Adverse Childhood Experiences Study (ACES)

The Adverse Childhood Experiences Study (ACE Study) is a research study conducted by the American health maintenance organization Kaiser Permanente and the Centers for Disease Control and Prevention. Participants were recruited to the study between 1995 and 1997 and have been in long-term follow up for health outcomes. The study has demonstrated an association of adverse childhood experiences (ACEs) with health and social problems as an adult. The study is frequently cited as a notable landmark in epidemiological research, and has produced more than 50 scientific articles and more than 100 conference and workshop presentations that look at the prevalence and consequences of ACEs.

Please click here for additional information about the ACE study.

The ACE Pyramid below represents the conceptual framework for the ACE Study. The ACE Study has uncovered how ACEs are strongly related to development of risk factors for disease, and well-being throughout the life course.

Adverse Childhood Experiences Study Pyramid

Adverse Childhood Experiences (ACEs) are common. Almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs.

The ACE score, a total sum of the different categories of ACEs reported by participants, is used to assess cumulative childhood stress. Study findings repeatedly reveal a graded dose-response relationship between ACEs and negative health and well-being outcomes across the life course.

As the number of ACEs increases so does the risk for the following (note: this list is not exhaustive):

  • Alcoholism and alcohol abuse
  • Chronic obstructive pulmonary disease
  • Depression
  • Fetal death
  • Health-related quality of life
  • Illicit drug use
  • Ischemic heart disease
  • Liver disease
  • Poor work performance
  • Financial stress
  • Risk for intimate partner violence
  • Multiple sexual partners
  • Sexually transmitted diseases
  • Smoking
  • Suicide attempts
  • Unintended pregnancies
  • Early initiation of smoking
  • Early initiation of sexual activity
  • Adolescent pregnancy
  • Risk for sexual violence
  • Poor academic achievement

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 who’s an alcoholic, a mother who’s 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 who’s 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.

While you were growing up, during your first 18 years of life:

  1. 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?
    No___ If Yes, enter 1 __
  2. 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?
    No___ If Yes, enter 1 __
  3. 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?
    No___ If Yes, enter 1 __
  4. 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 didn’t look out for each other, feel close to each other, or support each other?
    No___ If Yes, enter 1 __
  5. Did you often or very often feel that … You didn’t 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?
    No___ If Yes, enter 1 __
  6. Were your parents ever separated or divorced?
    No___ If Yes, enter 1 __
  7. 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?
    No___ If Yes, enter 1 __
  8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
    No___ If Yes, enter 1 __
  9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
    No___ If Yes, enter 1 __
  10. Did a household member go to prison?
    No___ If Yes, enter 1 __

Now add up your “Yes” answers: This is your ACE Score

The 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:

  • Childhood trauma was very common, even in employed white middle-class, college-educated people with great health insurance;
  • There was a direct link between childhood trauma and adult onset of chronic disease, as well as depression, suicide, being violent and a victim of violence;
  • More types of trauma increased the risk of health, social and emotional problems.
  • People usually experience more than one type of trauma – rarely is it only sex abuse or only verbal abuse.

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 CDC’s ACE Study.