Adverse Childhood Experiences (Aces) : © 2022 Elsevier Ltd. All Rights Reserved

Adverse Childhood Experiences (ACEs)
Tracie O Afifi, Ashley Stewart-Tufescu, Tamara Taillieu, Samantha Salmon, Janique Fortier, and Leslie E Roos, Departments of
Community Health Sciences and Psychiatry, University of Manitoba, Winnipeg, MB, Canada
© 2022 Elsevier Ltd. All rights reserved.
Adverse Childhood Experiences 1

Introduction 1
History of the ACE Study 1
How the Field Has Grown Over the Past 20 Years 2
Intergenerational Trauma 3
ACEs and Mental Health 4
Internalizing Disorders 4
Externalizing Disorders 4
Suicidality 5
ACEs and Mental Well-Being 5
ACEs and Physical Health 5
Cardiovascular Conditions 6
Respiratory Conditions 6
Metabolic Conditions 6
Gastrointestinal Conditions 7
Cancer 7
Pain Conditions 8
Potential Mechanisms Linking ACEs to Physical Health Conditions 8
Responding to ACEs With Therapeutic Interventions, Trauma-Informed Care, and Prevention Strategies 8
ACEs and Clinical Psychology 9
Therapeutic Interventions 9
Trauma-Informed Care 10
Prevention Intervention Strategies 10
Future Directions for Research and Clinical Practice for Clinical Psychologists 11
Defining ACEs 11
Tools for Measuring ACEs 11
Universal Screening for ACEs 12
Conclusion 12
References 12
Adverse Childhood Experiences

Introduction
Experiencing adversity in childhood is common and can have an impact on all areas of one’s life. The poor outcomes related to
childhood adversity can occur in childhood and adolescence and can continue across the lifespan. This chapter will review the
history of the field of adverse childhood experiences (ACEs), how ACEs are currently defined, the impact of ACEs on mental
and physical health, responding to and treatment for ACEs, prevention strategies, and future directions and current controversies
in the field (including definitions, tools for assessing ACEs measurement, and universal screening).
History of the ACE Study
The study of childhood adversity, today, is a global public health priority. There is a substantial body of evidence dating back
decades that describes its impact on the long-term consequences for health and wellbeing. Notably, it was the landmark Adverse
Childhood Experiences (ACE) Study, conducted by the Kaiser Permanente health maintenance organization in San Diego, which
led to the term ACEs and its conceptualization as a set of 10 potentially stressful and/or traumatic experiences that may occur during
childhood (Felitti et al., 1998).
The objective of the ACE Study was to examine the associations between adults’ retrospective reports of childhood adversity and
several leading causes of morbidity and mortality in the United States (US; Felitti et al., 1998). This research was guided by earlier
clinical observations during a weight loss program to treat adult obesity, in which it was noted that some patients dropped out of the
program despite successful weight loss and some quickly regained weight (Felitti, 1993). Interviews with these participants revealed
Reference Module in Neuroscience and Biobehavioral Psychology https://doi.org/10.1016/B978-0-12-818697-8.00038-8 1

2 Adverse Childhood Experiences (ACEs)
that many had experienced histories of child abuse and current or prior family challenges or dysfunction (Felitti, 1993). To further
understand the relationship between childhood adversity and adult obesity, a case-control study was conducted to compare the
histories of patients enrolled in the weight loss program to adults who had never been overweight (Felitti, 1993). It was observed
that participants in the obese group reported a significantly higher prevalence of adverse experiences during childhood, including
abuse, loss or prolonged absence of a parent (e.g., due to death, institutionalization, or divorce), a parent or close relative with
alcohol use disorder, and parent or sibling suicide. From these study findings, Felitti and colleagues conducted a large-scale
epidemiological study of childhood adversity and adult health in the US.
The ACE Study was designed as a retrospective cohort study conducted over two waves of data collection between 1995 and
1997. Mail-out questionnaires were sent to adults following a health care appointment at the San Diego Health Appraisal Clinic.
A total of 9508 respondents from Wave I (conducted between August 1995 and March 1996) and 8667 respondents from Wave II
(conducted between June and October 1997) returned the questionnaire (overall response rate ¼ 68%; Felitti et al., 1998; Dube
et al., 2001), which was then linked to their complete standardized medical evaluations. The ACE Study questionnaire from
Wave I assessed physical abuse, sexual abuse, emotional abuse, violence against the respondent’s mother, a household member
with substance use problems, a household member with mental illness, parental separation or divorce, and incarceration of a house-
hold member. The Wave II questionnaire was expanded to include physical and emotional neglect. In addition to the Felitti (1993)
study, prior literature informed the inclusion of these ACE categories (e.g., Ésthier et al., 1995; McCloskey et al., 1995); however,
theoretical or empirical evidence for the selection of these specific categories in the ACE Study has not been published. The 10 ACEs
are often categorized as child maltreatment (i.e., physical, sexual, and emotional abuse, physical and emotional neglect), and
household challenges or dysfunction (i.e., mother treated violently, household member substance abuse, household member
mental illness, parental separation or divorce, and household member incarceration). In many early ACE studies, a count of the
number of ACEs experienced from 0 to 10 is used rather than examining individual ACEs (e.g., Felitti et al., 1998; Dube et al., 2001).
The core publications from the original ACE Study contributed several key findings to the literature. First, the 10 ACEs were
found to be common among this adult cohort, with 64% reporting exposure to at least one ACE (Dube et al., 2001). The prevalence
of individual ACEs ranged from 5% for incarceration of a household member to 28% for physical abuse (Dube et al., 2001).
Second, ACEs were determined to be interrelated and often co-occurring (Felitti et al., 1998; Dong et al., 2004). Specifically, expo-
sure to a single ACE substantially increased the odds of reporting another and, for example, over half of these adults reported an
additional three or more ACEs (Dong et al., 2004). Third, ACEs are associated with numerous long-term health problems, including
mental health conditions and suicidal behavior, substance use and other risk-taking behavior, infectious and chronic diseases, and
poor physical health (Felitti et al., 1998). Fourth, ACEs were found to have strong dose-response relationships with many of the
health outcomes, indicating that exposure to multiple ACEs has a cumulative effect on the risk for poor health (Felitti et al., 1998).
How the Field Has Grown Over the Past 20 Years

Over the past 20 years, the ACEs field has evolved with an extensive and multidisciplinary literature. Early research focused on
understanding the scope of ACEs as a public health problem, with numerous studies replicating and expanding on findings
from the original ACE Study. In more recent years, several systematic reviews and meta-analyses have been conducted to synthesize
our knowledge of the impact of childhood adversity over the life course (e.g., Bellis et al., 2019; Hughes et al., 2017; Petruccelli et al.,
2019). This body of research extends globally and has established ACEs as pervasive across all populations; still, there are important
gaps in our knowledge due to a lack of data from nationally representative surveys, pediatric and emerging adult populations, and
lower income countries that would provide additional context on the diverse cultural and societal aspects related to this problem
(Massetti et al., 2020). More recently, additional research has highlighted the importance of an individual’s perceptions of early
adversities, such as maltreatment, for contributing risk to later life problems as opposed to objective (i.e., court documented)
records (Danese and Widom, 2020).
Since the ACE Study, the field of childhood adversity has also expanded on understanding the interrelationships of individual
ACEs to include other forms of violence and victimization. The polyvictimization literature highlights the importance of consid-
ering the cumulative impact of adverse experiences on health and wellbeing, which may extend beyond the original 10 ACEs to
include, for example, exposure to crime, bullying, or dating violence (Finkelhor et al., 2007). Even research within the original
10 ACEs suggests that interpersonal family victimization adversities (i.e., abuse, neglect, exposure to intimate partner violence)
are more strongly linked to adverse psychosocial outcomes, such as incarceration, compared to less interpersonal adversities
(i.e., parent mental illness, substance use, incarceration; Roos et al., 2016). Both theoretical and empirical evidence indicates
that victimization experienced within the family (e.g., ACEs) is related to victimization in other contexts, such as by peers, romantic
partners, and strangers (Furman and Wehner, 1994; Finkelhor et al., 2007). Victimization can also co-occur with non-victimization
forms of adversity, such as poverty, which may be a source of chronic toxic stress for the child (Walsh et al., 2019). Using a cumu-
lative risk model, researchers have found that individuals who experience multiple forms of victimization and adversity may have
higher risk of negative outcomes (Felitti et al., 1998; Finkelhor et al., 2007). Notably, in a recent meta-analysis it was found that
exposure to multiple adversities was strongly associated with outcomes such as violence perpetration, mental illness, and problem-
atic substance use, which may continue the intergenerational cycle of ACEs (Hughes et al., 2017). Further research is needed to
understand ACEs within a polyvictimization framework so that we can work toward preventing these adverse experiences from
occurring, and to also ensure that children who may be negatively affected receive supportive services and therapeutic interventions.
Adverse Childhood Experiences (ACEs) 3
With robust empirical support for the linkages between ACEs and various health and social outcomes, research over the past two
decades has also sought to enhance our knowledge of these relationships by investigating underlying developmental mechanisms.
Recent work theorizes neurodevelopmental plasticity as one potential mechanism (Sheridan and McLaughlin, 2020). Under the
dimensional model of adversity and psychopathology (DMAP), threat and deprivation are two dimensions through which different
adverse experiences impact neurodevelopment, and thus, health and wellbeing (McLaughlin et al., 2014; Sheridan and McLaughlin,
2014). This model suggests that, for example, child abuse and exposure to violence affect psychopathology through the increased
development of threat perception and hypervigilance, while neglect and poverty operate under the dimension of deprivation and
reductions in global neurodevelopment. This is consistent with research indicating that childhood adversity can impact health
differently depending on the distinct type of exposure, and consequently, may require tailored intervention and treatment (Sher-
idan and McLaughlin, 2020). Although additional research is needed, the DMAP may serve as a framework for the development
of effective intervention strategies to treat the detrimental outcomes associated with ACEs (Sheridan and McLaughlin, 2020).
Related developmental models highlight the role of early life adversities resulting in chronic stress-system activation, which can
fundamentally alter children neurobiology, across epigenetic, neurological, and immune-relate biological functions (Shonkoff
et al., 2012; Nusslock and Miller, 2016). Infants are highly dependent on responsive caregivers to meet basic needs and young chil-
dren need sensitive caregiving input to help cope with and recover from acute stress. In the absence of responsive caregiving (e.g.,
neglect) or in the presence of caregiving-related stressors (e.g., interpersonal violence, caregiver disruptions), children’s stress
response systems can exhibit hyperactivation, which floods the body with pro-inflammatory hormones (Hostinar and Gunnar,
2013). Chronic activation can fundamentally change neuroarchitecture and the cross-talk between brain and immune system,
which is theorized to lead to the persistent low-grade inflammation linked to adiposity, insulin resistance and other pre-disease
states. These physical health vulnerabilities are exacerbated by altered reward processing and threat perception, which contribute
to smoking, substance use, impulsivity and other health-risk behaviors (Nusslock and Miller, 2016).
In the last decade, ACEs research has increasingly prioritized understanding resilience in an effort to facilitate both the treatment
of poor health outcomes associated with ACEs and prevention of childhood adversity. Since some children exhibit resilience
despite exposure to ACEs and do not experience the same negative outcomes as would otherwise be expected, it is of great interest
to identify factors that allow for this positive adaptation. For example, emerging research highlights the role on benevolent child-
hood experiences in promoting psychosocial resilience in low-income pregnant women with high ACEs (Narayan et al., 2018).
Importantly, resilience should be studied within an ecological framework to identify protective factors that occur at the individual-,
family-, school-, and community-levels (Cheung et al., 2017, 2018). Findings from such studies would then be ideally situated to
facilitate the development of evidence-based interventions that foster resilience, help individuals attain health and wellbeing
following exposure to adversity and trauma, and where applicable, prevent the intergenerational transmission of ACEs and address
or challenge the socio-economic and systematic inequalities associated with adversity during childhood.
Intergenerational Trauma
Building on the foundational ACEs research focused primarily on within generational impacts of childhood adversity has generated
interest in elucidating the intergenerational transmission of childhood trauma from parent to offspring. This emerging area of
research involves examining the impact of parental experiences of childhood adversity including intimate partner violence and child
abuse, on child(ren)’s health and developmental outcomes (Thomas et al., 2018a,b), and the quality of the parent-child relation-
ship (Fenerci and DePrince, 2018; Shonkoff and Fisher, 2013). Previous research has put forth various mechanisms to explain this
transmission of trauma from parent to offspring including maladaptive recall and communication of traumatic memories to
offspring and maternal cognitive-related cognitions (Fenerci and DePrince, 2018; Narayan et al., 2019), environmental influences
including maladaptive social supports and punitive parenting practices (Babcock Fenerci and Allen, 2018; Thomas et al., 2018a,b;
Yehuda and Lehrner, 2018), and genetic and epigenetic mechanisms via biological risk factors (Bowers and Yehuda, 2016; Yehuda
and Lehrner, 2018). Developments from the field of epigenetics have found two broad categories of epigenetically mediated effects
including (1) developmentally programmed effects such as the influences of the child’s early environment exposures (e.g., quality of
maternal care and responsive caregiving), and (2) epigenetic changes associated with preconception trauma thought the germline
and fetoplacental interactions during embryonic development (Yehuda and Lehrner, 2018). A recent study of maternal ACEs and
infant stress reactivity found that the maternal hypothalamic–pituitary– adrenal (HPA) axis function during pregnancy mediated
the effects of maternal history of adversity of the infant’s HPA reactivity, therefore indicating that the HPA system plays an essential
role in the transmission of the mother’s experiences of childhood adversity to her offspring (Thomas et al., 2018a,b). In this same
study, social supports including pre-and post-natal supports moderated the relationship between the mother’s HPA axis and the
infant’s cortisol reactivity, indicating that bolstering maternal social supports may be a critical and malleable intervention to reduce
the risk of harmful effects of maternal ACEs on children’s outcomes.
Further developments from the fields of epigenetics, epidemiology, and the social sciences may provide additional insights into
the intergenerational transmission of ACEs that may inform ACEs intervention strategies to prevent the transmission of ACE from
parent to offspring or ameliorate the detrimental effects associated with intergenerational transmission of ACEs in children. Aware-
ness of these mechanisms associated with intergenerational transmission of ACEs from parent to offspring is of critical importance
for clinicians providing targeted interventions for individuals seeking trauma-focused treatments and supports for ACEs related
health impairments. Such clinical interventions may also function as preventative strategies to halt the intergenerational
transmission of ACEs and trauma for future generations.
ACEs and Mental Health
Research on the relationships between ACEs and mental health has accumulated since the original ACE Study over two decades ago
(Felitti et al., 1998) resulting in a robust literature. ACEs have been associated with mental health disorders including internalizing
disorders, externalizing disorders, and suicidality (Felitti et al., 1998; Hughes et al., 2017; Kalmakis and Chandler, 2015), as well as
reduced positive mental health outcomes (Hughes et al., 2016). Associations with poor mental health outcomes have been iden-
tified across the lifespan among children and youth (Scully et al., 2020) and persisting through adulthood (Afifi et al., 2008; Felitti
et al., 1998; Green et al., 2010; Kalmakis and Chandler, 2015; Kessler et al., 2010). Dose-response-type trends have been noted with
more experiences of ACEs associated with incremental increases in poor mental health outcomes (Afifi et al., 2008; Felitti et al.,
1998; Hughes et al., 2016; Kajeepeta et al., 2015; Kessler et al., 2010; Scully et al., 2020).
Researchers have quantified the public health impact of ACEs by estimating their contribution to mental health disorders across
the world using nationally representative samples of adults in countries of various income levels. One study across 21 countries,
ranging from low and middle income to high income, found about 30% of all Diagnostic and Statistical Manual (DSM-IV) mental
health disorders could potentially be attributable to experiences of 12 types of childhood adversities (i.e., parental death, parental
divorce, other separation from parents or caregivers, parental mental illness, parental substance misuse, parental criminality,
parental violence, child physical abuse, child sexual abuse, childhood neglect, life-threatening physical illness, and family economic
adversity; Kessler et al., 2010). A similar study examining the same variables in a nationally representative sample of adults in the US
found almost 45% of all childhood-onset mental health disorders and nearly 26%–32% of later-onset mental health disorders
could be attributed to these ACEs (Green et al., 2010). Another study in a nationally representative sample of US adults found
22%–32% of mental disorders among women and 20%–24% among men could potentially be attributed to child maltreatment
ACEs (i.e., experiencing any childhood physical abuse, sexual abuse, and/or witnessing domestic violence; Afifi et al., 2008). These
three studies illustrate the strong associations between ACEs and mental health disorders that persist through adulthood. The find-
ings also suggest that the prevention and elimination of ACEs may be associated with substantial reductions in mental health disor-
ders across the world. The following section briefly reviews the research on the associations between ACEs and mental health
disorders and well-being.
Internalizing Disorders
ACEs are associated with an increased risk of depressive and anxiety disorders and symptoms across the lifespan, as is consistently
documented in the literature, including several systematic reviews and meta-analyses (Afifi et al., 2008; Felitti et al., 1998; Kalmakis
and Chandler, 2015; Kessler et al., 2010; Li et al., 2016; Lindert et al., 2014; Scully et al., 2020). In Kessler et al.’s (2010) multi-
national study, it was estimated that preventing all ACEs experiences (i.e., the 12 types of childhood adversities listed above) could
potentially be associated with a reduction of about 23% of mood disorders and 31% of anxiety disorders. In Li et al.’s (2016) meta-
analysis, it was estimated that 58.6% of depression and anxiety cases worldwide could potentially be attributed to child maltreat-
ment ACEs (i.e., physical abuse, sexual abuse, and neglect). Reducing child maltreatment experiences by 25% could have the
potential to prevent about 80.3 million cases of depression and anxiety across the world (Li et al., 2016). In a nationally represen-
tative sample of US adults, Afifi et al. (2008) estimated that 25% of mood disorders among women and 23% among men and 22%
of anxiety disorders among women and 20% among men could potentially be attributable to experiences of child maltreatment
types of ACEs (i.e., physical abuse, sexual abuse, and witnessing domestic violence). ACEs are also associated with posttraumatic
stress disorder (PTSD) across the life course among children and youth (Scully et al., 2020) and persisting through adulthood
(Kalmakis and Chandler, 2015).
In Caslini et al.’s (2016) meta-analysis of 32 studies across nine countries, a general association was found between child
maltreatment ACEs (i.e., childhood sexual abuse, physical abuse, and emotional abuse) and eating disorders. There were consistent
associations between experiencing child maltreatment ACEs and bulimia nervosa and binge eating disorders, but mixed findings
related to their associations with anorexia nervosa (Caslini et al., 2016). In a more recent nationally representative sample of US
adults, seven types of child maltreatment (i.e., childhood physical abuse, sexual abuse, emotional abuse, emotional neglect, phys-
ical neglect, and witnessing domestic violence) and harsh forms of physical punishment were associated with anorexia nervosa,
bulimia nervosa, and binge eating disorder (Afifi et al., 2017). Sex differences were noted: among men, childhood sexual abuse
and physical neglect were most strongly associated with eating disorders while sexual abuse and emotional abuse were the strongest
among women (Afifi et al., 2017).
Kajeepeta et al. (2015) conducted a systematic review of the literature examining the association between ACEs and sleep disor-
ders and disturbances in adulthood. In the review, they found ACEs to be associated with sleep apnea, psychiatric sleep disorders,
narcolepsy, sleep paralysis, and nightmare distress (Kajeepeta et al., 2015).
Externalizing Disorders
ACEs are associated with problematic substance use and disorders (Afifi et al., 2008; Hughes et al., 2017; Kalmakis and Chandler,
2015). Kessler et al. (2010) estimated that preventing all ACEs experiences (i.e., the 12 types of childhood adversities listed above)
would be associated with a reduction of 27.5% in substance disorders across 21 countries. In the US, Afifi et al. (2008) found that
32% of substance use disorders among women and 22% among men could potentially be attributable to child maltreatment ACEs.
ACEs are associated with behavior disorders and symptoms among youth and adults (Kessler et al., 2010; Scully et al., 2020).
Abuse and neglect are associated with attention-deficit hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant
disorder (ODD) among children and adolescents (Scully et al., 2020). Among representative samples of adults in 21 countries, it
was estimated that 41.6% of behavior disorders, including ADHD, ODD, conduct disorder, and intermittent explosive disorder,
could potentially be attributable to experiences of 12 ACEs (listed above; Kessler et al., 2010). In a nationally representative study
of adults in the US, Afifi et al. (2019) also found child maltreatment ACEs (i.e., physical abuse, sexual abuse, emotional abuse, phys-
ical neglect, emotional neglect, and exposure to domestic violence) as well as harsh forms of physical punishment to be associated
with antisocial behaviors.
Suicidality
ACEs have been associated with increased risk of deliberate self-harm and suicide attempts among children and youth (Scully et al.,
2020) and suicidal thoughts and behaviors among adults (Afifi et al., 2008; Felitti et al., 1998; Kalmakis and Chandler, 2015). Two
nationally representative studies of adults in North America found child maltreatment ACEs (i.e., physical abuse, sexual abuse, and
exposure to intimate partner violence) to be associated with increased odds of suicidal ideation and suicide attempts (Afifi et al.,
2008; Fuller-Thomson et al., 2016). It was estimated that preventing ACEs experiences would be associated with a reduction of
16% of suicidal ideation among women and 21% among men and 50% of suicide attempts among women and 33% among
men (Afifi et al., 2008).
ACEs and Mental Well-Being

Mental health is not only the absence or presence of mental disorders and symptoms (WHO, 2014); therefore, it is important to
examine the association between ACEs and functioning and well-being that does not meet the criteria for diagnosis, but impacts
peoples’ lives nonetheless. One nationally representative study of adults in England found that nine types of ACEs (i.e., physical
abuse, verbal abuse, sexual abuse, parental separation, exposure to domestic violence, growing up in a household with mental
illness, alcohol abuse, and/or incarceration) were generally associated with low mental well-being and life satisfaction in adulthood
(Hughes et al., 2016).
There is extensive literature documenting the associations between ACEs, defined in multiple ways, and poor mental health
outcomes. There are several mechanisms through which ACEs are theorized to lead to poor mental health outcomes such as neuro-
developmental plasticity and DMAP described above. The cumulative findings suggest that prevention and elimination of ACEs
could potentially be associated with a significant reduction in mental health disorders worldwide. These are considerable findings
given the burden and public health impact of mental health disorders on the population – with an estimated 792 million people
living with a mental disorder globally (Ritchie and Roser, 2020). There are nonetheless limitations to this body of knowledge
including the cross-sectional nature of much of the literature which could benefit from additional longitudinal studies and meth-
odological improvements.
ACEs and Physical Health
There is considerable evidence that ACEs are related to poor physical health outcomes (Vig et al., 2020). Further, effect sizes from
various meta-analyses examining the relationship between ACEs and poor physical health outcomes are similar in magnitude as
those for the relationship between ACEs and mental health problems (Wegman and Stetler, 2009). ACEs are also strongly associated
with engagement in risky health behaviors such as smoking, overeating, risky sexual behaviors, and substance use (Bellis et al., 2019;
Brown et al., 2010; Campbell et al., 2016; Felitti et al., 1998; Hughes et al., 2017; Monnat and Chandler, 2015; Petruccelli et al.,
2019). These health harming behaviors, in turn, contribute to the development of chronic physical health conditions and premature
mortality.
ACEs are also associated with increased health care utilization (e.g., primary care visits, emergency room visits, hospitalizations,
rate of prescriptions) in adulthood (Bellis et al., 2017; Chartier et al., 2010; Vig et al., 2020). Often dose–response relationships are
noted, with increasing number of ACEs associated with increased risk of physical health conditions (Felitti et al., 1998; Bellis et al.,
2014), having multiple health conditions (Chartier et al., 2010), and mortality (Bellis et al., 2014; Brown et al., 2010). In fact, it is
estimated that a 10% reduction in the prevalence of ACEs would translate into an annual savings of $105 billion dollars across
Europe and North America (Bellis et al., 2019).
A combination of ACEs prevention, resilience building, and trauma-informed support could substantially reduce the costs asso-
ciated with ACEs (Bellis et al., 2019). However, interventions to reduce chronic physical health conditions usually target health
harming behaviors rather than the underlying risk factors, such as ACEs, strongly associated with engagement in these types of
behaviors (Bellis et al., 2019; Dong et al., 2004). Early intervention in preventing ACEs may be more effective in reducing chronic
physical health conditions and early death than attempts to modify health behaviors or improve health care access in adulthood
(Dong et al., 2004; Monnat and Chandler, 2015; Hughes et al., 2017). The following section briefly reviews research on the relation-
ship between ACEs and physical health conditions.
Cardiovascular Conditions
Research indicates consistent support for the relationship between ACEs and cardiovascular conditions. The original ACE Study
(seven ACEs assessed) found an association between having experienced four or more ACEs and ischemic heart disease and stroke
in adulthood (Felitti et al., 1998). This is similar to findings from other representative samples. For example, data from the 2011
Behavioral Risk Factor Surveillance System (BRFSS) from the US (N ¼ 48,526 adults from five states with the ACE module) found an
association between total number of ACEs and myocardial infarction, coronary heart disease, and stroke (Campbell et al., 2016). A
strong graded relationship between total number of ACEs and cardiovascular disease and stroke has also been noted in a nationally
representative sample from England (Bellis et al., 2014). In a representative adult sample from Canada, any child abuse was asso-
ciated with high blood pressure and stroke, but not heart disease (Afifi et al., 2016). Dose-response relationships between child
abuse and cardiovascular conditions were not found in the study, which could be due to the limited number of ACEs (i.e., physical
abuse, sexual abuse, and exposure to intimate partner violence) assessed in this study. However, meta-analytic findings suggest
a moderately strong relationship between child maltreatment history and cardiovascular disease and heart problems in adulthood
(Wegman and Stetler, 2009). In a meta-analysis examining the effects of multiple ACEs (defined as exposure to four or more ACEs)
on health, a moderate relationship was found between multiple ACEs and cardiovascular disease (Hughes et al., 2017). Different
meta-analytic findings also indicate a graded relationship between total ACEs and ischemic heart disease; however, relationships
between ACEs and stroke and hypertension were not significant (Petruccelli et al., 2019).
There is also research suggesting that individual types of ACEs are associated with cardiovascular conditions. Data from the ACEs
Study found that 9 of the 10 ACEs assessed (exception was parental separation/divorce), as well as total number of ACEs, were asso-
ciated with an increased risk of ischemic heart disease (Dong et al., 2004). In addition, dose–response relationships largely
remained significant after adjustment for sociodemographic covariates, and both traditional (i.e., smoking, physical inactivity,
body mass index, diabetes, and hypertension) and psychological (i.e., anger and depression) risk factors for cardiovascular disease
(Dong et al., 2004). Data from the 2011 BRFSS noted differences in associations for types of individual ACEs and cardiovascular
outcomes. For example, household member incarceration was associated with myocardial infarction, and verbal abuse was associ-
ated with coronary heart disease, but none of the individual ACEs were independently associated with stroke (Campbell et al.,
2016). Data from the 2009–12 BRFSS (N ¼ 52,250 US. adults from 14 states with ACE module) indicate that specific ACEs
(i.e., physical abuse, parental separation/divorce, household substance abuse, household member incarceration) were associated
with increased odds of heart attacks (Monnat and Chandler, 2015), independent of the effects of adult socioeconomic status
and concurrent ACEs.
Respiratory Conditions
Research also indicates consistent support for the relationship between ACEs and respiratory conditions. The original ACE Study
found a strong graded relationship between ACEs and chronic bronchitis and/or emphysema (Felitti et al., 1998). Of note, expe-
riencing even one ACE (vs. none) was associated with increased odds of chronic bronchitis/emphysema in this study (Felitti et al.,
1998). Using ACE follow-up data, graded relationships were also reported across different measures of chronic obstructive pulmo-
nary disease (COPD) including baseline reports as well as incident hospitalizations with COPD as discharge diagnosis and rate of
prescriptions to treat COPD in the follow-up period (Anda et al., 2008). Relationships between ACEs and COPD were only moder-
ately attenuated after adjustment for smoking status and other risk factors for COPD (i.e., socioeconomic indicators, obesity, and
diabetes). In a meta-analysis examining the effects of multiple ACEs on health (defined as four or more), a moderately strong rela-
tionship was found between multiple ACEs and respiratory disease (Hughes et al., 2017). Different meta-analytic findings also indi-
cate a significant relationship between total number of ACEs (Petruccelli et al., 2019) and child maltreatment history (Wegman and
Stetler, 2009) and an increased risk of respiratory conditions. Strong graded relationships between total number of ACEs and respi-
ratory disease have also been noted in nationally representative samples from England (Bellis et al., 2014) and the US (Cunningham
et al., 2014). However, in the US, the relationship only held for women (Cunningham et al., 2014). Dose–response relationships
between child abuse history and respiratory conditions (i.e., chronic bronchitis, emphysema, COPD) have also been reported in
a nationally representative sample from Canada (Afifi et al., 2016).
There is also some indication that specific types of individual ACEs are independently associated with an increased risk of respi-
ratory conditions. For example, Cunningham et al. (2014) found that verbal abuse, sexual abuse, witnessing domestic violence,
household member substance use, and parental separation/divorce (but not physical abuse, household member mental illness,
or household member incarceration) were significantly associated with COPD among women. Cunningham et al. (2014) also
examined the relationship between ACEs among never smokers, and found that physical abuse, sexual abuse, household member
substance use, and experiencing five or more ACEs were still significantly associated with COPD in never smoker women. Thus,
findings suggest that the relationship between ACEs and respiratory disease is not fully explained by smoking.
Metabolic Conditions
Unlike some other chronic health conditions (e.g., cardiovascular and respiratory disease), studies appear to show a threshold
response versus a dose-response relationship in the association between ACEs and diabetes (Huffhines et al., 2016). For example,
in the original ACEs Study, although increasing number of ACEs was associated with severe obesity (defined as a body mass index
35), ACEs were only associated (borderline significance) with an increased risk of diabetes at four or more ACEs (Felitti et al.,
1998). Data from 2011 BRFSS found an association between total number of ACEs and diabetes; however, effect sizes were similar
across different levels of exposure (Campbell et al., 2016). In contrast, a strong graded relationship between the total number of
ACEs and diabetes has been noted in a nationally representative sample from England, although the relationship between ACEs
and diabetes was only significant at four or more ACEs (Bellis et al., 2014). Meta-analytic findings suggest a weak to modest relation-
ship between multiple ACEs (defined as four or more) and diabetes (Hughes et al., 2017). Other meta-analytic findings have also
reported significant relationships between exposure to ACEs and risk of type 2 diabetes (Huang et al., 2015) and child maltreatment
history and metabolic disorders (Wegman and Stetler, 2009). In contrast, Petruccelli et al.’s (2019) meta-analysis failed to find
a significant relationship between the total number of ACEs and diabetes. However, studies included in the meta-analysis were
limited to those using the CDC-Kaiser ACE tool which could account for differences in findings. As well, the relationship between
any child abuse (i.e., physical abuse, sexual abuse, and/or exposure to intimate partner violence) or the total number of types of
child abuse (i.e., 0–3 types) and diabetes were not significant in a nationally representative Canadian sample (Afifi et al., 2016).
There is also some indication that specific types of individual ACEs are independently associated with an increased risk of dia-
betes. For example, data from the 2011 BRFSS indicated that only sexual abuse and verbal abuse were associated with a significantly
increased risk of diabetes (Campbell et al., 2016). In this study, exposure to domestic violence was associated with a decreased risk
of diabetes. Data from the 2009–12 BRFSS also indicated that specific ACEs (i.e., physical abuse, sexual abuse, and exposure to inti-
mate partner violence) were associated with increased odds of diabetes when all types of ACEs were entered into models simulta-
neously (Monnat and Chandler, 2015). However, relationships were largely mediated by adult socioeconomic status and coping.
Differences in the two studies using BRFSS data could be due to differences in the covariates included in multivariate models.
Finally, in a meta-analysis examining the association between ACEs and type 2 diabetes, effects sizes were larger for neglect relative
to physical and sexual child abuse.
Gastrointestinal Conditions
Meta-analytic findings suggest a graded relationship between total number of ACEs and gastrointestinal disease (Petruccelli et al.,
2019). Similarly, meta-analytic findings also report a significant relationship between the effects of multiple ACEs (defined as four
or more ACEs) and liver or digestive disease (Hughes et al., 2017). Exposure to four or more ACEs was also strongly associated with
increased risk of liver disease in a nationally representative sample from England (Bellis et al., 2014). Meta-analytic findings also
indicate moderately strong relationships between child maltreatment and gastrointestinal disorders (Wegman and Stetler, 2009).
This is similar to findings from a representative adult sample from Canada that found both any child abuse and the total number of
types of child abuse were associated with increased odds of bowel disease (i.e., Chrohn’s disease, ulcerative colitis, irritable bowel
syndrome (IBS), bowel incontinence; Afifi et al., 2016). There is also some preliminary evidence that relationships between ACEs
and IBS may vary as a function of the type of ACE. For example, in a case-control study (n ¼ 148 with IBS and n ¼ 154 healthy
controls), IBS patients reported a significantly higher prevalence of emotional abuse, household mental illness, and household
member incarceration than healthy controls (Park et al., 2016). No significant differences in the prevalence of other types of
ACEs (i.e., physical abuse, sexual abuse, parental separation/divorce, parent treated violently, or household substance use) were
found in the study. In addition, among IBS patients, the total ACE score was moderately correlated with both IBS severity and
abdominal pain (Park et al., 2016).
Cancer
There is also evidence suggesting a relationship between ACEs and cancer (Afifi et al., 2016; Brown et al., 2010; Felitti et al., 1998;
Holman et al., 2016; Hughes et al., 2017). For example, data from the original ACE Study found an association between four or
more ACEs and any type of cancer (Felitti et al., 1998). Data from the original ACE study also found a graded relationship between
total number of ACEs and lung cancer in the follow up period (Brown et al., 2010). In this study, relationships were attenuated, but
not entirely eliminated, after adjustment for smoking status suggesting other mechanisms may be implicated in the relationship
between ACE exposures and lung cancer (Brown et al., 2010). Strong graded relationships between ACEs and any cancer have
also been noted in other representative samples (Afifi et al., 2016; Bellis et al., 2014). In a meta-analysis examining the effects of
multiple ACEs (defined as four or more ACEs) on health, a moderate relationship was found between multiple ACEs and cancer
(Hughes et al., 2017). However, findings from a different meta-analysis based on studies using the CDC-Kaiser ACE scale failed
to find a significant relationship between ACEs and cancer risk (Petruccelli et al., 2019). There is also some indication that relation-
ships may vary as a function of the type of ACE. For example, a systematic review study found an association between child maltreat-
ment ACEs (i.e., physical, psychological, and sexual abuse) and the risk of cancer in adulthood (Holman et al., 2016). Of the five
studies included in the review that used ACE summary scores, all five found a significant relationship between ACEs score and adult
cancer risk (Holman et al., 2016). In addition, four studies examined individual ACEs and cancer risk, and found that physical and
psychological abuse significantly increased risk across studies. Other types of traditional ACEs (e.g., parental divorce, household
substance use, financial difficulties) were not generally associated with cancer risk (Holman et al., 2016). It is also important to
note that most studies examine the risk of any cancer, when different types of cancer actually represent distinct diseases with
different causal factors and etiologic pathways (Holman et al., 2016).
Pain Conditions
There is also increasing evidence that ACEs are associated with chronic pain conditions. For example, data from the original ACEs
Study reported a significant relationship between each individual ACE and the total number of ACEs and frequent headaches
(Anda et al., 2010). Similarly, individual ACEs and total number of ACEs have also been associated with pain conditions (i.e., oste-
oarthritis, chronic neck/back pain, and frequent or severe headaches) in a cross-sectional survey of adults from 10 countries (Scott
et al., 2011). The relationship between ACEs and different pain conditions has also been reported in other representative samples.
A nationally representative Canadian adult sample reported a significant association between any child abuse (i.e., physical abuse,
sexual abuse, and/or exposure to intimate partner violence) and pain conditions including arthritis, back problems, and migraines
(Afifi et al., 2016). Relationships between ACEs and adult onset neck/back pain and any pain have also been reported in a nationally
representative sample from Japan (Stickley et al., 2015). In addition, longitudinal data from the National Comorbidity Study found
a significant relationship between ACEs (retrospectively assessed at time 1) and the total number of painful medical conditions (e.g.,
arthritis/rheumatism, chronic neck/back problems, severe headaches, other chronic pain) assessed at the 10 year follow-up (Sachs-
Ericsson et al., 2015). Further, data from the longitudinal 1958 British Birth Cohort Study reported that ACEs (assessed at age 7 years)
were associated with chronic widespread pain at age 45 years (Jones et al., 2009). The relationship between ACEs and frequent or
severe headaches (Mansuri et al., 2020) and pediatric chronic pain (Nelson et al., 2017) has also been reported in child and adolescent
samples.
Meta-analytic findings have also reported a moderately strong association between child abuse and chronic pain (Davis et al.,
2005), as well as a significant graded relationship between total number of ACEs and somatic pain/headaches (Petruccelli et al.,
2019). However, a representative adult sample from Germany failed to find a significant association between ACEs and chronic
noncancer pain (Häuser et al., 2019) or arthritis/rheumatism or headache (Stickley et al., 2015). However, several studies have re-
ported a strong graded relationship between total number of ACEs and chronic pain conditions, including pain which restricts daily
activities (Chartier et al., 2010), somatic pain/headaches (Petruccelli et al., 2019), frequent and/or severe headaches (Anda et al.,
2010; Mansuri et al., 2020), neck/back pain (Stickley et al., 2015), and arthritis, back pain, and migraines (Afifi et al., 2016).
There is also some indication that individual types of ACEs are associated with chronic pain conditions. For example, financial
difficulties, maternal death, and period of institutional care (but not parental divorce or parental alcoholism) assessed at age 7 years
were all independent predictors of chronic pain at age 45 (Jones et al., 2009). In a representative adult sample from Ontario, Can-
ada, physical abuse, parental mental illness, and low parental education (but not sexual abuse, marital conflict, or poor parent-child
relationships) remained significant independent predictors of pain which restricts daily activities when all types of ACEs were
entered into models simultaneously (Chartier et al., 2010). Data from a nationally representative sample from the US found
that verbal abuse, sexual abuse, household mental illness, and early parental loss (but not physical abuse or family or origin
income) were independently associated with the total number of painful medical conditions (Sachs-Ericsson et al., 2015). A nation-
ally representative study from Japan found that physical abuse was independently associated with neck/back pain and both physical
and sexual abuse were independently associated with any chronic pain when all 11 ACEs entered into model simultaneously (Stick-
ley et al., 2015). Relationships between specific types of ACEs on chronic pain conditions is likely at least partially contingent on the
types of ACEs included in analyses as well as the specific pain outcome of interest. Stickley et al. (2015) also note that the cumulative
effects of multiple ACEs tend to be more strongly associated with pain conditions than any individual ACE.
Potential Mechanisms Linking ACEs to Physical Health Conditions

ACEs shape exposure to direct and indirect health risks (Monnat and Chandler, 2015). ACEs also lead to changes in psychological
and physiological responses to stress and increase allostatic load; therefore, increasing disease risk (Bellis et al., 2014; Vig et al.,
2020; Wegman and Stetler, 2009). Several potential mechanisms have been suggested as pathways through which ACEs contribute
to physical health conditions in adulthood. For example, ACEs are associated with engagement in risky health behaviors (Felitti
et al., 1998), which likely contribute to the development of physical health issues later in life. As well, ACEs are also strongly asso-
ciated with mental health problems across the lifespan (Afifi et al., 2008; Green et al., 2010; Kessler et al., 2010), and there is some
evidence that the relationships and ACEs is partially mediated by mental health problems (Dong et al., 2004: Sachs-Ericsson et al.,
2015). Early exposure to ACEs can also affect brain development as well as lead to lasting changes in neurological, hormonal, and
immunological functioning (Bellis et al., 2014, 2019), changes that have been implicated in the development of many different
physical health conditions such as chronic pain, cancer, and cardiovascular and respiratory disease. Research aimed at identifying
the specific pathways through which ACEs impact physical health, and how relationships might vary across types of ACEs and
health conditions, is an important avenue for future research (Monnat and Chandler, 2015).
Responding to ACEs With Therapeutic Interventions, Trauma-Informed Care, and Prevention Strategies
Given the global prevalence of ACEs, the robust body of evidence documenting the detrimental outcomes associated with ACEs over
the life course, and the widespread uptake of ACE screening practices, there is a need for evidence-based strategies to (1) prevent
ACEs from occurring, (2) increase caregiver capacities to promote child resilience in the face of ACEs and (3) treat individuals
with health impairments induced by adversity during childhood. Prevention strategies and therapeutic interventions are discussed
below. Beyond providing direct psychotherapy, clinical psychologists may be involved with consulting or supervising interdisci-
plinary treatment teams of other allied health professionals aiming to prevent of intervene on the consequences of ACES.
ACEs and Clinical Psychology

Addressing both ACEs prevention and treatment from a public health perspective requires a socio-ecological and multidisciplinary
collaborative approach. The discipline of clinical psychology is an essential component of any such approach. Clinical psychologists
are well-positioned to provide evidence-based treatments from a trauma-informed perspective for individuals identified as having
health impairments and psychopathology associated with exposure to adversity during childhood.
In the mental health domain, clinical psychology holds an important role in both providing psychotherapy for clients with
a history of ACEs and conducting clinical research to develop effective treatments. For example, cognitive behavioral therapy has
been identified as a particularly effective treatment for individuals with depression and a history of ACEs, with efficacy over and
above other treatment modalities (Harkness et al., 2012). Such a personalized treatment approach for individuals with ACEs history
is still very much in its infancy, with additional therapeutic modalities under-development, such Dialectical Behavior Therapy for
Post-Traumatic Stress Disorder amongst individuals with child abuse histories (Bohus et al., 2019).
Clinical psychologists can also play an important role in ACEs prevention efforts that include providing parenting supports to
prevent physical punishment and/or abuse in an effort to interrupt the intergenerational transmission of trauma associated with
ACEs (Korotana et al., 2016). Neglect is increasingly understood as a developmentally harmful and highly prevalent ACE, consis-
tently described as the most frequent reason for child welfare involvement (e.g., Kim and Drake, 2019). Importantly, neglect is both
linked to more systemic environmental stressors such as poverty and single-parent status in addition to being strongly linked to the
intergenerational transmission of maltreatment (Bartlett et al., 2017). Accordingly, experts in pediatrics and prevention science have
increasingly highlighted a need for clinical research on building caregiver capacities across domains such as mental health,
substance use, economic, and social support resources as a primary prevention approach to preventing exposure to child ACEs
and their sequalae (Shonkoff and Fisher, 2013).
Therapeutic Interventions
Implementing therapeutic interventions for ACEs is complex given that currently there is no single evidence-based intervention or
suite of interventions that have been proven to treat the myriad of mental and physical health impairments associated with adversity
experienced during childhood (Finkelhor, 2018; McLennan et al., 2020a,b). This may be attributed to several factors. First is the
scope and number of diverse experiences of adversity that are included in the original list of ACEs. This becomes ever more complex
as the list of ACEs continues to expand to include other contemporary experiences of adversity during childhood associated with
detrimental health outcomes, including physical punishment, peer victimization and cyberbullying, peer isolation/rejection, and
community violence exposure (Afifi et al., 2017; Finkelhor et al., 2015). Second, the tools used to assess ACEs are based primarily
on crude counts and do not typically assess chronicity, severity, and/or onset of the adversity. The limited information about an
individual’s ACE history garnered from commonly utilized ACEs tools (e.g., The ACEs Questionnaire, Felitti et al., 1998) makes
it challenging for any practitioner alone to refer a client to appropriate supportive services and/or to decide to administer a thera-
peutic treatment themselves, should one be available. Related, a third factor is the health and functional impairments associated
with ACEs. Many ACE assessment tools utilized in primary care and social services contexts evaluate exposures and risks, and do
not involve an assessment of ACE-associated health impairments and/or current symptomatology. Information about ACE-
specific health and functional impairments would need to be deduced through additional inquires by the practitioner, which
may result in client distress (Dube, 2018; Finkelhor, 2018). Accordingly, only practitioners with mental health training would
be advised to inquire about ACEs and would only be advised to do so, if it were to directly inform clinical care. Lastly, a fourth
factor is the concept of resiliency. Resilience is defined as a process whereby an individual with a history of exposure to adversity
is able to thrive with relative success despite the challenges experienced during their childhood (Masten 2013; Oshri et al., 2020).
Widely utilized ACE assessment tools tend to only focus on an individual’s history of childhood adversity and is a crude assessment
of risk factors. These tools do not consider the protective factors and individual resources and personal assets that may explain how
an individual is resilient in the context of adversity, and without any resulting impairments over the life course (Cicchetti, 2010;
Masten 2014). Research has found that positive childhood experiences such as social support and a sense of belonging are associ-
ated with lower adult depression and/or poor mental health and higher adult reported social and emotion support after adjusting
for ACEs (Bethell et al., 2019). Understanding both an individual’s risk and protective factors is essential for any practitioner to best
attend to the individual client’s presenting or underlying health impairments associated with their ACE history (Afifi et al., 2016;
Oshri et al., 2018). Together, these factors highlight the complexities and challenges associated with evidence-based therapeutic
interventions to treat ACEs. However, notable progress has been made in regards to the treatment of specific child maltreatment
ACEs, generally, and the sub-types of child maltreatment (e.g., physical abuse and sexual abuse), specifically.
A systemic review of evidence-based treatments for maltreated children with trauma-related mental health impairments found
that trauma-focused cognitive behavioral therapy (TF-CBT) was the best supported treatment approach for maltreated children with
psychopathologies, including PTSD (Leenarts et al., 2013). Other treatment interventions target parents directly to reduce child
maltreatment. Home visiting interventions focused primarily on injury prevention and home safety have demonstrated significant
reductions in child maltreatment, including physical abuse. For example, Project SafeCare was found to reduce the recurrence of
child maltreatment in families where maltreatment had previously been substantiated (Gershater-Molko et al., 2003). Another
intervention is the Nurse Family Partnership (NFP). This intervention entails nurses providing home visits to first time mothers
beginning during pregnancy and continuing for the first two years of the child’s life. During these visits the nurse aims to promote
improvements in the mother’s behavior thought to affect pregnancy outcomes and developmental outcomes of the child; to help
the mother to build a supportive parenting network; and to connect the mother with other health and social services that may
promote healthy life course development (Olds, 2006). The NFP has been rigorously evaluated in multiple countries and has
been found to reduce child maltreatment, including child protective service reports, by up to 42% (Mejdoubi et al., 2015). The
Parent-Child Interaction Therapy (PCIT), a parent behavior intervention that involves intense coaching from a trained therapist,
has also been shown to reduce recidivism of physical child abuse (Kennedy et al., 2016). Recently, emotion regulation skills
have been found to mediate the relationships between ACEs and poor mental and physical health conditions and quality of life
(Cameron et al., 2018). Emotion regulation-based interventions and resiliency training programs designed to target the deficits
in the social, emotional, and cognitive domains induced as a result of childhood adversity have been proposed as promising treat-
ment approaches for both adults and children with persistent distress (Cameron et al., 2018; LeBlanc et al., 2017; Purewal Boparai
et al., 2018). Additional rigorous research, including an assessment of the feasibility, relevance, effectiveness, and impact of ther-
apeutic interventions designed to target ACEs related mental and physical health impairments continues to be of importance.
Trauma-Informed Care
While not a therapeutic intervention or treatment, trauma-informed care (TIC) is an approach or perspective to client care that
focuses on understanding the effects of trauma and ACEs that is multi-disciplinary and widely applicable in diverse settings (Pio-
trowski, 2020). A common definition of TIC is “a child and family service system in which all parties involved recognize and
respond to the impact of traumatic stress on those who have contact with the system including children, caregivers, and service
providers. Programs and agencies within such a system infuse and sustain trauma awareness, knowledge, and skills into their orga-
nizational cultures, practices, and policies. They act in collaboration with all those who are involved with the child, using the best
available science, to maximize physical and psychological safety, facilitate the recovery of the child and family, and support their
ability to thrive” (The National Child Traumatic Stress Network, 2016, p. 1).
Central to a TIC approach is the consideration of trauma and traumatic responses from an ecological lens with an emphasis on
the historical, gendered, and cultural context that envelop the affected individual (Piotrowski, 2020). In practice, a TIC approach
involves asking the client to “Help me understand what has had happened to you”, rather than asking, “What is wrong with you?”. The
core components of a TIC approach include establishing physical and psychological safety, trustworthiness and transparency,
peer support, collaboration, empowerment, and humility and responsiveness (The National Child Traumatic Stress Network,
2016, p. 1). Implementing a TIC approach requires multi-system changes that involves not only the individual clinician in direct
or primary contact with the client, but the entire organization including the support staff and allied health professionals, the orga-
nizational policies and governance, and even the setup of the physical environment to avoid the risk of re-victimization and further
trauma to the individual (Pynoos et al., 2008; Racine et al., 2020; Shimmin et al., 2017). Ideally, all evidence-based therapeutic
interventions intended to support individuals with health impairments associated with childhood adversity should involve targeted
approaches that address their specific adversities and related impairments, and be initiated from a universal and system-wide,
trauma-informed approach (Bunting et al., 2019; Racine et al., 2020).
Prevention Intervention Strategies

While advancements related to therapeutic interventions and treatments are essential, more concerted efforts need to address ACEs
prevention efforts (Afifi and Asmundson, 2020; Tonmyr and Hovdestad, 2013; Tonmyr et al., 2020). From a public health perspec-
tive, ACEs prevention strategies involve formulating and implementing a multi-tier prevention framework that includes universal,
targeted, and indicated programmatic strategies aimed at preventing the root causes of all ACEs (Brennan et al., 2020). However, as
is the case with therapeutic interventions to treat the ACEs-related health impairments, currently, there is no single prevention strategy
or comprehensive effort that addresses all ACEs (Brennan et al., 2020).
The majority of evidence-based prevention efforts target a subset of ACEs, including specific forms of child maltreatment. The
majority of these prevention efforts aim to enhance positive parenting skills and encourage supportive parent-child interactions
through group support programs or individualized home-based supports (Gershoff et al., 2017). Many of these prevention efforts
and educational programs have shown promise at preventing child maltreatment including physical abuse in the context of the
family environment (Brennan et al., 2020); however, very little is known about how well these prevention interventions function
in diverse contexts and with populations that differ from the original evaluative setting and target population (Mikton and Butchart,
2009; Mikton et al., 2016). A significant gap in our understanding of prevention strategies is specific to the ACEs categorized as
“household challenges” (e.g., substance abuse, and caregiver’s incarceration). Prevention of these specific childhood adversities
requires broader community- and societal approaches that address the underlying structural, cultural, gendered, and historical
and contemporary roots causes of childhood adversity and underlying trauma. The social determinants of health (SDoH) frame-
work is a comprehensive approach to increase awareness of the household- and community-level ACEs in any prevention efforts
(Brennan et al., 2020). From a SDoH perspective, ACEs prevention efforts must address not only the individual-, and family-
related ACEs, but equally, consider the community- and societal-level factors associated with perpetuating adversity during
childhood. Utilizing a SDoH framework from a trauma-informed perspective to promote prevention efforts may help to mitigate
the risk factors associated with ACEs, and bolster the protective factors that may enhance resiliency in the context of childhood
adversity (Brennan et al., 2020; Danielson and Saxena, 2019).
In sum, while there is a need to advance research specific to evidence-based interventions to treat the numerous impairments
associated with ACEs among diverse populations and in diverse contexts, more attention, resources, and efforts must be directed
toward ACEs prevention efforts. This should include a multi-dimensional public health approach that addresses the various
determinants of health that target the systemic root causes of ACEs from a trauma-informed perspective. Together, targeted
evidence-based therapeutic interventions and comprehensive prevention strategies are the best defense against the intergenerational
transmission of ACEs for future generations.
Future Directions for Research and Clinical Practice for Clinical Psychologists
Defining ACEs
The term ACEs has been more consistently used to in the literature since the 1998 Felitti study to indicate the 10 ACEs from this
work (Felitti et al., 1998). Interestingly, however, the inclusion of these 10 ACEs in the original ACEs Study was not based on a theo-
retical perspective or empirical evidence. This is not an exhaustive list of all adverse events that could occur in childhood, nor was it
intended to be an exhaustive list. However, over the last two decades, the term ACEs generally refers to these 10 experiences. Impor-
tantly, inconsistencies do exist with what is included as ACEs in research studies. More specifically, not all studies that use the term
ACEs include all 10 ACEs. Some studies will only include some of the ACEs. Other studies may include some of the original 10
ACEs, but then also include additional adverse events such as community violence (e.g., Hambrick et al., 2018) or parental death
(e.g., Berg et al., 2018). There are many reasons why some ACEs studies do not include all 10 ACEs and why some studies add other
adverse experiences. These reasons include ethical restrictions on asking about adversity in some populations, not having all ACEs
assessed in existing data, adding other adverse experiences that are relevant to advance the knowledge, among others.
It is important to think more critically of this list of 10 ACEs and how we define ACEs. Having a short list of 10 ACEs makes it
easier for clinical practice and in research. However, these 10 ACEs do not adequately represent childhood adversity. Generating
a long list is possible and may be more comprehensive, but may not be of practical use in clinical practice or in research. In addition,
much of the ACEs work has been conducted in the US When considering ACEs from a global perspective, it may be important to
expand the definition of ACEs to include experiences that may be more typical in other countries. In fact, the WHO did develop the
Adverse Childhood Experiences International Questionnaire (ACE-IQ) to include a more global perspective on adversity (WHO,
2011a, 2011b, 2011c). However, to date only a small number of studies have been published using the ACE-IQ (Kiburi et al.,
2018; Naal et al., 2018; Almuneef et al., 2014; AlShawi and Lafta, 2014).
Rather than investing in efforts to revise or expand the list of ACEs, it may be more useful to not restrict the term ACEs to only
include the five types of child maltreatment and the five types of household challenges used in Felitti et al. original 1998 study.
Rather, it may be more useful to think of ACEs more broadly to still include experiences such as child maltreatment and household
challenges, but also include other ACEs such as spanking (Afifi et al., 2017), poverty (Finkelhor et al., 2013; Finkelhor et al., 2015),
parental death, sibling death, bullying (Finkelhor et al., 2013, 2015), foster care, sibling violence (Finkelhor et al., 2013, 2015), major
childhood illness, long-term separation due to deployment or immigration, and dating violence. It may not be important or reason-
able for one study to include all ACEs. Rather, researchers should focus on specific research questions and ACEs that are relevant to
specific research questions and then use valid and reliable tools to collect high quality data to advance the field. As well, clinicians
should not restrict their understanding of adversity in childhood to only these original 10 ACEs since these ACEs do not adequately
capture all adversity in childhood. More details on the definitions of ACEs can be found elsewhere (Afifi, 2020).
Tools for Measuring ACEs

To date, there are a number of valid and reliable instruments that have been developed to assess child maltreatment in research. A
review of some of these tools can be found elsewhere (Holden et al., 2020). However, the ACEs tool and its derivatives that are
commonly used to assess the original 10 ACEs have been constructed without any testing of psychometric properties to determine
validity and reliability. Instead, the commonly used ACEs tool includes some items taken from a variety of child maltreatment
instruments (Holden et al., 2020). Notably, however, even if the original instruments that the items were drawn from were deter-
mined to have good reliability and validity, it does not mean these psychometric properties will hold when items are extracted from
the original tools. Additionally, other items were included to assess household challenges. The ACEs tool is a short assessment with
“yes” or “no” questions asking about childhood adversity that will tally a score that is equal to the number of ACEs experience
(ranging from 0 to 10). The tool does not distinguish between single versus chronic or repeated occurrences of ACEs. The ACEs score
has been described as a crude measure of childhood stress (Anda et al., 2020). Despite the lack of rigor in the development of the
ACEs tool and its derivates, the tool has been widely used in clinical practice and in research.
Although the tool has been recommended for use, recently, some academics have begun to question the use of the ACEs tool.
Specifically, problems identified with the ACEs tool include: only assessing 10 ACEs, the collapsing of items and response options
for original tools, an overly simplistic scoring approach, and the absence of psychometric assessment (McLennan et al., 2019,
2020a,b). Because of these deficiencies, it has been recommended that the ACEs tool and its derivatives in the current forms no
longer be used for either clinical or research purposes (McLennan et al., 2019).
Universal Screening for ACEs

Screening for some health conditions has become a common practice. However, we do not screen all people for all conditions. Making
decisions on what conditions to screen for are based on a number of scientific criteria including developing technology to accurately
detect the condition, knowing that screening will not result in harm, and having evidence-based treatments or interventions available
when needed. Generally speaking, there are several questions that need to be answered when deciding on implementing a specific
universal screening program. These criteria specific to ACEs have been discussed in detail elsewhere (McLennan et al., 2020a,b).
Recently, there has been a push to conduct universal screening for ACEs. On the surface, this may seem like an excellent idea. We
know that ACEs are common and are related to numerous poor health and social outcomes. Screening for ACEs is a well-intentioned
idea, but one that is significantly flawed. First, it is important to remember that ACEs are not a health condition and may be risk
factors for health-related impairments. It is not common practice to screen for risk factors. Second, we do not have any evidence-
based tools to detect ACEs. As previously mentioned, there is currently an ACEs tool that is used to simply count the number of
ACEs one has experienced from 0 to 10. The ACEs tool is not a diagnostic tool (Anda et al., 2020). This tool was not developed
for screening and has never been tested to determine if it accurately detects ACEs. There are risks and consequences related to falsely
categorizing a person as having or not having experienced ACEs as there would be for falsely screening a patient for a health condi-
tion. In addition, the current tool provides a health care professional with a score of 0–10, corresponding to the number of ACEs they
may have experienced. A score of 3 for one person may mean they have experienced physical abuse, sexual abuse, and neglect. The
same score of 3 for a different person may represent experiences of parental divorce, parental problems with alcohol, and parental
depression. These are very different histories that may result in vastly different impairments with or without symptomatology that
may (or may not) require a therapeutic intervention. An individual’s current needs or health cannot be understood simply by the
number 3. The ACEs score may be able to demonstrate that more ACEs are related to worse outcomes, but beyond that it provides
very little information and should not be used to inform clinical decisions (Afifi et al., 2020). Finally, importantly with screening, if
a person screens positive for a condition, the next step is decisions on intervention. However, as was noted earlier, no evidence-based
ACEs intervention or suite of interventions currently exist. There are some evidence-based interventions that may reduce the recur-
rence of child maltreatment (e.g., Mejdoubi et al., 2015) or improve mental health symptoms among children who have been mal-
treated (e.g., Leenarts et al., 2013). However, there are no interventions for ACEs generally speaking, or for an ACEs score of 3. From
an ethics perspective, we may need to consider the appropriateness of screening a population when evidence-based interventions do
not exist and are not widely available. While it is without question that ACEs are related to a number of poor outcomes, there is no
evidence at this time to justify universal screening in clinical and public health practice (McLennan et al., 2019).
It is certain that we need to prevent ACEs in an effort to reduce violence in childhood and improve health across the lifespan.
Importantly, screening for ACEs will not prevent ACEs and may not improve health outcomes. The recommendation to not screen
for ACEs is not the same as a recommendation to do nothing. We need to be investing in evidence-based strategies that will prevent
ACEs. To measure efforts of prevention, sophisticated surveillance of child maltreatment at the national-level in countries should be
developed and invested in. We also need to intervene when ACEs are suspected or have been disclosed. This is not done with a check-
list, but rather using thoughtful and sensitive face-to-face trauma-informed interviewing in a safe environment. We then need to be
connecting individuals with evidence-based interventions when needed. Before investing in ACEs screening, we should be investing
in training professionals for sensitive interviewing to ensure safe disclosure of ACEs, developing effective interventions, and then
making these interventions accessible.
Conclusion
The literature on ACEs has grown substantially over the last two decades. We know from this robust literature that ACEs are related
to a number of poor mental and physical health outcomes in childhood, adolescence, and across the lifespan. Some effective inter-
ventions do exist for some individual child maltreatment ACEs. More work is necessary to develop and test intervention strategies
for proven efficacy and then to invest in these strategies to make them accessible. As well, we need to invest in effective strategies that
can prevent ACEs. Future work in this area includes reconsidering how we define and assess ACEs. ACEs are an important public
health problem worldwide. More work is needed to effectively respond to those who have experienced ACEs and for successful
prevention of childhood adversity.
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Adverse Childhood Experiences (ACEs)

Adverse Childhood Experiences 1

Adverse Childhood Experiences

History of the ACE Study

Reference Module in Neuroscience and Biobehavioral Psychology https://doi.org/10.1016/B978-0-12-818697-8.00038-8 1

How the Field Has Grown Over the Past 20 Years

ACEs and Mental Health

ACEs and Mental Well-Being

ACEs and Physical Health

Potential Mechanisms Linking ACEs to Physical Health Conditions

ACEs and Clinical Psychology

Prevention Intervention Strategies

Tools for Measuring ACEs

Universal Screening for ACEs

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