Course

Adverse Childhood Experiences (ACES)

Course Highlights


  • In this Adverse Childhood Experiences (ACES) course, we will learn about the three main categories of ACEs.
  • You’ll also learn the long-term impact on those who have experienced types of ACEs. 
  • You’ll leave this course with a broader understanding of where to report ACEs, and how to provide additional support to those who may need it. 

About

Contact Hours Awarded: 1

Course By:
Marybeth Anderson Keppler

BSN, RN

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The following course content

Introduction   

All children should grow and thrive in a caring, nurturing environment that meets their physical, emotional, and social needs. However, many are not so fortunate. Nearly every two in three Americans (64%) have experienced adverse childhood events (ACEs) (1, 2, 4, 5).  

ACEs are highly associated with future chronic health conditions, mental illness, premature death, and more (1). In fact, the more ACEs an individual has had, the higher their risk for having poor health outcomes as adults (13).  

Fortunately, there are preventive and protective measures that can be taken with the appropriate resources (1). With better awareness of ACEs and the right support in place, healthcare professionals can help improve the quality of life for a myriad of children and the adults they grow up to be. 

Definition 

Adverse childhood events, or ACEs, can occur from birth until age 18, and are great determinants of future health (1). These are any potentially traumatic events that happened to a child. ACEs are strongly linked to mental and physical disease in adults, contributing to at least half of the leading causes of death in the United States (1).  

The ACE score is a 10-item survey to identify any negative occurrences a person had before their 18th birthday (3). The higher a person’s ACE score, the more risk they have for an unhealthy adulthood (1,2). 

ACE was a term coined in a large-scale study published in 1998, describing them as childhood abuse and household dysfunction in seven specific areas (1, 2). In subsequent years, three more areas were added (3, 13). Altogether, the ten ACEs are comprised of the following examples of three broad categories:  

 

  • Childhood abuse 
    • Psychological 
    • Physical 
    • Sexual 
  • Household dysfunction 
    • Substance abuse 
    • Mental illness 
    • Parent treated violently. 
    • Family member incarcerated. 
  • Neglect 
    • Emotional  
    • Physical  
Quiz Questions

Self Quiz

Ask yourself...

  1. How would you briefly define adverse childhood experiences (ACEs)?  
  2. Would you add or subtract anything from the list above?  
  3. What other examples of ACEs exist?  
  4. Should one’s community and environment factor into ACEs as well? Why or why not?  

Statistics and Demographics 

The initial adverse childhood experience (ACE) study, conducted in the late 1990s, included over 17,000 adult participants and revealed the following key demographic data (1, 2, 5):  

  • Nearly 66% of women and 62% of men reported at least one ACE in their lives. 
  • More than 1 in 6 people (17.3%) said they had experienced four or more types of ACEs.  
  • Respondents’ races who reported ACEs were: 74.8% white, 11.2% Hispanic, 7.2% Asian/Pacific Islander, 4.5% black, and 2.3% other. 
  • About 49% of those with college degrees experienced at least one ACE, compared to 44% without a high school diploma.  
  • The age group who reported the highest incidence of ACEs was those from 35-49, where almost 70% had experienced at least one ACE. The lowest incidence was reported by those aged 65 and older, at 40%.  
  • Of all women reporting ACEs, 25% said they endured sexual abuse, 30% witnessed substance abuse in the home, and 25% of the respondents’ parents got divorced.  
  • Of all men reporting ACEs, 30% went through physical abuse, 24% saw substance abuse at home, and 22% of their parents were divorced.  

More recent data shows that at least 50% of the top causes of death in the US are associated with ACEs (6). As there is also a high association between ACES and depression, preventing these experiences could reduce adult depression by 44% (6).  

Quiz Questions

Self Quiz

Ask yourself...

  1. Did any of the statistics surprise you? Why or why not? 
  2. Reflect on your own life. How many of the 10 ACES might you have had, and how might you be able to manage them as an adult?  
  3. What other data gathering might be useful when it comes to identifying and preventing ACEs?  
  4. What would you identify as some of the highest risk factors for the occurrence of ACEs? 

Causes and Risk Factors 

The causes of adverse childhood events are varied and multifaceted. They can stem from familial or communal challenges, often referred to as social determinants of health. Many of these determinants can cause ACEs, and may include (8):  

  • Lack of access to healthcare or other resources 
  • Financial difficulties 
  • Homelessness or frequent moving 
  • Discrimination 
  • Any type of disrupted living situation  

 

As noted earlier, most of the American population has had some sort of adverse childhood experience. However, there are some factors that make it more likely for these to occur. Societal, communal, and familial cultures all play a role in adverse experiences.  

The following situations or conditions increase the likelihood of ACEs (7):   

 

Community Risk Factors: 
  • High rates of poverty, crime, and violence 
  • Limited educational, economic, and employment opportunities  
  • Lack of community activities for youth 
  • Unstable housing and frequent moves by community residents   
  • Readily accessible alcohol and drugs 
  • Frequent experiences of food insecurity  
Family and Individual Risk Factors:  
  • Social or developmental disabilities or delays  
  • Mental or chronic physical illnesses 
  • A history of abuse experienced by caregivers themselves. 
  • Youth dating or engaging in sexual activity early. 
  • Single-parent families, particularly those with young caregivers 
  • Low income and/or high economic stress 
  • Low education levels 
  • Children with few or no friends, or friends who partake in delinquent or aggressive behaviors 
  • Caregivers with limited understanding of child development  
  • Use of spanking or other corporal punishment as a form of discipline  
  • Inconsistent discipline and/or little parental supervision 
  • Families isolated from extended family, friends, and/or neighbors 
Quiz Questions

Self Quiz

Ask yourself...

  1. In the community where you live, what might be some factors that contribute to ACEs in those around you?  
  2. What are some ways your community might be able to mitigate some of the risk factors for ACEs?  
  3. Since nearly two in three people have experienced an ACE in their lives, it is likely that you interact with someone affected by this issue. What resources might you recommend to them, and what else might help?  

Cultural Considerations  

Though many people experience ACEs, some populations are affected disproportionately. This includes women and those in racial or ethnic minorities, who are at greater risk for experiencing 4 or more ACEs (6, 8). Specifically, African Americans, American Indians, and Alaska Natives (AI/AN) are far more likely to have multiple ACEs than any other race or ethnicity (9,10).  

The AI/AN community is a relatively young one, with poverty rates up to four times higher than the national average (10). Furthermore, the AI/AN group is often lumped together as “other” as a race category on surveys, making data harder to come by for this population (10).  

AI/AN children, when compared to the total US population, are more likely to have:  

  • Parents who are divorced (33% versus 21%) 
  • Lived with someone who abused a substance (24% versus 12%) 
  • Witnessed domestic violence (15% versus 6%) 
  • Lived with a parent who ultimately died (4% versus 2%) 

 

Lifespan Impact on the Individual 

While adverse childhood experiences affect most Americans, having been through four or more puts a person at significantly higher risk of health problems as an adult (1, 2, 9). In general, the more ACEs an individual has experienced, the more likely they will have poor outcomes later in life, with a specifically high correlation to diabetes, heart disease, obesity, depression, substance abuse, smoking, poor academic achievement, and early death (4).  

In fact, ACEs can reduce an individual’s life expectancy by as many as 20 years, compared to someone who has had zero ACEs (8).  

The original ACEs study was conducted to determine the link between childhood abuse and adult health risk factors (1). The conclusion was overwhelmingly that in the United States, the main causes of morbidity and mortality are related to many of the health behaviors exhibited by those who have experienced ACEs (1). More recent studies find that ACEs contribute significantly to substance abuse, violence, and self-harming behavior (11).  

At least 5 of the top 10 leading causes of death in the United States that are strongly related to ACEs include (9,11, 12):  

  • Heart disease (#1 cause of death) 
  • Stroke (#5) 
  • Chronic lower respiratory diseases (#6)  
  • Diabetes (#8) 
  • Chronic liver disease and cirrhosis (#9) 

As far as mental health goes, the link with ACEs is clear: The higher one’s ACE score, the more likely they are to be depressed, experience impaired work performance, and have suicidal tendencies (13). Harmful behaviors associated with high ACE scores include smoking, drinking, and drug abuse, as these methods are often used to cope with past traumatic experiences (13).  

Quiz Questions

Self Quiz

Ask yourself...

  1. In light of the correlation between ACEs and some of the top causes of mortality in the US, what interventions could possibly be made in childhood to prevent these deaths from occurring?  
  2. Though the top 10 causes of death in the US have a variety of causes, the link between ACEs has been well-established for nearly three decades. Why do you think more funding and attention aren’t given to this matter?  
  3. What other physical or mental health concerns not listed above might a person with a high ACE score have?  

Societal Implications 

Adverse childhood events are preventable and have been shown to contribute to at least half of the leading causes of death in the United States (1, 9, 11). Thus, the impact of ACEs on public health is vast. Since the CDC considers ACEs a public health concern, it is of utmost importance to decrease their incidence (1). Through the reduction and prevention of ACEs, general public health would improve markedly, drastically cutting down on healthcare costs and resources (1, 5, 6, 9).  

The societal implications for reducing ACEs are manifold:  

  • Dramatic reduction of preventable causes of death 
  • Longer lifespans for the general population  
  • Better mental health  
  • More cost-effective physical and mental healthcare 
  • Lower rates of disease and depression in the general population 
Quiz Questions

Self Quiz

Ask yourself...

  1. What other societal impacts might ACEs have? 
  2. How could you go about preventing some ACEs in your own life or community?  
  3. What are some local, national, or global resources to which you could introduce those in need? 

Ways to Mitigate ACEs 

Though ACEs are widely pervasive in American society, they need not be so. With proper resources and support systems, many -if not all- ACEs may be eradicated. The best way to mitigate ACEs would be to prevent them in the first place (4). This requires creating safe, stable, nurturing environments for children and their families (9). Furthermore, as ACEs can occur for a wide array of reasons, they need to be addressed at both the family and communal levels. 

With individuals, a first step would be prevention of ACEs in the home. This could involve a vast array of mental health, education, and social work services such as: home visits, parenting classes, therapy sessions, and more (8, 9). Different emotion management techniques and child development concepts could be taught to at-risk families, promoting bonding and trust between children and their caregivers.  

High-quality childcare and after-school programs with trusted adults can help mitigate ACEs as well (9). Screening for ACEs at regular intervals would also be helpful. This could include annual check-ups at the doctor’s office, visits with the school nurse or counselor, or a consultation with a home health provider. Medical management of physical and mental health conditions would be made available, including routine health screenings and necessary medications (4, 8, 9).  

At the community level, prevention could take the form of free education for family members, food and housing assistance, adequate access to healthcare services, and fostering safe neighborhoods (4, 9). Economic support for families could include family-friendly work policies, earned income tax credits, and so forth. Children could partake in community events like after-school clubs and sports, helping them build bonds with trusted and supportive adults.  

Three principles are the most helpful preventing long-term effects of ACEs, (4):  

  • Reducing stress by ensuring basic needs are met, as well as tending to abusive situations, community crime, substance abuse, discrimination, and poverty. 
  • Strengthening life skills can strengthen the resilience of children and their family members by practicing planning, focus, and self-control. 
  • Building responsive relationships by having adults listen to their children and respond adequately to their needs, thereby fostering a safe, trusting relationship. 
Quiz Questions

Self Quiz

Ask yourself...

  1. What specific local resources are available where you live or work that could help prevent ACEs from occurring in the first place?  
  2. What types of secondary and tertiary prevention resources can you identify for ACEs?  
  3. What are other ways ACEs can be mitigated or prevented at the state or federal level?  

Reporting ACEs 

Considering there are various types of ACEs, they can be difficult to identify and thus report. However, some are clear-cut. In situations where child abuse or neglect is occurring or suspected, a mandated reporter (e.g., nurse, teacher, counselor) would need to report it as soon as possible. If the child is in imminent danger, take them to a safe place and make a report.  

To report child abuse in the United States, call or text 1-800-4-A-CHILD (1-800-422-4453). The website is https://www.childhelphotline.org/ 

If there is suspicion that a child is being sexually exploited, the phone number to call is 1-800-THE-LOST (1-800-843-5678), and the website is https://report.cybertip.org/ 

To report human trafficking, call 1-888-373-7888, use TTY at 711, text BEFREE (233733), or visit the website at https://humantraffickinghotline.org/ 

For anyone experiencing feelings of self-harm or suicide, 988 is the national Suicide and Crisis Lifeline that can be called or texted. The website is https://988lifeline.org/ 

 

Support and Additional Resources 

While there is no single way to prevent ACEs from occurring, there is a plethora of resources available to help mitigate the effects and to educate others. Visting a healthcare provider can connect a patient to mental health professionals, support groups, or specialty services like social work and support groups (8).  

The Substance Abuse and Mental Health Services Administration (SAMHSA) has an abundance of resources on topics like trauma-informed care, early childhood mental health programs, Native Connections for the AI/AN population, school, and campus health, and much more. More information can be found at https://www.samhsa.gov/programs 

Healthy Outcomes from Positive Experiences (HOPE) is a national resource center offering research, training, and technical assistance in order to better the lives of children and their families. Their website is https://positiveexperience.org/ 

The Centers for Disease Control and Prevention (CDC) offers ACE-specific information at this website: https://www.cdc.gov/violenceprevention/aces/resources.html 

Conclusion

Adverse childhood events, or ACES, affect the majority of the American population. Strongly correlated with many leading causes of death, ACEs are preventable and warrant attention from healthcare providers and the general public alike. Fortunately, many resources exist at the individual, community, and national levels to provide care and prevention for these experiences.  

Though ACEs tend to lead to negative health outcomes, they need not condemn a person to lifelong problems. Through screening tools, community food and housing programs, mental health assistance, education, and adequate medical care, ACEs can be mitigated, well managed, and prevented.  

Despite the misfortune in a child’s life, there is still much hope available when they reach adulthood.  

 

Conclusion

Adverse childhood events, or ACES, affect the majority of the American population. Strongly correlated with many leading causes of death, ACEs are preventable and warrant attention from healthcare providers and the general public alike. Fortunately, many resources exist at the individual, community, and national levels to provide care and prevention for these experiences.  

Though ACEs tend to lead to negative health outcomes, they need not condemn a person to lifelong problems. Through screening tools, community food and housing programs, mental health assistance, education, and adequate medical care, ACEs can be mitigated, well managed, and prevented.  

Despite the misfortune in a child’s life, there is still much hope available when they reach adulthood.  

 

References + Disclaimer

  1. Centers for Disease Control and Prevention (CDC) (2023). Fast Facts: Preventing Adverse Childhood Experiences. https://www.cdc.gov/violenceprevention/aces/fastfact.html 
  2. 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. https://doi.org/10.1016/S0749-3797(98)00017-8. 
  3. Starecheski, L. (2015). Take the ACE quiz—And learn what it does and doesn’t mean. NPR. https://www.npr.org/sections/health-shots/2015/03/02/387007941/take-the-ace-quiz-and-learn-what-it-does-and-doesnt-mean 
  4. Center on the Developing Child at Harvard University (n.d.). What are ACEs? And how do they relate to toxic stress? https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/ 
  5. CDC, (2022). About the CDC-Kaiser ACE study. https://www.cdc.gov/violenceprevention/aces/about.html 
  6. CDC. (2021). Preventing adverse childhood experiences. https://www.cdc.gov/vitalsigns/aces/index.html 
  7. CDC (2023). Risk and protective factors. https://www.cdc.gov/violenceprevention/aces/riskprotectivefactors.html 
  8. Cleveland Clinic (2023). Adverse childhood experiences (ACEs) & childhood trauma. (2023). https://my.clevelandclinic.org/health/symptoms/24875-adverse-childhood-experiences-ace 
  9. Merrick, M. T. (2019). Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. Morbidity and Mortality Weekly Report, 68. https://doi.org/10.15585/mmwr.mm6844e1 
  10. Child Trends. (2018). American Indians and Alaska Natives must be included in research on adverse childhood experiences. https://www.childtrends.org/blog/american-indians-alaska-natives-adverse-childhood-experiences 
  11.  Hughes, K., Bellis, M.A., Hardcastle, K.A., Sethi, D., Butchart, A., Mikton, C., Jones, L., Dunne, M.P. (2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. Lancet Public Health; 2(8): e356-e366. doi: 10.1016/S2468-2667(17)30118-4.  
  12.  CDC (2023). Leading causes of death. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm 
  13. Merrick, M. T., Ports, K. A., Ford, D. C., Afifi, T. O., Gershoff, E. T., & Grogan-Kaylor, A. (2017). Unpacking the impact of adverse childhood experiences on adult mental health. Child Abuse & Neglect, 69, 10–19. https://doi.org/10.1016/j.chiabu.2017.03.016 
  14. Center on the Developing Child at Harvard University (n.d.). Take the ACE quiz – And learn what it does and doesn’t mean. https://developingchild.harvard.edu/media-coverage/take-the-ace-quiz-and-learn-what-it-does-and-doesnt-mean/ 
  15. National Conference of State Legislatures (2022). Adverse Childhood Experiences. https://www.ncsl.org/health/adverse-childhood-experience 
  16. National Center for Missing & Exploited Children (2023). CyberTipline http://www.missingkids.org/content/ncmec/en/gethelpnow/cybertipline.html 

 

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