What Are Adverse Childhood Experiences (ACEs)?

You might have heard the acronym ACEs — perhaps in relation to knowing one’s ACE score. ACEs stands for adverse childhood experiences. The term comes from a landmark study about the relationship between difficult childhood experiences and one’s risk for long-term health conditions. While it’s important to understand what ACEs can tell us about how trauma affects the mind and body over time, it’s just as important to understand the limits of the ACEs framework, and what knowing your own ACE score can and can’t tell you about your health.

The 1998 Adverse Childhood Experiences (ACE) Study made a direct connection between childhood trauma and long-term health problems — at a time when researchers were still grappling with evidence that a person’s psychological state had any relationship to their physical health. It found a significant link between childhood abuse and neglect and adult risk for a wide range of negative mental, physical, and behavioral health outcomes. The list included anxiety, depression, substance use disorders, heart disease, diabetes, cancer, and suicide. Subsequent studies have identified other risks, ranging from asthma to behavior such as bullying and intimate partner violence.

In the pioneering 1998 study, researchers asked more than 17,000 adults about seven specific ACEs that may have happened to them between the ages of 0 and 17. Today, the standard screener includes 10 ACEs, which fall into three categories:

Abuse

• Physical abuse includes an adult in the household pushing, grabbing, hitting, or throwing something at the child.
• Emotional abuse includes an adult in the household swearing at, insulting, humiliating, or physically intimidating the child.
• Sexual abuse includes any adult or older person touching, fondling, or engaging in a sexual act with the child.

Neglect

• Physical neglect is defined as a caregiver’s failure to meet the child’s basic physical needs, including adequate food, clean clothing, medical care, or consistent supervision — despite an ability to do so.
• Emotional neglect is most often defined as a caregiver’s failure to meet the child’s emotional needs. To a child, it might be experienced as consistently feeling unloved, unimportant, or not worthy of affection.

Household dysfunction

• Having a caregiver or household member who has substance use problems
• Having a caregiver of household member who struggles with mental health problems or tries to kill themselves
• Losing a parent though abandonment or divorce
• Witnessing violence at home
• Having a caregiver or household member go to prison

The original ACEs study yielded a several important insights that have informed decades of research and public policy.

The study found that experiences of childhood abuse, maltreatment, and adversity were not as rare as people had believed. This remains the case. According to the CDC’s 2023 Youth Risk Behavior Survey, three in four high school students reported experiencing one or more ACE, while one in five experienced four or more ACEs.

More recent research provides an important caveat: ACEs are common but not evenly distributed within the population. Women are more likely than men to experience four or more ACEs, as are certain sociodemographic groups.

Experts point out that the adult participants in the original study were a fairly homogenous population — predominantly white and middle-class — and they all had health insurance because the sample was drawn through a health insurance company. So, many have proposed expanding the standard ACE questionnaire to measure systemic and environmental factors, including racism, community violence, peer victimization, and poverty. While some individual screeners do include other questions in these areas, no expanded version has been universally adopted.

The original ACEs study also found that most of the people who had experienced an ACE or ACEs in one category had also experienced an ACE in at least one other category. This might look like someone who experienced physical abuse and also had a parent with a substance use problem or someone who witnessed domestic violence and had a parent who was incarcerated. ACEs often co-occur and actually amplify one another in terms of long-term risk, which leads to the third most important takeaway.

The ACEs study found that the more ACEs a person had, the greater their risk for a wide range of negative health outcomes in adulthood. To demonstrate this dose-response relationship — more ACEs, more risk — the study’s researchers developed the ACE score.

The ACE score is pretty straightforward. Each adverse childhood experience counts as one point, and the more points you accrue, the higher your risk. You can see what a standard ACE questionnaire looks like here.

But knowing your own ACE score isn’t actually very useful, because people experience — and are affected by — upsetting events differently. “Just because someone has an ACE doesn’t mean they’re going to develop a medical or psychiatric condition,” says Megan Ice, PhD, a psychologist at the Child Mind Institute. ACEs are more helpful in identifying what populations would benefit the most from resources to support families and children.

ACEs measure potential risk; they do not determine fate. But for those who may be concerned about a high score — or conversely, feeling like a low score doesn’t match their experience — consider a few factors that the ACE framework doesn’t take into account.

The ACE framework does not account for the frequency or intensity of an experience — for example, being physically abused a few times over a short period or regularly, with escalating violence, for many years, count the same. A therapist might approach these experiences differently, but an ACE score obscures any distinction.

Dr. Ice also observes that ACE scores don’t capture the response that a child received at the time. For example, a sexual assault survivor who reports abuse and is not believed, or one parent minimizing or ignoring another parent’s substance use problem. The response to an adverse experience can play a significant role in how it affects the child in the long term.

A child’s ability to cope with adversity is shaped by what are called protective factors. These may include a supportive caregiver, feeling like they are safe and loved, or a strong community. Protective factors help kids process stress and recover from upsetting experiences, and the ACE score does not take them into account. Researchers have developed a complementary framework to identify and nurture protective factors, though it is not yet widely used.

Having one or multiple ACEs doesn’t mean you or your child require treatment, but if you have concerns, a clinician can offer a diagnostic evaluation to find out what kind of treatment might be appropriate. Trauma treatment, for instance, often focuses on managing behavior and learning better ways of coping with emotions and stress.

Extremely upsetting experiences in childhood can affect the way your body handles stress on a biological level. For example, you might always feel like you’re on high alert, even when there is no immediate threat. “The chronic stress your body experienced resulted in it producing different chemicals in different amounts than other people’s, and that puts you at elevated risk for different health issues,” Dr. Ice explains, referring to the health conditions identified in ACEs research.

Some therapies that can help include trauma-focused cognitive behavioral therapy (TF-CBT) and EMDR therapy.

“I feel like a lot of kids who have a parent who’s incarcerated or a parent who has used substances might see a study like this and think, ‘I’m doomed,’” Dr. Ice observes. “And I would want to make sure that they know it doesn’t mean that they’re going to have all these medical problems. I want them to know that this is a factor to think about, but you choose your own future and there’s still lots of hope that you will be able to live a long, healthy life.”