What are ACEs?

Adverse childhood experiences (ACEs) describe a range of traumatic events during childhood that can have far-reaching health consequences later in life. ACEs include abuse, neglect, and other forms of household dysfunction, many of which are depicted in the graphic below (for more information on the effects of the ACE “incarcerated relative” please check out this page). These events have significant impacts on children while growing up, particularly in the form of toxic stress; however, they can also negatively affect a person’s health over the course of a lifetime. ACEs result in changes to brain development, which can cause mental health issues and an increase in risk-taking behaviors. ACEs also increase the risk for chronic diseases such as heart disease, diabetes, and cancer (CDC, 2020). 

How do ACEs relate to public health?

ACEs are connected to many of the ideas central to public health. In particular, they demonstrate how social determinants of health and the social environment translate into tangible health issues. Social determinants of health describe the factors in a person’s environment that shape their behaviors, which can in turn determine health outcomes. In the case of ACEs, social determinants can include material influences such as disposable family income or access to economic opportunities. Economic deprivation and poverty can compound the forms of abuse and neglect that are central to ACEs by adding an additional layer of household stress. Features of the social environment such as access to education and public safety also influence the likelihood of ACEs occurring. Without these forms of social infrastructure the behaviors that cause ACEs may be more permissible and more likely to occur. Further, social norms that tacitly accept violence or conflict in the home are another social determinant that can increase the behaviors that cause ACEs to appear (CDC, 2020).

ACEs also relate closely to the features of the socioecological model of public health. In the socioecological model, prevention strategies are directed at multiple levels: 1) the individual level, 2) the relationship level, 3) the community level, and 4) the societal level. ACEs can be prevented and treated at all four of these levels. Common interventions include trauma-informed care (individual level) and parenting classes (relationship and community levels). Additionally, interventions that expand social infrastructure, such as increasing education spending and providing economic support to families, can potentially operate on the societal level.

Find Your ACE Score

Quiz adapted from NPR, 2015.

Time's up

How to Interpret Your ACE Score

ACEs are very common. In fact, the CDC-Kaiser ACE Study (the first formal study of ACEs) found that 64% of US adults have experienced at least one ACE score, and 12.5% of adults have experienced four or more (CDC, 2020). ACEs are cumulative, meaning that as the number of ACEs increase, the effects from them are likely to be more severe.

Significantly, there are a number of important factors that ACE scores do not incorporate. For one, ACE scores do not take into account measures of resiliency, such as support networks from friends, family members, and mentors, which are vitally important for combatting the long-term impact of ACEs. Additionally, ACE scores do not include information related to genetic factors, such as individual differences in stress response and stress tolerance, as well as other health factors such as diet and family histories of health issues. Finally, ACE scores do not include differences related to discrimination based on race or other marginalized identities, which means that ACE scores may not appropriately reflect the additional stressors introduced by health disparities. Ultimately, ACE scores should not be treated as destiny. In fact, their effects can be significantly lessened through interventions like trauma-informed care (see more on this below) (NPR, 2015; Sacks and Murphey 2018).

How do ACEs affect health?

Toxic stress is the mechanism by which ACEs translate into serious lifelong health issues. ACEs are accompanied by a lack of safety and predictability, which increases stress in children. A certain level of stress is completely normal; however, ACEs can lead to unmitigated stress when there is no support from caring and loving relationships. This continuous stress causes constant activation of stress response systems, which can become toxic and change brain functions. These changes increase the risk for lifelong mental and physical health problems. According to the CDC, 5 of the 10 leading causes of death are correlated with ACE Scores, including chronic diseases like diabetes and cancer. Additionally, the significant impact that ACEs have on brain development can increase the likelihood of risky behaviors, such as unsafe sex, unintended pregnancy, and substance misuse (CDC, 2020).

The ACE pyramid (shown above) illustrates how ACEs translate from factors in the social environment into serious health issues. Initially, historical and intergenerational trauma can be passed on to a child based on their heritage or their location. These factors are especially common for children who belong to groups that have been historically marginalized or have faced systemic discrimination. If the features of the social environment include neglect, abuse, or any other factors that lead to toxic stress ACEs may occur, especially if circumstances make a child at-risk for ACEs. Over time, continuous toxic stress results in significant alterations to brain development that prioritize behaviors that seek to relieve that stress. However, these changes to brain development may also result in greater impulsivity and behaviors with near-term benefit but long-term risk. The adoption of these harmful behaviors creates health risks that can ultimately result in mental health challenges, chronic disease, and various forms of disability, all of which increase the probability of early death (CDC, 2020).

Preventing ACEs and Trauma-Informed Care

Prevention of ACEs is key to reducing these health impacts. The CDC found that implementation of ACE prevention programs could reduce a large number of health conditions. Below are some statistics about how implementing ACE prevention programs could reduce negative health behaviors and health outcomes.

It is important that we interrupt cycles of intergenerational trauma and prevent ACEs before they happen in addition to working with those who have experienced trauma. Here are some examples of local organizations working to prevent ACEs:

• Face2Face provides healthcare and social services to low-income and insecurely housed youth ages 11 to 24 in Ramsey County. Not only do they provide counselling to youth, they also take a prevention approach to their work. For example, they instituted a Teen Boys group that meets weekly for Boys ages 14-17 to discuss male stigma, depression/anxiety and coping skills, mindfulness skills, ACES education, relationship issues, and peer support. 
• The Native American Community Clinic provides healthcare services for Native American families in the Twin Cities. They are especially working to address healthcare disparities in behavioral health for Native Americans, providing counseling, group and family therapy, and treatment for depression, PTSD and substance abuse disorder. They are working to break the intergenerational cycle of ACEs in this high risk group as well as provide care for those who have experienced ACEs and trauma.

It is also important to provide Trauma-informed, Resilience-oriented care to those who have experienced ACEs or trauma. Trauma-informed care encourages providers to look at the patient and their past experiences with trauma holistically. It shifts the provider’s focus from “What’s wrong with you?” to “What happened to you?” and “What’s strong with you?” (National Center for Behavioral Health, 2021). One organization that is working to advance the field of Trauma-informed, Resilience-oriented care is the National Council for Behavioral Health. They empower healthcare organizations to sustainably implement evidence based best practices of trauma informed care.  

ACEs and Health Equity

ACEs disproportionately affect black and hispanic children. The percentage of children experiencing ACEs also varies by state. States with the highest prevalence of ACEs include Arizona, Arkansas, Montana, New Mexico, and Ohio, all with rates significantly higher than the national average (Sacks and Murphey 2018).

When discussing ACEs, it’s also important to consider who was not represented in the original ACE study which created the ACE questionnaire and collected much of the ACE data that is used today. Groups who were largely excluded include: 

• African Americans
• Latinx community
• Asian/Pacific Islanders
• Native Americans
• Immigrants
• Medicaid recipients
• People who are uninsured
• People experiencing homelessness
• Children

Lack of representation in the original ACE study has led to gaps in how we assess and treat ACEs. For example, community trauma – including exposure to firearm violence, occurrence of natural disasters, and concentrated poverty –  is a type of ACE which isn’t included on the questionnaire. Likewise, institutionalized and internalized racism can lead to ACEs and impact well-being (White 2018). Below are quotes from Dr. Flojaune Cofer, the state and research policy director for Public Health Advocates in California. These quotes provide some context about how our understanding of ACEs can change depending on the communities we are working with.

Thomas Gatewood and Lora Randa, February 2021.