ACEs Tools & Resources

What are ACEs?

According to the CDC, “Adverse Childhood Experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years) such as experiencing violence, abuse, or neglect; witnessing violence in the home; and having a family member attempt or die by suicide. Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding such as growing up in a household with substance misuse, mental health problems, or instability due to parental separation or incarceration of a parent, sibling, or other member of the household.”

Background: The ACE Study:

From 1995 to 1997, Kaiser Permanente collected surveys from HMO members on adverse childhood experiences. Over 17,000 members from Southern California completed surveys; more than half of respondents had at least one childhood exposure to traumatic events, a fourth of respondents had at least two childhood exposures to traumatic events, and there was “a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.” (source) For instance, respondents who had four or more childhood exposures to traumatic events had multiple-fold increase risks for alcoholism, drug abuse, depression, suicide attempts, smoking, etc.

The ACE Study “would reveal that adverse experiences in childhood were very common, even in the white middle-class, and that these experiences are linked to every major chronic illness and social problem that the United States grapples with – and spends billions of dollars on.” A fascinating history of how the study came to be can be found on the ACESTooHigh website.

The ACE Pyramid:

The CDC has said, “The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations of childhood abuse and neglect and household challenges and later-life health and well-being.” The study showed a direct correlation between ACEs and long-term health, illustrated by the ACE Pyramid, below.

The ACEs Pyramid graphic

Image Source:

The ACE Score:

The number of exposures to adverse childhood experiences is often referred to as an ACE score. The ACE Study measured 10 different types of childhood trauma exposure; those 10 types were chosen as the subject of the study because they were the types of trauma most commonly reported by a group of about 300 Kaiser members.

To get your ACE score, you can take a quiz on the ACESTooHigh website.

What does the ACE Score Mean?

The ACE Study proved that people with an ACE score of four or higher have a much higher risk of chronic health problems later in life. ACES produce toxic stress in young brains, which actually alters the function of the brain, profoundly damages the immune system, changes how the body responds to stress, and impacts the entire body which leads to long-term health consequences. ACESTooHigh reports that, “ACEs cause much of our burden of chronic disease, most mental illness, and are at the root of most violence.”

However, one thing to keep in mind is that the ACE score is only meant to be a guideline or indicator and is not an absolute predictor of future health. In fact, many mitigating factors can come into play, most significantly, your resiliency score.


According to the ACESTooHigh website, “Resilience generally describes the bounce-back ability of individuals who return to the similar shape, form and condition after misfortune, harm or injury.” Protective factors such as a safe environment, safe and nurturing relationships, stability, knowing you were loved, knowing someone cared about you, having a safe and stable person to turn to when you needed help, can all contribute to a person’s resiliency. The Minnesota Department of Health says, “Protective factors help a child feel safe more quickly after experiencing the toxic stress of ACEs and help to neutralize the physical changes that naturally occur during and after trauma. If the child’s protective networks are in good working order, development is strong even in the face of severe adversity… In sum, even the negative consequences of toxic stress from ACEs can be buffered with the support of caring, competent adults and appropriate intervention and support.”

Little girl hugging safe caregiver

What can public health workers do?

Public health can work to mitigate the effects of ACEs, work to prevent ACEs from being passed down, generation to generation, or even intervene before ACEs occur. This type of upstream intervention can change the long-term overall health of a community. Dr. Robert F. Anda, MD, MS, one of the developers of the original ACE Study, shared some practical ways to do this during his address at a conference in Minneapolis in 2011 (captured on the ACE Study DVD):

  • Education: Public health workers can educate the community at large and policy-makers on ACEs and their effects.
  • Creation of a standardized terminology: In addition, public health workers can help create a standardized terminology for addressing and assessing ACEs so that the prevalence of ACEs, interventions used to address them, and outcomes of those interventions are measurable, communicable, understandable, and repeatable.
  • Population-based or surveillance surveys to document the need which is useful for obtaining funding and political support. Surveys also assist with program planning and evaluation and surveillance helps maintain focus and momentum.

Additionally, public health workers can document their work using an electronic health record (EHR) with a fully integrated standardized terminology such as the Omaha System. The Omaha System is recognized by the American Nurses Association since 1992 and is in use in 96.5% of Minnesota counties. Nightingale Notes EHR by Champ Software has always fully integrated the Omaha System so that any piece of data put into the system can be reported on and outcomes can be fully documented (read about Kitsap County Public Health District’s success with measuring outcomes using Nightingale Notes).

Other suggested resources:

Blog article: Addressing Community Health Through Trauma-Informed Care

ACEs Tools & Resources