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Special Feature Series: Trauma Informed Care, Part 5 – Adverse Childhood Experiences Study

No matter how genetically sound a seed may be, factors such as sunlight, soil quality and irrigation must act on it properly if it is to germinate and grow into a healthy adult plant. [1] Gabor Mate

The ACE Study: background

In the last blog post (September 2013), I introduced the Adverse Childhood Experiences (ACE) study, a large-scale epidemiological study conducted by the US Centers for Disease Control and Kaiser Permanente. This research examined the general population and correlated adverse childhood experiences (ACEs) with both acute and chronic health issues later in life. With over 17,000 participants enrolled between 1995 and 1997, it is the largest study of its kind to-date.

Researchers looked at a number of categories, including psychological, physical and sexual child abuse, and household dysfunction. Under the category of household dysfunction, researchers looked at substance abuse, mental illness, violence in the home and criminal behaviour.

ACE scores

Each participant completed a survey that asked questions about childhood trauma, as well current health status and behaviors. From the survey instrument, an ACE score was calculated for each study participant. The Score Calculator assigned 1 point for each category of exposure to child abuse and/or neglect, for a maximum total of 10 points. Thus, a participant’s score was the number of adverse experiences that they had experienced in childhood.

You can view the survey instrument (and determine your own ACE score) on the ACE website.


More than half of those surveyed had experienced least one ACE during childhood. When one ACE was present, it was 84% more likely that another exposure category was also present.


A dose-response relationship was established between adverse childhood experiences and a range of health risks or effects. As ACE scores increased, so too did health problems throughout life.[2]  Identified health risks included:

  • Alcoholism and alcohol abuse
  • Illicit drug use
  • Depression & suicide attempts
  • Liver disease
  • Early initiation of sexual activity
  • Unintended pregnancies
  • Adolescent pregnancy
  • Risk for intimate partner violence
  • Multiple sexual partners
  • Sexually transmitted infections (STIs)
  • Health-related quality of life


The US Centres for Disease Control described the life continuum for people that have experienced ACEs in childhood.  This continuum is called the ACE Pyramid.[3]


Although schematic in nature, the pyramid illustrates the movement from adverse childhood experiences to the adoption of high-risk behaviours, which can lead to early death. To follow this pathway in greater detail involves a study of the impact ACEs have on an individual’s neurophysiology. Fortunately, with the advent of the concept of neuroplasticity, an individual can make changes at any level of this pyramid.

Of note is a retrospective study (N = 9323 people) that was published in Pediatrics in July 2000.[4] Researchers looked at the link between Adverse Childhood Experiences and self-reported sexually transmitted infections. Approximately 60% of men and women that reported an STI diagnosis also reported more than 1 ACE.


So clearly there is a strong graded relationship between ACEs and a self-reported history of STIs among adults.

What should we in public health do? Stay tuned for ideas in upcoming blog posts.


  1. Mate, Gabor. In the Realm of the Hungry Ghosts, Close Encounters with Addiction. Random House, Vancouver, 2008.
  2. http://www.cdc.gov/ace/findings.htm
  3. http://www.cdc.gov/ace/pyramid.htm
  4. Hillis SD, Anda RF, Felitti VJ, Nordenberg D, Marchbanks PA. Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study. Pediatrics, 2000 Jul;106(1):E11.

Next Installment

A report on the Wellspring Conference: Encounters with Trauma, Hope and Healing, held at St. Paul’s Hospital in October 2013.