Chapter 2

The ACE (Adverse Childhood Experiences)

ACE study results show a strong graded relationship between the number of categories of adverse childhood experiences (ACES) endured up through age 18, and a variety of later life health and social problems (Dube et al., 2003). Those growing up exposed to four ACE categories, for example, showed between a 4-to 12-fold corresponding increase in their risk for alcoholism, drug abuse, depression, and suicide attempts, and a 2-to 4-fold increase in smoking. Regarding suicide attempts, of those reporting no exposure to ACE categories up through age 18, the prevalence of self-reported attempts was 1.1 percent. For respondents reporting exposure to 7 or more the prevalence rose to 35.2 percent (Chapman, Dube, & Anda, 2007) There was also a 2-to 4-fold increase in their rate of sexually transmitted diseases, and a 2-to 4-fold increase in poor self-rated health. Those exposed to four or more ACE categories also showed a 1.4- to 1.6-fold increase in physical inactivity and severe obesity. But one of the most startling findings was the relationship between exposure to categories of adverse childhood experiences up through age 18 and the presence of life threatening diseases later in life. Those exposed to four or more ACE categories were significantly more likely to be suffering from diseases representing some of the leading causes of death among adult Americans today, diseases like ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease (Dube et al., 2003; Fellitti et al., 1998;

ACE study findings were also consistent across different generations. Researchers observed similar findings among four different birth cohorts dating back to 1900 (births for the first cohort were from 1900-1931, the second from 1932-1946, the third from 1947-1961, and the fourth from 1962-1978). This is somewhat unexpected, considering the different cultural and social factors impacting those born at different times during the last century. Studies show, for example, that for those born between 1894 and 1937, alcohol use in young adulthood was less than 50 percent, as opposed to 75 percent for those born between 1968 and 1974. Similarly, cigarette smoking was far less between 1900 and 1917, eventually peaking in frequency in 1960, and declining significantly since then. Sexual activity also increased significantly during later part of the last century in comparison to earlier in the century, likely contributing to increases in STDs, especially among adolescents. Yet, despite different cultural and social trends, findings remained consistent. Exposure to multiple categories of adverse childhood experiences exert a significant effect on later life physical and mental health outcomes, in spite of varying social, economic, political, and secular influences specific to the era in which persons were born and raised (Dube et al., 2003).

The ACE Score

The ACE Study identifies 10 categories of stressful or traumatic childhood experiences. Each has been shown through prior research to have significant adverse health or social implications. Each also has been the focus of public and private prevention efforts designed to reduce its frequency and consequences (Anda, 2011). The 10 ACEs fall within three broader areas of risk: Child abuse, child neglect, and growing up in a seriously dysfunctional household. The 10 ACEs are as follows: 1) emotional abuse, 2) physical abuse, 3) sexual abuse, 4) emotional neglect, 5) physical neglect, 6) parental discord as evidenced by separation or divorce; 7) witnessing domestic violence, 8) alcohol or other substance abuse in the home, 9) a household member who was depressed, suffered from mental illness or attempted suicide, and 10) crime in the home (having a household member who was imprisoned). ACES 1 through 3 are subsumed under the broader risk category of child abuse, ACES 4 and 5 under the broader risk category of child neglect, and ACES 7 through 10 under the broader risk category associated with growing up in a seriously dysfunctional household. The 10 ACEs are listed in the ACE Study Questionnaire (see ACE Study website at Respondents completing the questionnaire are asked to endorse either “yes” or “no” for each item as to its presence up to age 18. Each “yes” answer is assigned one point. The ACE score, which will range from 0 to 10, represents a summary of the amount of cumulative exposure to 10 adverse childhood experiences during a respondent’s childhood and adolescent years. According to co-principal investigator Robert Anda (2011), a respondent’s ACE score likely captures the cumulative neurodevelopmental consequences of childhood exposure to traumatic stress. Neurodevelopment isn’t only impacted by ADHD, learning disorders and other neurodevelopmentally based conditions described in the DSM-5. It’s impacted by traumatically stressful childhood experiences as well.

Underling Mechanisms That Help Explain How Multiple ACE Categories Can Lead to Eventual Biomedical Disease

Coping Mechanisms, Chronic Stress, Epigenetic Processes

Coping Mechanisms

“It’s hard to get enough of something that almost works.”                                                                                                                                                                                                                                  Vince Felitti, MD

The relief we seek from the effects of chronic stress exposure can lead to coping mechanisms that work well in the short term but that lead to serious health problems years later. Consider, for example, the immediate potential benefits that smokers derive. Published studies appearing in medical journals before the Surgeon General’s warnings about the perils of smoking cited  the psychoactive benefits of Nicotine, including potent antianxiety and antidepressant properties, appetite suppressant effects, as well anger suppressant properties (Felitti and Buczynski, 2011).

Today, we commonly associate smoking as a major risk factor leading to later life medical problems. But sometimes one’s need for immediate emotional relief can outweigh their later life health worries. And in these instances, one may turn to smoking for its psychoactive properties,

On a similar note, consider as well those who turn to street drugs, and more specifically, crystal meth. Few of us are likely aware that the same chemical was contained in Methadrine, the brand name for methamphetamine, which Burroughs Wellcome introduced for sale in the United States in 1940 as the first antidepressant medication (Felitti and Anda, 2010). One wonders how many of those who turn to crystal meth are self-medicating in an effort to relieve emotional suffering resulting from prolonged exposure to multiple ACES.

Smoking, substance abuse and other behaviors no doubt place us at significantly increased risk for later life biomedical disease. What we may have been paying far less attention to, however, is how, for some, they might represent immediate coping mechanisms that provide us a degree of relief when no other source of relief is in sight. 

To learn more, see Felitti & Anda, 2010; Felitti &  Buczynski, 2011 (referenced below).

Chronic Stress

We pay a physical price for having chronically elevated levels of cortisol circulating through our bodies. And this appears particularly so for our immune system. Consider, for example, the effects it can have on “pro-inflammatory cytokines.” These are body chemicals that set up inflammatory reactions in the lining of microscopic blood vessels. As a result of chronic stress exposure, these blood vessels may become inflamed, then scarify, and subsequently damage the region of the organ in which the blood vessel had been supplying blood.

Secondly, chronic stress has a significant dysregulatory effect, as noted by ACE Co-Principal Investigator Vince Felitti:

       “We are all producing low levels of malignant cells at all times. They are readily processed out by our immune systems and never know the difference. Therefore, getting cancer means one of two things: either you are producing malignant cells at an accelerated rate as might occur from being a heavy smoker or from exposure to dangerous amounts of radiation, etc; or your body’s ability to recognize and process out those cells are impaired. One form of impairment comes from the damage to your immune system while taking immunosuppressant drugs after organ transplantation. Another form comes from chronic major stress over prolonged periods of time.” (Felitti and Buczynski, page 9).

To learn more about how toxic stress can derail healthy development, log on to:

To learn more about how toxic stress can change brain architecture and affect physical, emotional, and mental health, log on to:

Epigenetic Processes

New research in the field of epigenetics is revealing how environmental influences, including chronic stress exposure, can impact gene expression. And in can occur in utero. One recent study, for example, linked psychosocial changes in children to mothers who were exposed to intimate partner violence while they were pregnant. Psychosocial changes were noted 10-19 years after the child’s birth (Radtke, et al., 2011).

Research is showing that ACE categories not only affect our health and well-being decades later. Their effects can also be transmitted from a mother to her unborn child.

To learn more about the study of epigenetics, log on to: Several videos on the topic are available for review at Also, the documentary, In Utero,  ( explores advances in the field of epigenetics, and particularly the many ways that environmental influences impact gene expression in utero.

Please Note: Updates to the above mentioned pathways from ACE categories to later life biomedical disease will be provided on an ongoing basis.

  • Anda, R. F. (2011). The health and social impact of growing up with adverse childhood experiences: The human and economic cost of the status quo. Retrieved from 
  • Chapman, D. P., Dube, S. R., & Anda, R. F. (2007). Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals, 37, 359-364.
  • Dube, S. R., Felitti, V. J., Dong, M., Giles, W. H., & Anda, R. F. (2003). The impact of adverse childhood experiences on health problems: Evidence from four birth cohorts dating back to 1900. Preventive Medicine, 37, 268-277.
  • Felitti, V., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V.,…Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences Study. (1998). American Journal of Preventive Medicine, 14(4), 245-257.
  • Felitti, V. J., & Anda, R. F. (2010). The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders, and sexual behavior: Implications for healthcare. In R. A. Lanius, E. Vermetten, & C. Paine (Eds.), The impact of early life trauma on health and disease (pp. 77-87). New York, NY: Cambridge University Press.
  • Felitti, V., & Buczynnski, R. (2011). Why the most significant factor in predicting chronic disease may be childhood trauma. A teleseminar session by the National Institute of Clinical Application of Behavioral Medicine. Retrieved from
  • Radtke, K. M., Ruf, M., Gunter, H. M., Dohrmann, K., Schauer, M., Mayer, A., & Elbert, T. (2011). Transgenerational impact of intimate partner violence on methylation in the promoter of the glucocorticoid receptor. Translational Psychiatry, 1, e21.  doi:10.1038/tp.2011.21