Impact of Adverse Childhood Experiences (ACEs)

Many have recognized the connection between childhood adversity and health. The Adverse Childhood Experiences study illuminates the powerful link between childhood stressors and a persons increased risk of medical, psychological, and social issues as an adult (1).

What are ACEs?

  • Childhood abuse

    • Emotional

    • Physical

    • Sexual

  • Neglect

    • Emotional

    • Physical

  • Growing up in a seriously dysfunctional household

    • Witnessing domestic violence

    • Alcohol or other substance abuse in the home

    • Mentally ill or suicidal household members

    • Parental marital discord (separation or divorce)

    • Crime in the home (household member imprisoned)

The ACE score is the total number of ACE that people experiences during childhood. For example, experiencing physical neglect would be an ACE score of one. Experiencing physical neglect and witnessing a parent being treated violently would be an ACE score of two. Compared with people who have none, people with four types of ACE’s are twice as likely to be smokers, 12 times more likely to attempt suicide, seven times more likely to be alcoholic, and 10 times more likely to inject street drugs.

However, Dr. Elena Quintana from Adler School of Professional Psychology reminds us: “It is important to remember an ACE score is not destiny, but is wind in your face…rather than at your back.”

Click here to calculate your ACE (and resilience) score (

The ACEs pyramid

ACE Pyramid

ACE Pyramid

During the time period of the 1980s and early 1990s, information about risk factors for disease had been widely researched and merged into public education and prevention programs. However, it was also clear that risk factors, such as smoking, alcohol abuse, and sexual behaviors for many common diseases were not randomly distributed in the population. In fact, it was known that risk factors for many chronic diseases tended to cluster, that is, persons who had one risk factor tended to have one or more other risk factors too.

Because of this knowledge, the ACE Study was designed to assess what we considered to be “scientific gaps” about the origins of risk factors. These gaps are depicted as the two arrows linking Adverse Childhood Experiences to risk factors that lead to the health and social consequences higher up the pyramid. Specifically, the study was designed to provide data that would help answer the question: “If risk factors for disease, disability, and early mortality are not randomly distributed, what influences precede the adoption or development of them?” By providing information to answer this question, researchers hoped to provide scientific information that would be useful for developing new and more effective prevention programs.

The ACE Study takes a whole life perspective, as indicated on the orange arrow leading from conception to death. By working within this framework, the ACE Study began to progressively uncover how adverse childhood experiences (ACE) are strongly related to development and prevalence of risk factors for disease and health and social well-being throughout the lifespan. For example, people with six ACEs die on average 20 years sooner than those with no ACEs.

Social emotional and cognitive adaptations refer to the adjustments people have been shown to make in their lives when faced with adversity that may lead to adoption of health risk behaviors, that lead to disease and possibly early death.


“We saw that things like intractable smoking, things like promiscuity, use of street drugs, heavy alcohol consumption, etc., these were fairly common in the backgrounds of many of the patients…These were merely techniques they were using, these were merely coping mechanisms that had gone into place.” Vincent Felitti, MD

Expanding our understanding about ACEs

The Philadelphia ACE study explored ACEs in context of an urban city with a socially and racially diverse population. They added five new definitions of trauma to the original ten: 1) Experiencing racism, 2) witnessing violence, 3) living in an unsafe neighborhood, 4) being placed in foster care, and 5) experiencing bullying. "The study found that 40.5% of Philadelphia adults witnessed violence while growing up, which includes seeing or hearing someone being beaten, stabbed or shot. Over one-third (34.5%) of adults reported experiencing discrimination based on their race or ethnicity, while almost three in ten adults (27.3%) reported having felt unsafe in their neighborhoods or not trusting their neighbors during childhood. In all, over 37% of Philadelphia respondents reported four or more ACEs. The findings from this study suggest the need for services that address the unique environmental stressors experienced in urban neighborhoods to mitigate their impact on individuals and prevent ACEs (2). 

The RYSE Center in Richmond, California knew that there was more to a person’s trauma than just their experiences and that youth come “into this world in structures and conditions already established” (3). The following expanded pyramid reflects the additional experiences and conditions that people reinforce systems of marginalization and oppression and contributes to people's experiences of ongoing trauma and adversity.  

RYSE ACE Pyramid

It is important to recognize that:

  • ACEs are common.

  • ACEs tend to occur in clusters, rather than single experiences.

  • The cumulative impact of multiple exposures can be captured in an ACE score.

  • The ACE score likely captures the cumulative neurodevelopmental consequences of adversity and traumatic stress.

  • The ACE score has a strong, graded relationship to numerous health, social, and behavioral problems throughout a person’s lifespan.

  • ACE-related problems tend to be co-morbid or co-occurring.

As a person's ACE score increases; the risk for the following health outcomes also increases

  • Alcoholism and alcohol abuse

  • Chronic obstructive pulmonary disease

  • Depression

  • Fetal death

  • Illicit drug use

  • Ischemic heart disease

  • Liver disease

  • Risk for intimate partner violence

  • Multiple sexual partners

  • Sexually transmitted diseases

  • Smoking

  • Suicide attempts

  • Unintended pregnancies

The cumulative stress of ACEs are the most powerful determinate of the public’s health and the strongest common driver of mental, physical and behavioral health costs. The gray area across the pie chart below represents the portion of risk attributable to ACEs. Like an oil spill, it defies predetermined boundaries and shows the interconnectedness between adverse childhood experiences and presenting public health issues (4).  

ACEs Oil Spill Image