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Adverse Childhood Experiences

Adverse Childhood Experiences (ACEs)


Figure 1. Linking Adverse Childhood Experiences to health behaviors. From the Centers for Disease Control and Prevention. 2019. https://www.cdc.gov/violenceprevention/acestudy/resources.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Fchildabuseandneglect%2Facestudy%2Fresources.html17

Any adverse childhood experience (ACE) has a long-lasting impact through adulthood. ACEs can influence future social, mental and physical health, as well as impact a person’s tendency to inflict violence toward others.11 ACEs can be prevented, but require community support to create enriched environments where children can thrive. General information about ACEs is listed below, including how ACEs are connected to substance use disorders and ways to prevent ACEs.   


About ACEs

ACEs are stressful or traumatic events that occur in the first 18 years of a person’s life. The more someone is exposed to ACEs, the greater the individual’s risk of developing numerous health, social and behavioral problems throughout life.1 ACEs also lead to multiple, simultaneous health outcomes.2 For example, childhood maltreatment can lead to poor self-esteem, which can result in early initiation of tobacco and alcohol use and other detrimental health problems later on in life.    


Figure 2. Tree Diagram linking environmental factors to ACEs from Ellis, W., and Dietz, W., 2017. https://publichealth.gwu.edu/departments/redstone-center/resilient-communities18

The roots in the figure above depict the environmental determinants (or risk factors) that increase the risk for an ACE, whereas the leaves represent exposure to ACEs. Treating these upstream factors (the roots) will lead to fewer children experiencing and reporting ACEs (the leaves).

Figure 3. The ACE Pyramid from the Centers for Disease Control and Prevention, 2019. https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/ace-graphics.html.19

The figure above highlights how experiencing any ACE can lead to numerous negative health outcomes. An ACE experience is typically followed by a change in brain development, followed by a change in social or emotional behavior. These changes can lead to adopting risky behaviors that lead to disease, disability and even early death.11


Risk and protective factors: Risk factors are events or experiences that potentially lead to children experiencing ACEs. Risk factors for ACEs include:

  • Physical, emotional, sexual abuse and neglect
  • Mental illnesses
  • Incarceration
  • Domestic abuse
  • Substance abuse
  • Divorce
  • Poverty
  • Homelessness
  • Violence14, 15

Protective factors are events or experiences that help people more effectively deal with stressful event. These can help mitigate the development of ACEs. Protective factors include:

  • Healthy relationship from parents
  • Supporting and safe social environment
  • Resilience among individuals, families, and communities with whom individuals live and interact
  • Help in identifying and cultivating a sense of purpose
  • Stable housing environment
  • Investment into educational opportunities
  • Socioeconomic advantages12,16


National and Indiana Data on ACEs

Figure 4. The Percentage of Children Ages 0-17 with Adverse Childhood Experiences, Indiana and United States. From the Balio, C., Greene, M.S.. 2018. https://fsph.iupui.edu/doc/research-centers/Adverse-Childhood-Experiences.pdf.20

The table above highlights the number of children in Indiana reporting any ACE event. In 2016, about 47% of youth living in Indiana experienced at least one ACE. This ranks Indiana as 28th in the country for reporting any ACE exposure and 32nd for reporting two or more.9 Furthermore, Indiana is exceeding national rankings for any ACE event and reporting two or more ACEs for children.10

Figure 5. How Common are ACEs? From the Centers for Disease Control and Prevention. 2016. https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/ace-graphics.html.21

The above figure depicts the prevalence of children reporting an ACE, and the type of ACE reported by percentage13. The majority of adults reported experiencing at least one ACE.


The connection between ACEs and health outcomes

Alcohol use:  ACEs are associated with early initiation of alcohol use, heavy drinking, self-reported alcoholism, and marrying an alcoholic.3 For every additional ACE score, the risk of alcohol misuse and abuse increases. There is a greater risk of alcohol misuse or abuse if a parent or guardian misused or abused alcohol in the household, regardless of the ACE score.4 

Tobacco use: Being a smoker and reporting frequent tobacco use was associated with having had two or more ACE exposures. According to a study, 25% of survey responders who experienced sexual abuse during their childhood initiated smoking earlier than those who did not experience sexual abuse.6 Those who reported sexual abuse also had a higher risk of continuing smoking.5, 6 

Substance use disorders: Substance use is perhaps the most widely studied outcome of ACEs. Studies have found positive relationships between ACEs and early initiation of drug use, lifetime drug use, and living with a substance use disorder. It is estimated that 56% of the lifetime drug use prevalence can be attributed to ACEs, as can 63 percent of the lifetime prevalence for people living with substance use disorders. Sexual abuse was found to increase the odds of developing drug dependence during adulthood by 2.6 times. For every additional ACE score, the rate of number of prescription drugs used increased by 62% .8 According to a study, each ACE increased the likelihood of early initiation into illicit drug use by 2- to 4-fold.7 Young adults with high ACEs scores reported more psychological symptoms.8


Figure 6. How do ACEs affect our lives? From the Centers for Disease Control and Prevention. 2016. https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/ace-graphics.html.21

The figure above highlights the association between various health outcomes and the number of ACEs children report.13


How to prevent ACEs

Figure 7. What can be done about ACES? From the Centers for Disease Control and Prevention. 2016. https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/ace-graphics.html.21

The figure shows that to prevent an accumulation of ACEs, communities need to be strengthened and stabilized to provide a safe and nurturing environment for children.10 The diagram above highlights some areas of intervention. Other ideas include changing social norms to support parents, providing quality education during early years of life, and intervening to prevent future risk of developing ACEs.10

The Indiana State Department of Health administers the Behavioral Risk Factor Surveillance System (BRFSS). From the BRFSS survey, we will understand more about ACEs for children throughout Indiana once the data is collected and analyzed. A link to data and findings from the BRFSS study in Indiana, once published, can be found here.



  1. Felitti, V. J. (1998). The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine14, 245-258.
  2. Substance Abuse and Mental Health Services Administration. (2011). Helping Children and Youth Who Have Experienced Traumatic Events. Retrieved from: https://store.samhsa.gov/product/Helping-Children-and-Youth-Who-Have-Experienced-Traumatic-Events/SMA11-4642
  3. Dube, S. R., Anda, R. F., Felitti, V. J., Edwards, V. J., & Croft, J. B. (2002). Adverse childhood experiences and personal alcohol abuse as an adult. Addictive behaviors, 27(5), 713-725.Choi, N.
  4. G., DiNitto, D. M., Marti, C. N., & Choi, B. Y. (2017). Association of adverse childhood experiences with lifetime mental and substance use disorders among men and women aged 50+ years. International psychogeriatrics29(3), 359-372.
  5. Ford, E. S., Anda, R. F., Edwards, V. J., Perry, G. S., Zhao, G., Li, C., & Croft, J. B. (2011). Adverse childhood experiences and smoking status in five states. Preventive medicine53(3), 188-193.
  6. Anda, R. F., Croft, J. B., Felitti, V. J., Nordenberg, D., Giles, W. H., Williamson, D. F., & Giovino, G. A. (1999). Adverse childhood experiences and smoking during adolescence and adulthood. Jama, 282(17), 1652-1658.
  7. Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics111(3), 564-572.
  8. Shin, S. H., McDonald, S. E., & Conley, D. (2018). Patterns of adverse childhood experiences and substance use among young adults: A latent class analysis. Addictive behaviors78, 187-192.
  9. Balio, C., Greene, M.S. (2018). Adverse Childhood Experiences (ACEs) and Their Impact on Substance Misuse & Overall Health [Internet]. Retrieved from https://fsph.iupui.edu/doc/research-centers/Adverse-Childhood-Experiences.pdf
  10.   About the CDC-Kaiser ACE Study. In: CDC [Internet]. 14 Jun 2016 [cited 3 Jan 2018]. Available: https://www.cdc.gov/violenceprevention/acestudy/about.html
  11. Centers for Disease Control and Prevention. (2019). About Adverse Childhood Experiences. Retrieved from https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/ace-brfss.html
  12. Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Preventing child abuse and neglect: A technical package for policy, norm, and programmatic activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention
  13. Centers for Disease Control and Prevention. (2019). Adverse Childhood Experiences Resources. Retrieved from https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/resources.html
  14. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., … & Marks, J. S. (2019). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine56(6), 774-786.
  15. Herman, D. B., Susser, E. S., Struening, E. L., & Link, B. L. (1997). Adverse childhood experiences: are they risk factors for adult homelessness? American Journal of Public Health87(2), 249-255.
  16. Minnesota Department of Health. (n.d.). Resilience to ACEs. Retrieved from https://www.health.state.mn.us/communities/ace/resilience.html
  17. Centers for Disease Control and Prevention. (2019). Linking Adverse Childhood Experiences to Health Behaviors. [Infographic]. Retrieved from https://www.cdc.gov/violenceprevention/acestudy/resources.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Fchildabuseandneglect%2Facestudy%2Fresources.html
  18. Ellis, W.R., & Dietz, W.H. (2017). Tree Diagram linking environmental factors to ACEs. [Diagram]. Retrieved from https://www.sciencedirect.com/science/article/pii/S1876285916305526
  19. Centers for Disease Control and Prevention. (2019). The ACE Pyramid. [Infographic]. Retrieved from https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/ace-graphics.html
  20. Balio, C., Greene, M.S. (2018). The Percentage of Children Ages 0-17 with Adverse Childhood Experiences, Indiana and United States. [Table]. Retrieved from https://fsph.iupui.edu/doc/research-centers/Adverse-Childhood-Experiences.pdf
  21. Centers for Disease Control and Prevention. (2016). How common are ACES. [Infographic]. Retrieved from https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/ace-graphics.html


Page last updated 07/15/2019