Research Roundup June 2021:

ACEs Score Strengths, Limitations, and Misapplications

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

If you are reading this column, chances are you are already aware that ACEs are strongly associated with a range of poor outcomes across the life course. There is an enormous amount of literature on the health impacts of ACEs, with studies in a range of settings and across many populations; this work has been summarized in several reviews.1,2,3 Effective interventions to prevent ACEs and to prevent their negative impacts, however, are less well studied. Just recently, some authors of the original ACE study have cautioned against misapplications of the ACE questionnaire as a risk prediction tool,4 and other studies have found that while ACE scores are very good at predicting outcomes at a population level, they perform poorly in measuring individual risk.5 In this month’s column, we summarize and interpret some of these recent commentaries on ACEs score strengths, limitations, and misapplications. We also highlight two studies about how the ACE framework can be used in addressing the consequences of childhood trauma while avoiding its pitfalls. One paper describes the approach of an integrated, multi-level approach to preventing ACEs,6 while another summarizes the evidence for intervening on ACEs after they have occurred.7 We hope you will find this roundup helpful in understanding how ACEs scores are best interpreted and the importance of building an evidence base around effective interventions.

The ACEs questionnaire is good at predicting population-level risk, but does not perform as well in predicting individual risk.

In a recent editorial,4 Anda and colleagues note a trend toward interpreting or using ACE scores as screening toolsthat is, using the ACE questionnaire to predict an individual’s risk of experiencing poor outcomes. While ACEs have been shown to be associated with many adverse outcomes, the use of the ACE questionnaire as a screening tool may be prematureand in some cases, inappropriate. Anda, one of the principal investigators of the original ACEs study, raises several cautions. First, the ACE questionnaire cannot assess the frequency, intensity, or timing of different ACE exposures. These are all important contributors to individual risk. Second, while ACEs are strongly associated with a range of poor health outcomes, many of these health outcomes are caused by a multitude of factors, and the relative impact of ACEs may be small. Finally, there may be risks associated with screening, including stigma and discrimination, anxiety about the results of screening, and misclassification of an individual as high or low risk. These concerns are echoed in a recent study by Baldwin and colleagues,5 who note that ACE scores are highly predictive of group-level risk, but perform poorly at predicting individual outcomes. The study used data from 2,972 participants in two longitudinal studies to track ACE exposure and health over several decades. In both studies, ACE scores were associated with poor later health outcomes, consistent with the existing body of literature on ACEs. However, in both studies, the ACE score performed only slightly better than a chance at predicting an individual’s risk of mental or physical health problems. Why is this? Simply put, this result (good prediction at a group level but poor prediction at an individual level) can occur when outcomes vary substantially among people with the same risk score. That is—ACE scores will perform well at an individual level if people with the same ACE score reliably experience the same degree of physical or mental health impairment. But if effects on ill health are less consistent across individuals with the same ACE score, the measure may perform poorly at predicting individual risk even if it predicts elevated risk when results are aggregated at a group level.

Are ACE scores still useful?

In our view, yes, ACE scores are still useful. When presented correctly, we believe ACEs are an intuitive and accessible way to help people understand the impacts of childhood trauma. There is also work being conducted to build on the original ACE questionnaire, although these are in the early stages of development: in previous roundups, we have brought up efforts to develop instruments that provide a richer picture of an individual’s ACE experiences, incorporating timing, frequency, and duration of various ACE exposures. We have also presented research that ACEs that occur together may have unique impacts on future risk. As research around ACEs becomes more granular and more sophisticated, we should keep in mind what these advances mean (or don’t mean!) for the appropriate application of ACEs to policy and practice. Two recent papers provide insight on current best practices.

Best practices for preventing and addressing ACEs

Srivastav and colleagues draw on their recent experience in developing the Empower Action Model as part of the South Carolina ACE Initiative, focusing on community-based efforts to prevent and mitigate the effects of ACEs.6 The authors drew from a well-known public health framework called the socio-ecological model. The model states that influences on health occur at multiple levels including the individual, interpersonal, and community, and the authors emphasize the need for a multi-level approach to ACE prevention and mitigation. The authors also emphasize the importance of a life-course perspective (recognizing that timing matters) and the centrality of race equity and inclusion. Finally, the authors emphasize the importance of engaging community leaders and community members to lead the use of their model. A diagram of the model, and a more in-depth review of the program can be found in the original article. In addition to this ongoing work, a recently published review by Lorenc and colleagues examines which interventions are most effective in supporting people exposed to ACEs. 7 While findings were inconclusive overall—consistent with cautions raised by Anda, Baldwin, and others—there was some evidence of positive results for several interventions. The strongest evidence base is for cognitive-behavioral therapy for people exposed to abuse, with some evidence that psychological therapies, parent training, and broader support interventions may also be effective. The authors further note that most approaches to date have focused on mitigating individual psychological harms of ACEs, but less focus has been given to social pathways leading from ACEs to health impacts.

Conclusion: ACEs Score Strengths, Limitations, and Misapplications

It is not always straightforward to determine how we can best use and interpret the ACE questionnaire and framework to improving outcomes. There are important limitations to keep in mind when thinking about the application of ACEs as a screening tool, but there remains much to be done to expand the breadth, depth, and rigor of ACE research. There are also important case studies that we can draw from in developing empowering and community-centered programs that use the ACE framework to communicate and develop visions of better physical and mental health for all. The growing body of work on ACEs, including critiques, as well as supportive evidence, will help us all to build effective interventions that best address the impacts of childhood trauma.


1 Hughes, Karen, et al. “The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis.” The Lancet Public Health 2.8 (2017): e356-e366. 2 Kalmakis, K. A., & Chandler, G. E. (2015). Health consequences of adverse childhood experiences: a systematic review. Journal of the American Association of Nurse Practitioners, 27(8), 457-465. 3 Petruccelli, K., Davis, J., & Berman, T. (2019). Adverse childhood experiences and associated health outcomes: A systematic review and meta-analysis. Child abuse & neglect, 97, 104127. 4 Anda, R. F., Porter, L. E., & Brown, D. W. (2020). Inside the adverse childhood experience score: strengths, limitations, and misapplications. American Journal of Preventive Medicine, 59(2), 293-295. 5 Baldwin, J. R., Caspi, A., Meehan, A. J., Ambler, A., Arseneault, L., Fisher, H. L., … & Danese, A. (2021). Population vs individual prediction of poor health from results of adverse childhood experiences screening. JAMA pediatrics, 175(4), 385-393. 6 Srivastav, A., Strompolis, M., Moseley, A., & Daniels, K. (2020). The Empower Action Model: a framework for preventing adverse childhood experiences by promoting health, equity, and well-being across the life span. Health promotion practice, 21(4), 525-534. 7 Lorenc, T., Lester, S., Sutcliffe, K., Stansfield, C., & Thomas, J. (2020). Interventions to support people exposed to adverse childhood experiences: systematic review of systematic reviews. BMC public health, 20, 1-10.

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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.