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Adverse childhood experiences
Traumatic events that occur during childhood From Wikipedia, the free encyclopedia
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Adverse childhood experiences (ACEs) are traumatic and stressful events that occur to a child before the age of 18. Broadly defined these events are organized into three clusters abuse (emotional, physical, or sexual abuse), household challenges (violence against women, substance abuse, mental illness, incarceration, or divorce), and neglect (emotional, or physical). The topic was raised as an important emerging public health issue and framework following the publication of the Adverse Childhood Experiences Study in 1998 by the CDC and Kaiser Permanente. The study found a strong dose-response pattern between ACEs and numerous health related outcomes.
 | The examples and perspective in this deal primarily with the United States and do not represent a worldwide view of the subject. (August 2025) |
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Definition and types
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Perspective
Starting from the first published examination of ACEs Dr.Felitti and their team isolated ten specific types of adverse experiences linked to negative life outcomes.[1] This study involved over 17,000 people from southern California.[1][2] The authors found that more than half of the participants had reported at least one ACE, a quarter had reported at least two ACEs.[1] The authors found a dose-response pattern in their study where people with four or more ACEs were 4-12 times more likely to have health risks for alcoholism, drug abuse, depression, or attempted suicide.[1] This extended to health behaviors as well with the same group showing an increased risk in tobacco use, and number of sexual partners.[1][3] Felitti and colleagues found that these ACEs often co-occur, as someone experiences one type of ACE they are more likely to also experience another ACE in life.[4][5][6] The original ACEs framework was grouped into three domains: abuse, neglect, and household dysfunction.[1][7] Since the publication of this article the definition of what an ACE is has expanded as scholarship on the topic has grown.[8][9][10]
The Original ACEs Framework
Abuse
Neglect
Household Dysfunction
- Witnessing Violence Against Women: Observing a woman in the family being treated violently.[1][16]
- Household Substance Use: Living with a household member who has a substance use disorder.[1][17]
- Household Mental Illness: Living with a household member who is mentally ill.[1][18]
- Parental Separation or Divorce: Experiencing the separation or divorce of parents.[1][19]
- Incarcerated Household Member: Having a household member serve time in jail or prison.[1][20]
Community-Level ACEs
Exposure to ACEs doesn't end within the home, they can also expand outside of the home and into the wider community.[21][22][23] This can include
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Prevalence
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Perspective
Number of ACEs
- Zero (39.9%)
- One (22.4%)
- Two (13.0%)
- Three (8.70%)
- Four+ (16.1%)
Research published since the original ACE study has shown that ACEs are a common feature across the world with estimates that 60% of adults worldwide report experiencing at least one ACE during childhood, and 16% reporting four or more ACEs.[35] Individual ACEs vary in prevalence globally with emotional neglect being the most common, followed by physical abuse.[35] This prevalence and reporting vary significantly across populations and geographies.[36][37] Western countries report higher levels of ACE prevalence than Asian countries.[38] But with approximately 90% of published ACE studies focused on populations in North America and Europe,[39] this creates a gap in our tracking of adversity in other countries.[39]
Gender
Women have a higher prevalence of ACEs compared to men,[40] and with varying ACE types based on gender.[1] Using Behavioral Risk Factor Surveillance System (BRFSS) data 19.2% of women in the US report an ACE score of four or more compared to 15.2% of men.[41] Men and women reported similar prevalences for each ACE, with the exception of sexual abuse (17.7% for women and 7.0% for men), physical abuse (22.7% for women and 24.0% for men),and, living with a mentally ill household member (19.9% for women and 14.4% for men).[41] Gender minorities such as transgender and non-binary peoples also report being exposed to more ACEs than cisgendered people.[42][43]
10
20
30
40
Emotional Abuse
Physical Abuse
Sexual Abuse
Witnessed IPA
Household Substance Use
Household mental illness
Divorce
Incarcerated household member
- Women
- Men
Sexuality
Sexual minority individuals have a higher prevalence of ACEs compared to heterosexual children.[44][45][46] According to BRFSS data sexual minorities were more than twice as likely to report abuse,[47] with bisexuals reporting the highest number of ACEs.[48] This prevalence is slowly retreating with younger queer peoples experiencing fewer ACEs than previous generations,[49] this should be tempered as ACEs are associated with early death.[50] But rates among queer people of color are still some of the highest across all demographic groups,[51] particularly among bisexual men and women of color.[43]
Socioeconomic Status
ACEs are correlated with lower socioeconomic status.[52][53] Adults with lower educational attainment and lower household incomes report significantly higher rates of multiple ACEs.[54] According to the CDC 24.1% of adults with a household income below $15,000 reported four or more ACEs, compared to less than 15% for higher income brackets.[41]
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Health outcomes
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Perspective
Childhood
The prevalence of ACEs in younger children is common, with about 40% of children having at least one ACE and 15% having four or more ACEs.[35][55] Research on ACEs has shown that children who experience ACEs are more likely than their similar-aged peers to experience challenges in their biological, emotional, social, and cognitive functioning.[56] Also, children who have experienced an ACE are at higher risk of being re-traumatized or suffering multiple ACEs.[57] The amount and types of ACEs can cause significant negative impacts and increase the risk of internalizing and externalizing in children.[58][59][60] Additionally behavioral challenges can arise in children who have been exposed to ACEs including juvenile recidivism,[61] reduced resiliency,[62] and lower academic performance.[63][64]
Adulthood
Adults with ACE exposure report having worse mental and physical health, more serious symptoms related to illnesses, and poorer life outcomes.[65][66] Across numerous studies these effects go beyond behavioral and medical issues, and include changes in gene expression,[66] higher levels of stress hormones,[67] and reduced immune function.[68] Due to many of the early life stressors caused by exposure to ACEs there are noted changes to the body in people with ACE exposures compared to people with little to no ACE exposure.[69] This is most evident in structural changes in the brain[70] with the hippocampus,[71][72] the amygdala,[73] and the corpus callosum.[71] These areas of the brain are more vulnerable than others due to the higher density of glucocorticoid receptors in these regions of the brain.[74][75] Multiple effects have been noted including diminished thickness,[76] reduced size,[77] and reduced size of connective networks in the brain.[78]
Physical health
ACEs have been linked to numerous negative health and lifestyle issues into adulthood across multiple countries and regions including the United States,[79] the European Union,[80] South Africa,[81] and Asia.[82] Across all these groups researchers have reported seeing the adoption of higher rates of unhealthy lifestyle behavior including sexual risk taking,[83] smoking,[84] heavy drinking,[85] and obesity.[86][87] The associations between these lifestyle issues and ACEs shows a dose response relationship with people having four or more ACEs tend to have significantly more of these lifestyle problems.[88][89] Two studies that also showed a dose-response relationship between ACEs and alcoholism found that individuals who had witnessed household substance abuse were more likely to abuse alcohol, regardless of ACE score.[90][91]
Physical health problems arise in people with ACEs with a similar dose response relationship.[83] Chronic illnesses such as asthma,[92] arthritis,[83] cardiovascular disease,[93] cancer,[94] diabetes,[95] stroke,[96] and migraines[97] show increased symptom severity in step with exposure to ACEs.[83]
Research shows that substance abuse is not an inevitable outcome of ACEs.[98] Adoption of health-risky behaviors may be influenced by genetics and environmental factors.[98]
Mental health
The link between mental health and childhood trauma and ACEs has been well known with multiple studies highlighting this link.[59][102] Multiple mental health conditions found to have a dose response relationship with symptom severity and prevalence including depression,[103][104] attention-deficit/hyperactivity disorder,[105][106] anxiety[107][108] suicidality,[109] bipolar disorder and schizophrenia.[110]
Depressive symptoms in adulthood show one of the strongest dose response relationships with ACEs.[103][111][112] This relationship holds across ages, gender, and with different types of depression including postpartum depression.[113][114][115]
Research has also demonstrated that ACE scores are related to increased rates and severity of psychiatric and mental disorders, as well as higher rates of prescription psychotropic medication use[116] and higher rates of substance abuse/addiction.[117]
Special populations
Additionally, epigenetic transmission may occur due to stress during pregnancy or during interactions between mother and newborns. Maternal stress, depression, and exposure to partner violence have all been shown to have epigenetic effects on infants.[121][122]
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Implementing practices
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Perspective
Globally knowledge about the prevalence and consequences of adverse childhood experiences has shifted policy makers and mental health practitioners towards increasing, trauma-informed and resilience-building practices.[123][124][125] This work has been over 20 years in the making, bringing together research that is implemented in communities, education settings,[126] public health departments, social services, faith-based organizations and criminal justice.[127][128]
Communities
As knowledge about the prevalence and consequences of ACEs increases, more communities seek to integrate trauma-informed and resilience-building practices into their agencies and systems.[129][130]
Indigenous populations show similar patterns of mental and physical health challenges as other minority groups.[131] Interventions have been developed in American Indian tribal communities and have demonstrated that social support and cultural involvement can ameliorate the negative physical health effects of ACEs.[132]
Education
ACEs exposure is widespread globally, one study from the National Survey of Children's Health in the United States reported that approximately 68% of children 0–17 years old had experienced one or more ACEs.[133] The impact of ACEs on children can manifest in difficulties focusing, self regulating, trusting others, and can lead to negative cognitive effects. One study found that a child with 4 or more ACEs was 32 times more likely to be labeled with a behavioral or cognitive problem than a child with no ACEs.[134]
Trauma-informed education refers to the specific use of knowledge about trauma and its expression to modify support for children to improve their developmental success.[135] The National Child Traumatic Stress Network (NCTSN) describes a trauma-informed school system as a place where school community members work to provide trauma awareness, knowledge and skills to respond to potentially negative outcomes following traumatic stress.[136] The NCTSN published a study that discussed the Attachment, Self-Regulation, and Competency (ARC) model, which other researchers have based their subsequent studies of trauma-informed education practices off of.[134][137]
Social services
Social service providers—including welfare systems, housing authorities, homeless shelters, and domestic violence centers – are adopting trauma-informed approaches that help to prevent ACEs or minimize their impact. Utilizing tools that screen for trauma can help a social service worker direct their clients to interventions that meet their specific needs.[138]
Housing authorities are also becoming trauma-informed. Supportive housing can sometimes recreate control and power dynamics associated with clients' early trauma. This can be reduced through trauma-informed practices, such as training staff to be respectful of clients' space by scheduling appointments and not letting themselves into clients' private spaces, and also understanding that an aggressive response may be trauma-related coping strategies.[139]
A study in the UK looked at the views of young people exposed to ACEs on what support they needed from social services. The study grouped the findings into three categories: emotional support, practical support and service delivery. Emotional support included interacting with other young people for support and a sense solidarity, and supportive relationships with adults that are based on empathy, active listening and non-judgement. Practical support meant information about the available services, practical advice about everyday challenges and respite from these challenges through recreation. Young people expected service delivery to be continuous and dependable, and they needed flexibility and control over the support processes.[140][141] The needs of young people with ACEs were found not to match the types of support they are offered.[142]
Health care services
Screening for or talking about ACEs with parents and children can help to foster healthy physical and psychological development and can help doctors understand the circumstances that children and their parents are facing. By screening for ACEs in children, pediatric doctors and nurses can better understand behavioral problems. Some doctors have questioned whether some behaviors resulting in attention deficit hyperactivity disorder (ADHD) diagnoses are in fact reactions to trauma. Children who have experienced four or more ACEs are three times as likely to take ADHD medication when compared with children with less than four ACEs.[143] Screening parents for their ACEs allows doctors to provide the appropriate support to parents who have experienced trauma, helping them to build resilience, foster attachment with their children, and prevent a family cycle of ACEs.[144][145]
For people whose adverse childhood experiences were of abuse or neglect cognitive behavioural therapy has been studied and shown to be effective.[146]
Public health
Objections to screening for ACEs include the lack of randomized controlled trials that show that such measures can be used to actually improve health outcomes, the scale collapses items and has limited item coverage, there are no standard protocols for how to use the information gathered, and that revisiting negative childhood experiences could be emotionally traumatic.[147][148] Other obstacles to adoption include that the technique is not taught in medical schools, is not billable, and the nature of the conversation makes some doctors personally uncomfortable.[147] Some public health centers see ACEs as an important way (especially for mothers and children)[139] to target health interventions for individuals during sensitive periods of development.
Resilience and resources
Resilience is the ability to adapt or cope in the face of significant adversity and threats such as health problems, stress experienced in the workplace or home.[149] Resiliency can mediate the relationship of the effects of ACEs and health problem in adulthood.[150][62] Being able use emotion regulation resources such as cognitive reappraisal and mindfulness people are able to protect themselves from the potential negative effects of stressors. These skills can be taught to people but people living with ACEs score lower on measures of resilience and emotion regulation.[62][151]
Resilience and access to other resources are protective factors against the effects of exposure to ACEs.[132][152][153] Increasing resilience in children can help provide a buffer for those who have been exposed to trauma and have a higher ACE score.[62] People and children who have fostered resiliency have the skills and abilities to embrace behaviors that can foster growth.[154] In childhood, resiliency and attachment security can be fostered from having a caring adult in a child's life.[155][156]
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Adverse Childhood Experiences Study
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Perspective
The Adverse Childhood Experiences Study was a collaborative effort between the US private healthcare organization Kaiser Permanente and the government-run Centers for Disease Control and Prevention to examine the long-term relationship between adverse childhood experiences and a variety of health behaviors and health outcomes in adulthood. An underlying thesis of the ACE Study is that stressful or traumatic childhood experiences have negative neurodevelopmental impacts that persist over the lifespan and increase the risk of a variety of health and social problems.[1]
The ACE Study was based at Kaiser Permanente's San Diego Health Appraisal Clinic, a primary care clinic where each year more than 50,000 adult members of the Kaiser Permanente Health Maintenance Organization receive an annual, standardized, biopsychosocial medical examination.[157] Each member who visits the Health Appraisal Clinic completes a standardized medical questionnaire.[1] The medical history is completed by a health care provider who also performs a general physical examination and reviews laboratory test results with the patient.[1] Appointments for most members are obtained by self-referral with 20% referred by their health care provider.[1]
In the 1980s, the dropout rate of participants at Kaiser Permanente's obesity clinic in San Diego, California, was about 50%; despite all of the dropouts successfully losing weight under the program.[158] Vincent Felitti, head of Kaiser Permanente's Department of Preventive Medicine in San Diego, conducted interviews with people who had left the program, and discovered that a majority of 286 people he interviewed had experienced childhood sexual abuse. The interview findings suggested to Felitti that weight gain might be a coping mechanism for depression, anxiety, and fear.[158]
Felitti and Robert Anda from the Centers for Disease Control and Prevention (CDC) went on to survey childhood trauma experiences of over 17,000 Kaiser Permanente patient volunteers.[158] The 17,337 participants were volunteers from approximately 26,000 consecutive Kaiser Permanente members.[159] Participants were asked about different types of adverse childhood experiences that had been identified in earlier research literature: physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, exposure to domestic violence, household substance abuse, household mental illness, parental separation or divorce, incarcerated household member.[160]
This article incorporates text from this source, which is by David W Brown, Robert F Anda, Vincent J Felitti, Valerie J Edwards, Ann Marie Malarcher, Janet B Croft, and Wayne H Giles available under the CC BY 2.0 license.
Findings
According to the United States' Substance Abuse and Mental Health Services Administration, the ACE study found that:
- Adverse childhood experiences are common. For example, 28% of study participants reported physical abuse and 21% reported sexual abuse. Many also reported experiencing a divorce or parental separation, or having a parent with a mental and/or substance use disorder.[165]
- Adverse childhood experiences often occur together. Almost 40% of the original sample reported two or more ACEs and 12.5% experienced four or more. Because ACEs occur in clusters, many subsequent studies have examined the cumulative effects of ACEs rather than the individual effects of each.[165]
- Adverse childhood experiences have an exponential[166] dose–response relationship with many health problems. As researchers followed participants over time, they discovered that a person's cumulative ACEs score has a strong, graded relationship to numerous health, social, and behavioral problems throughout their lifespan, including substance use disorders. Furthermore, many problems related to ACEs tend to be comorbid, or co-occurring.[165]
About two-thirds of individuals reported at least one adverse childhood experience; 87% of individuals who reported one ACE reported at least one additional ACE.[160] The number of ACEs was strongly associated with adulthood high-risk health behaviors such as smoking, alcohol and drug abuse, promiscuity, and severe obesity,[87] which were correlated with ill health, including depression,[167] heart disease, cancer,[94] chronic lung disease and shortened lifespan.[160][1] [168] Compared to an ACE score of zero, having four adverse childhood experiences was associated with:
- a seven-fold (700%) increase in alcoholism
- an elevenfold (1100%) increase in using drugs
- a twofold (200%) increase in smoking[166]
- a threefold (300%) increase in smoking before the age of 14
- a doubling risk of being diagnosed with cancer
- a four-fold increase in emphysema
- a 3.9-fold (390%) increase in risk of being diagnosed with COPD
An ACE score above six was associated with a 30-fold (3000%) increase in attempted suicide. The study also found that two-thirds of suicide attempts are directly linked to ACEs.[166]
The effects of ACEs on lifestyle problems also depend on the types of ACEs experienced with studies reporting that individuals who experienced household substance abuse during childhood were 3.3 times as likely[169] to abuse substances as adults compared to people with the same ACE score but who did not experience household substance abuse during childhood.[91]
Other studies
One study conducted in the United Kingdom found that having four or more ACEs was associated with a twofold increase in alcoholism.
Subsequent surveys
The ACE Study has produced more than 50 articles that look at the prevalence and consequences of ACEs.[7][170]
The original study questions have been used to develop a 10-item screening questionnaire.[171][172]
The Behavioral Risk Factor Surveillance System (BRFSS) which is run by the CDC,[173] is an annual survey conducted in waves by groups of individual state and territory health departments. An expanded ACE survey instrument was included in several states found each state.[171] Adverse childhood experiences were even more frequent in studies in urban Philadelphia[174] and in a survey of young mothers.[175] Surveys of adverse childhood experiences have been conducted in multiple EU member countries.[83][176]
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ACE Measures
Adverse Childhood Experiences International Questionnaire
A measure created by the World Health Organization, 43-item screening questionnaire[177] intended to measure types of child abuse or trauma; neglect; household dysfunction; peer violence; sexual and emotional abuse, and exposure to community and collective violence.[178][179] ACE-IQ is meant to be administered to people 18 years or older in all countries.[178][179] A majority of study that use this measure are found in Asia or Africa which results in few studies from Europe, the Americas and Oceania.[180]
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See also
References
External links
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