Adverse Childhood Experiences (ACEs)

Adverse childhood experiences, better known as ACEs, are traumatic experiences that an individual may experience in their childhood (0-17 years of age). For example, these experiences may include violence, abuse, neglect, witnessing a suicide attempt, growing up around substance abuse or mental health problems. The original study of ACEs came in the mid 1900s during the Kaiser study, in which participants were surveyed about their past experience with child maltreatment. The study found a correlation between childhood trauma and chronic diseases, which prompted immediate interest in the negative impact of ACEs. (Felitti, 1998).  Unfortunately, ACEs are common in society, with over 61% of adults in the US having experienced at least one ACE and 1 in 6 having experienced more than four or more ACEs (Centers for Disease Control and Prevention, 2022). 

ACEs have been linked to several negative outcomes such as chronic health problems, mental health problems and substance abuse. For example, the Centers for Disease Control and Prevention (2022) reported that preventing ACEs could save up to 1.9 million depression cases and 21 million depression in the US alone. In a study by Merrick et al. (2019), they found that at least five of the top leading causes of death, like respiratory and cardiovascular diseases, cancer and suicide have all been associated with ACEs. The mechanism underlying the effects of ACEs is toxic stress, which is prolonged or excessive activation of the stress response system. Although everyone experiences stress, like applying for a job, if that stress is prolonged over time or is traumatic, it can damage the body and the brain long-term, leading to mental health issues like PTSD, complex trauma, depression and substance use (Jo Hill, n.d.). ACEs have also been associated with increased risk of smoking, obesity and drug use, alcoholism and STDs. (Felitti, 1998).
ACEs are commonly identified using a questionnaire that scores individuals based on the number of ACEs they’ve experienced in their childhood. Although ACEs can happen to everyone, there are some groups that are more likely to score a 1 or more on the ACEs questionnaire that can affect the individual long-term. For example, children who experience abuse or neglect are more likely to experience mental health issues and consequently abuse or neglect their own children in the future, leading to an intergenerational pattern of abuse/neglect (Jo Hill, n.d.). Women and certain minority groups were at greater risk of ACEs and may be associated with being marginalized in society. Other parental factors were associated with higher risk of ACEs, like low-income, low education status, violence, drug/alcohol abuse and single parents (Centers for Disease Control and Prevention, 2022).  
Not only does ACE influence the individual, it also incurs costs to the families, communities and societies. A study by Peterson (2018) estimated that based on the US population cases of child maltreatment in 2015, an estimated cost of $800,000 per victim and a total lifetime burden of $428 billion are incurred annually due to the effects of ACEs. These costs include costs of health consequences, reduced quality of life and intangible costs like pain and grief.  
Due to the prevalence of ACEs and its impact on the lives of many, standard ACE questionnaires were made to screen for ACEs. These ACE questionnaires have been incorporated into clinical and research purposes to further examine the negative impact of ACEs. 
Typically in ACE questionnaires, “yes or no” type questions are asked to the respondent and the answers to these questions are scored to identify the ACEs in the individual’s childhood. However, these ACE questionnaires are not without their flaws (McLennan, 2020).​

For example, McLennan (2020), in his evaluation of ACE questionnaires, identifies several flaws with the most commonly used ACE questionnaire, called the ACEs-10. For one, some necessary variables of ACEs were not included in the questionnaire such as peer victimization, community violence and socioeconomic status. Second, there were problems with the construction of some of the questions in the questionnaire with some questions being potentially leading. For example, one question was preceded with the line: “Stressful life events experienced by children and teens can have a profound effect on their physical and mental health.” This information may affect the answers of the respondent as it may signal to the respondent that the clinician anticipates this relationship (McLennan, 2020). Some questions, on the other hand, were not given enough context to accurately answer the question. Lastly, a big limitation of the questionnaire was that each question was given one point and these points were summed to give an end score to determine the number of ACEs. However, this would imply that each ACE carried an equivalent weight in influencing the negative outcomes of each individual. This is obviously not true, as some experiences impact one’s life more than others (McLennan, 2020).
Although no perfect method of screening for ACEs has been discovered, there exist preventive methods that may help prevent the prevalence of ACEs. It is also important for professionals who utilize the ACEs questionnaire to also consider its limitations and look at the client’s history that may also impact their presenting problems. CDC suggests that providing more financial support to families may help prevent the prevalence of ACEs in low-income families. Another method is promoting societal norms that protect against violence like education campaigns. Lastly, teaching skills like emotional learning, social skills, safe dating and parental skills may prevent the occurrence of ACEs (Centers for Disease Control and Prevention, 2022).
If you're interested in taking a look at the ACE questionnaire or would like to see what your ACEs score is, we provided the link below: 

https://www.theannainstitute.org/Finding%20Your%20ACE%20Score.pdf

References
Centers for Disease Control and Prevention. (2022, April 6). Fast facts: Preventing adverse childhood experiences |violence prevention|injury Center|CDC. Adverse Childhood Experiences (ACEs). 
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. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/s0749-3797(98)00017-8 
McLennan, J. D., MacMillan, H. L., & Afifi, T. O. (2020). Questioning the use of adverse childhood experiences (aces) questionnaires. Child Abuse & Neglect, 101, 104331. https://doi.org/10.1016/j.chiabu.2019.104331 
Merrick, M. T., Ford, D. C., Ports, K. A., Guinn, A. S., Chen, J., Klevens, J., Metzler, M., Jones, C. M., Simon, T. R., Daniel, V. M., Ottley, P., & Mercy, J. A. (2019). vital signs: estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention — 25 states, 2015–2017. MMWR. Morbidity and Mortality Weekly Report, 68(44), 999–1005. https://doi.org/10.15585/mmwr.mm6844e1 
Peterson, C., Florence, C., & Klevens, J. (2018). The economic burden of child maltreatment in the United States, 2015. Child abuse & neglect, 86, 178–183. https://doi.org/10.1016/j.chiabu.2018.09.018
Tammy Jo Hill, A. G. (n.d.). Adverse childhood experiences. Retrieved October 9, 2022, from https://www.ncsl.org/research/health/adverse-childhood-experiences-aces.aspx