs and Addiction

Research has consistently found a relationship between childhood adversity and later substance use.

People who experience multiple ACEs are statistically more likely to experience problematic alcohol use, tobacco use, illicit drug use and substance use disorders later in life.

This does not mean that trauma automatically causes addiction.

Many people with significant childhood adversity never develop a substance use disorder. Addiction can also develop in people who report few or no ACEs.

Genetics, mental health, family environment, access to substances, peer relationships, community conditions and many other factors contribute to addiction.

ACEs are better understood as one group of risk factors that can interact with the rest of a person’s life.

For some people, substances initially serve a purpose.

Alcohol or drugs may temporarily:

• Reduce anxiety
• Quiet intrusive thoughts or memories
• Create emotional numbness
• Increase confidence
• Make social situations easier
• Help someone sleep
• Provide relief from loneliness or emotional pain

This can help explain why substance use sometimes becomes so powerful.

If a behavior provides immediate relief from emotional pain, the brain learns that the behavior works.

Unfortunately, short-term relief can create serious long-term consequences.

Repeated substance use can eventually lead to tolerance, withdrawal, cravings and changes in the brain’s reward and learning systems. What may have started as a coping strategy can gradually become a substance use disorder.

Understanding this connection can help reduce shame.

Instead of asking only, “Why would someone keep using when it is destroying their life?” it can also be helpful to ask, “What was the substance doing for that person?”

Treatment then becomes about developing healthier ways to meet those same needs.

What Kind of Treatment Can Help?

There is no single treatment for “having ACEs.”

Treatment should focus on the difficulties a person is currently experiencing, such as PTSD, substance use disorder, depression, anxiety, emotion dysregulation or relationship problems.

Treatment should also consider the person’s goals, preferences, safety and readiness.

A trauma-informed approach recognizes that trauma may influence behavior and works to create safety, choice, collaboration and respect.

Several evidence-based treatments may be helpful.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy, commonly called CBT, focuses on the relationship between thoughts, emotions and behaviors.

People who experienced childhood trauma sometimes develop beliefs that made sense in their earlier environment but create difficulties later in life.

Examples may include:

• “I cannot trust anyone.”
• “Something bad is always about to happen.”
• “Everything is my fault.”
• “I have to handle everything alone.”
• “If someone is upset with me, they are going to leave.”
• “My feelings are too much to handle.”

CBT helps people identify automatic thoughts, examine whether those thoughts are completely accurate and develop more balanced ways of thinking.

CBT-based strategies are also commonly used in addiction treatment.

They can help people identify triggers, recognize relapse thinking, manage cravings, solve problems and develop healthier coping behaviors.

Cognitive Processing Therapy

Cognitive Processing Therapy, or CPT, is a trauma-focused therapy commonly used to treat PTSD.

CPT focuses on beliefs that may become stuck after trauma.

For example, someone may believe:

“I should have stopped it.”

“I can never trust anyone again.”

“The world is completely dangerous.”

“What happened proves that I am damaged.”

During CPT, clients learn to examine these beliefs and develop perspectives that are more balanced and accurate.

The goal is not to convince someone that what happened was acceptable.

The goal is to help the person stop carrying beliefs that continue to create suffering.

Prolonged Exposure Therapy

Prolonged Exposure, often called PE, is another evidence-based treatment for PTSD.

After trauma, people often avoid memories, emotions, places, conversations or situations connected to what happened.

Avoidance can provide temporary relief, but it can also reinforce the brain’s belief that trauma reminders are dangerous.

PE gradually and safely helps people approach memories and situations they have been avoiding.

Over time, this can help the brain learn an important distinction:

Remembering danger is not the same as being in danger now.

EMDR

Eye Movement Desensitization and Reprocessing, or EMDR, is another well-established treatment for PTSD.

During EMDR, a trained therapist guides the client through structured processing of traumatic memories while using bilateral stimulation, which often involves guided eye movements.

The goal is to help traumatic memories become less emotionally overwhelming.

People still remember what happened, but the memory may begin to feel more like something that happened in the past rather than something that is still happening emotionally in the present.

Dialectical Behavior Therapy

Dialectical Behavior Therapy, or DBT, can be especially helpful for people who struggle with intense emotions, impulsive behaviors, self-harm, difficulty tolerating distress or unstable relationships.

DBT teaches four major groups of skills:

• Mindfulness
• Distress tolerance
• Emotion regulation
• Interpersonal effectiveness

DBT is not primarily a trauma-processing therapy in the same way that CPT, PE or EMDR are.

However, DBT skills can be extremely valuable for people who need stronger coping skills before or alongside trauma-focused treatment.

For example, someone may first need to learn how to tolerate painful emotions without using substances before directly processing traumatic memories.

Treating Trauma and Addiction Together

When trauma symptoms and substance use occur together, both deserve attention.

Historically, some treatment programs required people to maintain long periods of sobriety before beginning trauma treatment.

Current approaches increasingly recognize that trauma symptoms and substance use may be closely connected.

For some people, untreated trauma symptoms repeatedly trigger substance use.

Integrated treatment can address both problems.

Treatment may include:

• Trauma-focused therapy
• Relapse-prevention strategies
• Cognitive behavioral therapy
• Recovery support groups
• Medication for opioid or alcohol use disorder when appropriate
• Contingency management
• Case management
• Mental health treatment
• Skills for regulating emotions and tolerating distress

Treatment should always consider safety, withdrawal risk, medical needs and the person’s readiness for trauma work.

Healing Is More Than Talking About Trauma

Healing does not always mean repeatedly discussing painful experiences.

In fact, recovery often involves building things that may have been missing earlier in life.

That might include:

• Predictable routines
• Safe relationships
• Healthy boundaries
• Emotional coping skills
• Stable housing
• Medical care
• Adequate sleep
• Meaningful work
• Education
• Spirituality
• Creativity
• Community
• Healthy recreation
• A sense of purpose

These are not minor parts of recovery.

They help teach the nervous system that life can be different.

A person who grew up in chaos may benefit from creating structure.

A person who learned not to trust anyone may benefit from slowly developing safe relationships.

A person who learned to numb emotions may learn that difficult feelings can be experienced without becoming overwhelmed.

Resilience: The Other Side of the ACE Story

Discussions about ACEs often focus heavily on risk.

Risk is important, but it is only part of the story.

The other part is resilience.

Resilience does not mean that trauma did not matter.

It does not mean someone simply needs to “be stronger.”

Resilience refers to the ability to adapt, recover and continue developing despite adversity.

Protective relationships are especially important.

A supportive adult, family member, teacher, counselor, coach, sponsor, mentor or friend can make an enormous difference.

Adults can continue developing resilience too.

Protective factors may include:

• Healthy relationships
• Therapy
• Recovery communities
• Education
• Spiritual or cultural connection
• Coping skills
• Stable routines
• Physical activity
• Meaningful responsibilities
• Safe housing
• Parenting differently than one was parented
• Learning how to ask for help

The brain and nervous system continue to learn throughout life.

Someone who learned to constantly watch for danger can gradually learn how to recognize safety.

Someone who learned to numb emotions can learn how to tolerate and express them.

Someone who learned that relationships are unsafe can learn how to identify trustworthy people and create boundaries with people who are not safe.

Someone who learned to survive by using substances can learn new ways to cope with pain, stress and difficult memories.

These changes usually do not happen all at once.

Recovery is often built through hundreds of small experiences that teach the brain something new.

A Note About ACE Scores

ACE questionnaires can be useful tools for education and reflection, but they have limitations.

An ACE score does not measure:

• The severity of what happened
• How often it happened
• The age when it occurred
• How long it continued
• Every possible form of trauma
• Cultural and community experiences
• Positive childhood experiences
• The presence of supportive adults
• Individual strengths
• A person’s ability to recover

A higher ACE score reflects greater exposure to categories of adversity at a population level.

It does not tell an individual what illnesses they will develop.

It does not mean they will develop an addiction.

It does not tell anyone how successful they can be in recovery.

People are much more complex than a number.

If completing an ACE questionnaire brings up painful memories or strong emotions, it is okay to pause.

No one has to share their ACE score or describe traumatic experiences in a group in order to benefit from learning about ACEs.

The Main Message

Adverse childhood experiences can influence health, relationships, stress responses and vulnerability to addiction.

But risk is not destiny.

Effective treatments exist.

Trauma-focused therapies such as Cognitive Processing Therapy, Prolonged Exposure and EMDR can reduce PTSD symptoms.

CBT can help people recognize patterns in thoughts and behavior.

DBT can strengthen emotional regulation, distress tolerance and relationship skills.

Addiction treatment can address cravings, habits, withdrawal, triggers and recovery supports.

Healthy relationships, structure, purpose and repeated experiences of safety can strengthen resilience.

A person cannot change what happened during childhood.

But healing can change what happens next.

The past may help explain how someone learned to survive.

Recovery gives them the opportunity to learn a different way to live.