Understanding the Adverse Childhood Experiences (ACE) questionnaire & its results

What is an “adverse childhood experience?”

An adverse childhood experience, or ACE, can be defined as any potentially traumatic event that occurs during an individual’s childhood (from ages zero to 17).

ACEs are fairly common, perhaps more than you might think. According to the Centers for Disease Control and Prevention (CDC), some 64% of adults in the US reported they had experienced at least one before age 18. Likewise, nearly one in six (17.3%0 of adults reported they had experienced four or more types of ACEs.

Not only are they disruptive and potentially damaging, but ACEs can also potentially increase a person’s risk of many common health conditions. As a result, preventing ACEs could help providers reduce the frequency of some of the most prevalent chronic conditions that impact patients.

For instance, CDC estimates suggest that as many as 21 million depression cases could potentially have been avoided by preventing ACEs. Estimates also suggest that 1.9 million heart disease cases could also be prevented when ACEs are addressed.

So, overall, ACEs are a problem for several reasons: they’re disruptive, potentially harmful, and cause lasting effects on health and well-being that can last well into adulthood. They also may increase the risk of injury, sexually transmitted infections, and leading causes of death, such as cancer or diabetes.

ACEs are also costly. The CDC reports that ACEs-related health consequences create an estimated economic burden of $748 billion annually between the United States, Canada, and Bermuda.

Understanding the ACE Questionnaire

The ACE questionnaire is a screening tool that has been developed based on guidelines from what is often known simply as the “ACE study.”

The original CDC-Kaiser Permanente ACE study was one of the largest investigations of abuse, neglect, and household challenges that occurred during childhood and their impact on later-life health and well-being. It was conducted at Kaiser Permanente from 1995 to 1997.

While the original data set from the study is currently unavailable to the public, data collection is still ongoing. Insights from the study and the model it uses to measure ACEs are accessible, though, and shed some light on how ACE questionnaires capture valuable information.

As outlined by the ACE study, adverse experiences can be categorized into three groups:

1. Abuse
2. Neglect
3. Household challenges

Each of these categories can also be further divided into several subcategories. Items on the ACE questionnaire aim to tie to each of these subcategories and their potential impact on quality of life.

Abuse

The subcategories for abuse include the following:

• Emotional abuse. A parent, guardian, or adult living in the home swore at, insulted, put down, or acted in a way that made the respondent fear they might be physically hurt.
• Physical abuse. A parent, guardian, or adult living in the home pushed, slapped, grabbed, or hit the respondent so hard that they had marks or were injured.
• Sexual abuse. An adult, family friend, relative, or stranger who was at least five years older than the respondent ever touched or fondled their body in a sexual manner, made the respondent touch their body in a sexual way, or attempted to have any type of sexual intercourse with the respondent.

Neglect

There are also several subcategories that can reflect different types of neglect throughout childhood.

*Information related to neglect is typically only collected during a second wave (“Wave 2”) of screening. 

• Emotional neglect. Someone in the family or home never or rarely helped the participant feel special or important. They may have never or rarely felt loved. People in the home or family never or rarely looked out for each other and felt close to each other, or the family was never or rarely a source of strength and support.
• Physical neglect. There was rarely or never someone to take care of the respondent, protect them, or take them to the doctor when needed. The respondent didn’t have enough to eat, their parents were too drunk or high to take care of them, or they had to wear dirty clothes.

Household Challenges

This category covers several types of issues or risk factors that may exist within the home and cause trauma.

• Violence. While the original language used in the ACE study refers to mothers being treated violently, this may apply to parents of any gender. The respondent’s mother, stepmother, or parent was pushed, slapped, grabbed, kicked, bitten, etc., or ever threatened or hurt by a weapon by their partner, boyfriend, or the other parent.
• Substance abuse in the household. A household member frequently drank or used street drugs.
• Mental illness in the household. A household member was mentally ill, depressed, or attempted suicide.
• Parental separation or divorce. The respondent’s parents were ever separated or divorced.
• Incarcerated household member. A household member spent time in prison.

ACE Questionnaire Example

To find an individual’s “ACE score,” providers can create and distribute an ACE questionnaire that asks respondents to answer “yes” or “no” to certain questions. Below is an example of an item from an ACE questionnaire and sample instructions:

While you were growing up, during the first 18 years of your life:

Did a parent or other adult in the household often or very often swear at you, insult you, put you down, humiliate you, OR act in a way that made you afraid that you might be physically hurt?

When respondents answer “yes” to any item, enter a score of 1. For “no” responses, enter a score of 0.

To preview an example of a full ACE questionnaire, visit this resource from the National Council of Juvenile and Family Court Judges (PDF).

ACE Questionnaire Scoring

Since each “yes” response gets a score of 1 and each “no” a 0, calculating the total score for each ACE screener is simple. Add together the scores from each item to get a score that ranges from 0-10.

Generally speaking, the higher your ACE score, the higher your risk of disease and social and emotional problems as an adult. But this isn’t always the case. For one thing, the ACE questionnaire is short, and it may not consider all socioeconomic factors that contribute to its items.

Likewise, every person who takes the ACE assessment is different. Adverse experiences during childhood can affect each person in unique ways.

Experiencing several ACEs does not automatically mean that a person is guaranteed to experience later social, emotional, or health problems. Some children – due to genetic factors and personal differences – may be predisposed to being more sensitive to adversity than others.

Furthermore, an ACE quiz doesn’t necessarily provide insight into whether an individual child had any protective relationships in place that could buffer them from stress or traumatic events.

Overall, the ACE questionnaire offers insight into who might be most at risk for certain challenges later in life. But it’s not a diagnostic tool, and its results should not be taken as an indication that health issues are imminent.

Access the ACE and other questionnaires with Linear Health

While the ACE assessment might not be a foolproof measure of a person’s risk for chronic health issues, it’s still a valuable resource for providers of all kinds. It may be particularly useful in behavioral and mental health care spaces, where patient populations generally experience higher rates of trauma and related health conditions.

To make creating and distributing screeners like ACE quizzes accessible and simple, Linear Health has created a powerful, HIPAA-compliant form builder and digital clinical assessment tools.

Our platform gives clinicians the power to automate the sending and recording of assessments and patient health data so that they can deliver quality care to their patients.

To learn more about how our platform can help you engage with and learn more about patients, reach out to us today to book a demo.