Most people are aware of common risk factors for many of the most common adult chronic health problems. Obesity is a risk factor for diabetes; smoking is a risk factor for heart disease, and so on. 

In the 1990s, researchers began to notice that these diseases and their risk factors were not randomly distributed in the population and that risk factors tended to cluster together. One risk factor is usually accompanied by others in the same patient or cohort. The Centers for Disease Control and Prevention (CDC) decided to fund research to look into why this might be.

One of these studies is the the Adverse Childhood Experiences Study (ACE). Dr. Vincent Felitti of the University of California, San Diego, and colleagues posited that what happens to us in childhood affects the incidence of chronic health problems later in life. 
The initial cohort included 9,000 patients within the Kaiser Permanente health system. The participants were given a questionnaire prior to a regular primary care office visit that asked a number of questions about adverse childhood events including sexual abuse, violence, drug use in family members, and mental illness in addition to usual demographic and health history information.

The initial results were published in 1998 in the American Journal of Preventive Medicine:

Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity.
The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life.

The main components of the ACE study have been condensed into a 10-question test that generates an ACE Score. A higher score indicates a greater risk of life-long health issues.  Proponents of this test say it should be used routinely when evaluating patients. Here are some examples of the kinds of questions on the ACE test:

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Before your 18th birthday, did a parent or other adult in the household often or very often…
a) Swear at you, insult you, put you down, or humiliate you?
b) Act in a way that made you afraid that you might be physically hurt?

Here’s another:

Before your 18th birthday, was your mother or stepmother:
a) Often or very often pushed, grabbed, slapped, or had something thrown at her?
b) Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard?
c) Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

The ACE test generates a metric that basically assigns a numerical value to the question, “How bad was your childhood?”

 The test is a little bit like the Glasgow Coma Scale (GCS) in trauma assessment: a number to indicate just how badly hurt someone is.

Intuitively we understand that terrible events in childhood have long-lasting effects, both in terms of psychological health and physical health, just as we intuitively know how badly hurt someone is in the ER. 

But medicine loves numbers, and the numbers generated through the ACE test provide a shorthand way of communicating severity. The test is really just a series of questions that serve as reminders to health care professionals — a checklist to prevent us from forgetting anything. 

Almost all health evaluations include a question like: “Do you feel safe at home?” or some variant seeking to screen for things like domestic violence.  It is usually asked in passing, buried in the family history or list of medications.

What the ACE test does is put questions about bad childhood experiences front and center, in part by their wording.  It doesn’t just ask, “Were you abused as a child?” which requires that the patient not only label themselves as abused but also leaves open the question of what the patient defines as abuse. They are jolting questions. They create vivid images and visceral responses.  They cannot be ignored. 

I don’t think the ACE test should be used with everyone, any more than you would use the GCS on everyone in the ER, or a depression index on anyone coming in with cold symptoms. As with any test, it should be given with a good understanding of what will be done with the information, and targeted to patients at risk.

The ACE test is a tool that can generate dialogue around childhood history by giving patients permission to talk about their experiences. It is also a powerful reminder that investment in childhood is one that pays dividends for all of us.


  1. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. “Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.”  Am J Prev Med. 1998;14(4): 245-258.