Adverse Childhood Experiences: What They Are and How to Screen for Them

Adverse childhood experiences can have long-term effects on development. Indeed, ACEs are linked to the onset of mental health and physical health problems in childhood and adulthood. Screening clients for ACEs is a natural extension of trauma-informed care, as it recognizes the role of trauma in negative health outcomes. Understanding these experiences and the effects they can have will help behavioral health professionals provide better whole-person care to their clients.

What are adverse childhood experiences?

Adverse childhood experiences, often referred to as ACEs, are stressful or traumatic events that occur in a person’s life before the age of 18. Originally outlined in 1995, ACEs have been the subject of considerable research. This research has identified the following experiences as contributing factors to adverse childhood experiences:

• Abuse (emotional, physical, and/or sexual)
• Bullying
• Discrimination
• Feeling unsafe at home or in your neighborhood
• Parental issues (financial stress, substance use disorders, mental health disorders)
• Witnessing violence

ACEs are, unfortunately, rather common. Two-thirds of the population have at least one adverse experience, while one-in-four people experience three or more adverse experiences in childhood.

How ACEs can lead to toxic stress

ACEs are experiences that cause toxic stress. Toxic stress can be thought of as the excessive activation of the stress-response system. Over time, this can harm the body and is directly tied to ACEs.

Toxic stress has been shown to have negative effects on the body and mind. For instance, those who experience toxic stress are more likely to:

• Develop a chronic disease, such as cardiovascular disease and type 2 diabetes
• Experience mental illness, such as a mood disorder, anxiety disorder, posttraumatic-stress disorder, or substance use disorder
• Have difficulties with suicidal ideation and acts
• Show violence towards others

How do ACEs impact people?

Adverse childhood experiences can have a lasting impact on a person’s health, well-being, and academic and professional achievement.

After adverse experiences, children are three times more likely to struggle academically, five times more likely to have issues with school attendance, and six times more likely to develop behavioral issues.

The longer someone who has experienced ACEs goes without proper therapeutic treatment, the worse the outcome. Adults who had adverse childhood experiences are more likely to be diagnosed with cancer, heart disease, diabetes, COPD, depression, and substance use. This population also has a lower life expectancy than the general population. The more ACEs one experiences, the more likely these issues become.

How to use the ACEs Questionnaire

The ACEs Questionnaire assesses for the presence of 10 types of childhood trauma. It is usually completed by an adult client without input from their behavioral health provider. Adaptations have also been made to the ACEs Questionnaire so that you can administer it to children.

Five questions assess the client’s personal experiences of childhood trauma. These questions assess for the presence of:

• Childhood physical, sexual, or emotional abuse
• Childhood physical or emotional neglect

The remaining five questions assess for stressors related to the client’s family members. These questions inquire about the presence of:

• A family member with mental illness
• Violence towards a caregiver or parent
• Caregiver substance abuse
• Separation or divorce of the caregivers

The presence of any factor counts towards the total ACE score.

It should be noted that the total score can be misleading. In general, the more ACEs endorsed by the client, the higher the likelihood that they will have poor health outcomes. However, some clients who experienced a high number of ACEs (e.g., 5 or more) can manage these experiences in healthy ways. In contrast, some people who have only one or two ACEs may continue to be affected by them well into adulthood.

Reviewing the ACEs Questionnaire results

It is important for providers to review the results of the ACEs Questionnaire with the client. The client’s caregiver may also be present when screening for ACEs with a youth client. Providers should take a non-judgmental stance while discussing results. This will help build the therapeutic alliance and support a collaborative approach towards healthcare.

Some other tips you can use with your clients who had adverse childhood experiences are:

• Discuss ways to reduce the stress caused by ACEs.
• Link any current health concerns to the ACEs Questionnaire score.
• Share that most people in the US have experienced ACEs.
• Collaborate on treatment planning.
• Re-administer the ACEs Questionnaire on occasion to account for changes and realign with the treatment plan.