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Research Roundup April 2021:

ACEs Patterns and Their Impact

Our monthly column highlights recent studies of Adverse Childhood Experiences (ACEs): causes, consequences, and the interventions that work.

As one might suspect, different ACEs act on health risks and other poor outcomes in different ways.

Researchers have tried to study the impacts of specific ACE exposures in different ways—some have focused on one type of ACE, others have tried to study which types of ACEs are likely to occur together, and still others have tried to group ACEs into meaningful categories to assess how exposure to ACEs within a given category affects health risk.

This month, we review some of the research conducted in recent years examining ACEs patterns and their impact, that is, what they mean for health outcomes.

We then highlight a recent article by Briggs and colleagues that provides a more comprehensive assessment of how various ACEs may interact with each other. Simply put, the authors examine whether experiencing two ACEs more than doubles the risk for poor outcomes compared to experiencing one ACE—and whether it matters which two ACEs occur at the same time.

ACEs Patterns: ACEs be meaningfully grouped into distinct categories that predict health risk

In order to determine whether different ACEs can be grouped into meaningful categories to gain insight into ACEs patterns, it is important to observe:

  1. Differences in ACEs patterns among those who experience ACEs.
  2. Differences in health and other life-course outcomes based on these patterns.

Previous research has investigated one or both of these questions.

In a 2019 study by Brown and colleagues, 1 the authors used data from 5,870 participants in the National Survey of Child and Adolescent Well-Being to identify distinct subgroups of infants, children, and adolescents whose households had been investigated for child maltreatment.

Within each age band, the authors were able to identify three to four distinct categories of ACEs that characterized different ACEs patterns of abuse or maltreatment.

Across age bands, physical neglect, emotional abuse, household dysfunction, and caregiver victimization often appeared to cluster together in various groupings, and emotional abuse and caregiver divorce appeared to cluster together in older children and adolescents.

Other studies have performed similar analyses, often creating ACE groupings and then evaluating the relative risk of poor health based on group membership.

We highlight recent studies on ACEs patterns here, although many more have been conducted.

Studies using community samples have identified patterning by low vs. high exposure, as well as identifying other particularly distinct subgroups.

Using a community sample of 336 adolescents, Shin and colleagues (2018) identified four distinct groups by pattern of maltreatment:

  1. Low ACEs (characterized by low probabilities of response to any ACE item, range=[0.01,0.22])
  2. Household Dysfunction/Community Violence
  3. Emotional ACEs
  4. High/Multiple ACEs (characterized by high probabilities of direct victimization and moderate probabilities of family and community-related adversities). 2

They then examined the risk of substance abuse problems in each group and found that those experiencing in the High/Multiple ACEs category were more likely to report alcohol-related problems, current tobacco use, and experiencing psychological symptoms than those in other categories.

Separately, Merians and colleagues (2019) examined a sample of 8,997 college students, finding four distinct classes of ACEs patterns:

  1. High ACEs
  2. Moderate Risk of Non-Violent Household Dysfunction
  3. Emotional and Physical Child Abuse
  4. Low ACEs3

There were significant differences between classes on a range of outcomes, including mental health, substance use, poor physical health (although not for academic performance).

The largest differences in outcomes were between the high and low ACE categories, although those in household dysfunction and emotional and physical child abuse also had generally worse outcomes than those experiencing no ACEs.

Other studies have identified somewhat similar ACEs patterns in samples of youth at higher risk of ACE exposure.

In a longitudinal sample of 732 youth aging out of foster care, Rebbe and colleagues (2017) identified three subgroups of ACEs patterns:

  1. Complex adversity
  2. Environmental adversity (characterized by exposure to environmental harms such as witnessing violence and life-threatening accidents)
  3. Lower adversity4

Youth included in this study experienced a high number of ACEs relative to the general population; however, distinct patterns of health and behavioral risk emerged based on exposure profiles.

Youth in the complex adversity group were more likely to be homeless, experience depressive symptoms, and have received treatment for mental health. Those in the environmental adversity group were more likely to be arrested, and youth in either group were more likely to report PTSD, substance abuse symptoms, involvement with the justice system, and to self-report illegal behaviors compared to those in the lower adversity group.

ACEs may interact with each other to compound vulnerabilities

Recently, Briggs and colleagues (2021) expanded on previous work to characterize co-occurrence and distinct risk patterning of ACEs by assessing whether certain ACEs compound each other’s effects. 5

They find evidence that many ACEs do interact to place children who experience multiple forms of ACEs at even greater risk.

However, “synergistic pairs” (the specific pairs of ACEs that interact to increase risk) differ by gender and age. In particular, the authors found that sexual abuse may have particularly detrimental effects when experiences alongside other types of ACEs, and that the co-occurrence of multiple ACEs may be particularly harmful among those ages 6-12 and ages 13-18.

This research, which build on existing work characterizing the co-occurrence and unique risks associated with different ACEs patterns, is important for health care professionals and policymakers alike.

These insights provide depth to the ACEs framework, counting not only how many ACEs one has experienced, but seeking to explain how outcomes are shaped by the type of ACEs experienced and in identifying how vulnerabilities may be compounded.

Works Cited



1Brown, S. M., Rienks, S., McCrae, J. S., & Watamura, S. E. (2019). The co-occurrence of adverse childhood experiences among children investigated for child maltreatment: A latent class analysis. Child Abuse & Neglect, 87, 18-27.
2Shin, S. H., McDonald, S. E., & Conley, D. (2018). Patterns of adverse childhood experiences and substance use among young adults: A latent class analysis. Addictive behaviors, 78, 187-192.
3Merians, A. N., Baker, M. R., Frazier, P., & Lust, K. (2019). Outcomes related to adverse childhood experiences in college students: comparing latent class analysis and cumulative risk. Child abuse & neglect, 87, 51-64.
4Rebbe, R., Nurius, P. S., Ahrens, K. R., & Courtney, M. E. (2017). Adverse childhood experiences among youth aging out of foster care: A latent class analysis. Children and youth services review, 74, 108-116.
5Briggs, E. C., Amaya-Jackson, L., Putnam, K. T., & Putnam, F. W. (2021). All adverse childhood experiences are not equal: The contribution of synergy to adverse childhood experience scores. American Psychologist, 76(2), 243.

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Gloria Hu
Gloria Hu

Doctoral Student, Epidemiology, Mailman School of Public Health

Gloria is an incoming doctoral student in epidemiology at the Mailman School of Public Health. Her recent research includes work with the Global Violence Against Children and Youth Surveys (VACS) and qualitative research involving HIV-positive, formerly incarcerated individuals and the reentry process. She has also previously volunteered at youth correctional facilities in upstate New York.

Authors express their own opinions which do not necessarily reflect the opinions of the Stop Abuse Campaign.

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