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Adverse Childhood Experiences

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by Meagan McClafferty (Fall 2016)

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Adverse Childhood Experiences (ACEs) are stressful or traumatic events that occur during childhood and fall under three categories as seen in the figure below: abuse (physical, emotional, or sexual), neglect (physical or emotional), and household dysfunction (mental illness, incarcerated relative, mother treated violently, substance abuse, and divorce) (1). These myriad experiences are outlined in Figure 1, below. ACEs have been strongly associated with chronic health problems, risky health behaviors, low life potential, and early death. ACEs have also been shown to have a dose-response effect on health outcomes; increased number of ACEs is associated with increased risk of negative health outcomes (4). Analysis of ACEs helps to explain the confusing and challenging subject of health risk behaviors, helping us better understand how early formative experiences can shape how people make decisions that can be hazardous to their health (5). This pathway from ACE to behaviors and health outcomes is further explored in Figure 2, the ACE pyramid (1). 

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Figure 1. Source: Centers for Disease Control and Prevention (1)


As shown in Figure 2 below, the ACE Pyramid illustrates the mechanisms by which ACEs manifest as poor outcomes including early death (1). At the base of the pyramid are the ACEs, which lead to disrupted neurodevelopment. This leads to social, emotional, and cognitive impairment, which further results in adoption of risky health behaviors. As you move up the pyramid following the arrow at right from conception to death, the risk behaviors lead to disease, disability, and social problems, which finally culminate in early death. A striking example of this progression is Zakariyya (Joe Lacks) of The Immortal Lives of Henrietta Lacks by Rebecca Skloot. Zakariyya experienced a number of ACEs including physical abuse, neglect, and household dysfunction. As he grew older, he demonstrated impairments in development and social/emotional capacities. He developed poor health habits and became morbidly obese, and often demonstrated violent tendencies. He has spent much of his adult life in and out of prison. This model may be helpful in determining where to implement interventions to reduce the negative outcomes ACEs often develop into.

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Figure 2. Source: Centers for Disease Control and Prevention (1)



ACEs as a scientific classification of traumatic experiences came to prominence through the landmark 1998 "ACE Study" by Feletti et al. (4). The authors initially collected data regarding childhood experiences and current health behaviors and status from over 17,000 subjects between 1995 and 1997, then followed them for 15 years. The authors found that ACEs were very common among the study population: nearly two thirds of participants reported at least one ACE, and over a fifth reported three or more ACEs. The number of ACEs was tallied across all ACE categories to create a composite "ACE Score". A major finding of the study was that there was a graduated dose-response relationship between increased ACE score and risk for poor outcomes including: alcoholism and alcohol abuse, chronic obstructive pulmonary disease (COPD), depression, fetal death, health­ related quality of life, illicit drug use, ischemic heart disease, liver disease, poor work performance, financial stress, intimate partner violence, multiple sexual partners, sexually transmitted disease (STDs), smoking, suicide attempts, unintended pregnancies, early initiation of smoking, early initiation of sexual activity, adolescent pregnancy, risk for sexual violence, and poor academic achievement. One of the most startling findings was that those who experienced six or more ACEs died nearly 20 years earlier on average than those without ACEs (4).


Applications to global health and practice

Study of ACEs and interventions have been largely limited to Western contexts, though relevant research in global settings is emerging. One such study in Sri Lanka investigated the link between ACE score and perpetration of intimate partner violence (IPV) among Sri Lankan men (6). IPV is a major problem in Sri Lanka; one in three women experience IPV in their lifetime. The authors found a significant association between ACEs in Sri Lankan men and perpetration of emotional, sexual, financial, and physical IPV. Though the women were not evaluated for ACEs, they suffered the negative outcomes their partner's ACEs had developed into. Studies like this are a crucial first step in developing countries that exhibit high rates of IPV or other potential outcomes of ACEs. The authors recommend interventions to prevent childhood abuse in Sri Lanka to prevent future ACEs and by extension IPV in adulthood. Another possible intervention would be systematic assessment of children for ACEs in the healthcare system.


The Center for Youth Wellness recommends follow-up through a multi­ disciplinary, two-generation approach that includes assessment, home visits, education, psychotherapy, psychiatry, coping skills, and referrals (2).



A major limitation of the use of the ACE score to determine risk of negative health outcomes is that it disregards positive experiences that may offset the ACEs one experienced. This is often referred to as resilience. Positive experiences, such as having a positive mentor, can temper the negative impact of ACEs and in effect reduce one's risk of negative outcomes despite a high ACE score. There are many different scales to calculate a "resilience score", though there is no single widely accepted scoring method (7). Further study is needed to merge ACE score and resilience score to study the net outcome and examine the interplay between the two factors.

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(1) Adverse Childhood Experiences (ACEs) [Internet]. CDC.gov 2016. [cited 26 October 2016]. Available from: http://www.cdc.gov/violenceprevention/acestudy/index.html.


(2) Clinical Programs [Internet]. Centerforyouthwellness.org 2016. [cited 26 October 2016]. Available from: http://centerforyouthwellness.org/what-we-are-doing/clinical-programs


(3) Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 2003 Mar 1;111(3):564-72.


(4) Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. 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. 1998 May 31;14(4):245-58.


(5) Foege WH. Adverse childhood experiences. A public health perspective. Am J Prev Med. 1998 May;14(4):354-55.


(6) Fonseka RW, Minnis AM, Gomez AM. Impact of adverse childhood experiences on intimate partner violence perpetration among Sri Lankan men. PLoS one. 2015 Aug 21;10(8):eo13632i.


(7) Windle G, Bennet KM, Noyes J. A methodological review of resilience measurement scales. Health and quality of life outcomes. 2011 Feb 4:9(1):1.


Useful resources

Adverse Childhood Experiences & ACE Study Infographic, Veto Violence (CDC)



Interactive portal to information about ACEs, the ACE study, ACE research, and prevention strategies, CDC



Children's Bureau index of child abuse related topics, programs, and resources



Interactive ACE quiz and explanation, NPR


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