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