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In 1998, Felitti, Anda, et al. published the landmark Adverse Childhood Experience (ACE) Study. The collaborative effort between San Diego's Kaiser Permanente and the Centers for Disease Control (CDC) was completed in two survey cycles over two years. More than 17,000 primary care patients with a baseline history and medical examination participated in a follow-up survey about their exposure to childhood traumas.

The ACE Study identified ten traumatic childhood stressors that were strong predictors of lifelong negative impacts on health and wellbeing. These stressors were divided into three categories: Abuse (Physical, Emotional, and Sexual); Household Dysfunction (Household Substance Abuse, Household Mental Illness, Incarcerated Family Member, Parental Separation or Divorce, and Mother Treated Violently); and Neglect (Physical and Emotional).

The ACE Study

Adverse Childhood Experience / ACE/ Physical Abuse / Emotional Abuse / Sexual Abuse / Household Substance Abuse / Household Mental Illness / Incarcerated Family Member / Parental Separation / Divorce / Mother Treated Violently / Physical Neglect / Emotional Neglect / KidsMates / Dr. Rosemary Martoma

 Adverse Childhood Experiences (ACEs). A KidsMates Graphic. Data retrieved from on 9/22/2020

 ACE Prevalence

In the original ACE Study, two-thirds of participants reported exposure to at least one of ten ACEs, and more than one in five participants reported exposure to three or more ACEs. In 2009, the CDC began collecting national data about ACE prevalence through an annual phone survey called the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS ACE module asked about exposure to eight ACEs (from the childhood abuse and household dysfunction categories). In 2019, the CDC expanded the survey to include two other ACEs (from the childhood neglect category). 

Analysis of more than 200,000 surveys completed between 2011 to 2014 revealed results similar to the original ACE Study. Almost two-thirds of the BRFSS survey respondents reported exposure to at least one of eight selected ACEs, and almost one-quarter of survey respondents reported exposure to three or more ACEs.

Adverse Childhood Experience / ACE ACE Score / Toxic Stress / Resilience /  Tolerable Stress / Childhood Trauma / KidsMates / Dr. Rosemary Martoma

Adverse Childhood Experiences Prevalence 2011 - 2014. A KidsMates Graphic. Data source: Prevalence of Adverse Childhood Experiences From the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States. JAMA Pediatrics, 172(11), 1038-1044. Retrieved 9/23/2020. * Does not include childhood neglect data.

The Graded Relationship Between ACE Score and Risk to Health and Wellbeing. A KidsMates Graphic.

 ACE Score

The ACE Score corresponds to the number of ACE exposures. Since there are a total of 10 ACEs, the score can range from 0 to 10. 

The ACE Study revealed a graded response between ACE Scores and multiple risk factors for several leading causes of death in adults.

Adverse Childhood Experience / ACE ACE Score / Toxic Stress / Resilience /  Tolerable Stress / Childhood Trauma / KidsMates / Dr. Rosemary Martoma
Risks to Health & Well-Being

The ACE Study exposed powerful relationships between exposure to ACEs during the first 18 years of life and to adult morbidity, mortality, and disability. ​A series of studies linked ACEs to:

  • Injuries: Skeletal Fractures, Sexual Victimization, Brain Injury;

  • Risky Behaviors: Obesity, Alcohol Abuse, Drug Abuse, Smoking, Risky Sexual Behavior;

  • Chronic Disease: Autoimmune Diseases, Cancer, Ischemic Heart Disease, Chronic Obstructive Pulmonary Disease, Liver Disease, Frequent Headaches;

  • Mental Health Disorders: Childhood Autobiographical Memory Disturbance, Depression, Hallucinations, Neurobiological Impairment, Suicide Attempts;

  • Infectious Disease: Human Immunodeficiency Virus, Sexually Transmitted Diseases;

  • Negative Maternal Health: Unintended Pregnancy, Promiscuity, Fetal Death;

  • Decreased Life Opportunities: Academic Failure, Impaired Work Performance, Homelessness.


KidsMates ACE Arrow demonstrates how ACEs lead to Negative Health & Well-Being Outcomes. A KidsMates Graphic.

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