Adverse Childhood Experiences

Opening scenario
What are ACEs?
What’s Your ACE Score?

What's your ACE Score?
What’s Your Resilience Score?

Get your ACE Card for

In Spanish

Why do ACEs matter?
The Cost
How can you prevent ACEs from damaging lives?
Signs your child may be impacted from ACEs
Student Wellness Surveys - Oregon - Curry County - 2014 and 2016
Student Wellness Surveys - Oregon - Curry County - 2014 and 2016 with BHSD Extension
Adverse Childhood Experiences SAMHSA
Adverse childhood experiences, gender, and HIV risk behaviors: Results from a population-based sample
Adverse Childhood Experiences Study - Wikipedia
ACEs and Child Trauma Leave Lasting Scars [INFOGRAPHIC] (21 pages)
Prevalence of Adverse Childhood Experiences (Adult Retrospective)
Resources to Strengthen Communities and Promote Systemic Change
Teen Depression

Opening Scenario
Your child witnesses violence at school, but hardly reacts at all. You might think that the incident was merely one of many insignificant moments to your child, but research shows that particular Adverse Childhood Event (ACE) may alter the way your child reacts to daily stressors. Even more startling: With multiple ACEs, your child’s brain development may be stunted leading to a lack of self-awareness and cognitive deficiencies. ACEs put children at high risk for serious mental, physical, emotional, and social health complications.

ACE expert Jane Ellen Stevens succinctly broke down the negative effects of ACEs on developing minds:

“They respond to the world as a place of constant danger. With their brains overloaded with stress hormones and unable to function appropriately, they can’t focus on learning. “They fall behind in school or fail to develop healthy relationships with peers or create problems with teachers and principals because they are unable to trust adults.”

What Are ACEs?

ACEs, or Adverse Childhood Experiences, are different for everyone, but in the broadest sense, they are negative moments or events that have the potential to leave lasting harmful effects on a child. ACEs come in many forms from: abuse, neglect, household dysfunction to witnessing violence. ACEs are important to identify due to their uncanny ability to mold and shape who our children grow up to be. When unchecked and unnoticed, ACEs can lead to a future of lifelong health concerns, risk aversion, passivity, and violence (both as a perpetrator and victim).  

Researchers have identified three categories of ACEs:

  • Abuse
  • Neglect
  • Household Dysfunction

Within these three categories are a plethora of experiences and events. To properly study how ACEs affect people as adults, researchers chose 10 types of childhood trauma and asked study participants to note whether or not they had experienced them as children.

64% had at least 1 ACE. 22% had 3 or more. 12.5% had 4 or more.

The ACE Test

In the first ACE study, Dr. Vincent Felitti and Dr. Robert Anda devised a test. There were 10 questions, each pertaining to a different type of ACE. For every question with a “Yes” (meaning they had an ACE) the test taker received a one point.

Sample Question:

Before your 18th birthday, 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 did they act in a way that made you afraid you might be physically hurt?

The test only counted types of ACEs, not the number or separate incidents of the same type of ACE. So, if they experience physical abuse 25 times, and no other types of experiences, their score would be 1. The goal of the test was to see how ACEs correlated with the test takers’ health.


The results were shocking, and led to emotional moments between therapists and study participants.

What’s Your ACE Score?

There are 10 types of childhood trauma measured in the ACE Study. Five are personal — physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to other family members: a parent who’s an alcoholic, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment. Each type of trauma counts as one. So a person who’s been physically abused, with one alcoholic parent, and a mother who was beaten up has an ACE score of three.

There are, of course, many other types of childhood trauma — watching a sibling being abused, losing a caregiver (grandmother, mother, grandfather, etc.), homelessness, surviving and recovering from a severe accident, witnessing a father being abused by a mother, witnessing a grandmother abusing a father, etc. The ACE Study included only those 10 childhood traumas because those were mentioned as most common by a group of about 300 Kaiser members; those traumas were also well studied individually in the research literature.

The most important thing to remember is that the ACE score is meant as a guideline: If you experienced other types of toxic stress over months or years, then those would likely increase your risk of health consequences.

What's your ACE Score? (prior to your 18th birthday)


If Yes enter 1

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 touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal 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?

Were your parents ever separated or divorced?

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?

Now add up your “Yes” answers: _ This is your ACE Scor

Source: Click here for a blank copy of this survey

Now that you’ve got your ACE score, what does it mean?

First….a tiny bit of background to help you figure this out…..(if you want the back story about the fascinating origins of the ACE Study, read The Adverse Childhood Experiences Study — the largest, most important public health study you never heard of — began in an obesity clinic.)

The CDC’s Adverse Childhood Experiences Study (ACE Study) uncovered a stunning link between childhood trauma and the chronic diseases people develop as adults, as well as social and emotional problems. This includes heart disease, lung cancer, diabetes and many autoimmune diseases, as well as depression, violence, being a victim of violence, and suicide.

The first research results were published in 1998, followed by 57 other publications through 2011. They showed that:

  • childhood trauma was very common, even in employed white middle-class, college-educated people with great health insurance;
  • there was a direct link between childhood trauma and adult onset of chronic disease, as well as depression, suicide, being violent and a victim of violence;
  • more types of trauma increased the risk of health, social and emotional problems.
  • people usually experience more than one type of trauma – rarely is it only sex abuse or only verbal abuse.

A whopping two thirds of the 17,000 people in the ACE Study had an ACE score of at least one — 87 percent of those had more than one. Eighteen states have done their own ACE surveys; their results are similar to the CDC’s ACE Study.

What’s Your ACE Score? (and, at the end, What’s Your Resilience Score?)
# of ACEs
4 or more


The study’s researchers came up with an ACE score to explain a person’s risk for chronic disease. Think of it as a cholesterol score for childhood toxic stress. You get one point for each type of trauma. The higher your ACE score, the higher your risk of health and social problems. (Of course, other types of trauma exist that could contribute to an ACE score, so it is conceivable that people could have ACE scores higher than 10; however, the ACE Study measured only 10 types.)

As your ACE score increases, so does the risk of disease, social and emotional problems. With an ACE score of 4 or more, things start getting serious. The likelihood of chronic pulmonary lung disease increases 390 percent; hepatitis, 240 percent; depression 460 percent; suicide, 1,220 percent.

(By the way, lest you think that the ACE Study was yet another involving inner-city poor people of color, take note: The study’s participants were 17,000 mostly white, middle and upper-middle class college-educated San Diegans with good jobs and great health care – they all belonged to the Kaiser Permanente health maintenance organization.)

Adult Childhood Experiences are Common

The CDC gave a questionairre with these 10 types of childhood trauma and assigned a score of 1 for each trauma experienced.

  • Household substance abuse (27%)
  • Parental separation/divorce (23%0
  • Family member with a mental illmess (17%)
  • Violence between parents/ause of mother (13%)
  • Incacerated household member (6%
  • Psychological/emotional abuse (11%)
  • Physical abuse (28%)
  • Sexual abuse (21%)
  • Emotional neglect (15%)
  • Physical neglect (10%)

What’s Your Resilience Score?

This questionnaire was developed by the early childhood service providers, pediatricians, psychologists, and health advocates of Southern Kennebec Healthy Start, Augusta, Maine, in 2006, and updated in February 2013. Two psychologists in the group, Mark Rains and Kate McClinn, came up with the 14 statements with editing suggestions by the other members of the group. The scoring system was modeled after the ACE Study questions. The content of the questions was based on a number of research studies from the literature over the past 40 years including that of Emmy Werner and others. Its purpose is limited to parenting education. It was not developed for research.

RESILIENCE Questionnaire
Please check the most accurate answer under each statement


Definitely true
Probably true
Not sure
Probably Not True
Definitely Not True

1. I believe that my mother loved me when I was little.

2. I believe that my father loved me when I was little

3. When I was little, other people helped my mother and father take care of me and they seemed to love me.

4. I’ve heard that when I was an infant someone in my family enjoyed playing with me, and I enjoyed it, too.

5. When I was a child, there were relatives in my family who made me feel better if I was sad or worried.

6. When I was a child, neighbors or my friends’ parents seemed to like me.

7. When I was a child, teachers, coaches, youth leaders or ministers were there to help me.

8. Someone in my family cared about how I was doing in school

9. My family, neighbors and friends talked often about making our lives better.

10. We had rules in our house and were expected to keep them.

11. When I felt really bad, I could almost always find someone I trusted to talk to.

12. As a youth, people noticed that I was capable and could get things done.

13. I was independent and a go-getter.

14. I believed that life is what you make it.

How many of these 14 protective factors did I have as a child and youth? (How many of the 14 were checked “Definitely True” or “Probably True”?) _______

Of these circled, how many are still true for me? _______

Source: Click here for a blank copy of this survey.

Here are some specific graphic examples of how increasing ACE scores increase the risk of some diseases, social and emotional problems. All of these graphs come from “The relationship of adverse childhood experiences to adult health, well being, social function and health care”, a book chapter by Drs. Vincent Felitti and Robert Anda, co-founders of the ACE Study, in “The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease.”


ACE Test Results

When Dr. Anda got the first results back he was overcome with sadness. He said, “I saw how much people had suffered and I wept.”

The study largely focused on the consequences of several different types of trauma. The 1995 study found that over 66% of participants had at least 1 ACE. Startling enough on its own, but that was only the beginning:

  • 22% had an ACE score of 3 or more
  • 12.5% had an ACE score of 4 or more

When they dug into the scores, researchers discovered that over a quarter of participants had experienced physical abuse, household substance use, economic hardship, or a combination of the three.

  • 28% experienced physical abuse
  • 27% saw household substance abuse
  • 26% experienced economic hardship

The study showed that many had been neglected in their childhood and over 1/5 were sexually abused:

  • 21% experienced sexual abuse
  • 15% were emotionally neglected
  • 10% physically neglected

After discovering how prevalent these ACEs were in people’s lives, Anda and Felitti looked for correlations between ACEs and mental and physical health concerns. What they found, led to some shocking, but profound and beneficial trends. Most notably: An almost exact correlation between childhood trauma and mental illnesses, chronic diseases, incarceration, and employment status.

Why Do ACEs Matter?

When an adverse childhood experience occurs, the child’s brain is flooded with adrenaline in what is often called “Fight or Flight”. While this reaction helps the child react to any immediate dangers, it becomes toxic when turned on for too long.

When children are forced to constantly focus on surviving and avoiding harm, they are unable to focus on learning or developing skills to serve them in adulthood. Their ability to trust and relate to others never fully forms and they often experience depression, self-consciousness, and avoidance of challenges. This has a snowball effect where children may turn to self-medicating or other troublesome behaviors to deal with the pain.

  • When 4 or more ACEs occur, students are 32x more likely to have learning or behavior problems in school.

People who experience childhood trauma tend to respond to daily stresses with high anxiety, or try to avoid stressors at all costs. This may include high pressure situations like giving a presentation at work, or more minor situations, like making small talk at a school fundraising event.

Health Impact of Multiple ACEs

A single adverse childhood experience can harm a child’s future by increasing the risk of homelessness, exposure to violence, and work absenteeism. When multiple ACEs happen, the likelihood of mental, physical, and social concerns goes up exponentially.

Repeated abusive and traumatic situations often lead to Complex PTSD. This type of trauma happens before a child is allowed to fully develop cognitive maturity and an understanding of how to respond to stressful situations. A person suffering from Complex PTSD will have trouble regulating their stress hormones and responding to normal situations as if they were threatening situations. These reactions can lead to chronic health issues and dangerous behaviors to deal with stress.

A score of 2 or more on the ACE test, when correlated with test taker’s health records showed the following compared to someone with a score of 0:

  • 3x more likely to have attempted suicide
  • 4x more likely to consider themselves alcoholics
  • Nearly 3x more likely to have used illicit drugs

A score of 4 had even more dire and sobering correlations:

  • 12x more likely to have attempted suicide
  • Over 7x more likely to consider themselves an alcoholic
  • 390% higher risk of Chronic Obstructive Pulmonary Disease (COPD)
  • 10x more likely to use illicit drugs
  • Twice as likely to be addicted to nicotine
  • 460% more likely to suffer from depression

In a more recent study, they found that when people had a score of 6 or more, the consequences were fatal. A person with 6 or more ACEs dies, on average, 20 years earlier than someone with 0.

The effects of ACEs go far beyond health concerns.

Economic Impact of ACEs

With problems reconciling fears, stress, and ambition, people suffering from ACEs can fail to secure financial stability and steady employment. While certainly a major strain on their own lives, this lack of financial support also puts a strain on the American economy.

ACEs cost the economy $124 billion in over the lifetime of all those affected by ACEs.
$83.5 billion in productivity losses

$25 billion spent for health care to combat the effects of ACEs

Child maltreatment and domestic abuse combined cost the economy roughly $500 billion a year. Health is certainly the #1 concern in combating ACEs, but the benefits of uncovering and treating ACEs are indefinite.

Signs You or Your Child May Be Impacted by ACEs

Possibly just knowing what ACEs are will help you determine if you or someone you know is impacted by ACEs. But for those more underlying and not talked about experiences look for the following ACE effects.

Many suffering from Complex PTSD, ACEs, and child trauma feel physical effects that can disrupt daily life:

  • Suffering from numerous health problems
  • Alcohol and/or illicit drug abuse
  • Poor sleep habits
  • Dealing with never-ending money management issues

More often than not these are coupled with emotional and social deficiencies. These issues consistently get in the way of victims’ ambitions and goals and can put a strain on their relationships.

  • Unable to control emotions and moods
  • Depression and/or living in isolation
  • Constantly worrying about just surviving and not enjoying life
  • Problems controlling anger and aggression
  • Unmotivated unless presented with severe consequences
  • Believing that bad things happen to you on purpose
  • Viewing humans as threats, not friends

87% of people with ACEs in Anda’s test had multiple types of trauma. That means only 13% had an isolated type of ACE. It appears that when someone has an ACE, many more are soon to follow. With multiple types of trauma, come multiple types of negative effects.


Therapists stress that the view should not be “Why are you behaving like this?” but “What happened to you?” If you or someone you know struggles with any of the above-mentioned concerns, take a look at the ACE test. It could lead to a path of recovery or at least an understanding of what events impacted the person you are today.

How You Can Prevent ACEs from Damaging Lives

Sometimes ACEs are unavoidable. Children will undoubtedly find themselves in adverse situations where they need to use that “Fight or Flight” adrenaline rush. But when coupled with protective and positive childhood experiences, adverse events can actually help children develop resilience.

The first step is creating an open dialogue between children and caring adults. There needs to be a trust between you and the child. They need a safe and loving environment where they can rid themselves of stresses and just be a kid.

Positive Childhood Experiences

It is vital to give your children positive life experiences and work with them to develop healthy self-regulation. Some of these include:

  • Reading and talking with your child
  • Providing good nutrition and plentiful sleep
  • Giving them an understanding of what is in their control
  • Working with them towards goals
  • Developing effective problem solving skills with your child

Teaching Self-Control

As they are still developing self-regulation and responses to stress, show and explain to them proper coping and conflict resolution techniques:

  • Direct them away from yelling and violent behavior
  • Limit exposure to violence in media
  • Discuss collaboration and compromising
  • Empathizing with others

A study on ACEs and their connection to problems with self-control stated,

“Innovative policies that put self-control center stage might reduce a panoply of costs that now heavily burden citizens and governments.”

While there is no cure-all for deafening the impact of ACEs, providing children with positive childhood experiences can dramatically limit some potentially fatal ACE effects. Resilience to negative events and an understanding that there are positive things in life are vital to living a fruitful life.

For adults living with the effects of ACEs, you’re not alone. A benefit of the recent understanding of ACEs is that many people are finding the courage and strength to overcome roadblocks from their childhood trauma. The dialogue is open; please join in.


Join the ACEs Connection Network
ACEs Response Toolkit
Resources from The National Child Traumatic Stress Network

Related content from Rawhide's site
Teen Depression in America – Troubling Statistics & Trends [INFOGRAPHIC]
Teen Sleep Deprivation: A Health Threat [INFOGRAPHIC]
ADHD: A Growing Concern for Youth and Adults [INFOGRAPHIC]
Teen Cyberbullying and Social Media Use on the Rise [INFOGRAPHIC]
Selfie Obsession: The Rise of Social Media Narcissism [INFOGRAPHIC]
Teen Anger & Aggression – Causes & Treatment [INFOGRAPHIC]

Why do ACEs matter?

When an ACE occurs, the child's brain is flooded with adrenaline in what is often called "Fight or Flight". While this reaction helps thr child react to any immediate dangers, it bcomes toxic when turned on for too long.

  • 32x more likiely to have learning or behavior problems in school with 4 or more ACEs
  • This stunted growth can lead to a snowball effect of poor decision making and an inability to process fear appropriately.
  • Brain development is paused to deal with threAts to safety.
  • Respond to daily stresses with hugher anxiety and view them as dangerous

Impact of ACEs

An ACE score of 2: 

  • 3x more likely to attempt suicide
  • 4x more likely to consider themselves an alcoholic
  • Nearly 3x more likely to use illicit drugs

An ACE score of 4:

  • 2x more likely to use tobacco
  • 4x higher risk for Chronic Obstructive Pulmonsry Disease (COPD)
  • 5x more likely to suffer from depression
  • 7x more likely to consider themselves an alcoholic
  • 10x more likely to use illicit drugs
  • 12x more likely to attempt suicide

An ACE score of 6:

  • Died 20 yeears earlier than those without ACEs

The Cost

ACEs cost the econhomy $124 billion over the lifetime of all those affected by ACEs: $83.5 billion in productivity losses and $25 billion spent on health care to combat the effects of ACEs (Editor's note: This probably doesn't include the cost to provide public safety caused by fACE affected peoolle and possibly homelessness, domestic vgiolence, etc.)

Signs your child may be impacted from ACEs

  • Anger management problems
  • Manipulations
  • Lack of motivation

When developmental trauma is present:

  • View humans as threats, not friends
  • Believe bad things happen on purpose
  • Avoid risks at all costs

How can you prevent ACEs from damaging lives?

Give your children positive life experiences and work with them to develop healthy self-regulation.

Undersanding of what is in their control
Working towards goals
Cresting effective problem solving skills
Empathizing with others

Read and talk with your teen
Create a community of loving people for your child to interact with
Provide good nutrition and the right amount of sleep
Listen to your child's needs
Discuss collaboration and compromising
Direct themaway from yelling and aggressive behavior
Avoid exposure to violence in media, community and at home.


Resources to Strengthen Communities and Promote Systemic Change

Community Development

The resources in this section focus on the development of community-wide systems to prevent and mitigate the impact of adverse childhood experiences and toxic stress.


This section includes resources which could be used by individuals, groups or entire communities to inform political leaders, legislators, and the legislative process around issues related to adverse childhood experiences (ACEs) and toxic stress.


This section includes links to professional and social networks with a focus on the topics of adverse childhood experiences (ACEs), toxic stress, resiliency, and other related components of this work.

Cultural Awareness

This section includes resources that acknowledge cultural groups and highlight the need for cultural sensitivity when working with diverse groups or communities on topics related to adverse childhood experiences (ACEs) and toxic stress.

Social Determinants of Health

The links in this section describe the influence of social factors such as poverty, race and socioeconomics, on health equity and lifelong health outcomes.

Trauma Informed Care

The links in this section describe the framework of Trauma Informed Care, which calls for a cultural shift that can be applied in any setting. Trauma Informed Care is not a specific intervention or a clinical response. Rather, it highlights the need for a broader understanding of the impact trauma has on everyone.

Trauma-Informed Interventions

This section includes links to examples of specific interventions created through a trauma-informed lens.