Adverse Childhood 

Experiences and the

Role of Substance 

Misuse Prevention

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Contents

What are Adverse Childhood Experiences (ACEs)? ........................3

The Scope of ACEs.......................................................................................4

Types of ACEs.................................................................................................5

What are Protective and Compensatory 

Childhood Experiences (PACEs)? ...........................................................6

Types of PACEs..............................................................................................7

The Impact of ACEs......................................................................................8

Disparities within ACEs............................................................................10

ACEs and Toxic Stress .............................................................................12

What Substance Use Prevention 

Can Do to Address ACEs ........................................................................14

Endnotes........................................................................................................16

2

BACK TO 

BEGINNING
What are Adverse 

Childhood Experiences?

Adverse childhood experiences (ACEs) are stressful 

or traumatic events that occur between the ages of 0 

and 17.1 ACEs can undermine a child’s sense of safety, 

stability, and bonding, and can have effects that persist 

for years.2

ACEs are strongly associated with a wide range of health 

problems that can persist throughout a person’s lifespan, 

including an increased risk of substance misuse, serious 

emotional disturbances, and mental health disorders. The 

more ACEs a person has, the greater the risk for negative 

outcomes. In addition, epigenics research shows that the 

trauma associated with ACEs can be passed down from 

generation to generation. For these reasons, addressing 

ACEs is critical to developing healthier people and 

stronger communities.

The substance use prevention field can play a vital role in 

helping to address the risk factors and prevent the harms 

associated with ACEs and provide support for building 

protective factors against these harmful experiences. 

3
The Scope 

of ACEs

45%

of children experience 

at least one ACE.3

61%

of adults experience 

at least one ACE in 

their lifetime.3 4

1in 6

adults (16%) report 

experiencing 4+ ACEs 

in their lifetime.5 6

1/4

The most common ACEs 

are parental separation 

and economic hardship, 

with 1/4 of children 

experiencing at least one 

of these events.7 8

4+

ACES

Females and racial/ethnic 

minorities are at greater risk 

for experiencing 4+ ACEs.9 10

5 OF THE

TOP10

leading causes of 

death relate to ACEs.11

4
Types of ACEs12 13 14

• ABUSE: Physical, Emotional, Sexual

• NEGLECT: Physical, Emotional

• HOUSEHOLD DYSFUNCTION:

Mental illness, Interpersonal or family 

violence, Incarcerated relative, Divorce, 

Substance misuse

• COMMUNITY AND ENVIRONMENTAL:

Racism, Bullying, Discrimination, Poverty 

or homelessness, Community violence, 

Living in foster care, Experiences of being 

an immigrant, Involvement with the criminal 

justice system, Witnessing or experiencing 

acts of terrorism, Attending a school that 

enforces a zero-tolerance discipline policy, 

Natural disasters

ACEs can be prevented. People who have 

these experiences can also build resiliency, 

heal their trauma, and work towards recovery.1516

Because ACEs are common and strongly related 

to many substance use and behavioral health 

outcomes, identifying and reducing the trauma 

of ACEs can have a significant impact on people’s 

social, emotional, and physical wellbeing, and on 

their economic security. 

5

Physical

Emotional

Sexual Physical

Emotional

Mental

Illness

Incarcerated

Relative

Interpersonal

Violence

Substance

Misuse

Divorce

HOU SE HOL D DYSF U NCT ION

A B U SE

N E G LE CT

COMMUNIT Y AND ENVIRONMENTAL

Livin

g in

Foster

Care

Bullying

Community

Viole

n

c

e

Neighborhood Safety

Racism

ACEs 
What are Protective 

and Compensatory 

Childhood Experiences?

Protective and compensatory childhood experiences 

(PACEs) are positive experiences during childhood 

that can lessen the negative effects of ACEs. PACEs 

protect against harm, including mental or physical 

illness. Research shows that adults with many PACEs are 

healthier—physically, mentally, and emotionally—than 

adults with fewer PACEs, regardless of their ACEs. PACEs 

also buffer against intergenerational transmission of 

ACEs.17 18 19 20 21

6
Types of PACEs22

• SUPPORTIVE RELATIONSHIPS:

Unconditional love from a caregiver or parent, 

Having or spending time with a best friend, 

Volunteering in the community or helping 

others, Being part of a social group, Having a 

mentor outside of the family

• ENRICHING RESOURCES: 

Living in a safe home where needs are met, 

Quality education, Having a hobby, Physical 

activity, Fair rules and routines at home

7
The Impact of ACEs23 24 25 26

ACEs can increase the risk for disease and early death, as well 

as affect a person’s ability to thrive socially and economically. 

CHRONIC 

HEALTH 

CONDITIONS:

Coronary heart 

disease, Stroke, 

Asthma, Chronic 

obstructive 

pulmonary disease, 

Cancer, Kidney 

disease, Diabetes, 

Obesity, Stroke, 

Broken bones

MENTAL HEALTH 

CONDITIONS: 

Depression and 

suicidal thoughts or 

behaviors

HEALTH RISK 

BEHAVIORS: 

Smoking, 

Heavy drinking 

or alcoholism, 

Unprotected sex, 

Lack of physical 

activity

ANTI-SOCIAL 

BEHAVIOR: 

Future violence 

victimization or 

perpetration, 

Difficulty forming 

healthy and stable 

relationships

ECONOMIC 

ROADBLOCKS:

Lower graduation 

rates and academic 

achievement, 

Missing work, 

Financial struggles, 

Unemployment

8
People with 4 or 

more ACEs are:27 28

12x more at risk for suicide

7x more likely to 

develop alcoholism

4x more likely to develop 

depression

2-4x higher risk of using 

alcohol or other drugs

2-4x more likely to begin substance 

use at a young age

2x higher rate of heart 

disease or lung cancer

People with 5 or 

more ACEs are:29 30

7-10x more likely to use 

illicit substances

7-10x greater risk for illicit 

substance use addiction

7-10x more likely to inject illicit 

substances

3x higher risk for misuse 

of prescription pain 

medications

9
Disparities within ACEs

Some children are affected disproportionately by ACEs 

due to the social, structural, and political contexts in which 

they grow up. For example, discriminatory practices and 

behaviors lead to undue stress on families of color raising 

young children. 

Decades of research on 

ACEs has shown that:

• Lower socioeconomic status increases the 

probability of experiencing an ACE, as well as 

having a higher number of ACEs.

• Gay and bisexual individuals experience a higher 

number of ACEs compared to heterosexual individuals.31

• Women are more likely than men to report higher 

numbers of ACEs.32

• Children who experience one ACE face an increased 

risk of experiencing other ACEs.33

10
ACEs are more prevalent among 

racial or ethnic minority groups

11

61%

of non-Hispanic 

Black children

EXPERIENCE 

AT LEAST 

ONE ACE 

COMPARED TO

23%

of non-Hispanic 

Asian children.34 35 36

Other variables can also further influence the effects of 

ACEs. For instance, White children generally have fewer 

ACEs than other children. However, White children who are 

economically disadvantaged report more ACEs than Black 

or Hispanic children from the same economic group.37

There are also disparities in what kinds of ACEs people can 

experience. Women report more experiences with emotional 

abuse, childhood sexual abuse, and living in a household 

with a family member who had a mental health or substance 

use issue compared to men. Conversely, men report 

experiencing more bullying and community violence.38

51%

of Hispanic 

children

40%

of non-Hispanic 

White children

EXPERIENCE 

AT LEAST 

ONE ACE 

COMPARED TO

} }

} }
1

POSITIVE 

Normal brief 

physical response 

to a tense situation 

or event, such as 

job interviews or 

taking a test

2

TOLERABLE

Stress response 

to a long lasting or 

severe situation 

or event, such as 

loss of a loved one 

or caring for a sick 

family member

3

TOXIC

Extended or 

excessive stress 

response to 

frequent and 

intense situations 

or events, such as 

prolonged abuse 

or witnessing 

domestic violence

ACEs and Toxic Stress

Not all stress is harmful. In fact, most people experience 

some stress or adversity in their lives, and these 

experiences can actually help build healthy coping 

strategies. But the ongoing and repeated stressors that 

occur because of ACEs are not productive, and often lead 

to the development of toxic stress.39 Toxic stress can deeply 

damage a person’s body and brain. This risk is particularly 

acute for children, who are undergoing a critical time in their 

growth and development.40 41 42 A buildup of toxic stress can 

lead to or worsen the negative consequences associated 

with ACEs. Children who experience many ACEs are more 

likely to develop toxic stress.43 44 45

The Three Types of Stress46

12
Sustained activation of the body’s stress response can 

negatively affect those areas of the brain that govern 

how people make decisions, process information, and 

regulate emotions.47 Toxic stress can lead to negative 

genetic changes, which can be another source of 

intergenerational transmission of ACEs.48

Toxic Stress and the Brain49 50

• STRESS PATHWAYS: Anxiety, depression, 

and impaired learning and memory

• CONNECTIVITY: Difficulty understanding the 

significance of situations and determining the 

appropriate response

• EMOTIONAL PROCESSING AND REGULATION: 

Hypervigilance and reduced ability to pay attention

• REWARD MECHANISMS: Damaged pleasure and 

rewards center can lead to difficulty experiencing joy

• DISINHIBITION: Difficulty with impulse control 

13
What Substance Use 

Prevention Can Do to

Address ACEs

Substance use prevention professionals can support 

efforts to minimize ACEs and promote PACEs by selecting 

and implementing best-fit, evidence-based, and scalable 

programs and policies that affect adverse childhood 

experiences.51 52 These include efforts to strengthen 

economic supports, develop healthy skills, and engage 

youth in the community. Additional information is 

available through the Substance Abuse and Mental 

Health Services Administration.

A comprehensive strategic planning process, such 

as SAMHSA’s Strategic Prevention Framework (SPF), 

can aid in these efforts. The SPF’s five steps support 

the identification and implementation of appropriate 

strategies that address substance use risk and protective 

factors, including ACEs and PACEs. When engaging 

in strategic planning, prevention professionals should 

also take steps to incorporate cultural competency and 

humility into their work. Through these efforts, prevention 

professionals can better address disparities and advance 

health equity by understanding and honoring the 

contexts within which they are working.53 54

14
Incorporating ACEs and PACEs Into the SPF

ASSESSMENT

Collect state- and 

local-level data on 

ACEs and PACEs 

to inform decisionmaking. 

Expand data 

collection 

instruments to 

include ACEs and 

PACEs indicators.

Use ACEs data to 

identify populations 

at higher risk for 

substance use 

disorders and 

potentially in need of 

prevention services.

CAPACITY

Increase awareness 

of ACEs and PACEs 

among stateand communitylevel prevention 

professionals.

Emphasize the 

relevance of ACEs 

and PACEs among 

behavioral health 

partners.

PLANNING

Include ACEs and 

PACEs among the 

primary risk and 

protective factors 

considered when 

planning prevention 

efforts.

IMPLEMENTATION

Select and implement 

programs and 

strategies that 

address ACEs 

and encourage 

PACEs, including 

efforts to reduce 

intergenerational 

transmission of ACEs.

EVALUATION

Continuously 

evaluate intervention 

processes and 

outcomes and refine 

implementation to 

better address ACEs 

and sustain PACEs.

Analyze and publish 

findings to build the 

ACEs and PACEs 

research base.

15
Endnotes

1 Centers for Disease Control and Prevention (2019). Preventing 

Adverse Childhood Experiences: Leveraging the Best Available 

Evidence. Atlanta, GA: National Center for Injury Prevention and 

Control, Centers for Disease Control and Prevention

2 Centers for Disease Control and Prevention. Fast Facts: Preventing Adverse Childhood Experiences. 2022. https://www.cdc.gov/

violenceprevention/aces/fastfact.html

3 Wu, S., Lindstrom Johnson, S., Wolfersteig, W. et al. The power 

of local research to inform adverse childhood experiences in 

substance use prevention in adolescents and adults. BMC Public 

Health 22, 1197 (2022). https://doi.org/10.1186/s12889-022-

13503-3

4 Centers for Disease Control and Prevention. Fast Facts: Preventing Adverse Childhood Experiences. 2022. https://www.cdc.gov/

violenceprevention/aces/fastfact.html

5 Centers for Disease Control: Vital Signs. 2019. Adverse Childhood Experiences (ACEs). Preventing Early Trauma to Improve 

Adult Health. https://www.cdc.gov/vitalsigns/aces/pdf/vs-1105-

aces-H.pdf

6 Centers for Disease Control: Vital Signs. 2019. Adverse Childhood Experiences (ACEs). Preventing Early Trauma to Improve 

Adult Health. https://www.cdc.gov/vitalsigns/aces/pdf/vs-1105-

aces-H.pdf

7 National Conference of State Legislatures. Adverse Childhood 

Experiences. 2022. https://www.ncsl.org/health/adverse-childhood-experiences

8 Sacks, V. & Murphey, D. 2018. The Prevalence of Adverse Childhood Experiences, Nationally, by State, and by Race or Ethnicity. 

Child Trends. https://www.childtrends.org/publications/prevalence-adverse-childhood-experiences-nationally-state-race-ethnicity#

9 Centers for Disease Control and Prevention. Fast Facts: Preventing Adverse Childhood Experiences. 2022. https://www.cdc.gov/

violenceprevention/aces/fastfact.html

10 Centers for Disease Control and Prevention: Vital Signs. 2019. 

Adverse Childhood Experiences (ACEs). Preventing Early Trauma 

to Improve Adult Health. https://www.cdc.gov/vitalsigns/aces/pdf/

vs-1105-aces-H.pdf

11 Centers for Disease Control and Prevention: Vital Signs. 2019. 

Adverse Childhood Experiences (ACEs). Preventing Early Trauma 

to Improve Adult Health. https://www.cdc.gov/vitalsigns/aces/pdf/

vs-1105-aces-H.pdf

12 Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., 

Edwards, V., & Koss, M. P. (1998) Relationship of childhood abuse 

and household dysfunction to many of the leading causes of 

death in adults: The Adverse Childhood Experiences (ACE) Study. 

American journal of Preventive Medicine 14(4), 245-258

13 Public Health Management Corporation. (2013). Findings from 

the Philadelphia Urban ACE Survey. https://www.philadelphiaaces.org/philadelphia-ace-survey

14 PACEs Connection. 3 Realms of ACEs. https://www.pacesconnection.com/ws/Handouts_3RealmsACEs_EN.pdf

15 Centers for Disease Control and Prevention: Vital Signs. 2019. 

Adverse Childhood Experiences (ACEs). Preventing Early Trauma 

to Improve Adult Health. https://www.cdc.gov/vitalsigns/aces/pdf/

vs-1105-aces-H.pdf

16 Centers for Disease Control and Prevention. Adverse Childhood 

Experiences Prevention Strategy. Atlanta, GA: National Center for 

Injury Prevention and Control, Centers for Disease Control and 

Prevention, 2021. https://www.cdc.gov/injury/pdfs/priority/ACEs-Strategic-Plan_Final_508.pdf 

17 Bethell C, Jones J, Gombojav N, Linkenbach J, Sege R. Positive 

Childhood Experiences and Adult Mental and Relational Health 

in a Statewide Sample: Associations Across Adverse Childhood Experiences Levels. JAMA Pediatr. 2019;173(11):e193007. 

doi:10.1001/jamapediatrics.2019.3007

18 Morris, A. S., & Hays-Grudo, J. (2023). Protective and compensatory childhood experiences and their impact on adult mental 

health. World psychiatry : official journal of the World Psychiatric Association (WPA), 22(1), 150–151. https://doi.org/10.1002/

wps.21042

19 Oklahoma Cooperative Extension Service. 2020. PACEs for 

Children: Overcoming Adversity and Building Resilience. 

https://extension.okstate.edu/fact-sheets/print-publications/t/

paces-for-children-overcoming-adversity-and-building-resilience-t-2146.pdf

20 PACEs Connection. 3 Realms of ACEs. https://www.pacesconnection.com/ws/Handouts_3RealmsACEs_EN.pdf

21 Morris, A. S., Hays-Grudo, J., Zapata, M. I., Treat, A., & Kerr, K. 

L. (2021). Adverse and Protective Childhood Experiences and 

Parenting Attitudes: the Role of Cumulative Protection in Understanding Resilience. Adversity and resilience science, 2(3), 

181–192. https://doi.org/10.1007/s42844-021-00036-8

16
22 Morris, A. S., & Hays-Grudo, J. (2023). Protective and compensatory childhood experiences and their impact on adult mental 

health. World psychiatry : official journal of the World Psychiatric Association (WPA), 22(1), 150–151. https://doi.org/10.1002/

wps.21042

23 National Conference of State Legislatures. Adverse Childhood 

Experiences. 2022. https://www.ncsl.org/health/adverse-childhood-experiences

24 Centers for Disease Control and Prevention (2019). Preventing 

Adverse Childhood Experiences: Leveraging the Best Available 

Evidence. Atlanta, GA: National Center for Injury Prevention and 

Control, Centers for Disease Control and Prevention

25 Centers for Disease Control and Prevention. Fast Facts: Preventing Adverse Childhood Experiences. 2022. https://www.cdc.gov/

violenceprevention/aces/fastfact.html

26 Centers for Disease Control. 2020. Behavioral Risk Factor Surveillance System ACE Data. https://www.cdc.gov/violenceprevention/aces/ace-brfss.html

27 Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., 

Edwards, V., & Koss, M. P. (1998) Relationship of childhood abuse 

and household dysfunction to many of the leading causes of 

death in adults: The Adverse Childhood Experiences (ACE) Study. 

American journal of Preventive Medicine 14(4), 245-258

28 PACEs Connection. 3 Realms of ACEs. https://www.pacesconnection.com/ws/Handouts_3RealmsACEs_EN.pdf

29 Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, 

A.M., Edwards, V., & Koss, M. P. (1998) Relationship of childhood 

abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) 

Study. American journal of Preventive Medicine 14(4), 245-258

30 PACEs Connection. 3 Realms of ACEs. https://www.pacesconnection.com/ws/Handouts_3RealmsACEs_EN.pdf

31 Giano, Z., Wheeler, D.L. & Hubach, R.D. The frequencies and disparities of adverse childhood experiences in the U.S. BMC Public 

Health 20, 1327 (2020). https://doi.org/10.1186/s12889-020-

09411-z

32 National Governors Association. 2021. State Actions to Prevent 

and Mitigate Adverse Childhood Experiences. https://www.nga.

org/wp-content/uploads/2021/12/NGA_State_Actions_to_Prevent_Mitigate_ACEs_Dec_2021.pdf

33 Centers for Disease Control and Prevention. Fast Facts: Preventing Adverse Childhood Experiences. 2022. https://www.cdc.gov/

violenceprevention/aces/fastfact.html

34 Mersky JP, Choi C, Plummer Lee C, Janczewski CE. Disparities 

in adverse childhood experiences by race/ethnicity, gender, and 

economic status: Intersectional analysis of a nationally representative sample. Child Abuse Negl. 2021 Jul;117:105066. 

doi: 10.1016/j.chiabu.2021.105066. Epub 2021 Apr 9. PMID: 

33845239.

35 Joshua P. Mersky, Changyong Choi, ChienTi Plummer Lee, 

Colleen E. Janczewski. 2021. Disparities in adverse childhood 

experiences by race/ethnicity, gender, and economic status: Intersectional analysis of a nationally representative sample. Child 

Abuse & Neglect, Volume 117, 105066, ISSN 0145-2134 https://

doi.org/10.1016/j.chiabu.2021.105066

36 Sacks, V. & Murphey, D. 2018. The Prevalence of Adverse Childhood 

Experiences, Nationally, by State, and by Race or Ethnicity. Child 

Trends. https://www.childtrends.org/publications/prevalence-adverse-childhood-experiences-nationally-state-race-ethnicity#

37 Joshua P. Mersky, Changyong Choi, ChienTi Plummer Lee, 

Colleen E. Janczewski. 2021. Disparities in adverse childhood 

experiences by race/ethnicity, gender, and economic status: Intersectional analysis of a nationally representative sample. Child 

Abuse & Neglect, Volume 117, 105066, ISSN 0145-2134 https://

doi.org/10.1016/j.chiabu.2021.105066

38 Joshua P. Mersky, Changyong Choi, ChienTi Plummer Lee, 

Colleen E. Janczewski. 2021. Disparities in adverse childhood 

experiences by race/ethnicity, gender, and economic status: Intersectional analysis of a nationally representative sample. Child 

Abuse & Neglect, Volume 117, 105066, ISSN 0145-2134 https://

doi.org/10.1016/j.chiabu.2021.105066

39 Centers for Disease Control and Prevention. Adverse Childhood 

Experiences Prevention Strategy. Atlanta, GA: National Center for 

Injury Prevention and Control, Centers for Disease Control and 

Prevention, 2021. https://www.cdc.gov/injury/pdfs/priority/ACEs-Strategic-Plan_Final_508.pdf

40 Shonkoff, J. P. & Garner, A.S. (2012). The Lifelong Effects of Early 

Childhood Adversity and Toxic Stress. Pediatrics: Official Journal 

of the American Academy of Pediatrics, 129(1), e232–e246

41 National Conference of State Legislatures. Adverse Childhood 

Experiences. 2022. https://www.ncsl.org/health/adverse-childhood-experiences

17

Endnotes continued
42 McEwen BS. Effects of stress on the developing brain. Cerebrum. 

2011 Sep;2011:14. Epub 2011 Sep 21. PMID: 23447783; PMCID: 

PMC3574783.

43 Centers for Disease Control and Prevention (2019). Preventing 

Adverse Childhood Experiences: Leveraging the Best Available 

Evidence. Atlanta, GA: National Center for Injury Prevention and 

Control, Centers for Disease Control and Prevention

44 Centers for Disease Control and Prevention. Fast Facts: Preventing Adverse Childhood Experiences. 2022. https://www.cdc.gov/

violenceprevention/aces/fastfact.html

45 Center on the Developing Child, Harvard University. ACEs and 

Toxic Stress: Frequently Asked Questions. https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequentlyasked-questions/

46 Shonkoff, Jack P. Andrew S. Garner. “The Lifelong Effects of Early 

Childhood Adversity and Toxic Stress.” Pediatrics: Official Journal 

of the American Academy of Pediatrics. December 26, 2011

47	 Centers for Disease Control and Prevention. Adverse Childhood Experiences Prevention

Strategy. Atlanta, GA: National Center for Injury Prevention and Control, Centers for

Disease Control and Prevention, 2021. https://www.cdc.gov/injury/pdfs/priority/ACEs-Strategic-Plan_Final_508.pdf

48 Shonkoff, J. P. & Garner, A.S. (2012). The Lifelong Effects of Early 

Childhood Adversity and Toxic Stress. Pediatrics: Official Journal 

of the American Academy of Pediatrics, 129(1), e232–e246

49 Shonkoff, Jack P. Andrew S. Garner. The Lifelong Effects of Early 

Childhood Adversity and Toxic Stress. Pediatrics: Official Journal 

of the American Academy of Pediatrics. December 26, 2011

50 Center on the Developing Child, Harvard University. ACEs and 

Toxic Stress: Frequently Asked Questions. https://developingchild.

harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/

51 Shonkoff, Jack P. Andrew S. Garner. The Lifelong Effects of Early 

Childhood Adversity and Toxic Stress. Pediatrics: Official Journal 

of the American Academy of Pediatrics. December 26, 2011

52 Substance Abuse and Mental Health Services Administration: A 

Guide to SAMHSA’s Strategic Prevention Framework. Rockville, 

MD: Center for Substance Abuse Prevention. Substance Abuse 

and Mental Health Services Administration, 2019

Endnotes continued

18
SPTAC is a national training and technical assistance 

system dedicated to advancing the application of culturally 

responsive, evidence-informed substance misuse 

prevention programs guided by SAMHSA’s Strategic 

Prevention Framework.

For more information contact: SPTAC@edc.org