https://orcid.org/0000-0002-5036-6604
Figures
Abstract
Background
Adverse Childhood Experiences (ACE) have been associated with poor long-term mental health outcomes. Measuring ACE scores in youth undergoing treatment, as well as their caregiver(s), may help inform treatment approaches and practice. This novel study examined a unique sample to attempt to help elucidate the relationship of trauma histories between youth survivors of child sexual abuse (CSA) and their biological mothers. Secondarily, we aimed to examine the distribution of ACE scores in order to evaluate if they demonstrate common underlying factors.
Materials and methods
Children and adolescent CSA survivors aged 8–17 who were enrolled into a comprehensive multimodal 1-year treatment program for their abuse completed the Center for Youth Wellness ACE Questionnaire (CYW ACE-Q). Secondarily, a caregiver of each child was asked to complete the original 10-item ACE questionnaire (ACE-Q). Based on the available data, we report findings from a convenience sample of biological mothers of the CSA survivors. Biological mother ACE scores were statistically compared to determine if their trauma histories were associated with their child’s ACE score. Secondarily, a Principle Factor Analysis (PFA) was conducted to assess any underlying common factors among reported ACE scores.
Results
A statistically significant moderate positive correlation was found between the biological mother and their child CSA survivor in terms of their ACE scores (r(107) = 0.56, p < 0.0001). Examining the underlying factor structure of the ACE scores, two factors (which we labelled neglect and abuse) accounted for the most variance in our sample (41.7%).
Conclusions
The results of this study demonstrate a surprisingly strong, and highly statistically significant, correlation in the rates of high ACE scores between child CSA survivors and their biological mothers. These results strongly support the need for trauma-informed approaches when working with CSA survivors, and in particular all treatment approaches should also consider parental trauma histories. The findings of this study suggest that a family-centered, trauma-informed care approach should be considered, instead of only programming which is focused on the impacted child.
Citation: Reeson M, Pazderka H, Polzin W, Agyapong V, Greenshaw AJ, Wei Y, et al. (2026) Highly significant correlation between rates of adverse childhood experiences (ACE) in youth survivors of child sexual abuse (CSA) and their biological mothers. PLoS One 21(1): e0340591. https://doi.org/10.1371/journal.pone.0340591
Editor: Saraswati Dhungana, Tribhuvan University Institute of Medicine, NEPAL
Received: February 14, 2025; Accepted: December 23, 2025; Published: January 12, 2026
Copyright: © 2026 Reeson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be shared publicly because the data analyzed for this study was collected as part of programming at a multimodal treatment center for child sexual abuse (CSA) survivors. This data is collected by the program as a means of informing treatment and clinical approaches. De-identified data were provided for the research team to conduct a secondary analysis on pre-collected data. As such, the original data is not available for open access as it is personal information collected by the treatment center. The researchers do not have consent to share the de-identified data at this time without a specific request from researchers who meet the criteria for access to confidential data. Data are available from the Little Warriors Clinical Director, Melanie Jonkman (Email: Melanie@littlewarriors.ca; Phone: 780-952-4301) for researchers who meet the criteria for access to confidential data.
Funding: Lead author received postdoctoral funding through a Mitacs Elevate Award (IT39291). No other authors received funding for this project. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Brain development is a process that begins shortly after conception and continues into early adulthood [1]. Early-life toxic stress—when a child experiences strong, frequent, and/or prolonged adversity without adequate support—can impair brain development and increase the risk for stress-related disease and cognitive impairment [2,3]. Research on the biology of early-life stress has identified that chronic adversity during critical developmental periods can impair brain development and architecture [4,5]. Adverse Childhood Experiences (ACE) are defined as traumatizing events that occur before the age of 18. ACE are generally assessed using the ACE questionnaire (ACE-Q), which measures an individual’s exposure to toxic stress experiences from birth to 18 years of age. ACE have been consistently associated with a variety of negative psychiatric outcomes, including early onset mental illness and cognitive deficits [6–7]. The seminal ACE Study examined the connection between early-life adversity and long-term health outcomes in 18,000 adults, and showed that a higher level of exposure to early-life stress had a clear, dose-response relationship to an individual’s likelihood of developing physical, behavioral, and social problems in adulthood, as well as a higher likelihood of future victimization [8]. Subsequent studies have shown that higher ACE scores are associated with a variety of mental health issues, including depression, anxiety, substance abuse, suicidal ideation, and addiction [9–12], and can also impact parent-child relationships and healthy attachments [13–15].
Child Sexual Abuse (CSA) is a common ACE, and studies from the United States suggest approximately 8% of men and 16% of women have experienced at least one incident of sexual abuse prior to the age of 18 [16,17]. A recent meta-analysis on the prevalence of sexual violence among children reported a lifetime prevalence of 9.5% for girls and 5.5% for boys for any form of sexual contact or forced intercourse [18]. Rates of CSA in Canada are comparable, with an estimated 10% for males and 20% for females [19,20]. However, despite an increase in disclosure rates, a significant number of CSA incidents go unreported to the proper authorities; as such, these estimates undoubtedly understate the severity of the problem [21,22]. Of further consequence, there is evidence suggesting that there are particularly sensitive periods in childhood in which the deleterious effects of CSA can be amplified [23,24]. Some of this can potentially be mitigated, and research on resilience has shown that providing stable, responsive, nurturing relationships in the earliest years of life can prevent or even reverse the damaging effects of early life stress, with lifelong benefits for learning, behavior, and health [25–27].
Recent developments have begun to shed some light on the biological mechanisms involved in mediating traumatic experiences, some of which may involve epigenetic inheritance [2,28]. Contemporary research has suggested that the effects of childhood trauma may be transmitted to subsequent generations; in fact, a caregiver’s own unresolved trauma increases the risk that their child(ren) may be exposed to adverse events [29]. Mothers who were CSA survivors are more likely to have children who experience CSA; further, the presence of maternal CSA has been linked to psychological difficulties later in life for the child [30]. Children of CSA survivors are more likely to experience a higher level of childhood abuse and neglect when compared to those whose mothers did not have a CSA history [31]. Women sexually abused as children are at an increased risk for risky sexual behaviour and, consequently, teenage pregnancy, which can also lead to an increased risk of sexual victimization for children [32]. It has been well established that the effects of early-life stress on one individual can be passed down to subsequent generations [29,33,34]. In Canada, this is of particular significance to Indigenous populations. Bombay et al. [35] found greater depressive symptoms in the offspring of individuals who had been forced to attend Indian Residential Schools. Further research in these populations has shown an intergenerational link with alcoholism, suicide, and early death [36]. Using epigenetic markers, Yehuda et al. [37] found an increase in methylation in the functional region of the FKBP5 gene in the children of Holocaust survivors. The FKBP5 gene plays an important role in the regulation of the Hypothalamic-Pituitary-Adrenal (HPA) axis—a key pathway in stress regulation—and can be effectively disrupted through epigenetic modifications, such as methylation. Similarly, Yang and colleagues found altered methylation patterns at numerous sites for a group of maltreated children who were removed from their parents, compared to a group of age-matched controls [38]. Additionally, aside from genetic factors, caregivers may also transmit their unresolved trauma histories to their children via behavioural means, such as increased anxiety, unwillingness to allow developmentally appropriate behaviours such as exploration, and overreaction to hearing about their child’s negative experiences [28]. For these reasons, a better understanding of the transgenerational effects of ACE on mental health may help to develop preventative measures and alleviate these widespread problems. Furthermore, investigating the ways in which ACE pool into categories may elucidate a better understanding of the way certain ACE are related to specific behavioural and psychological outcomes.
Analyzing ACE data from both CSA survivors and their biological caregivers may provide a greater understanding of these relationships as well as determine best practices relating to intergenerational trauma. In this study, we present novel data collected from the Be Brave Ranch (BBR), a treatment facility specifically designed for youth CSA survivors [39–41]. As part of their regular intake activities, the BBR routinely collects self-report assessments, including ACE history. To our knowledge, no study has evaluated ACE histories in youth CSA survivors and their biological mothers. Using this novel data set, we aim to compare ACE scores from both youth and their caregivers. Before data collection, we hypothesized that there would be a statistically significant association between the ACE scores of CSA survivors and those of their biological caregivers. After data collection, the vast majority of respondents were biological mothers, so we limited the analysis to compare ACE scores in CSA survivors and their biological mothers. Secondarily, we conducted Principal Factor Analysis (PFA) to examine the relation of each ACE item among participants.
Methods
Study design
Here we present results from a convenience sample involving secondary use of de-identified data collected during routine admission to the Be Brave Ranch (BBR) program. Data for this study was collected on 219 youth CSA survivors and their biological caregivers from 01/01/2022–31/12/2024 based on data availability and the collection of data on an adequate sample size. As participants attend the program in a cohort sequential manner, gathering data on an adequate sample size required a longer study period. Of the 219 CSA survivors, 107 biological caregivers were able to complete the required surveys. Of the total sample collected, 44 (20.1%) participants had either CFS or foster care involvement and no biological caregiver was available to complete the surveys. Sixty-eight caregivers (31.1%) did not complete the survey. As a result, the 112 CSA survivors who did not have caregiver information were not included in the correlation analysis. From the 107 caregivers who did complete the survey, only 2 (0.9%) were completed by both the biological mother and father.
Participants were not directly recruited into this study; rather, the measurement-based care approach adopted by the BBR requires clients and their caregivers to complete standardized outcome measures to inform and evaluate programming. At intake into the program, all primary caregivers were required to complete written consent forms allowing for the collection of data for themselves and their child(ren). Consent forms were completed onsite with a staff member and included consent to conduct a secondary analysis of the data. Collected data was de-identified and provided to the research team for a secondary analysis of this collected data. No modifications were made in the data collection procedure during the study period. Ethics approval was obtained from the University of Alberta Human Ethics review board for this secondary use of the data (HREB ID Pro00089614).
Participants
Youth CSA survivors.
Youth participants included in this study were children and adolescents admitted to a comprehensive 1-year multimodal treatment program specifically designed for child and adolescent survivors of CSA aged 8–17, the only one of its kind. Each participant underwent an initial screening interview conducted by a staff member to determine inclusion into the program. Individuals can be referred to the program through direct or online contact with program administrators. The criteria below are already put in place for program intake at the multimodal treatment program. These criteria were selected so that children can perform necessary self-care for daily living and can have the best chance of completing the full treatment program. Participants for the treatment program are required to:
- (1) Have a history of child sexual abuse – disclosed to at least one adult
- (2) Be aged 8–17
- (3) Perform self-care necessary for daily living
- (4) Have an IQ > 80 as determined by previous assessments. The program has certain psychoeducational components that require a functioning level above 80.
- (5) Be mentally medically stable and compliant with prescribed medication. Medication are bubble-packed prior to admission into the program and are administered by trained staff on site.
- (6) Have a family member/caregiver identified and involved
- (7) Complete a readiness assessment which involves a screening interview by trained transition coordinators who determine eligibility and appropriateness for inclusion.
Exclusion criteria for children include:
- (1) Severe mental health issues such as suicide attempt, self-harm, homicidal thoughts/actions, violent behaviors, and significant eating disorder. Actively in psychosis and/or not medically compliant with antipsychotic medication
- (2) A significant runaway risk
- (3) Serious behavioral problems
- (4) Significant drug or alcohol use
- (5) A history of sexual violence toward others
- (6) Unstable medical conditions
Caregivers of CSA survivors.
Participants were recruited from a pool of caregivers who were positively involved in the treatment program and, as such, were not people who had been identified as perpetrators. Caregivers of CSA survivors in this study were fluent in English (based on observation when a staff team member assesses this at the time of intake), able to provide consent, and were caring for children who were enrolled in the multimodal treatment program. Non-biological parents (e.g., foster parents, CFS caseworkers, group home workers, etc.) were not included in this study as the intergenerational effects of ACE was the primary outcome under consideration. Further, biological fathers were not included as only two participants (0.9%) had both biological parents complete a survey and the sample size was not adequate to include these participants in the analysis. As such, to increase homogeneity of our sample, only biological mothers were included in this analysis. There were no explicit inclusion/exclusion criteria for the caregiver sample as mothers were not directly involved in treatment and were asked to complete surveys voluntarily.
Outcome measures
Upon admission into the program, participants and caregivers are asked to complete a number of questionnaires which are used to guide individual treatment and to evaluate the efficacy of the program. Completion of these questionnaires is mandatory for program admission. To measure history of early-life trauma, primary caregivers were administered the ACE Questionnaire (ACE-Q), a 10-question self-report survey designed to measure an individual’s history of early-life adversity. Each question is a yes/no variable that asks about the individual’s history of a number of early traumatic life events. For the youth CSA survivors participating in the program, ACE history was measured using the Center for Youth Wellness ACE-Questionnaire (CYW ACE-Q). Both the ACE-Q and the CYW ACE-Q are considered a validated outcome measures for trauma histories [42]. The CYW ACE-Q is an 18-question survey that asks binary “yes/no” questions pertaining to a variety of common adverse events experienced by youth, including the standard 10 ACE items. Scores with an answer of “yes” are given 1 point and the total is summed. As such, higher scores indicate more ACE experienced by the individual. The CYW ACE-Q asks the participant about extra items outside the original 10 ACE, including experiencing bullying at school, living in foster care, being separated from a primary caregiver, and experiencing verbal or physical abuse from a romantic partner, among others. This questionnaire is designed specifically for youth and was given to the child and adolescent participants in this study. Given the association between ACE and the risk for mental health concerns, CYW ACE-Q score of >4 combined with symptomatology is generally considered a potential indicator for treatment referral [43].
Statistical analysis
Descriptive statistics.
Demographic information was collected at the time of survey collection. Demographic information included participant age, sex assigned at birth, gender identity, Indigenous status, prior treatment for mental illness, prior pharmacotherapy for mental illness, and average annual household income.
Correlation analysis.
Correlation analysis was used to compare child and caregiver ACE scores. A correlation coefficient of r > 0.6 was considered strong, 0.4 < r < 0.6 moderate, and r < 0.4 weak [43]. Statistical significance was considered if p < 0.05.
Principal axis factor analysis.
The use of adverse events during childhood in research has shown to be highly dependable, as test-retest reliability in ACE questions has been assessed as good to excellent [44]. As such, we sought to explore if there was a more-or-less stable pattern of scores amongst survivors, potentially representing common factors underlying risk for sexual abuse at an early age.
To further examine the underlying structure of ACE scores in the patients, a Principal Axis Factor Analysis (PFA) with varimax rotation was performed (Table 3). Factor analysis is interested in investigating the underlying constructs of a given phenomenon [45]. In effect, PFA can determine which latent constructs drive responses by measuring interrelationships on our measured trauma variables. Varimax rotation was used in order to obtain orthogonal loadings for the factors. Analysis was limited to the 10 original ACE questionnaire items, less the sexual abuse question which was de facto experienced by everyone in the sample (i.e., all participants admitted for CSA treatment). The analysis passed the Kaiser-Meyer-Olkin Measure of Sampling Adequacy (.654), as well as Bartlett’s Test of Sphericity (<.001).
Results
Demographics
Demographic information for the CSA treatment participants and their caregivers are summarized in Table 1. In total, CYW-ACE data was collected for 219 youth CSA survivors (70 children and 149 adolescents). The average age of the child participants was 10.9 (1.5) years; for the adolescents 14.4 (1.3) years. Forty-six (65.7%) of the children and 143 (96.0%) of the adolescents were female assigned at birth (1 Because the adolescent program is limited to females for safety reasons, our data necessarily oversamples females); while 38 (54.3%) of the children and 121 (81.2%) of the adolescents identified with a female gender identity. Nine (12.9%) of the child participants and 23 (15.4%) of the adolescents identified with a non-binary gender. Twenty-three (32.9%) of the children and 63 (42.3%) of the adolescents identified as an Indigenous Canadian.
From the total sample, one hundred and seven children had their corresponding biological mother completed an ACE-Q. As such, 107 child-mother pairs were available for correlation analysis. The average age of the biological mothers was 38.4 (7.7) years. Thirty-five (32.7%) identified as an Indigenous Canadian. Of the youth participants, 48.9% (107) had been previously treated for a mental illness, and 75 (34.3%) had been pharmacologically medicated for their mental illness. For the mothers, 67 (62.6%) had been previously treated for mental illness and 52 (48.6%) had been pharmacologically medicated. Nearly half (42.1%) of the caregivers reported an average family income of under $30 000/year, and only 12 (11.2%) reported an annual income over $100 000.
Nature of the CSA
As part of the intake surveys, caregivers are asked a few questions about their child’s sexual abuse. The 107 biological mothers included in this survey reported that 88 (82.2%) had been sexually abused on multiple occasions. The reported mean age at first traumatic incident was 6.7 ± 3.3 years old. The vast majority of survivors (94.4%) knew their offender prior to the abuse. Seventy-five (70.1%) of abusers were adults, 27 (25.2%) were adolescents, and 5 (4.7%) of offenders were other children.
Caregiver versus child ACE score
Correlation analysis was used to compare child and caregiver ACE scores. Fig 1 shows the correlation of child versus maternal ACE score. This analysis found a statistically significant correlation coefficient of r(107) = 0.56, (p < 0.001). Hence, this data supports the possibility that there is likely to be a strong to moderate correlation between ACE scores of children with CSA and their biological mothers.
The variables have a correlation coefficient of r(107) = 0.56 (p < 0.0001), which is considered a moderate correlation.
Distribution of ACE
The distribution of traumatic early-life events experienced by participants and caregivers is summarized in Table 2. As was expected, all youth participants reported having survived of sexual abuse; 54.2% of caregivers reported being sexually abused prior to the age of 18. Outside of sexual abuse, the most common ACE for the youth survivors were experiencing harassment or bullying at school (n = 182, 83.1%), experiencing verbal abuse (n = 171, 78.1%), living with a mentally ill household member (n = 170, 77.6%), and having parents who are separated or divorced (n = 169, 77.2%). For the mothers, the most commonly reported ACE were having parents who are separated or divorced (n = 76, 71.0%), surviving verbal abuse (n = 66, 61.7%), living with a household member with a substance use disorder (n = 60, 56.1%), and emotional neglect (n = 60, 56.1%).
Principal factor analysis
After the PFA was conducted, three factors were suggested given visual analysis of the scree plot as well as eigenvalues > 1.0. Table 3. displays the items and factor loadings for the rotated factors, with loadings less than.40 omitted for clarity. Upon examination, the three factors translated roughly as: Neglect/abandonment, characterized by not having food in the house, a parent who had been incarcerated and/or substance abusing, and verbal abuse; Abuse, characterized by either verbal or physical abuse; and Family Breakdown, which was marked by witnessing abuse, divorce, and (to a lesser extent) a cross-loading for incarceration. Note, however, that the accompanying interpretations for the factors are based upon subjective interpretation, and could reasonably be construed in other ways. Taken together, these three factors explain 53.76% of the variance in the data. These components are illustrated graphically by a biplot of the data, shown in Fig 2.
We also sought to assess the internal consistency of each of these factors, to determine whether they are measuring the same underlying construct. While Cronbach’s alpha values over.70 are generally considered desirable, it has been observed that when there are a small number (fewer than 10) of items in each scale, scores on this measure may be lower than expected. As such, scores above.50 are generally considered acceptable, but should be reported alongside mean inter-item correlations.
The first two factors each displayed adequate internal consistency. Cronbach’s alpha for Neglect was.612, with a mean inter-item correlation of.281. Similarly, Cronbach’s alpha for Abuse was.633, with a mean inter-item correlation of.465. Both of these factors could be described as fairly robust, considered the low number of variables in each factor (four and two, respectively). However, the same could not be said of the third factor, Family Breakdown, which had a Cronbach’s alpha score of only.349, and mean inter-item correlation of.153. As a result, we suggest only the first two factors should be regarded as underlying constructs of trauma amongst survivors of CSA.
Discussion
Distribution of ACE scores and implications
The results from the present analysis support our hypothesis that there would be a statistically significant positive correlation between youth child sexual abuse (CSA) survivor ACE scores and those of their biological mothers. These findings support the current evidence that the risk for CSA is higher in children whose parents have a significant history of early-life trauma [30,31]. Although an association between early-life trauma in biological caregivers and children been established in other literature [2,33,46,47], this study provides the first collection of trauma histories from sample of youth CSA survivors and their biological mothers. From this data, we found that the number of ACE reported by both caregivers and their children were significantly higher than the surveyed general population [48,49]. The high prevalence of these ACE in this population supports the notion that CSA survivors are 2–3 times more likely to experience other forms of trauma as compared to those with no history of CSA [50]. Unfortunately, to our knowledge, no Canadian data regarding the prevalence of ACE in youth, as measured by the CYW ACE-Q, currently exists. The 2014 US National Survey of Children’s Exposure to Violence collected ACE scores for 1,949 children and adolescents aged 10–17 [48]. In this study, the reported prevalence of each ACE item was significantly lower for than in our sample. Notably, our sample reported significantly higher rates of physical abuse (62.6% vs. 13.3%), verbal abuse (78.1% vs. 13.5%), and emotional neglect (67.1% vs. 6.4%). Of the nearly 2,000 youth sampled in the Us National Survey, 11.8% of respondents reported 5 or more of the original 10 ACE items; in our sample, 78.6% reported experience 5 or more ACE. This highlights the way in which ACE often pool in certain populations. An unexpected finding from our analysis was the high proportion of mothers who are survivors of CSA themselves, with over half reporting some form of sexual abuse prior to the age of 18. A comparison sample of over 44,000 adult ACE scores from the Canadian Longitudinal Study on Aging reported a prevalence of 17.3% for CSA compared to 54.2% of our sample [49]. The frequency of ACE reported in the biological mother sample was notably higher for all the ACE items collected, primarily parental separation and divorce, victim of physical abuse, and witness of domestic violence, as compared to other adult ACE studies [50]. A recent meta-analysis of ACE prevalence worldwide found that roughly 40% of the population has experienced no ACE and 16% have experienced more than 4 [51]. A similar recent study of over 200,000 American adults found a mean ACE score of 1.56, further highlighting the observed disparity [52]. In our sample, only two mothers reported an ACE of 0 (1.9%) and the median ACE score was 5. For the child and adolescent participants, the median score on the first 10 items of the CYW ACE-Q was 7. In other words, both the caregivers and the youth survivors showed scores several times higher than multiple comparison populations, and appears to be increasing intergenerationally.
Findings of the principal axis factor analysis
The principal axis exploratory factor analysis conducted in this study revealed three factors associated with a history of CSA: neglect, abuse, and family breakdown. Neglect—which included reports of having endured long periods without food or shelter, having a family member who was incarcerated, having a family member with a substance use disorder, and feeling unloved—accounted for the highest explained variance (21%) in the youth surveyed, which may suggest that childhood neglect is a greater risk factor for CSA than other ACE factors. Children who are left to care for themselves are more susceptible to sexual abuse as their caregivers are often absent and unable to protect them from potential offenders [53]. They may also feel less comfortable turning to available adults with their concerns. Importantly, these findings also call into question the tendency to lump abuse and neglect together, which remains common practice despite evidence suggesting the experiences are very different and result in distinct consequences. As Golden et al. [54] notes, “Most think about abuse and neglect as if they go together. They are linked in our language and legislation as well as in our minds.” Neglect involves a situation in which there is a failure to meet the emotional, physical, and health needs of the child, rather than bullying, intimidation, or overt acts of violence, making it materially different from abuse. Although there is some evidence for an increased risk of CSA in children of parents with substance use disorder (SUD) or severe mental illness, the relationship is complicated by the identity of the offender—be it the affected parent or someone else [55]. However, children whose parents have a lifetime diagnosis of a SUD are more likely to suffer more severe neglect [56], which may also increase their vulnerability to sexual abuse due to parent absenteeism. Furthermore, children of substance abusive parents with high ACE scores are more likely themselves to suffer from a number of ACE, including physical and verbal abuse, highlighting the transgenerational and cyclical transmission of early-life stress and mental illness [12].
The factor analysis also revealed an association between CSA and either verbal/physical abuse, (abuse factor), and with divorce, incarceration, and the witnessing of abuse (family breakdown factor)—although these were relatively weaker than the neglect factor, each accounting for 15.6% and 12.1% of the variance, respectively. However, upon closer examination, the family breakdown factor showed poor internal consistency. This is likely because the items comprising the factor (divorce, witnessing abuse, and incarceration) may or may not co-occur. The finding that neglect explains more of the variance than abuse is perhaps counterintuitive, as it appears common to think of neglect as being somehow benign, but our analysis suggests that, when it comes to CSA, this is not the case.
Differentiating early-life traumatic experiences by subtype may be useful in assisting health professionals to determine which psychopathologies an individual is most susceptible to, based on their trauma history [57]. Recognizing that both neglect and abuse play a role in CSA, it may be useful to consider the differentiating impacts of neglect and abuse on long-term outcomes and the way in which a specific ACE may manifest psychologically. For example, emotional triggers may differ for an individual who was physically neglected (e.g., hunger) as opposed to an individual with a history of verbal abuse (e.g., loud noises). Understanding patterns of ACE scores likely to be seen in CSA survivors may offer fruitful suggestions for treatment approaches.
Implications for policy and program development
These results highlight the way in which ACE can disproportionately impact and accumulate in certain populations, potentially making subsequent generations more vulnerable to other forms of early-life trauma. These findings also emphasize the importance of trauma-informed education for both CSA survivors and their caregivers. Trauma-informed developmental care within children’s mental health and treatment programming has been defined as best practice [58]. This includes, but is not limited to, consideration of the child’s developmental age versus chronological age, identifying and addressing trauma in its earliest stages wherever possible, and addressing care plans and service delivery based upon mindful reflection of how trauma impacts people’s lives, their family system, as well as their unique service needs [59]. Trauma-informed approaches emphasize the three pillars of trauma-informed care, which are: (1) establishing a sense of safety; (2) enhancing coping skills to manage emotions; and (3) promoting positive social connections [60]. Trauma-focused family systems intervention and care could be a useful addition to treatment program design. Support for caregivers is important to help them learn to be self-reflective, attachment based, and trauma-informed in their parenting styles, so that intergenerational trauma cycles are not unintentionally passed from caregiver(s) to their child(ren) [61]. Further, mental health supports should be considered within the context of the family system whenever early childhood trauma and early childhood sexual abuse is identified [62]. This is in contrast to current practice which treats child and parent (or caregiver) separately, usually without support for the family as a whole [63].
These findings emphasize that it may be more appropriate to incorporate dyadic and/or family systems therapy into standard treatment for children with developmental trauma disorder, with a particular eye to potential shared trauma histories. It has become evident that family-centered, trauma-informed approaches with the child as well as their caregiver(s) is necessary and invaluable [64]. As there is a complex interplay between the trauma narratives of both the child and caregiver, how those narratives affect their present can impact their response to therapy. For example, the trauma history of the parent or caregiver may interfere with a child’s treatment, via emotional and behavioral strategies that reflect issues with the adults’ coping with their own trauma rather than the current functioning of the child. This family-centered approach necessitates involving a key caregiver in the treatment, recognizing the crucial role of the caregiver in helping to provide a safe environment for the child, and giving them the tools to resolve their own issues. This approach may also delve into the caregiver’s history and their need for clinical interventions and supports, something which our current healthcare structure does not advocate. In so doing, we recognize the patient as the family unit versus any one individual. Family programming and caregiver supports function under the belief that a family-centered, trauma-informed approach can be integrated into clinical practice and policy by expanding service beyond the individual child/ teen programming to include targeted family psycho-education and therapy. Teaching caregivers how trauma impacts the entire family unit and identifying and interrupting dysfunctional patterns can reduce stress, improve communication and foster resilience. Additionally, including the family and viewing them as integral to healing helps normalize for the client that they are not alone and that healing doesn’t always happen in isolation. Evidenced-based strategies such as Emotion-Focused Family Therapy and tailored family therapy sessions help caregivers respond more effectively to their child’s emotional, behavioural and mental health needs, while also addressing their own caregiver blocks [64,65]. This model strengthens family functioning and enhances treatment outcomes for the individual client. For optimal outcomes, treatment best practice should be delivered by an integrated team who have a broad understanding of how to help both the child survivor and their caregiver and/or family.
In this context, the ACE-Q and the CYW ACE-Q are valuable tools for assisting the clinical team in identifying the past narrative context, and how those narratives may influence the present story for both the caregiver and child. Trauma-informed family care and intervention supports the belief that traumatic experiences are relatively common and that people and families often encounter numerous adverse experiences throughout their lifetime. This assertion is further supported by the growing literature noting the association of parental ACE as a risk factor for trans-generational childhood adversity [33]. Epigenetic research has elucidated the potential biological mechanisms that mediated this intergenerational transmission of trauma [66]. There is evidence to suggest that survivors of traumatic experiences can pass down heritable predispositions to stress dysregulation and psychopathology [37,67]. In fact, the finding that parental neglect is the factor explaining the greatest amount of variance in our sample may reflect that parents with high levels of ACE themselves may be challenged in providing adequate care to their offspring. Accordingly, maternal trauma history accounts for up to one-third of the variance in predicting child maltreatment, and may therefore be a better predictor of child ACE score [68]. In working with mental health and addictions therapists, children and families can present with a complex range of symptoms which have not previously been connected with their trauma history [69]. By identifying the ACE score of both child and caregiver, trauma-informed intervention and treatment can engage with a family-focused approach. Understanding ACE history may enhance caregiver empathy towards their child as they reflect on their own experiences and develop a better connection to their child [70]. Effective programs to support caregiver relationships are key to the successful emotional, social, and cognitive development of children [64]. The results from the present analysis demonstrate that the ACE score of adult caregivers may provide helpful information for families and clinicians.
Limitations
There were a few limitations that need to be kept in mind in interpreting our findings. Firstly, there was no direct control group to compare to those in the program or their caregivers. Specifically, it would have been helpful to have data from a non-CSA population, gathered at the same time and using the same methods, to compare directly against. Secondly, ACE scores for caregivers encompass the first 18-years of their lives; as the children in the program had an average age of 12, their scores may not adequately represent a complete ACE history—which makes their elevated scores that much more significant. Although both these measures are intended to measure trauma history, the complex nature of trauma is inevitably difficult to fully capture through surveys or scales, which should be considered when interpreting these findings. It should be noted that, since all of the children admitted to the program are survivors of sexual abuse, and because sexual abuse is one of the ACE included in the ACE-Q, a priori none of the youth participants could have a CYW ACE-Q score of zero. Finally, our convenience sample was limited to biological mothers as there were too few participants representing other types of caregivers (biological fathers, foster parents, care providers, etc.). This limits the generalizability of the findings to any caregiver of CSA survivors; however, we felt including data from non-biological mothers would have introduced significant heterogeneity into the sample. Gathering data on biological fathers as well as mothers may elucidate further findings in regard to dyadic trauma histories. Larger sample sizes that include a variety of caregivers would provide better clarity on the link between caregiver and child ACE scores in the context of CSA.
Future directions
The findings of this study demonstrate the need for future research to look beyond treating child developmental trauma in isolation. Contemporary research on trauma-informed care and leading clinical practices encourage an approach to treat the family system as a whole [71]. There continues to be a significant need to look at risk factors for ACE in an attempt to mitigate their prevalence. Future research should also try and identify resiliency factors alongside the collection of ACE scores. At the same time, improving policy-makers’ understanding of the significance of ACE is imperative to improving awareness and driving effective research. Finally, when working in the area of developmental and generational trauma, encouraging therapists to work from a trauma-informed, family-centered lens is essential.
Additionally, future research should directly examine whether the unresolved parental/caregiver trauma can interfere with the treatment goals of the child, thereby altering the trajectory of healing. Evidence informed outcomes should be measured for child, dyad, and family. Furthermore, funding allocations based on a positive outcomes approach, instead of the current situation where funding is allocated solely based upon the number of individuals treated, would be optimal. By collecting both child and caregiver ACE, early targeted interventions for children at a high risk for toxic stress, adversity, and disrupted attachments, can be developed.
Conclusion
The key finding from the present analysis is that biological caregivers for survivors of CSA may themselves have experienced multiple types of trauma in their own childhoods, including CSA. From this standpoint, it is important to recognize that ACE, as they relate to an individual child, cannot be understood in isolation. The interplay between the child, their caregiver(s), and the combined history of adverse events, invokes a necessary conversation for healing and treating developmental trauma. In clinical practice, some protective factors for supporting children and adolescents with their developmental trauma comes within the context of treating the entire family; understanding this highlights the importance of factors that predict resilience.
In many jurisdictions the mental healthcare system is separate for children and for adults, with little to no integration of the parent-child dyad. Specialized services tend to focus on a specific population due to funding limitations and implications. Yet high correlations in intrafamilial ACE demonstrate the transmission of trauma and adversity. These results support clinical observations suggesting that there may be an intergenerational relationship between trauma experienced by the parent (and/or caregiver) and that of the child. Our conclusion from this analysis is that the status quo in treating childhood developmental trauma needs to shift towards a seamless family system approach. It is believed that this integrated approach would better address the longer-term term negative mental health and addictions symptoms that are tightly associated with childhood abuse.
References
- 1. Spenrath MA, Clarke ME, Kutcher S. The science of brain and biological development: implications for mental health research, practice and policy. J Can Acad Child Adolesc Psychiatry. 2011;20(4):298–304. pmid:22114611
- 2. Agorastos A, Pervanidou P, Chrousos GP, Baker DG. Developmental Trajectories of Early Life Stress and Trauma: A Narrative Review on Neurobiological Aspects Beyond Stress System Dysregulation. Front Psychiatry. 2019;10:118. pmid:30914979
- 3. Heim C, Binder EB. Current research trends in early life stress and depression: review of human studies on sensitive periods, gene-environment interactions, and epigenetics. Exp Neurol. 2012;233(1):102–11. pmid:22101006
- 4. Danese A, Caspi A, Williams B, Ambler A, Sugden K, Mika J, et al. Biological embedding of stress through inflammation processes in childhood. Mol Psychiatry. 2011;16(3):244–6. pmid:20157309
- 5. Baker LM, Williams LM, Korgaonkar MS, Cohen RA, Heaps JM, Paul RH. Impact of early vs. late childhood early life stress on brain morphometrics. Brain Imaging Behav. 2013;7(2):196–203. pmid:23247614
- 6. Schury K, Kolassa I-T. Biological memory of childhood maltreatment: current knowledge and recommendations for future research. Ann N Y Acad Sci. 2012;1262:93–100. pmid:22823440
- 7. Fergusson DM, Boden JM, Horwood LJ. Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child Abuse Negl. 2008;32(6):607–19. pmid:18565580
- 8. Lee V, Hoaken PNS. Cognition, emotion, and neurobiological development: mediating the relation between maltreatment and aggression. Child Maltreat. 2007;12(3):281–98. pmid:17631627
- 9. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245–58. pmid:9635069
- 10. Brodsky BS, Stanley B. Adverse childhood experiences and suicidal behavior. Psychiatr Clin North Am. 2008;31(2):223–35. pmid:18439446
- 11. Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord. 2004;82(2):217–25. pmid:15488250
- 12. Anda RF, Whitfield CL, Felitti VJ, Chapman D, Edwards VJ, Dube SR, et al. Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression. Psychiatr Serv. 2002;53(8):1001–9. pmid:12161676
- 13. Shonkoff JP, Fisher PA. Rethinking evidence-based practice and two-generation programs to create the future of early childhood policy. Dev Psychopathol. 2013;25(4 Pt 2):1635–53. pmid:24342860
- 14. Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232–46. pmid:22201156
- 15.
Ludy-Dobson CR, Perry BD. The role of healthy relational interactions in buffering the impact of childhood trauma. In: Gil E, editor. Working with children to heal interpersonal trauma: The power of play. New York: The Guilford Press; 2010. p. 26–43.
- 16. Barth J, Bermetz L, Heim E, Trelle S, Tonia T. The current prevalence of child sexual abuse worldwide: a systematic review and meta-analysis. Int J Public Health. 2013;58(3):469–83. pmid:23178922
- 17. Chiu GR, Lutfey KE, Litman HJ, Link CL, Hall SA, McKinlay JB. Prevalence and overlap of childhood and adult physical, sexual, and emotional abuse: a descriptive analysis of results from the Boston Area Community Health (BACH) survey. Violence Vict. 2013;28(3):381–402. pmid:23862305
- 18. Piolanti A, Schmid IE, Fiderer FJ, Ward CL, Stöckl H, Foran HM. Global prevalence of sexual violence against children: A systematic review and meta-analysis. JAMA Pediatr. 2025.
- 19. MacMillan HL, Tanaka M, Duku E, Vaillancourt T, Boyle MH. Child physical and sexual abuse in a community sample of young adults: results from the Ontario Child Health Study. Child Abuse Negl. 2013;37(1):14–21. pmid:23290623
- 20. Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg MJ. A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreat. 2011;16(2):79–101. pmid:21511741
- 21. Martin EK, Silverstone PH. How Much Child Sexual Abuse is “Below the Surface,” and Can We Help Adults Identify it Early? Front Psychiatry. 2013;4:58. pmid:23874306
- 22. McElvaney R. Disclosure of Child Sexual Abuse: Delays, Non‐disclosure and Partial Disclosure. What the Research Tells Us and Implications for Practice. Child Abuse Rev. 2013;24(3):159–69.
- 23. Pereda N, Guilera G, Forns M, Gómez-Benito J. The international epidemiology of child sexual abuse: a continuation of Finkelhor (1994). Child Abuse Negl. 2009;33(6):331–42. pmid:19477003
- 24. Andersen SL, Tomada A, Vincow ES, Valente E, Polcari A, Teicher MH. Preliminary evidence for sensitive periods in the effect of childhood sexual abuse on regional brain development. J Neuropsychiatry Clin Neurosci. 2008;20(3):292–301. pmid:18806232
- 25. Afifi TO, Macmillan HL. Resilience following child maltreatment: a review of protective factors. Can J Psychiatry. 2011;56(5):266–72. pmid:21586192
- 26. Collishaw S, Pickles A, Messer J, Rutter M, Shearer C, Maughan B. Resilience to adult psychopathology following childhood maltreatment: evidence from a community sample. Child Abuse Negl. 2007;31(3):211–29. pmid:17399786
- 27. Luby JL, Belden AC, Spitznagel E. Risk factors for preschool depression: the mediating role of early stressful life events. J Child Psychol Psychiatry. 2006;47(12):1292–8. pmid:17176384
- 28. Kundakovic M, Champagne FA. Early-life experience, epigenetics, and the developing brain. Neuropsychopharmacology. 2015;40(1):141–53. pmid:24917200
- 29. Lev–Wiesel R. Intergenerational Transmission of Trauma across Three Generations: A Preliminary Study. Qual Soc Work. 2007;6(1):75–94.
- 30. Borelli JL, Cohen C, Pettit C, Normandin L, Target M, Fonagy P, et al. Maternal and Child Sexual Abuse History: An Intergenerational Exploration of Children’s Adjustment and Maternal Trauma-Reflective Functioning. Front Psychol. 2019;10:1062. pmid:31156503
- 31. Robboy J, Anderson KG. Intergenerational child abuse and coping. J Interpers Viol. 2011;26(17):3526–41. pmid:21602207
- 32. Smith DK, Leve LD, Chamberlain P. Adolescent girls’ offending and health-risking sexual behavior: the predictive role of trauma. Child Maltreat. 2006;11(4):346–53. pmid:17043319
- 33. Jones CW, Esteves KC, Gray SAO, Clarke TN, Callerame K, Theall KP, et al. The transgenerational transmission of maternal adverse childhood experiences (ACEs): Insights from placental aging and infant autonomic nervous system reactivity. Psychoneuroendocrinology. 2019;106:20–7. pmid:30947082
- 34. Martos SN, Tang W-Y, Wang Z. Elusive inheritance: Transgenerational effects and epigenetic inheritance in human environmental disease. Prog Biophys Mol Biol. 2015;118(1–2):44–54. pmid:25792089
- 35. Bombay A, Matheson K, Anisman H. The impact of stressors on second generation Indian Residential School survivors. Transcult Psychiatry. 2011;48(4):367–91. pmid:21911507
- 36. Nelson SE, Wilson K. The mental health of Indigenous peoples in Canada: A critical review of research. Soc Sci Med. 2017;176:93–112. pmid:28135694
- 37. Yehuda R, Daskalakis NP, Bierer LM, Bader HN, Klengel T, Holsboer F, et al. Holocaust Exposure Induced Intergenerational Effects on FKBP5 Methylation. Biol Psychiatry. 2016;80(5):372–80. pmid:26410355
- 38. Yang B-Z, Zhang H, Ge W, Weder N, Douglas-Palumberi H, Perepletchikova F, et al. Child abuse and epigenetic mechanisms of disease risk. Am J Prev Med. 2013;44(2):101–7. pmid:23332324
- 39. Reeson M, Polzin W, Pazderka H, Agyapong V, Greenshaw AJ, Hnatko G, et al. A Novel 2-week Intensive Multimodal Treatment Program for Child Sexual Abuse (CSA) Survivors is Associated with Mental Health Benefits for Females aged 13-16. J Can Acad Child Adolesc Psychiatry. 2020;29(3):165–76. pmid:32774399
- 40. Silverstone PH. A Complex Multimodal 4-Week Residential Treatment Program Significantly Reduces PTSD Symptoms in Child Sexual Abuse Victims: The Be Brave Ranch. J Child Adolesc Behav. 2016;04(01).
- 41. Oh DL, Jerman P, Purewal Boparai SK, Koita K, Briner S, Bucci M, et al. Review of Tools for Measuring Exposure to Adversity in Children and Adolescents. J Pediatr Health Care. 2018;32(6):564–83. pmid:30369409
- 42.
Harris NB, Renschler T. Center for Youth Wellness ACE-Questionnaire (CYW ACE-Q child, teen, teen SR). 7th edition. San Francisco (CA): Center for Youth Wellness; 2015.
- 43. Akoglu H. User’s guide to correlation coefficients. Turk J Emerg Med. 2018;18(3):91–3. pmid:30191186
- 44. Oláh B, Fekete Z, Kuritárné Szabó I, Kovács-Tóth B. Validity and reliability of the 10-Item Adverse Childhood Experiences Questionnaire (ACE-10) among adolescents in the child welfare system. Front Public Health. 2023;11:1258798. pmid:38045975
- 45. Widaman KF. On Common Factor and Principal Component Representations of Data: Implications for Theory and for Confirmatory Replications. Struct Equ Model. 2018;25(6):829–47.
- 46. Racine N, Deneault A-A, Thiemann R, Turgeon J, Zhu J, Cooke J, et al. Intergenerational transmission of parent adverse childhood experiences to child outcomes: A systematic review and meta-analysis. Child Abuse Negl. 2025;168(Pt 1):106479. pmid:37821290
- 47. Randell KA, O’Malley D, Dowd MD. Association of Parental Adverse Childhood Experiences and Current Child Adversity. JAMA Pediatr. 2015;169(8):786–7. pmid:26030177
- 48. Finkelhor D, Shattuck A, Turner H, Hamby S. A revised inventory of Adverse Childhood Experiences. Child Abuse Negl. 2015;48:13–21. pmid:26259971
- 49. Joshi D, Raina P, Tonmyr L, MacMillan HL, Gonzalez A. Prevalence of adverse childhood experiences among individuals aged 45 to 85 years: a cross-sectional analysis of the Canadian Longitudinal Study on Aging. CMAJ Open. 2021;9(1):E158–66. pmid:33653771
- 50. Pérez-Fuentes G, Olfson M, Villegas L, Morcillo C, Wang S, Blanco C. Prevalence and correlates of child sexual abuse: a national study. Compr Psychiatry. 2013;54(1):16–27. pmid:22854279
- 51. Madigan S, Deneault A-A, Racine N, Park J, Thiemann R, Zhu J, et al. Adverse childhood experiences: a meta-analysis of prevalence and moderators among half a million adults in 206 studies. World Psychiatry. 2023;22(3):463–71. pmid:37713544
- 52. Giano Z, Wheeler DL, Hubach RD. The frequencies and disparities of adverse childhood experiences in the U.S. BMC Public Health. 2020;20(1):1327. pmid:32907569
- 53. Austin AE, Lesak AM, Shanahan ME. Risk and protective factors for child maltreatment: A review. Curr Epidemiol Rep. 2020;7(4):334–42. pmid:34141519
- 54. Golden MH, Samuels MP, Southall DP. How to distinguish between neglect and deprivational abuse. Arch Dis Child. 2003;88(2):105–7. pmid:12538306
- 55. Widom CS, Hiller-Sturmhöfel S. Alcohol abuse as a risk factor for and consequence of child abuse. Alcohol Res Health. 2001;25(1):52–7. pmid:11496967
- 56. Kirisci L, Dunn MG, Mezzich AC, Tarter RE. Impact of parental substance use disorder and child neglect severity on substance use involvement in male offspring. Prev Sci. 2001;2(4):241–55. pmid:11833927
- 57. Carr CP, Martins CMS, Stingel AM, Lemgruber VB, Juruena MF. The role of early life stress in adult psychiatric disorders: a systematic review according to childhood trauma subtypes. J Nerv Ment Dis. 2013;201(12):1007–20. pmid:24284634
- 58. Bremness A, Polzin W. Trauma informed care. J Can Acad Child Adolesc Psychiatry. 2014;23(2):86. pmid:24872823
- 59. Ashton CK, O’Brien-Langer A, Silverstone PH. The CASA Trauma and Attachment Group (TAG) Program for Children who have Attachment Issues Following Early Developmental Trauma. J Can Acad Child Adolesc Psychiatry. 2016;25(1):35–42. pmid:27047555
- 60. Bath H. The three pillars of trauma-informed care. Reclaim Child Youth. 2008;17(4):17–21.
- 61. Sullivan RM. The Neurobiology of Attachment to Nurturing and Abusive Caregivers. Hastings Law J. 2012;63(6):1553–70. pmid:24049190
- 62. Narayan AJ, Lieberman AF, Masten AS. Intergenerational transmission and prevention of adverse childhood experiences (ACEs). Clin Psychol Rev. 2021;85:101997. pmid:33689982
- 63. Tavkar P, Hansen DJ. Interventions for families victimized by child sexual abuse: Clinical issues and approaches for child advocacy center-based services. Aggress Viol Behav. 2011;16(3):188–99.
- 64. Kerig PK, Alexander JF. Family Matters: Integrating Trauma Treatment into Functional Family Therapy for Traumatized Delinquent Youth. J Child Adol Trauma. 2012;5(3):205–23.
- 65. Mlotek AE, Paivio SC. Emotion-focused therapy for complex trauma. Pers-Centered Exp Psychother. 2017;16(3):198–214.
- 66. Neves I, Dinis-Oliveira RJ, Magalhães T. Epigenomic mediation after adverse childhood experiences: a systematic review and meta-analysis. Forensic Sci Res. 2019;6(2):103–14. pmid:34377567
- 67. Zhou A, Ryan J. Biological Embedding of Early-Life Adversity and a Scoping Review of the Evidence for Intergenerational Epigenetic Transmission of Stress and Trauma in Humans. Genes (Basel). 2023;14(8):1639. pmid:37628690
- 68. Dong M, Anda RF, Dube SR, Giles WH, Felitti VJ. The relationship of exposure to childhood sexual abuse to other forms of abuse, neglect, and household dysfunction during childhood. Child Abuse Negl. 2003;27(6):625–39. pmid:12818611
- 69. Zelechoski AD, Sharma R, Beserra K, Miguel JL, DeMarco M, Spinazzola J. Traumatized Youth in Residential Treatment Settings: Prevalence, Clinical Presentation, Treatment, and Policy Implications. J Fam Viol. 2013;28(7):639–52.
- 70. Garon-Bissonnette J, Duguay G, Lemieux R, Dubois-Comtois K, Berthelot N. Maternal childhood abuse and neglect predicts offspring development in early childhood: The roles of reflective functioning and child sex. Child Abuse Negl. 2022;128:105030. pmid:33752901
- 71. Karakurt G, Silver KE. Emotional abuse in intimate relationships: the role of gender and age. Violence Vict. 2013;28(5):804–21. pmid:24364124