Adverse Childhood Experiences
Get your ACE Card for
do ACEs matter?
ACE expert Jane Ellen Stevens succinctly broke down the negative effects of ACEs on developing minds:
They respond to the world as a place of constant danger. With their brains overloaded with stress hormones and unable to function appropriately, they cant focus on learning. They fall behind in school or fail to develop healthy relationships with peers or create problems with teachers and principals because they are unable to trust adults.
ACEs, or Adverse Childhood Experiences, are different for everyone, but in the broadest sense, they are negative moments or events that have the potential to leave lasting harmful effects on a child. ACEs come in many forms from: abuse, neglect, household dysfunction to witnessing violence. ACEs are important to identify due to their uncanny ability to mold and shape who our children grow up to be. When unchecked and unnoticed, ACEs can lead to a future of lifelong health concerns, risk aversion, passivity, and violence (both as a perpetrator and victim).
Researchers have identified three categories of ACEs:
Within these three categories are a plethora of experiences and events. To properly study how ACEs affect people as adults, researchers chose 10 types of childhood trauma and asked study participants to note whether or not they had experienced them as children.
64% had at least 1 ACE. 22% had 3 or more. 12.5% had 4 or more.
The ACE Test
In the first ACE study, Dr. Vincent Felitti and Dr. Robert Anda devised a test. There were 10 questions, each pertaining to a different type of ACE. For every question with a Yes (meaning they had an ACE) the test taker received a one point.
Before your 18th birthday, did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you? Or did they act in a way that made you afraid you might be physically hurt?
The test only counted types of ACEs, not the number or separate incidents of the same type of ACE. So, if they experience physical abuse 25 times, and no other types of experiences, their score would be 1. The goal of the test was to see how ACEs correlated with the test takers health.
The results were shocking, and led to
emotional moments between therapists and study
There are 10 types of childhood trauma measured in the ACE Study. Five are personal physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to other family members: a parent whos an alcoholic, a mother whos a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment. Each type of trauma counts as one. So a person whos been physically abused, with one alcoholic parent, and a mother who was beaten up has an ACE score of three.
There are, of course, many other types of childhood trauma watching a sibling being abused, losing a caregiver (grandmother, mother, grandfather, etc.), homelessness, surviving and recovering from a severe accident, witnessing a father being abused by a mother, witnessing a grandmother abusing a father, etc. The ACE Study included only those 10 childhood traumas because those were mentioned as most common by a group of about 300 Kaiser members; those traumas were also well studied individually in the research literature.
The most important thing to remember is that the ACE score is meant as a guideline: If you experienced other types of toxic stress over months or years, then those would likely increase your risk of health consequences.
Question Did a parent or
other adult in the household often or very
Swear at you, insult you, put you down,
or humiliate you? or Act in a way that made you
afraid that you might be physically
hurt? Did a parent or
other adult in the household often or very
Push, grab, slap, or throw something at
you? or Ever hit you so hard that you had marks or
were injured? Did an adult or
person at least 5 years older than you ever
Touch or fondle you or have you touch their body in
a sexual way? or Attempt or actually have oral,
anal, or vaginal intercourse with you? Did you often or
very often feel that
No one in your family
loved you or thought you were important or special?
or Your family didnt look out for each other,
feel close to each other, or support each
other? Did you often or
very often feel that
You didnt have
enough to eat, had to wear dirty clothes, and had
no one to protect you? or Your parents were too
drunk or high to take care of you or take you to
the doctor if you needed it? Were your parents
ever separated or divorced? Was your mother or
stepmother: Often or very often
pushed, grabbed, slapped, or had something thrown
at her? or Sometimes, often, or very often kicked,
bitten, hit with a fist, or hit with something
hard? or Ever repeatedly hit over at least a few
minutes or threatened with a gun or
knife? Did you live with
anyone who was a problem drinker or alcoholic, or
who used street drugs? Was a household
member depressed or mentally ill, or did a
household member attempt suicide? Did a household
member go to prison? Now add up your
Yes answers: _ This is your ACE
Did a parent or other adult in the household often or very often Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
Did a parent or other adult in the household often or very often Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
Did an adult or person at least 5 years older than you ever Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
Did you often or very often feel that No one in your family loved you or thought you were important or special? or Your family didnt look out for each other, feel close to each other, or support each other?
Did you often or very often feel that You didnt have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Were your parents ever separated or divorced?
Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
Was a household member depressed or mentally ill, or did a household member attempt suicide?
Did a household member go to prison?
Now add up your Yes answers: _ This is your ACE Scor
Now that youve got your ACE score, what does it mean?
First .a tiny bit of background to help you figure this out ..(if you want the back story about the fascinating origins of the ACE Study, read The Adverse Childhood Experiences Study the largest, most important public health study you never heard of began in an obesity clinic.)
The CDCs Adverse Childhood Experiences Study (ACE Study) uncovered a stunning link between childhood trauma and the chronic diseases people develop as adults, as well as social and emotional problems. This includes heart disease, lung cancer, diabetes and many autoimmune diseases, as well as depression, violence, being a victim of violence, and suicide.
The first research results were published in 1998, followed by 57 other publications through 2011. They showed that:
A whopping two thirds of the 17,000 people in the ACE Study had an ACE score of at least one 87 percent of those had more than one. Eighteen states have done their own ACE surveys; their results are similar to the CDCs ACE Study.
The studys researchers came up with an ACE score to explain a persons risk for chronic disease. Think of it as a cholesterol score for childhood toxic stress. You get one point for each type of trauma. The higher your ACE score, the higher your risk of health and social problems. (Of course, other types of trauma exist that could contribute to an ACE score, so it is conceivable that people could have ACE scores higher than 10; however, the ACE Study measured only 10 types.)
As your ACE score increases, so does the risk of disease, social and emotional problems. With an ACE score of 4 or more, things start getting serious. The likelihood of chronic pulmonary lung disease increases 390 percent; hepatitis, 240 percent; depression 460 percent; suicide, 1,220 percent.
(By the way, lest you think that the ACE Study was yet another involving inner-city poor people of color, take note: The studys participants were 17,000 mostly white, middle and upper-middle class college-educated San Diegans with good jobs and great health care they all belonged to the Kaiser Permanente health maintenance organization.)
Adult Childhood Experiences are Common
The CDC gave a questionairre with these 10 types of childhood trauma and assigned a score of 1 for each trauma experienced.
Whats Your Resilience Score?
This questionnaire was developed by the early childhood service providers, pediatricians, psychologists, and health advocates of Southern Kennebec Healthy Start, Augusta, Maine, in 2006, and updated in February 2013. Two psychologists in the group, Mark Rains and Kate McClinn, came up with the 14 statements with editing suggestions by the other members of the group. The scoring system was modeled after the ACE Study questions. The content of the questions was based on a number of research studies from the literature over the past 40 years including that of Emmy Werner and others. Its purpose is limited to parenting education. It was not developed for research.
Here are some specific graphic examples of how increasing ACE scores increase the risk of some diseases, social and emotional problems. All of these graphs come from The relationship of adverse childhood experiences to adult health, well being, social function and health care, a book chapter by Drs. Vincent Felitti and Robert Anda, co-founders of the ACE Study, in The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease.
ACE Test Results
When Dr. Anda got the first results back he was overcome with sadness. He said, I saw how much people had suffered and I wept.
The study largely focused on the consequences of several different types of trauma. The 1995 study found that over 66% of participants had at least 1 ACE. Startling enough on its own, but that was only the beginning:
When they dug into the scores, researchers discovered that over a quarter of participants had experienced physical abuse, household substance use, economic hardship, or a combination of the three.
The study showed that many had been neglected in their childhood and over 1/5 were sexually abused:
After discovering how prevalent these ACEs were in peoples lives, Anda and Felitti looked for correlations between ACEs and mental and physical health concerns. What they found, led to some shocking, but profound and beneficial trends. Most notably: An almost exact correlation between childhood trauma and mental illnesses, chronic diseases, incarceration, and employment status.
Why Do ACEs Matter?
When an adverse childhood experience occurs, the childs brain is flooded with adrenaline in what is often called Fight or Flight. While this reaction helps the child react to any immediate dangers, it becomes toxic when turned on for too long.
When children are forced to constantly focus on surviving and avoiding harm, they are unable to focus on learning or developing skills to serve them in adulthood. Their ability to trust and relate to others never fully forms and they often experience depression, self-consciousness, and avoidance of challenges. This has a snowball effect where children may turn to self-medicating or other troublesome behaviors to deal with the pain.
People who experience childhood trauma tend to respond to daily stresses with high anxiety, or try to avoid stressors at all costs. This may include high pressure situations like giving a presentation at work, or more minor situations, like making small talk at a school fundraising event.
Health Impact of Multiple ACEs
A single adverse childhood experience can harm a childs future by increasing the risk of homelessness, exposure to violence, and work absenteeism. When multiple ACEs happen, the likelihood of mental, physical, and social concerns goes up exponentially.
Repeated abusive and traumatic situations often lead to Complex PTSD. This type of trauma happens before a child is allowed to fully develop cognitive maturity and an understanding of how to respond to stressful situations. A person suffering from Complex PTSD will have trouble regulating their stress hormones and responding to normal situations as if they were threatening situations. These reactions can lead to chronic health issues and dangerous behaviors to deal with stress.
A score of 2 or more on the ACE test, when correlated with test takers health records showed the following compared to someone with a score of 0:
A score of 4 had even more dire and sobering correlations:
In a more recent study, they found that when people had a score of 6 or more, the consequences were fatal. A person with 6 or more ACEs dies, on average, 20 years earlier than someone with 0.
The effects of ACEs go far beyond health concerns.
Economic Impact of ACEs
With problems reconciling fears, stress, and ambition, people suffering from ACEs can fail to secure financial stability and steady employment. While certainly a major strain on their own lives, this lack of financial support also puts a strain on the American economy.
ACEs cost the economy $124 billion in over the lifetime of all those affected by ACEs.$83.5 billion in productivity losses
Child maltreatment and domestic abuse combined cost the economy roughly $500 billion a year. Health is certainly the #1 concern in combating ACEs, but the benefits of uncovering and treating ACEs are indefinite.
Signs You or Your Child May Be Impacted by ACEs
Possibly just knowing what ACEs are will help you determine if you or someone you know is impacted by ACEs. But for those more underlying and not talked about experiences look for the following ACE effects.
Many suffering from Complex PTSD, ACEs, and child trauma feel physical effects that can disrupt daily life:
More often than not these are coupled with emotional and social deficiencies. These issues consistently get in the way of victims ambitions and goals and can put a strain on their relationships.
87% of people with ACEs in Andas test had multiple types of trauma. That means only 13% had an isolated type of ACE. It appears that when someone has an ACE, many more are soon to follow. With multiple types of trauma, come multiple types of negative effects.
Therapists stress that the view should not be Why are you behaving like this? but What happened to you? If you or someone you know struggles with any of the above-mentioned concerns, take a look at the ACE test. It could lead to a path of recovery or at least an understanding of what events impacted the person you are today.
How You Can Prevent ACEs from Damaging Lives
Sometimes ACEs are unavoidable. Children will undoubtedly find themselves in adverse situations where they need to use that Fight or Flight adrenaline rush. But when coupled with protective and positive childhood experiences, adverse events can actually help children develop resilience.
The first step is creating an open dialogue between children and caring adults. There needs to be a trust between you and the child. They need a safe and loving environment where they can rid themselves of stresses and just be a kid.
Positive Childhood Experiences
It is vital to give your children positive life experiences and work with them to develop healthy self-regulation. Some of these include:
As they are still developing self-regulation and responses to stress, show and explain to them proper coping and conflict resolution techniques:
A study on ACEs and their connection to problems with self-control stated,
Innovative policies that put self-control center stage might reduce a panoply of costs that now heavily burden citizens and governments.
While there is no cure-all for deafening the impact of ACEs, providing children with positive childhood experiences can dramatically limit some potentially fatal ACE effects. Resilience to negative events and an understanding that there are positive things in life are vital to living a fruitful life.
For adults living with the effects of ACEs, youre not alone. A benefit of the recent understanding of ACEs is that many people are finding the courage and strength to overcome roadblocks from their childhood trauma. The dialogue is open; please join in.
Related content from Rawhide's
Trauma And Its Lifelong Health Effects More Prevalent Among
But the first major study to focus on adverse childhood experiences (ACEs) was limited to a single healthcare system in San Diego. A study published Monday in JAMA Pediatrics the largest nationally representative study to date on ACEs confirms that these experiences are universal, yet highlights some disparities among socioeconomic groups. People with low-income and educational attainment, people of color and people who identified as gay, lesbian or bisexual had significantly higher chance of having experienced adversity in childhood.
The study finds three out of five adults across the U.S. had at least one adverse experience in their childhood, such as divorce, a parent's death, physical or emotional abuse, or a family member's incarceration or substance abuse problem. A quarter of adults have at least three such experiences in childhood, which according to other research increases their risk for most common chronic diseases, from heart disease and cancer to depression and substance abuse.
"This is the first study of this kind that allows us to talk about adverse childhood experience as a public health problem in the same way we talk about obesity or hypertension or any other highly prevalent population risk factor," says Adam Schickedanz, an assistant professor of pediatrics at the David Geffen School of Medicine at UCLA, who was not involved in the research. "Up until now, we haven't really had a study that takes a national look."
The study researchers, led by Centers for Disease Control and Prevention researcher Melissa T. Merrick, analyzed data from 214,157 adults in 23 states between 2011 and 2014. The participants answered 11 questions about whether they'd experienced what have now become well recognized as ACEs: parental separation or divorce, child abuse (physical, emotional and sexual), domestic violence and living with someone who has been incarcerated or has a mental illness or a substance use disorder.
Nearly 62 percent of respondents had at least one ACE and a quarter reported three or more. The remaining respondents had at least two ACEs, including 16 percent with four or more such experiences.
Those identifying as black or Latino and those with less than a high school education or an annual income below $15,000 were more likely to have more ACEs. But a relatively new finding was that multiracial and gay, lesbian and bisexual individuals carried the greatest burden.
Multiracial participants reported roughly 2.5 ACEs, and bisexual adults reported 3.1, both the highest scores reported. Women, younger adults, unemployed people and those unable to work also tended to have higher scores.
But Schickedanz cautions that, while the disparities are real, it's important to recognize how common these experiences are among all people, including white and middle class families.
"This [study] shows that ACEs affect people from all walks of life everywhere," he says.
The link between trauma and health
The original ACE study, published in 1998, analyzed data from more than 9,000 primarily middle class adults in the San Diego area, starting in 1995-1997. Its publication opened people's eyes to how common adverse experiences are even among children in seemingly more privileged homes. Nearly 40 percent of participants had at least a college degree, and 75 percent were white.
More than a quarter of those original participants reported physical abuse in childhood, and one in five reported sexual abuse. And the study identified the link between adverse childhood experiences and poor physical and mental health decades later.
Since that study, an increasing number of states have begun collecting data on ACEs with the Behavioral Risk Factor Surveillance System, the database used by the new study's researchers. All states use the system, and 32 states since 2009 have collected ACEs data.
The CDC tracks the many ACE-related studies published on a website section specifically about ACEs. Studies have linked a greater number of ACEs with greater risk of heart disease, cancer, bone fractures and chronic lung or liver diseases, diabetes and stroke. Those with the most ACEs, four to six or more, tend to have higher rates of mental illness.
Scientists have just begun understanding the social and biological mechanisms that might explain how highly stressful experiences in childhood could translate to greater risks for heart disease or diabetes. One way has to do with the stress response itself: the body produces and releases the hormones cortisol and adrenaline while increasing blood sugar and blood pressure all of which help with the body's need for fight or flight.
But chronic stress means chronically high levels of these substances, which isn't healthy in the long term. Consistently high blood sugar, for example, increases the risk of diabetes, and high blood pressure is linked to heart disease.
Opportunities for intervention
This new study suggests a need to target prevention resources where they can help most, says Jack Shonkoff, a professor of child health and development at the Harvard T.H. Chan School of Public Health. This also requires identifying what makes some people more susceptible than others to the effects of adversity.
"Nobody is immune to adverse experiences in childhood but for some population groups, they're a larger burden of childhood adversity than others," he says. "We needto focus on targeting limited resources to the people at greatest risk and making sure those resources go into programs that reduce or mitigate adversity."
Doing that will require developing tools to screen for people's sensitivity to adversity, he says. He also notes that ACEs alone don't account for health disparities. Genetics play a key role in health outcomes as well, he explains.
"Environmental risk factors are only part of the story. You can't separate genetics from environment," Shonkoff says.
To address the consequences of childhood adversity, it will be important to develop programs that help children learn healthy coping mechanisms and strengthen families and communities overall, says Andrew Garner, a clinical professor of pediatrics at Case Western Reserve University School of Medicine in Cleveland.
"Our objective is not to put kids in a bubble but teach kids how to deal with adversity in a healthy manner," Garner says. "If parents are in survival mode, their kids are in survival mode too, and they're not going to learn as well and learn coping mechanisms. Those poor coping mechanisms are what we think links adversity to poor health outcomes."
For example, youth who cope by using drugs, alcohol, sex or other risky behaviors are increasing their risk of substance abuse problems, teen pregnancy and sexually transmitted infections, all of which increase risk of other chronic diseases later on.
Garner and Schickedanz both pointed to increasing levels of social isolation documented by other researchers as a substantial likely contributor to the health outcomes linked to ACEs.
"If you look the very highest risk group, it's bisexuals, and we know they may feel isolated. The second highest is multiracial people who may not necessary feel they belong in any particular group," Garner says. "We know from biology that it's really bad to be socially isolated and we're seeing that disparities in adversity are mirrored in health outcomes later on."
But Garner emphasizes that an ACE score is "not destiny." In addition to social programs that address underlying income and racial disparities, it's vital to teach kids resilience.
"Resilience reflects using skills, and
the beauty of that is that skills can be learned, taught,
modeled, practiced and reinforced, and kids learn better
when they're in relationships," he says. "We need to do
better job of primary prevention by focusing on emotional
learning and promoting safe, stable, nurturing
Childhood Experiences and Suicide Attempts
The ACEs included in the study were (1) psychological abuse; (2) physical abuse; (3) sexual abuse; (4) emotional neglect; (5) physical neglect; (6) witnessing violence against a mother or other adult female; (7) substance misuse by a parent or other household member; (8) mental illness, suicide attempt, or suicide death of a parent or other household member; (9) incarceration of a parent or other household member; and (10) parents separation or divorce.
Researchers found that:
The age at which respondents experienced ACEs, and the duration and severity of ACEs, were not measured. For this reason, the researchers cautioned that these results could not prove that ACEs caused the increase in suicide attempts. However, the findings still highlight the need for early detection of ACEs and targeted interventions to prevent future suicide attempts.
Choi, N. G., Dinitto, D. M., Marti, C.
N., & Segal, S. P. (2017). Adverse childhood experiences
and suicide attempts among those with mental and substance
use disorders. Child Abuse & Neglect, 69,
Why do ACEs
An ACE score of 2:
An ACE score of 4:
An ACE score of 6:
When developmental trauma is present:
Undersanding of what is in their control
The resources in this section focus on the development of community-wide systems to prevent and mitigate the impact of adverse childhood experiences and toxic stress.
This section includes resources which could be used by individuals, groups or entire communities to inform political leaders, legislators, and the legislative process around issues related to adverse childhood experiences (ACEs) and toxic stress.
This section includes links to professional and social networks with a focus on the topics of adverse childhood experiences (ACEs), toxic stress, resiliency, and other related components of this work.
This section includes resources that acknowledge cultural groups and highlight the need for cultural sensitivity when working with diverse groups or communities on topics related to adverse childhood experiences (ACEs) and toxic stress.
Social Determinants of Health
The links in this section describe the influence of social factors such as poverty, race and socioeconomics, on health equity and lifelong health outcomes.
Trauma Informed Care
The links in this section describe the framework of Trauma Informed Care, which calls for a cultural shift that can be applied in any setting. Trauma Informed Care is not a specific intervention or a clinical response. Rather, it highlights the need for a broader understanding of the impact trauma has on everyone.
This section includes links to examples of specific interventions created through a trauma-informed lens.