Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood (up to age 18). ACEs can include adversities such as abuse, neglect, and household challenges like growing up in a home with incarceration, mental illness or substance dependence. Toxic stress from ACEs can change brain development and affect how the body responds to stress. ACEs are strongly associated with some of the most common, serious, and costly health conditions facing our society today; however, ACEs can be prevented.
What are ACEs?
- The term Adverse Childhood Experiences (ACEs) comes from the landmark 1998 study conducted among more than 17,000 adult patients by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente, referred to as the ACE Study.
- Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood (up to age 18).
- Though often used colloquially to refer to a variety of adversities in childhood, when capitalized, the term ACEs specifically refers to 10 categories of adversities in three domains – abuse, neglect, and household challenges:
- Abuse: physical, emotional, and sexual abuse
- Neglect: physical and emotional neglect
- Household challenges: growing up in a household with incarceration, mental illness, substance dependence, absence due to parental separation or divorce, or intimate partner violence
What is the ACEs Aware initiative?
- ACEs Aware is an initiative of the Office of the California Surgeon General and the California Department of Health Care Services.
- The ACEs Aware initiative is led by Dr. Nadine Burke Harris, California Surgeon General, and Dr. Karen Mark, Medical Director of the Department of Health Care Services.
- The ACEs Aware initiative offers Medi-Cal providers training, screening tools, clinical protocols, and payment for screening children and adults for Adverse Childhood Experiences (ACEs). Screening for ACEs, assessing risk for toxic stress, and responding with evidence-based interventions and trauma-informed care can significantly improve the health and well-being of individuals and families.
- The California Surgeon General has set a bold goal to cut ACEs in half in one generation.
- The ACEs Aware effort is part of Gov. Newsom’s California For All initiative.
What are ACE Screenings?
Screening for ACEs and toxic stress and providing targeted, evidence-based interventions for toxic stress can improve efficacy and efficiency of health care, better support individual and family health and well-being, and reduce long-term health costs.
De-identified screening tool: Respondents count the number of ACE categories on the screening tool that they or their child has experienced and indicate only the total score — without identifying which ACE(s) they or their child experienced.
Identified screening tool: Respondents count the number of ACE categories on the screening tool that they or their child has experienced and specify which ACE(s) they or their child experienced.
ACE Score: Refers to the total reported exposure to the 10 ACE categories indicated in the ACE screening tool – Part 1 of the PEARLS and in the ACE Questionnaire for Adults. ACE scores range from 0 to 10.
What are ACE-associated health conditions?
ACE-Associated Health Conditions are health conditions that have empirical evidence showing associations between ACE exposure and the health outcome. They include cardiovascular, pulmonary, immune, metabolic, mental health, and substance use conditions.
Find the ACE-Associated Health Conditions for pediatrics and adults as part of the ACE Screening Workflows, Risk Assessment and Treatment Algorithms, ACE-Associated Health Conditions at ACEsAware.org/assessment-and-treatment.
How do I find ACEs Aware Health Providers?
For a list of Ventura County medical providers who have been ACEs Aware trained and certified please visit:
Where can I find more information about ACEs?
California Surgeon General's report on ACEs and Toxic Stress:
How prevalent are ACEs?
- ACEs are highly prevalent. In California, 62% of California adults have experienced at least one ACE and 16% have experienced four or more ACEs.[i]
- ACEs affect all communities. They cross ethnic, socioeconomic, gender, and geographic lines. However, some populations are disproportionately affected.
Annual Cost of ACEs in California
- A recent study estimated the total annual cost of ACEs in California to be $112.5 billion, including $10.5 billion in personal health care spending and, $102 billion in years of productive life lost due to early death and disability.
- These cost estimates include only the ACE-attributable costs associated with the ACE-Associated Health Conditions shown here, which are some of the most common and serious conditions associated with ACEs – cardiovascular disease, asthma, arthritis, depression, chronic obstructive pulmonary disease, obesity, smoking, and heavy drinking.
- The study included only these 8 ACE-Associated Health Conditions – the cost would likely be much greater if all ACE-Associated Health Conditions were included.[ii]
[i] California Department of Public Health, Injury and Violence Prevention Branch (CDPH/IVPB), University of California, Davis, Violence Prevention Research Program, California Behavioral Risk Factor Surveillance System (BRFSS), 2011-2017.
[ii] Miller TR, Waehrer GM, Oh DL, Purewal Boparai S, Ohlsson Walker S, Silverio Marques S, et al. (2020) Adult health burden and costs in California during 2013 associated with prior adverse childhood experiences. PLoS ONE 15(1): e0228019. https://doi.org/10.1371/journal.pone.0228019
How do ACEs affect health?
ACEs are strongly associated, in a dose-response fashion, with some of the most common, serious, and costly health conditions facing our society today, including at least nine of the 10 leading causes of death in the United States, as well as earlier mortality.
- 2 – 2.3 times as likely to have a stroke, cancer, or heart disease
- 3.1 times as likely to have chronic lower respiratory disease
- 11.2 times as likely to have Alzheimer’s or dementia
- 1.4 times as likely to have diabetes
- 37.5 times as likely to attempt suicide
Toxic Stress Response:
- It is now known that one important way in which ACEs increase risk of poor physical, mental and behavioral health is through prolonged activation of the biological stress response and associated changes to brain development as well as immune, hormonal, immune and genetic regulation. These long-term changes are known as the toxic stress response.
- Repeated or prolonged activation of a child’s stress response, without the buffering of trusted, nurturing caregivers and safe, stable environments, leads to long-term changes in the structure and functioning of the developing brain, metabolic, immune, and neuroendocrine responses, and even the way DNA is read and transcribed. Development of the toxic stress response is influenced by a combination of cumulative adversity, buffering or protective factors, and predisposing vulnerability.[i]
[i] Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812.
Can ACEs be prevented?
Protective Factors: Intrinsic or extrinsic conditions or attributes that mitigate risk for toxic stress.
Intrinsic factors include:
- Curiosity in learning
- Ability to pay attention
- Ability to regulate emotions
- Neuro, endocrine, metabolic, immune, genetic, and epigenetic factors
Extrinsic factors include:
- Buffering relationships
- Supportive environments
- Community resources
Social Determinants of Health: Additional adversities are risk factors for toxic stress. “Conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. According to the World Health Organization, the social determinants of health are education, employment, health systems and services, housing, income and wealth, the physical environment, public safety, the social environment (including structures, institutions, and policies), and transportation.”
While validated odds ratios are available in large, population-based studies using the 10 standardized ACE criteria, the strengths of association between other experiences/social determinants on health and health outcomes have not been similarly standardized.
How are ACEs treated?
It is well established that early identification and intervention are key to ameliorating the impacts of toxic stress and reducing the risk of negative health and social outcomes.
Clinical Response to ACEs: Clinical response to identification of ACEs and increased risk of toxic stress should include:
- Applying principles of trauma-informed care, including establishing trust, safety, and collaborative decision-making
- Supplementing usual care for ACE-Associated Health Conditions with patient education on toxic stress and offering strategies to regulate the stress response, including:
- Supportive relationships, including with caregivers (for children), other family members, and peers;
- High-quality, sufficient sleep;
- Balanced nutrition;
- Regular physical activity;
- Mindfulness and meditation;
- Access to nature; and
- Mental health care, including psychotherapy or psychiatric care, and substance use disorder treatment, when indicated.
Medi-Cal providers trained in ACEs Aware practices work with Community Care Coordination teams to connect families with resource options and services that fit their care needs. Member agencies are carefully trained in ACE appropriate strategies so that all are highly qualified to serve referred families. The goal is to support children and their families with high ACEs scores and align care for all children across the developmental spectrum to lead to greater access for screenings, referrals and intervention services for children and families.
Participating medical agencies have noted an abundance of families who exhibit high ACEs risk factors, along with a lack of clarity on how to support patients beyond the identification process. Their feedback reinforces the need for a dimensional approach to link families with appropriate support structures. Learn about opportunities for training in ACEs Aware Trama-Informed Care and how to connect patients with a personalized care plan to begin healing, build resilience, and stop the generational tendencies which lead to ACEs.
The Child Abuse Prevention Council; The Partnership For Safe Families and Communities is a 501(c)(3) nonprofit organization based in Ventura County, California that focuses on child abuse and family/community violence prevention. As a multi-disciplinary team, we function as a major collaborating, coordinating, networking, educational, outreach, and communication resource for children in Ventura County. We provide a safe place for families as they deal with varied ACE factors, furthering our mission, “To promote a community committed to safe, healthy and peaceful families.”
The Partnership is committed to protecting children, communities, and families; giving hope to those seeking to break the sometimes-generational bonds of abuse, poverty and trauma. The Partnership for Safe Families and Communities of Ventura County is ready to expand the impact of ACEs resourcing in Ventura County through the creation of support structures that add intentional organization and relational support into the care connection process. We've assembled a team of professionals from various organizations throughout the county to create and strengthen the network of care for families in crisis and for identified individuals with high ACE scores who may be at increased risk of developing certain health conditions as a result of early childhood trauma and toxic stress.
The ACEs Aware Network of Care strives to bring the very best in Trama-Informed Care to our community by uniting various organizations and care coordination teams with healthcare providers to ensure each family and individual receives the resources necessary for healing and support.