Childhood trauma and adverse childhood experiences

Key points

• Childhood trauma is not a diagnosis. It is an experience that can raise the risk of later difficulties.
• Around 29.0% of adults in England and Wales, some 13.6 million people, report abuse before age 18 [4].
• The ACE score counts how many of ten categories of adversity a person reports. It was built for population research and predicts nothing about an individual [5][7].
• People reporting four or more ACEs have higher rates of several health problems, but most do not develop them [6].
• One trusted adult in childhood is associated with better adult mental wellbeing among people reporting high adversity [9].
• UK treatment targets the conditions that follow trauma, not childhood trauma itself [1].

What childhood trauma is

Childhood trauma is not itself a diagnosis. It describes frightening, harmful or neglectful experiences before the age of 18: abuse, neglect, or growing up in a household affected by violence, substance misuse, serious mental illness or separation [5]. Researchers call these adverse childhood experiences, or ACEs. Around 29.0% of adults in England and Wales report childhood abuse [4].

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger. Worried about a child: NSPCC Helpline, 0808 800 5000. Adult survivor of childhood abuse: NAPAC support line, 0808 801 0331.

Nobody is diagnosed with childhood trauma. What can be diagnosed are conditions that sometimes follow it: post-traumatic stress disorder, complex PTSD, depression, anxiety and substance use problems [2].

Symptoms

Childhood trauma has no symptom list of its own. What follows is how it is commonly described in adulthood, and each item has other possible causes.

Emotional and mental

• Shame, self-blame or a negative view of oneself [1].
• Emotions that shift quickly or are hard to settle [1].
• Intrusive memories, nightmares or flashbacks [1].

Behaviour and relationships

• Difficulty trusting people, and trouble in close relationships [1].
• Avoiding places or conversations that revive memories [1].
• Drinking or drug use to manage feelings [6].
• Constant alertness for danger, and broken sleep [1].

It is commonly confused with borderline personality disorder, complex PTSD, ADHD and depression.

Types

Childhood trauma has no official subtypes. Research sorts it into categories of adversity, which is what an ACE score counts. The original study used ten, under three headings [5].

• Abuse: emotional, physical and sexual abuse.
• Neglect: emotional and physical neglect.
• Household adversity: a mother treated violently, household substance misuse, household mental illness, parental separation or divorce, and a household member in prison.

Later work argues the list omits adversities such as bullying, racism and poverty, and studies use different lists, so two ACE scores do not always count the same things [7].

“Developmental trauma” and “complex trauma” are informal terms for repeated harm within a caregiving relationship. Neither is a diagnosis in ICD-11, the World Health Organization’s current classification, or in DSM-5-TR. The nearest recognised one is complex PTSD, which the NHS links to childhood abuse and neglect [2].

Causes and risk factors

Childhood adversity arises from a child’s environment, never from anything the child did. Rates are higher where there is poverty, parental substance misuse, parental mental illness or domestic abuse, but it occurs in every kind of household [5].

The best known finding is dose-response: the more categories reported, the higher the average rate of poor outcomes. A meta-analysis of 37 studies covering 253,719 people found adults reporting four or more ACEs had raised odds across many outcomes, largest for problematic drug use and violence [6].

Three limitations matter when reading those numbers.

• The data are retrospective. A meta-analysis of 16 studies and 25,471 people found poor agreement between childhood records of maltreatment and adults’ recall, so the two identify largely different groups [8].
• These are associations, not proven causes. Adversity clusters with poverty, discrimination and parental illness, which are hard to separate.
• Group risk is not individual risk. Raised odds across a population are compatible with most of the high-risk group never developing the outcome. The score’s limitations, including its use for individual screening, are set out in its own literature [7].

Protective factors rest on the same retrospective evidence. In a UK survey of 7,047 adults, people with four or more ACEs who had an always-available trusted adult in childhood were about 3.3 times more likely to report low mental wellbeing than people with no ACEs, against 8.3 times for those without such support [9]. That is an association, not proof of cause.

How it is diagnosed

Childhood trauma is not diagnosed, because it is an experience, not a condition. What is assessed is whether a diagnosable condition is present now.

GPs take responsibility for initial assessment where post-traumatic symptoms appear [1]. NICE advises professionals to ask directly about traumatic events, giving childhood abuse as an example, and about re-experiencing, avoidance, hyperarousal, dissociation and changes in mood [1]. Diagnosis is made by a clinical or counselling psychologist, psychiatrist or other trained professional. Adults in England can also refer themselves to NHS Talking Therapies without a GP referral or diagnosis, and PTSD is among the conditions treated [3]. More complex cases go on to a community mental health team.

Online ACE quizzes are not diagnostic instruments. A score of six does not mean illness is coming, and zero does not mean nothing happened. No cut-off marks an individual as needing treatment [7].

Treatment

There is no NICE guideline on childhood trauma itself. Treatment follows the guideline for whatever condition is diagnosed. Where that is PTSD, NG116 applies [1].

• Trauma-focused CBT is offered first to adults diagnosed with PTSD more than a month after the event, typically over 8 to 12 sessions, with more if clinically indicated, for example after multiple traumas [1].
• EMDR, eye movement desensitisation and reprocessing, is recommended for adults with PTSD after non-combat trauma, more than three months afterwards [1].
• Extra time to build trust should be allowed for people with additional needs, by adding sessions and addressing dissociation, emotional dysregulation and negative self-perception [1].
• Medication is not first line. NICE says venlafaxine or an SSRI such as sertraline may be considered for adults who prefer drug treatment, and an antipsychotic only alongside therapy in severe unresponsive cases [1]. Such decisions rest with a prescriber.

NICE is explicit that nobody should be excluded from PTSD treatment on the basis of drug or alcohol misuse alone [1]. Evidence for adapting these therapies to repeated childhood trauma is thinner than for single-event PTSD, and NICE addresses that mainly by allowing longer courses of the same treatments [1].

“Trauma-informed” is used loosely, often as a service label. The UK working definition states that its purpose “is not to treat trauma-related difficulties, which is the role of trauma-specialist services and practitioners” [10]. A trauma-informed service is not treatment.

Living with childhood trauma

You do not need a diagnosis to ask for help, and you do not have to describe what happened.

• Sleep, alcohol and routine affect symptom load more than most people expect, but work on them alongside treatment, not instead of it.
• Ask a therapist which model they use, which register they hold and what experience they have with childhood trauma. HCPC, BPS, BACP, UKCP and GMC registers can be checked online.
• Trauma-focused therapy can raise distress before it settles, so ask what the plan is for difficult weeks.
• Adjustments at work or university can be requested without naming a diagnosis.
• NAPAC, the National Association for People Abused in Childhood, runs a support line for adult survivors on 0808 801 0331. It offers listening and information, not therapy.

When to speak to a professional

Speak to your GP, or refer yourself to NHS Talking Therapies, if any of these apply.

• Memories, nightmares or flashbacks intrude on daily life.
• You avoid places or people to keep memories away.
• Low mood, anxiety or anger has lasted more than a few weeks.
• You drink or use drugs to manage feelings.

Contact NHS 111 and choose the mental health option, or ask for an urgent GP appointment, if you cannot keep yourself safe or symptoms escalate suddenly. Call 999 if anyone is in immediate danger. If you are worried about a child, call the NSPCC Helpline on 0808 800 5000, weekdays 10am to 4pm.

Common questions

What does my ACE score actually mean?

It means you reported that number of the ten listed categories of adversity before age 18. It is not a diagnosis, a prediction or a measure of harm done [7].

Does a high ACE score mean I will become ill?

No. Population studies show higher average rates of several problems among people reporting four or more ACEs, but most in that group do not develop the outcomes studied [6]. Group averages do not describe individuals.

Is trauma-informed therapy a type of treatment?

No. Trauma-informed practice describes how a service treats people, not a therapy, and the UK definition states that its purpose is not to treat trauma-related difficulties [10]. For treatment, ask about trauma-focused CBT or EMDR.

Clinical review pending

References

1. National Institute for Health and Care Excellence. Post-traumatic stress disorder. NICE Guideline No. 116, 2018. https://www.ncbi.nlm.nih.gov/books/NBK542453/
2. NHS. Complex PTSD: Post-traumatic stress disorder. https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/complex/
3. NHS. Find NHS talking therapies for anxiety and depression. https://www.nhs.uk/nhs-services/mental-health-services/find-nhs-talking-therapies-for-anxiety-and-depression/
4. Office for National Statistics. Abuse during childhood in England and Wales: March 2024. ONS, 5 November 2025. https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/bulletins/abuseduringchildhoodinenglandandwales/march2024
5. Centers for Disease Control and Prevention. About the CDC-Kaiser ACE Study. https://www.cdc.gov/violenceprevention/aces/about.html
6. Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, Jones L, Dunne MP. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. The Lancet Public Health, 2017. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30118-4/fulltext
7. Inside the Adverse Childhood Experience Score: Strengths, Limitations, and Misapplications. American Journal of Preventive Medicine, 2020. https://www.ajpmonline.org/article/S0749-3797(20)30058-1/fulltext
8. Baldwin JR, Reuben A, Newbury JB, Danese A. Agreement Between Prospective and Retrospective Measures of Childhood Maltreatment: A Systematic Review and Meta-analysis. JAMA Psychiatry, 2019. https://research-information.bris.ac.uk/ws/files/244627520/jamapsychiatry_baldwin_2019_oi_190006.pdf
9. Bellis MA, Hardcastle K, Ford K, et al. Does continuous trusted adult support in childhood impart life-course resilience against adverse childhood experiences: a retrospective study on adult health-harming behaviours and mental well-being. BMC Psychiatry, 2017. https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-017-1260-z
10. Office for Health Improvement and Disparities. Working definition of trauma-informed practice. GOV.UK, 2 November 2022. https://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice/working-definition-of-trauma-informed-practice