Adverse Childhood Experiences (ACEs Scale)

Adverse Childhood Experiences (ACEs) describe difficult childhood experiences that can negatively impact future health.
ACEs scores are derived from a study by Felitti et al. (1998) in their article Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults.Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (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.  This study surveyed a vast number of children and found there was a significant relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults. They created the ACEs assessment that are given to children prior to their 18th birthday.
The questionnaire is somewhat limited by its short length, its failure to distinguish severity and frequency of adverse events, and its neglect of cultural differences. However, it has sparked important research and conversation about improving wellness.
== Questions ==
The assessment is comprised of 10 questions that are asked in a yes or no answer way. ACEs score is derived by calculating the number of questions a child answers yes to from this questionnaire.https://www.cdc.gov/violenceprevention/aces/index.html 
Below are the administered questions:
# 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? 
# 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? 
# Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touched their body in a sexual way? or Attempt or actually have oral or anal intercourse with you?  
# 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? 
# 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?  
# Was a biological parent ever lost to you through divorced, abandonment, or other reason?  
# 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?  
# Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?  
# Was a household member depressed or mentally ill?  or Did a household member attempt suicide?  
# Did a household member go to prison? 
The ACEs question are broken down into three categories; abuse, neglect, and household dysfunction.https://www.ncsl.org/research/health/adverse-childhood-experiences-aces.aspx   The types of abuse include physical, emotional, and sexual abuse. In addition, neglect is measured as both physical and emotion. Lastly, household dysfunction is described as mental illness in the home, abuse of the mother, an incarcerated family member, substance use, and divorce. 
=== Expanded ACEs ===
A 2019 paper sought to expand the definition of ACEs to cover additional difficult childhood experiences.Karatekin C, Hill M. Expanding the Original Definition of Adverse Childhood Experiences (ACEs). J Child Adolesc Trauma. 2018 Nov 12;12(3):289-306. doi: 10.1007/s40653-018-0237-5. PMID: 32318200; PMCID: PMC7163861. The Philadelphia expanded ACEs scale includes questions on bullying, witnessing violence, neighborhood safety, racism, and living in foster care.The Original ACE Study, National Human Trafficking Training and Technical Assistance CenterPhiladelphia ACE Survey, Philadelphia ACE Project
== Effects of ACEs ==
The ACEs pyramid, as seen in the diagram, represents how negative life experiences in childhood compound the likelihood of additional risk factors in adulthood that lead to early death. This provides a visual representation of how as ACEs build in childhood, the impacts continue to felt throughout the rest of a person's life.
Higher ACEs are linked with higher levels of psychological distress later in life.
== ACEs in different groups ==
In general, a stressed family is more likely to experience crises. The CDC reports demographic, caregiver habits, and community issues associated with a higher risk of ACEs. These include:Risk and Protective Factors, CDC
* Demographics: low income, young/single caregivers, poor caregiver education, disabled child in the family, caregivers who were abused or neglected as children
* Caregiver habits: spanking or other forms of corporal punishment, inconsistent discipline, low levels of supervision, isolation, poor understanding of children's needs, poor communication with children
* Community: high crime rates, low income and opportunities, easy access to drugs and alcohol, food and housing insecurity, few community activities for young people
Similarly, children in stable, supportive families in positive communities are less likely to experience ACEs.
=== Children in foster care ===
Approximately 6% of children in the United States will be involved in one way or another with the foster care system between their birth and their 18th birthday.Turney, K., & Wildeman, C. (2017). Adverse childhood experiences among children placed in and adopted from foster care: Evidence from a nationally representative survey. Child Abuse & Neglect, 64, 117-129. This represents a reasonable portion of children in the United States as well as a particularly vulnerable subset of the population. Research has shown that children in foster care are at a greater risk for ACEs as compared to the general population of children not in foster care. Children in foster care are already at risk of significant trauma and foster care puts them at greater risk of additional ACEs.Bruskas, D., & Tessin, D. H. (2013). Adverse childhood experiences and psychosocial well-being of women who were in foster care as children. The Permanente journal, 17(3), e131–e141.   Furthermore, children with higher ACEs were significantly more likely to experience instability in their placement homes.Liming, K. W., Akin, B., & Brook, J. (2021). Adverse Childhood Experiences and Foster Care Placement Stability. Pediatrics, 148(6), e2021052700. Examples of psychological distress that children in foster care with high ACEs are more susceptible to include behavioral issues and attachment disorders which impact their quality of life.https://txicfw.socialwork.utexas.edu/aces-foster-care-rethinking-trauma-informed-care/ 
Addressing ACEs for children in foster care is an ongoing project. A study by Liming et al. reported that their findings on the negative health consequences based on ACES and instability in foster care can begin to provide the basis for creating legislation and social work guidelines to help protect foster children. Additionally, the Bruskas et al. study asserted that based on their research there needs to be further training and education for social workers to give them the resources to help children in foster care with their complex needs. 
Overall, this population is at a greater need for care, particularly trauma informed care, that is standardized and lawful in order to have a better quality of life after all of the trauma they have endured in childhood. 
=== LGBTQPIA+ Youth ===
Kids in the LGBT+ community are at increased risk for ACEs. One statistic that is particularly jarring is that of the surveyed population 25% of heterosexual children reported 4 or more ACEs whereas 41.6% of LGBT children reported 4 or more ACEs.Adverse Childhood Experiences and LGBTQ Communities (PDF), California LGBTQ Health Further studies have supported this reality that children in the LGBTQPIA+ community are likely to have higher rates of ACEs than heterosexual children.Andersen, J. P., & Blosnich, J. (2013). Disparities in adverse childhood experiences among sexual minority and heterosexual adults: results from a multi-state probability-based sample. PloS one, 8(1), e54691. In a study by Andersen et al. they found that LGBTQPIA children have increased exposure to multiple developmental risk factors like physical abuse, sexual abuse, and emotional abuse which increases their ACEs score.
Furthermore, there is research that shows that LGBTQPIA children showed a greater risk for suicidal behavior.Clements-Nolle, K., Lensch, T., Baxa, A., Gay, C., Larson, S., & Yang, W. (2018). Sexual Identity, Adverse Childhood Experiences, and Suicidal Behaviors. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 62(2), 198–204. They additionally showed a relationship between the number of ACEs and suicidal behaviors.Clements-Nolle, K., Lensch, T., Baxa, A., Gay, C., Larson, S., & Yang, W. (2018). Sexual Identity, Adverse Childhood Experiences, and Suicidal Behaviors. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 62(2), 198–204. All of these studies paint an ugly picture that depicts a disproportionate number of ACEs in the LGBTQPIA community.
Youth in the LGBTQPIA community typically report higher ACE scores and are risk of high rates of poor mental health in adolescences and adulthood.Schnarrs, P. W., Stone, A. L., Salcido, R., Georgiou, C., Zhou, X., & Nemeroff, C. B. (2020). The Moderating Effect of Resilience on the Relationship between Adverse Childhood Experiences (ACEs) and Quality of Physical and Mental Health among Adult Sexual and Gender Minorities. Behavioral medicine (Washington, D.C.), 46(3-4), 366–374. Furthermore, due to the fact that children in the LGBTQPIA community are at a greater risk there needs to be further research conducted into have to address the high ACEs score in order to inform policy and standards of care. One suggestion made in the study by Clements et al. suggests that there is a need from trauma-informed interventions for children in the LGBT community. In addition, the ACEs score is beneficial in informing care providers with a better picture of the the difficulties a a child is experiencing. Lastly, additional recommendation is that care providers give all children in the LBGTQPIA community the ACEs assessment in order to gain a better understanding of the children trauma then be able to create a more individualized treatment plan. The children in the LGBTQPIA community are in need of better care that hopefully future research and policy can help to provide. 
=== Disabled youth ===
Children with developmental disabilities, especially autistic children and those with intellectual disability, are at higher risk of ACEs.Morgart, K., Harrison, J.N., Hoon, A.H., Jr and Wilms Floet, A.M. (2021), Adverse childhood experiences and developmental disabilities: risks, resiliency, and policy. Dev Med Child Neurol, 63: 1149-1154. https://doi.org/10.1111/dmcn.14911Vervoort-Schel, Jessica, et al. Prevalence of and relationship between adverse childhood experiences and family context risk factors among children with intellectual disabilities and borderline intellectual functioning, Research in Developmental Disabilities. So are children with special healthcare needs.Seok, Deborah, Murphey, David, and Abdi, Fadumo. Children with special health care needs are more likely to have adverse childhood experiences, Child Trends
Disabled children may not know how to to identify abuse, defend themselves, or report abuse. They may be isolated, dependent on others, and conditioned to be compliant. Even if they can report it, people may blame them or say that abuse by caregivers is understandable because helping disabled children is stressful. "Diagnostic overshadowing," or people blaming everything on the disability, is another risk.Marcal, Steve. Adverse Childhood Experiences and Developmental Disabilities (PDF), Paces Connection
== Limitations of ACEs ==
The original ACEs study was groundbreaking when it first came out and has been an instrumental first step into understanding childhood trauma. However, it is limited. First, it uses only 10 questions, which limits the scope of information.Anda, R. F., Porter, L. E., & Brown, D. W. (2020). Inside the Adverse Childhood Experience Score: Strengths, Limitations, and Misapplications. American journal of preventive medicine, 59(2), 293–295. Furthermore, the questions are normed based on white, middle-class families, which is not representative of general population.Cronholm, P. F., Forke, C. M., Wade, R., Bair-Merritt, M. H., Davis, M., Harkins-Schwarz, M., Pachter, L. M., & Fein, J. A. (2015). Adverse Childhood Experiences: Expanding the Concept of Adversity. American journal of preventive medicine, 49(3), 354–361. 
The ACEs scale asks simple yes/no questions. It doesn't measure factors like severity, duration, and age(s) at which the events happened. Thus, a child who briefly stayed with a caregiver who hit them and a child who was hit weekly for a decade would receive the same score for that question.
The ACEs assessment does not look critically at gender. It asks if a child's mother or stepmother was abused, when abuse can happen to caregivers of any gender. One paper suggests that treating male and female children differently may overlook gender differences in how children experience the world.
It also doesn't measure certain cultural factors. For example, children in families with immigration issues can be negatively impacted. They may experience worries over family stability or even watch a loved one be detained or deported.Flores, G., & Salazar, J. C. (2017). Immigrant Latino Children and the Limits of Questionnaires in Capturing Adverse Childhood Events. Pediatrics, 140(5), e20172842. While the expanded ACEs scale does mention racism, it does not mention issues like immigration or other forms of discrimination.
Overall, the ACEs scale has provided a substantial baseline for the past almost 25 years, but it does not address the full complexity of adverse experiences. More comprehensive assessments can provide greater insights and catch more important details. 
== Impact ==
There is a push to use the research on ACEs to advocate for trauma-informed care because the ACEs scores provide data that children are experiencing trauma on all levels.Oral, R., Ramirez, M., Coohey, C., Nakada, S., Walz, A., Kuntz, A., Benoit, J., & Peek-Asa, C. (2016). Adverse childhood experiences and trauma informed care: the future of health care. Pediatric research, 79(1-2), 227–233. 
Trauma-informed care is especially important in the wake of the COVID-19 pandemic, which led to isolation, fear, and loss for many people. 
While there have been strides made to incorporate ACEs into policy, as of 2018, only 37 states have enacted ACEs related legislation. There is hope that advancing the ACEs measure and incorporation ACEs into legislation can further improve the quality of life for children and adults with childhood trauma. 
== See also ==
* Battered Woman's Syndrome
* Dialectical Behavior Therapy
* Spanking children
== References ==
Category:Children and Adolescents
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Category:Clinical Psychology
Category:Trauma