Journal Club: ACE Study

The Adverse Childhood Experiences (ACE) Study was published in 1998. This study was the first of its kind to assess the relationship of adult health risk behaviors, health status, and disease states to childhood abuse and household dysfunction. It’s also the subject of a fantastic TED talk by Dr. Nadine Burke Harris. 


Study characteristics:

The ACE study initially surveyed 8,056 patients at a primary care clinic in San Diego.

  • Mean age of 56.1yo (range 19-92yo); 52.1% women, 79.4% white, 43% college graduates

Survey asked about 7 categories of childhood exposures: 

  • 3 categories related to childhood abuse: psychological, physical, and sexual
  • 4 categories related to household dysfunction: exposure to substance abuse, exposure to mental illness, exposure to violent treatment of mother or step-mother, and exposure to criminal behavior

The study assessed multiple risk factors and diseases that contribute to the leading causes of mortality and morbidity in the US:

  • Risk factors: smoking, severe obesity (BMI ≥35), physical inactivity, depressed mood, suicide attempts, alcohol use, drug abuse, high lifetime number of sexual partners (︎≥50), and history of having an STI
  • Diseases: history of ischemic heart disease (including MI or use of nitroglycerin for exertional chest pain), cancer, stroke, COPD, diabetes, hepatitis, and skeletal fractures (proxy for risk of unintentional injuries)

Study findings: 

52% of respondents experienced ≥1 ACE; 6.2% reported ≥4 ACEs. 

The most prevalent childhood exposure was substance abuse in the household (25.6%!)

Patients with ≥4 ACEs were 

  • 4-12x more likely to consider themselves to be an alcoholic, use illicit drugs, and attempt suicide
  • 2-4x more likely to smoke cigarettes, have ≥50 sexual partners, and have an STI 
  • 2-4x more likely to have ischemic heart disease, stroke, COPD, cancer, and hepatitis

Strong dose-response relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults. 

The findings suggested that the impact of ACEs on adult health status is strong and cumulative. 

  • “An essential question posed by our observations is, “Exactly how are ACEs linked to health risk behaviors and adult diseases?” The linking mechanisms appear to center on behaviors such as smoking, alcohol or drug abuse, overeating, or sexual behaviors that may be consciously or unconsciously used because they have immediate pharmacological or psychological benefit as coping devices in the face of the stress of abuse, domestic violence, or other forms of family and household dysfunction. High levels of exposure to ACEs would expectedly produce anxiety, anger, and depression in children. To the degree that behaviors such as smoking, alcohol, or drug use are found to be effective as coping devices, they would tend to be used chronically.”
Source: CDC | About the CDC-Kaiser ACE Study

Follow-up studies

Additional studies estimate that 61% of adults have ≥1 ACE and 16% of adults (1 in 6!) have ≥4 ACEs. 

At least 5 of the 10 leading causes of death are associated with ACEs. 

Preventing ACEs could reduce a large number of health conditions: 

  • up to 21 million cases of depression
  • up to 1.9 million cases of heart disease
  • up to 2.5 million cases of overweight/obesity

What can we do?

Prevention strategies per the CDC: 

  • Strengthen economic supports for families by strengthening household financial security and family-friendly work policies
  • Promote social norms that protect against violence and adversity through public education campaigns, legislative approaches to reduce corporal punishment, bystander approaches, and men/boys as allies in prevention
  • Ensure a strong start for children through early childhood home visitation, high-quality childcare, preschool enrichment and family relationship approaches
  • Teach skills including social-emotional learning, safe dating and healthy relationship skill programs, parenting skills and family relationship approaches
  • Connect youth to caring adults and activities such as mentoring programs and after-school programs
  • Intervene to lessen immediate and long-term harms including enhanced primary care, victim-centered services, treatment to lessen the harms of ACEs, treatment to prevent problem behavior and future involvement in violence, family-centered treatment for substance use disorders