PFI_12mmX178mm.

pdf + eps format

Journal of Child Psychology and Psychiatry **:* (2019), pp **–** doi:10.1111/jcpp.13135

Practitioner Review: Twenty years of research with

adverse childhood experience scores – Advantages,
disadvantages and applications to practice
Rebecca E. Lacey,1 and Helen Minnis2
1
Research Department of Epidemiology and Public Health, University College London, London, UK; 2Institute of
Health and Wellbeing, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK

Background: Adverse childhood experience (ACE) scores have become a common approach for considering childhood
adversities and are highly influential in public policy and clinical practice. Their use is also controversial. Other ways of
measuring adversity - examining single adversities, or using theoretically or empirically driven methods - might have
advantages over ACE scores. Methods: In this narrative review we critique the conceptualisation and measurement of
ACEs in research, clinical practice, public health and public discourse. Results: The ACE score approach has the
advantages – and limitations – of simplicity: its simplicity facilitates wide-ranging applications in public policy, public
health and clinical settings but risks over-simplistic communication of risk/causality, determinism and stigma. The
other common approach – focussing on single adversities - is also limited because adversities tend to co-occur.
Researchers are using rapidly accruing datasets on ACEs to facilitate new theoretical and empirical approaches but this
work is at an early stage, e.g. weighting ACEs and including severity, frequency, duration and timing. More research is
needed to establish what should be included as an ACE, how individual ACEs should be weighted, how ACEs cluster,
and the implications of these findings for clinical work and policy. New ways of conceptualising and measuring ACEs
that incorporate this new knowledge, while maintaining some of the simplicity of the current ACE questionnaire, could
be helpful for clinicians, practitioners, patients and the public. Conclusions: Although we welcome the current focus
on ACEs, a more critical view of their conceptualisation, measurement, and application to practice settings is urgently
needed. Keywords: Adversity; child abuse; early life experience; social work; social psychiatry.

recommendations for researchers and practitioners

Introduction
for the future of ACEs research and its application.
Childhood adversities have long been known to be
associated with poor health and other outcomes
across the lifecourse e.g. (Hughes et al., 2017;
Rutter, 1978). The availability of the Adverse Child- Methods
Whilst this is a narrative rather than systematic review, our
hood Experiences (ACEs) Questionnaire and demon-
literature search methods included searching Medline, Psy-
stration of dose-response associations between the chINFO, key child maltreatment journals (e.g. Child Abuse and
number of ACEs and a wide range of physical and Neglect and Child Maltreatment) and clinical child and
mental health problems has led to an exponential adolescent mental health journals (e.g. Journal of the Child
increase in research (Kelly-Irving & Delpierre, 2019) Abuse and Neglect, Journal of Child Psychology and Psychi-
atry, Clinical Child Psychology and Psychiatry) using search
and, more recently, policy interest in ACEs e.g.
terms such as ‘abuse and neglect’ and ‘adverse childhood
(Couper & Mackie, 2016). However, the ACEs field experiences’. Additional relevant papers were sourced via
has been strongly criticised. The aim of this review is reference lists and Google Scholar searches for terms such
to highlight the research evidence and current as ‘child abuse and neglect*cluster/overlap/polyvictimisation’
applications of ACEs research to practice. The and ‘adverse childhood experiences’. Google Scholar search
alerts for similar terms and journal content alerts were
evidence and its application have been limited in
followed for at least two years prior to drafting this review.
two overarching ways involving conceptual and mea- We also asked research, policy and clinical experts to read
surement issues. Specifically, we focus on cumula- early drafts to ensure we were up to date with practice and
tive risk (e.g. ACE scores), single adversity policy initiatives.
approaches, theoretically- and empirically-driven
methods for measuring childhood adversities, and
their advantages and disadvantages. We then con- What is an ACE? Conceptual issues
sider the ways ACEs research is applied to clinical Childhood adversity is ‘a construct in search of a
practice, public policy and public health pro- definition’ (McLaughlin, 2016: p. 363) and a funda-
grammes, exploring the intended goals and potential mental consideration in ACEs research and transla-
challenges of these activities. We end with a series of tion is what constitutes an ‘adversity’? There has
been much recent debate on this issue, beyond the
scope of this review: we refer the reader to other
authors for considerations about whether wider
Conflict of interest statement: no conflicts declared.

© 2019 Association for Child and Adolescent Mental Health

Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
2 Rebecca E. Lacey and Helen Minnis

societal risks, such as community dysfunction and experience, frequency and duration of experience
ethnic minority status, should be considered as are not considered. For example, neglect could be
adversities (Cronholm et al., 2015; Edwards et al., conceptualised as an event or a condition: being
2017; Hartas, 2019; McEwen & Gregerson, 2019). left unattended for a short time probably would not
We consider adversities to be those experiences constitute neglect but repeated and ongoing lack of
which require significant adaptation by the develop- supervision would. Most studies (77%) identified in
ing child in terms of psychological, social and neu- Appleton et al. (2017) systematic review used
rodevelopmental systems, and which are outside of unweighted cumulative risk scores and only three
the normal expected environment, adapted from studies weighted adversities by their perceived
(McLaughlin, 2016). ACEs investigated thus far severity (Crowell et al., 2016; Davis et al., 2014;
typically include the same ACEs as the study by Slopen, Koenen, & Kubzansky, 2014). The adult
Felitti et al. (1998). This study asked more than life events literature could potentially offer guid-
8,000 adults presenting at the Kaiser Permanente ance on how to better model severity and fre-
San Diego Health Appraisal Clinic for a medical quency data. In 1979 Ross and Mirowsky reviewed
examination between 1995 and 1996 to complete a the life events literature and suggested that simply
questionnaire on ACEs. The ACEs included were adding up undesirable events was still giving the
abuse (psychological, physical and sexual) and best prediction of psychiatric symptomatology
household dysfunction (living with a household (Ross & Mirowsky, 1979). Despite their proposing
member with substance abuse problems, mental more sophisticated weighting systems, such as
illness or who had ever been to prison, and mother weighting adversities according to their statistical
was treated violently). The ACEs included were effect, this body of literature, now forty years old,
expanded by Anda et al. (1999) to add parental does not appear to have influenced modern ACEs
separation/divorce, and emotional and physical research.
neglect were later included by Dong et al (2004). The key conceptual issues in ACEs research are
These ten ACEs have been used in many subsequent summarised in Table 1, alongside some considera-
studies and in translation to practice. However, the tions/recommendations that researchers might take
choice of these ACEs has rarely been questioned. No into account in future studies. Such issues are
rationale for inclusion of those specific adversities, central for informing future ACEs research and
or for not including others, was given in the original translation into practice, and for considering mea-
Felitti paper (1998). Many subsequent studies have surement (considered in the next section).
included additional ACEs. In a systematic review of
studies assessing the association between ACEs and
cardiovascular risk factors (Appleton, Holdsworth,
Ryan, & Tracy, 2017), a third included poverty as an Table 1 Summary of conceptual issues and considerations for
ACE and a third included parenting styles. Poverty, future ACEs work
particularly, is conceptually distinct from psychoso-
cial adversities as it is a broader structural issue Considerations/
recommendations for future
determined largely by political and economic influ- Conceptual issues research
ences (Children1st, 2018).
Adverse childhood experience screening tools are Lack of internationally agreed Be explicit in definitions about
consequently far from uniform (Bethell et al., 2017); definitions of adversity what is and is not considered
to be an adversity, and why.
the ACE Questionnaire (ACE-Q) used by the Center Conduct research on
for Youth Wellness (Bucci et al., 2015) includes the clustering of ACEs and their
same items from the Felliti study, whereas the relative prognostic
World Health Organisation ACE International Ques- significance, both
tionnaire (ACE-IQ) includes additional adversities individually and in
combination
such as bullying, war and parental death (WHO, Assigning individuals into Consider including
2018). Finkelhor et al. (2013) suggest that associ- binary categories regarding information on perceived
ations between ACE scores and health are improved ACEs (experienced vs. not severity or effect of
when adversities, such as peer rejection, peer experienced) experience too, as well as
victimisation, and community violence, are added. timing and duration of
experience.
These varying conceptualisations make comparison Lack of justification for using Consider inclusion of other
of study findings challenging and can create ten- original ten Kaiser adversities too – but justify
sions about how different studies should inform Permanente ACEs their inclusion based on
practice. clustering and prognostic
Another conceptual issue is the yes/no nature of significance
Differing items in various ACE Need for greater consensus on
ACE recording: individuals are usually assigned screening questionnaires which items to include and
into simply experiencing or not experiencing each why
adversity (Evans, Li, & Whipple, 2013). This means
that risk is arbitrarily attributed and the severity of ACE, adverse childhood experience.

© 2019 Association for Child and Adolescent Mental Health

 ACE scores: pros, cons and applications to practice 3

of health outcomes, including risky health beha-

How are ACEs measured? Comparison of
viours, heart disease, cancer, stroke, type 2 dia-
different approaches and their strengths and
betes, chronic bronchitis, fractures, hepatitis and
limitations
poor self-rated health. The ACE score has since
The way in which adversities have been measured in
become the dominant approach in ACEs research
previous studies are limited. We consider strengths
and has been replicated in hundreds of studies with
and limitations of the commonly used approaches in
wide ranging outcomes, such as depression (Chap-
research studies: cumulative risk or ACE scores;
man et al., 2004), alcohol use (Dube et al., 2006),
single adversities; and data- and empirically-driven
obesity (Isohookana, Marttunen, Hakko, Riipinen, &
methods.
Riala, 2016), premature mortality (Kelly-Irving et al.,
2013), receipt of disability pension (Bj€ orkenstam,
Cumulative risk scores Hjern, & Vinnerljung, 2017) and sleep disorders
(Kajeepeta, Gelaye, Jackson, & Williams, 2015).
A cumulative risk approach involves summing dif-
ferent adversities to represent the total number of
adversities experienced by an individual. The cumu- Strengths of ACE scores
lative risk approach to adversities was first applied
The main advantages of the ACE score approach are
by Holmes and Rahe (1967) in their Schedule of
that:
Recent Experiences. This was a checklist of major
life events retrospectively reported by adults. Each
1. It is simple to calculate and understand. Conse-
event was weighted in a somewhat arbitrary fashion
quently it has been considered a useful tool for
by a series of external ‘judges’ and each event
engaging non-academic audiences in considering
assigned a score between 1 (not stressful) and 100
how early life social circumstances might have
(very stressful) ‘Life Change Units’, then summed
long-term effects on population health (McLaugh-
across to create a total score. The cumulative risk
lin & Sheridan, 2016).
score approach was first applied to childhood adver-
2. From a statistical perspective, by summing sev-
sities in the Isle of Wight study (Rutter, 1978) in
eral variables, researchers are more likely to find
which a ‘family adversity index’ was constructed by
strong, statistically significant associations
summing exposure to disadvantaged parental
which are more likely to be ‘harder hitting’ and
socioeconomic position, large family size, marital
easier for engaging with non-academic audiences
discord, maternal psychopathology, foster care
(Evans et al., 2013).
placement and parental criminality. This study
3. The use of ACE scores acknowledges the high
found that children with four or more family adver-
level of co-occurrence of different childhood
sities had the highest risk of child conduct disorder.
adversities (Dong et al., 2004; Felitti et al.,
The premise behind cumulative risk scores is that
1998), and that, on average, experiencing more
childhood challenges in a single domain are easier to
adversities is associated with poorer outcomes.
negotiate than challenges occurring within multiple
Between 81% and 98% of respondents in the
domains, echoing Bronfenbrenner’s (1979) Ecologi-
Kaiser Permanente study who reported one ACE
cal Systems theory. The cumulative risk approach
also reported at least one other (Dong et al.,
for predicting child outcomes was later applied by
2004).
Werner and Smith (1982) to show that children who
4. ACE scores have also been used as simple prac-
had four or more risk factors at age 2 exhibited
tice tools for identifying people at the highest risk
poorer adjustment in adolescence. Similarly, Samer-
of poor outcomes, e.g. (Center for Youth Wellness,
off et al. (1987) showed that a cumulative risk score
2017). However, care is needed in directly trans-
comprising ten aspects of the family social environ-
lating risk from population level studies to indi-
ment1 was associated with poorer cognitive and
viduals (discussed below).
socioemotional development in children in the
Rochester Longitudinal Study.
The most highly cited and widely replicated
Limitations of ACE scores
approach to cumulative risk in childhood adversities
comes from Felitti et al. (1998). The participants of
1. The ACE score approach assumes that each
the Adverse Childhood Experiences study were
adversity is equally important for outcomes
asked whether they had experienced abuse (psycho-
(McLaughlin, Sheridan, & Lambert, 2014),
logical, physical and sexual) and household dys-
which is unlikely.
function (living with a household member with
2. ACE scores disregard the specific patterning of
substance abuse problems, mental illness or who
ACEs. A child who witnesses domestic violence,
had ever been to prison, and mother was treated
parental divorce and has a parent with a mental
violently) as a child. These seven adversities were
health problem is assigned an ACE score of three,
summed to create an ‘ACE score’. The authors
as is a child who experiences emotional, physical
showed strongly graded relationships with a range
and sexual abuse. This implies that both children

© 2019 Association for Child and Adolescent Mental Health

4 Rebecca E. Lacey and Helen Minnis

have the same risk of poor outcomes – another practice and policy, but developments of the ACE
unlikely assumption. score approach will be necessary before meaningful
3. ACE scores are uninformative in elucidating the progress can be made on mechanisms, protective
mechanisms through which adversities might factors, and the development of more focussed
lead to poorer outcomes individually and with preventative and treatment interventions for ACE-
other adversities. We need to know about the associated poor outcomes.
effects of separate adversities, how and which
different adversities interact or co-occur and the
Alternative approaches to measuring ACEs
effects of these patterns of co-occurrence (Lanier,
Maguire-Jack, Lombardi, Frey, & Rose, 2018). What are the alternative approaches to measuring
4. The ACE score approach assumes that everyone ACEs in research and their implications for practice?
with the same ACE score will receive the same We consider three common methods – single adver-
benefit from an intervention regardless of what sities; theoretically driven models; and empirically
those adversities were. Understanding mecha- driven methods.
nisms is key to developing better interventions. At
present a ‘one size fits all’ approach to practice Single adversity approaches. There are thousands
and policy is assumed, because we have limited of research studies, many long pre-dating the focus
knowledge on how different ACE combinations on ACE scores, which examine one single adversity.
affect health (Lanier et al., 2018). There are also studies that disaggregate the ACE
5. Revisiting Felitti’s (1998) study there was no score into its component parts and examine the
rationale for why the adversities were summed effect of each adversity independently. For example
rather than applying other statistical approaches Merrick et al. (2017) used the Kaiser Permanente
to deal with the co-occurrence of adversities. study to examine associations between each ACE
Associations between ACE scores and outcomes and health without adjusting for the effect of each of
might be driven by the effect of one or a sub-set of the other adversities, making it possible to compare
adversities. Despite the known limitations of sim- the strength of associations between different adver-
ple summative approaches, and the longstanding sities and specific outcomes. The strongest associa-
existence of more sophisticated approaches e.g. tions were observed between parental substance
(Ross & Mirowsky, 1979), the cumulative risk misuse and the participant’s own engagement with
approach has rarely been questioned. risky health behaviours. Dennison et al (2017) found
6. There has been a reliance on retrospective report- associations of differing magnitude between trauma
ing of ACEs despite poor agreement between (assessed via the Childhood Trauma Questionnaire),
prospective and retrospectively-reported ACEs caregiver neglect and food insecurity on reward
(Baldwin, Reuben, Newbury, & Danese, 2019; processing. Alcala et al. (2018) also found different
Newbury et al., 2018). The equivalence between associations between different adversities and out-
retrospectively and prospectively reported ACEs comes; participants who reported childhood physical
therefore cannot be assumed. Longitudinal abuse were less likely to attend prostate, breast or
research has shown that retrospectively recorded cervical screening, while no associations were
ACEs are more strongly associated with health observed between sexual abuse and screening atten-
outcomes than those that were objectively dance. The key strength of these single adversity
assessed prospectively (Reuben et al., 2016). approaches is that one can examine the potential
7. Few studies have considered the importance of mechanisms linking a specific adversity to a specific
timing, chronicity and discontinuity of adversi- outcome (McLaughlin, 2016), but this is an under-
ties, although there are some exceptions (Alastalo researched area.
et al., 2013; Crowell et al., 2016; Davis et al., The main limitation of the single adversity
2014; Friedman, Montez, Sheehan, Guenewald, approach is that it ignores the presence of other
& Seeman, 2015; Schooling et al., 2011; Slopen adversities when we know there is a high level of co-
et al., 2014, 2015). Few studies use repeated ACE occurrence (Finkelhor et al., 2007). It is therefore
scores at different ages, and often just use a possible that any association observed between a
single ACE score for the whole of childhood/ specific adversity and outcome is in fact explained by
adolescence (Howe, Tilling, & Lawlor, 2015). the experience of other adversities not accounted for
There has been a greater focus on adult outcomes in the analysis. The increasing recognition of the
with less focus on how ACEs might affect chil- clustering of adversities has resulted in a decline in
dren. This is likely driven by the reliance on the single adversity approach and a subsequent
retrospective reporting in adult populations but increase in research which applies an ACE score
also by issues surrounding the disclosure of approach (McLaughlin et al., 2014) – with the
adversities by children (considered later). limitations we have already discussed.
The use of cumulative ACE scores has been
Theoretically driven models of adversity. The
profoundly influential in medical and social science,
appreciation of the clustering of adversities and the

© 2019 Association for Child and Adolescent Mental Health

 ACE scores: pros, cons and applications to practice 5

limitations in ACE scores has resulted in theoreti-

Empirically driven methods. Two alternative
cally driven dimensional models of adversity. Dimen-
empirical approaches emerged in ACEs research –
sional models group adversities according to how
variable-centred (e.g. factor analysis, FA) and per-
they might similarly affect a specific outcome. For
son-centred (e.g. latent class analysis, LCA) meth-
instance, McLaughlin et al. (2014) proposed a
ods. FA groups ACEs by the degree to which they are
Dimensional Model of Adversity and Psychopathology
correlated with one another. LCA is a person-centred
(DMAP), suggesting that deprivation- (e.g. institu-
clustering technique that groups people to show the
tionalisation, neglect and poverty) and threat-based
adversities they tend to report. The focus of this
adversities (e.g. abuse) affect psychopathological
approach is on how prevalent different combinations
outcomes to a similar extent but via different mech-
of adversities are and whether different combina-
anisms. Evidence from animal studies shows that
tions of adversities matter. Recent applications of
deprivation-based adversities affect neurodevelop-
these methods to ACEs research have found various
ment through the absence of stimulation leading to
ways of grouping ACEs or individuals (Caleyachetty
excessive pruning of synapses in the Central Ner-
et al., 2018, 2016; Denholm, Power, Thomas, & Li,
vous System e.g. (Bennett, Rosenzweig, Diamond,
2013; Green et al., 2010; Lanier et al., 2018;
Morimoto, & Hebert, 1974) and that the effects of
Westermair et al., 2018). For example, Ford et al
deprivation on CNS structure are reversible following
(2014) applied FA and found three groups of ACEs in
exposure to enriched, cognitively stimulating envi-
the 2010 Behavioral Risk Factor Surveillance Sys-
ronments (Diamond, Rosenzweig, Bennett, Lindner,
tem - Household dysfunction (e.g. family member
& Lyon, 1972). Threat-based adversities are thought
substance misuse, parental separation, parental
to affect neurodevelopment through changes in
incarceration); Emotional and physical abuse, and
amygdala and hippocampal functioning resulting in
Sexual abuse. In contrast, a FA by Mersky et al
altered emotional development (van Marle, Hermans,
(2017) found two groups of adversities: child mal-
Qin, & Fern andez, 2009). However, it could be
treatment and household dysfunction. A recent
argued that neglect and deprivation are not mutually
study found that the number of clusters and the
exclusive domains, as threat responses might be
types of adversity that clustered together varied by
mobilised by having unmet needs. DMAP was
age (Brown, Rienks, McCrae, & Watamura, 2017).
recently empirically tested and studies have shown
This suggests that using a single ACE score for the
that threat- and deprivation-based adversities affect
whole of early life might miss age-variation in when
outcomes such as internalising and externalising
adversities occur and how adversities are reported.
behaviours (Miller et al., 2018), physiological reac-
The main advantage of FA and LCA methods,
tivity to stressful tasks (Busso, McLaughlin, &
rather than just relying on cumulative counts of
Sheridan, 2016) and biological ageing (Sumner,
ACEs, is that they allow researchers to understand
Colich, Uddin, Armstrong, & McLaughlin, 2018) via
the prevalence and impact of different ACE combi-
different mechanisms.
nations. These methods also weight adversities
Several other possible theoretical groupings have
depending on their relationship with outcomes of
been suggested, such as by harshness and unpre-
interest and do not assume that each adversity has
dictability (Belsky, Schlomer, & Ellis, 2012; Ellis,
an equal effect (Ford et al., 2014). These methods
Figueredo, Brumbach, & Schlomer, 2009; McLaugh-
have the potential to inform the targeting of inter-
lin et al., 2014), the interconnectedness of different
ventions to address specific ACE patterns and to
forms of interpersonal violence (Hamby & Grych,
prioritise interventions for children who report the
2013), familial versus extra-familial adversities, nat-
most problematic combinations (Lanier et al., 2018).
ural disasters versus human-caused, severe versus
More work is needed (including examining how
mild, or stigmatising versus non-stigmatising.
certain groupings predict outcomes) before we can
The advantages of theoretical models are that,
come to a consensus about how best to group ACEs
unlike cumulative ACE scores, they recognise that
and what this means in terms of mechanisms,
different adversities are likely to have differing
prevention and treatment.
mechanisms through which they affect outcomes.
Empirically driven methods have their limitations.
However, they are often difficult to test comprehen-
First, we still know little about the predictive power
sively, particularly in large population studies,
of FA and LCA-derived adversity variables, although
requiring detailed information on both adversities
interesting findings are beginning to emerge; in the
and variables capturing mechanisms. Until more is
US National Longitudinal Study of Adolescent to
known about mechanisms, it will be difficult to
Adult Health, adversity variables derived by FA more
group adversities logically. For instance, using the
strongly predicted later depressive symptoms and
DMAP model, parental separation might have
heavy drinking than a simple ACE score (Brumley,
aspects of both deprivation and threat. Conse-
Brumley, & Jaffee, 2018). Second, we do not know
quently, while these models are promising, mecha-
whether clusters derived via FA or LCA share similar
nistic knowledge is at an early stage that they are
mechanisms leading to poorer outcomes or whether
difficult to translate into practice. Further empirical
these occur to the same people. Third, large sample
research is required.

© 2019 Association for Child and Adolescent Mental Health

6 Rebecca E. Lacey and Helen Minnis

Table 2 Summary of strengths and limitations of the main approaches to measuring adversities

Measurement approach Strengths Limitations

ACE score
Simple to understand and carry out
Assumes that each adversity has same

More likely to find strong, statistically sig- association with outcomes of interest
nificant associations with outcomes
Ignores the specific patterning of ACEs i.e.

Acknowledges that adversities tend to co- which adversities tend to co-occur?
occur
Unhelpful if interested in mechanisms
through which adversities might affect out-
comes

The specific adversities in an ACE score are
rarely justified or questioned

Largely reliant on retrospective reports which
are likely to be biased/unreliable

Consequently, larger focus on adult out-
comes rather than child outcomes
Single adversities
Can investigate mechanisms linking specific
Ignores the co-occurrence of adversities (i.e.
adversities with outcomes of interest associations seen could be confounded by

Can compare effects of different adversities presence of other adversities)

Theoretically driven adversity
Adversities grouped theoretically based on
Often difficult to test in a comprehensive way
models how they are thought to affect outcomes and to separate adversities into different

Therefore useful for investigating mecha- types
nisms linking different types of adversities
with outcomes

Empirically driven methods
Allow researchers to better understand the
Little currently known about the predictive
(e.g. variable-centred and co-occurrence of adversities and the impact power of these methods and how they com-
person-centred methods) and prevalence of different combinations pare to other methods, e.g. ACE scores, for

Adversities are weighted depending on how outcomes
strongly they influence outcomes
Require large sample sizes

Useful for identifying prevalent and harmful
Often criticised for being ‘analysis-specific’
ACE patterns and consequently to prioritise and therefore not easily generalised to other
interventions populations. However there is evidence of
replication of adversity clusters across dif-
ferent samples as these methods become
more common

Most of the research using these methods
has concentrated on maltreatment rather
than broader ACEs

ACE, adverse childhood experience.

sizes are needed, particularly when there is a need to

Application of ACEs research to clinical work,
compare different adversity dimensions simultane-
public policy and public health programmes
ously. Fourth, these methods effectively omit adver-
Adverse childhood experience scores and findings
sities which are not correlated with other adversities
from ACE research are used in different ways in
(Evans et al., 2013), potentially missing an indepen-
public policy, public health and clinical work with a
dent effect of that adversity. Fifth, findings derived
variety of goals. If we want ACE scores to do more
from these methods are analysis-specific and there-
than predict broad population risks and instead
fore difficult to translate across studies, as different
prioritise and develop interventions or build models
studies might find different numbers and types of
of development, then more nuanced research and
adversity clusters. Some trends across studies are
applications of that research is needed. In Table 3 we
emerging; a systematic review of studies applying
consider the ways ACEs research is currently used in
person-centred methods to child maltreatment
each of these activities in turn, along with their goals
found that most studies identified ‘low risk’ and
and challenges.
‘polyvictimisation’ clusters (Debowska, Willmott,
Boduszek, & Jones, 2017). Finally, most of the
research that has applied empirical methods, par- Public policy
ticularly LCA, has focused on the co-occurrence of
In the Public Policy arena, there are two main ACE-
abuse and neglect rather than on broader ACEs.
related activities: ‘ACE awareness’ for the general
The strengths and limitations of the main
population and the development of ‘Trauma-in-
approaches to adversity measurement are sum-
formed’ public services.
marised in Table 2.

© 2019 Association for Child and Adolescent Mental Health

 ACE scores: pros, cons and applications to practice 7

might be another mechanism for reducing ACE

Increasing public awareness – ‘ACE aware-
prevalence in the population. ACE awareness initia-
ness’. Findings from population level studies are
tives often have a narrow focus on individual/family
frequently used to raise public awareness of the
level causes of ACEs but little focus on these societal
potential long-term effects of ACEs (increasing ‘ACE
level factors (Fond, Haydon, & Kendall-Taylor, 2015).
awareness’). Scotland and Wales aim to become the
‘first ACE-Aware Nations’ (ACE Aware Scotland,
Training of frontline workers to be ‘trauma infor-
2018; ACE Aware Wales, 2019). The ultimate goal is
med’. Recent initiatives have trained frontline
to prevent ACEs in the first place (primary preven-
workers, such as the police, teachers, health and
tion) and to reduce violence through creating a more
social care workers, to be ‘trauma informed’ or
compassionate society. Whilst these goals are mer-
‘trauma aware’ (Ko et al., 2008; NHS Highlands,
ited, care should be taken that the messages from
2018). Workers are encouraged to recognise that the
ACEs research are not communicated in a determin-
people they encounter may be in their current
istic way. Crucially, risk at the population level does
situation as a consequence of ACEs (Sullivan, Mur-
not imply that an individual is going to have negative
ray, & Ake, 2016) and to consider ‘what happened to
future outcomes, yet many of the current educational
you?’ rather than ‘what’s wrong with you?’ The aims
materials about ACEs imply just this e.g. (Ford et al.,
of ‘trauma informed’ initiatives are to increase com-
2016; PublicHealthWales, n.d.). If the ACE-aware
passion, improve relationships between the public
movement gains momentum and the language of
and public service representatives and hence reduce
ACEs becomes current in society, there could be
violence. Trauma informed training also aims to
unintended negative effects on children if, say, a ten-
minimise the potential long-term effects of ACEs by
year-old child with a history of multiple adversities
building resilience (secondary prevention) and pre-
comes to feel stigmatised and doomed to poor phys-
venting re-occurrence (tertiary prevention) (Couper
ical and mental health. It is crucial that alongside
& Mackie, 2016). Trauma informed practices can be
public discussion of ACEs there is at least as much
extended beyond frontline staff training to all layers
emphasis on resilience and potential for change
of organisations, such as policies and procedures,
towards more positive trajectories. Linked to this,
recruitment and leadership style (NHS Highlands,
much of the current public education about ACEs
2018).
assumes that they have a causal role in negative
Little is yet known about the impact of trauma
outcomes, yet most research on ACEs is correlational
informed practices in, for example, in improving
and was conducted retrospectively. There is therefore
therapeutic support for children whose traumatic
the potential for recall bias and confounding, i.e.
experiences have been recognised (Berliner & Kolko,
ACEs could be markers for other risks that could be
2016). As with ACE awareness initiatives, the issues
causing negative health outcomes. For example,
surrounding the communication of risk discussed
there is increasing evidence that the association
above also apply to how research findings are
between ACEs and negative health outcomes might
presented in training materials. In these public
be confounded by neurodevelopmental problems,
policy campaigns, caution is required to ensure that
such as autism and ADHD. Both autism and ADHD
the public, and public service workers, understand
are independently associated with a wide range of
that multiple ACEs do not mean that poor outcomes
health risks (Croen et al., 2015) and premature
are inevitable – and that factors such as committed,
mortality (Dalsgaard, Ostergaard, Leckman, Morten-
stable care from nurturing adults are crucial to
sen, & Pedersen, 2015; Hirvikoski et al., 2016) – and
reduce risk. If conducted well, these public policy
children with disabilities are at higher risk of being
approaches have great potential to create a language
maltreated (Maclean et al., 2017). Recent beha-
that transcends public and professional groups,
vioural genetic research has shown that, although
increases partnership working across agencies and,
co-occurring neurodevelopmental problems such as
ultimately, increases compassion and reduces vio-
ADHD and learning disabilities are more common in
lence in society. ACE-awareness campaigns led by
children who have experienced abuse and neglect
governments and supported by a wide range of
than those who have not, the maltreatment does not
services, such as are happening in Scotland and
appear to cause these overlapping disorders (Dinkler
Wales, are an interesting natural experiment. There
et al., 2017). Longitudinal studies have shown that
is an opportunity for rigorous research to test
cognitive problems (Danese et al., 2017) and ADHD
whether these goals can be achieved.
(Stern et al., 2018) may precede abuse and neglect. If
ACEs can be the result of treatable neurodevelop-
mental problems such as ADHD then the burden of Public health
ACEs could potentially be reduced in the population
Public health approaches overlap with public policy
by better supporting families whose children have
campaigns but are more targeted towards improving
these difficulties. Similarly, family economic circum-
population health through prevention and interven-
stances are an important determinant of ACEs (Lim-
tion. We have included, here, Routine Enquiry and
ing, 2018) and a focus on alleviating child poverty
screening for ACEs.

© 2019 Association for Child and Adolescent Mental Health

 8
Table 3 The main ways ACEs are used in public policy, public health and clinical work, their intended goals and challenges

Activity Level Intended goals Challenges

Public policy approaches

‘ACE awareness’ promotion - using Whole
To increase public awareness that ACEs increase risk of physical and
Correlation 6¼ causation
data from population-level studies population mental health problems across the lifespan so ALL of us should be
Research findings are often communicated in a
to increase public awareness doing what we can to prevent them deterministic way
about ACEs
To increase public awareness that the opportunity to confide in at
Little focus on resilience
least one supportive adult can ameliorate the ‘impact’ of ACEs
Individual level focus despite research findings being

To develop ‘kinder, more compassionate societies’ ultimately to at a population level
support primary prevention of ACEs, increase compassion and
Lack of rigorous evaluation of programme effects
understanding for people who have suffered multiple ACEs

‘Trauma informed’ training of Whole
‘Trauma-focussed’ encounters with clients/patients i.e. increasing As above
frontline staff working with services understanding by practitioners of what might have happened to their
children or adults (e.g. police, patients/clients and consequently why they might be in their current
Rebecca E. Lacey and Helen Minnis

teachers and health and social situation

care workers) sometimes drawing
Hence to improve client/practitioner relationships, create a more
on service-level audit data. May compassionate workforce
also include ‘routine enquiry’
Early detection of ACEs during childhood in order to prevent/reduce
about ACEs (see below) by staff negative impacts (i.e. Secondary prevention)

Attempts to reduce impact of ACEs on individuals in adulthood (i.e.
tertiary prevention)
Public health approaches
Routine enquiry – a requirement of Whole
‘Trauma-focussed’ encounters with clients/patients i.e. increasing
Clarity about how ACE information is used (e.g.
staff within public services to ask services understanding by practitioners of what has happened to their issues around child protection)
about and routinely record patients/clients and consequently why they might be in their current
Appropriate services need to be in place to support
information about ACEs situation treatment

Hence to improve client/practitioner relationships, create a more
Concerns about use of ACE questionnaires by
compassionate workforce and reduce violence within services untrained staff (especially if regarding children)

Early detection of ACEs during childhood in order to prevent/reduce
Consider asking about more than the Kaiser Per-
negative impacts (i.e. Secondary prevention) manente ACE items

Attempts to reduce impact of ACEs on individuals in adulthood (i.e.
More than an ACE score needed – e.g. enquiry about
tertiary prevention) by directing individuals to appropriate services severity, timing, context
Screening Population/ populations
Identify people who have experienced ACEs
sub-
Provide interventions that prevent poor outcomes

Screening is not possible or

appropriate here since ACEs are not
an early stage of disease and, even if
they were, evidence-based
interventions to prevent their
development into a full-blown
disease state are not available
Use of ACEs information in treatment and treatment planning

(continued)

© 2019 Association for Child and Adolescent Mental Health

 ACE scores: pros, cons and applications to practice 9

ACE score not as informative as information about Routine enquiry. Routine Enquiry aims to train

psychopathology stems entirely from ACEs, espe-

also have complex neurodevelopmental problems

cially as we now know that individuals who have
experienced abuse and neglect are more likely to
severity, timing and context regarding individual

Simplistic recording of ACEs (e.g. in social work

frontline practitioners to routinely ask all patients/

Clinicians must be careful not to assume that

clients about ACEs. The rationale is that, since
datasets) might mask multiple adversities spontaneous disclosure of ACEs is uncommon,
knowledge about ACEs can aid treatment (Read,
Harper, Tucker, & Kennedy, 2018). There is little
evidence in support of routine enquiry as yet (Ford
et al., 2019), however various programmes now exist
to encourage it, such as the Routine Enquiry into
Adversity in Childhood (REACh) programme com-
missioned by Public Health Blackburn (RealLifeR-
esearch, 2015). REACh trains practitioners, who
have first line contact with adults presenting with
risky behaviours and a range of health issues, to
routinely conduct ACE questionnaires with their
Challenges

ACEs

clients with the aim of responding appropriately

and planning interventions. In adult mental health
services, the use of routine enquiry is growing, but

should not be tick box exercises to derive an ACE

score but instead be an entry point to further
patients/clients with the aim of making correct assessments and

focussed CBT – where trauma symptoms are linked with specific

Better surveillance to guide appropriate treatments e.g. trauma-
More compassionate and ‘trauma-focussed’ encounters with the

sensitive discussion, support and intervention where

indicated. Appropriate and effective services need to
be in place to appropriately manage disclosures
(Finkelhor, 2018; Howard, 2017).
There have been calls for routine enquiry to be
conducted with children and adolescents, but indis-
criminate and inappropriate use of ACE question-
naires by untrained staff could be harmful, especially
for children (Barrett, 2018). Abuse disclosure in
childhood has child protection implications and rou-
tine enquiries by adults could affect children’s evi-
dence if disclosures lead to legal proceedings
(Andrews, Lamb, & Lyon, 2015). Yet a report by the
National Society for the Prevention of Cruelty to
Children (NSPCC) describing the process of disclosure
planning treatment

for children and young people found that, while 80% of

children and adolescents tried to disclose the mal-
treatment before the age of 18, less than 60% of
Intended goals

disclosures were acted upon at the time (Allnock &

ACEs

Miller, 2013). Rather than simply translating princi-

ples of adult routine enquiry to children, considera-
tion is needed about how to train children’s front line

workers to better recognise and ‘hear’ disclosure.

patients/
Individual

clients

Screening. The term ‘screening’ in the ACEs field is

Level

often used loosely and sometimes as a synonym for

routine enquiry, but is in fact a very different under-
taking. Screening is only appropriate when there is a
where there is already knowledge

ACE, adverse childhood experience.

ACE-aware or ‘trauma-focussed’

recognisable early stage of disease and when inter-

individual or group treatment

ventions exist that are known to be effective in

preventing progression to the full-blown disease state
(Andermann, Blancquaert, Beauchamp, & D ery,
2008; Wilson & Jungner, 1968). ACEs do not
Table 3 (continued)

inevitably lead to disease, so cannot be considered

to be such an early stage and it is not ethical or
about ACEs

justified to screen for ACEs where effective treatment

cannot be assured (Finkelhor, 2018). This crucial
Activity

difference has been highlighted in the field of domestic

violence: like ACEs, domestic violence is not a disease.

© 2019 Association for Child and Adolescent Mental Health

10 Rebecca E. Lacey and Helen Minnis

Instead, both domestic violence and ACEs are ‘health-

Could new ways of recording and measuring ACEs
related risk factors’ (Taket, Wathen, & MacMillan,
inform clinical practice?
2004). Screening children for ACEs is even more
problematic. Detailed ‘screening’ programmes have Patients who experienced ACEs are more likely than
been described in the United States where paediatric the general population to have complex problems
clinics routinely collect total ACE scores on children that can include both neurodevelopmental (Dinkler
via parental or caregiver report (Purewal et al., 2016). et al., 2017) and trauma-related problems (van der
It is striking that, in the description of these services, Kolk, 2005). Data-driven research approaches might
little mention is made of social work or child protec- help tease apart the impact of ACEs at different
tion and the ethical issues regarding lack of evidence- developmental stages and the interplay between
based interventions for children with high ACE scores ACEs and other key developmental factors. This will
(Finkelhor, 2018). require new ways of recording ACEs in administra-
tive datasets. For example, encouraging social ser-
vices to record all types of maltreatment at the time
Use of ACEs information in treatment and
of entry to care rather than just the reason that
treatment planning
precipitated the current episode of care-entry could
Knowledge about ACEs can be helpful in formulating provide important information for future research.
treatment plans for individual patients. Some goals This knowledge could support development of new
are shared with trauma-informed population and more effective treatments for maltreated indi-
approaches e.g. increasing understanding and com- viduals.
passion for the patient. Understanding from ACEs
research has also been helpful in treatment devel-
opment e.g. knowledge that adversities often co- Recommendations for the future of ACEs
occur (Hughes et al., 2017) and that ACEs can have research and its applications
clinical correlates that are both general (e.g. stress) There is now a large body of evidence showing that
and specific (e.g. PTSD) (Cohen & Mannarino, 2008). ACEs may have long-term consequences, at a pop-
The traditional recording of ACEs in mental health ulation level. This knowledge has resulted in a wide
and social work practice might actually mask multi- range of policy and practice initiatives, but rigorous
ple adversities. For example, a child who came into research on the benefits and harms of these initia-
care due to ‘intra-familial sexual abuse’ would, by tives is lacking and is urgently needed. The simplic-
definition, also have experienced emotional abuse, ity of ACE scores can help practitioners consider
physical abuse and neglect (of basic developmental what adversities someone has experienced in child-
needs). In other words, sexual abuse as a reason for hood and have been useful for highlighting the
coming into care might actually indicate high co- importance of ACEs amongst broad audiences.
occurrence of adversities yet treatment programmes However, simple ACE scores have limitations. They
often focus solely on sexual abuse (Fletcher, Elklit, have not facilitated the building of the detailed
Shevlin, & Armour, 2017). The use of a simple ACE models of development that could better inform
score is likely to be limited in informing treatment clinical and public policy approaches and help
plans. Children’s well-being may best be understood prioritise interventions. We argue that it is now time
by ‘using a method that captures the entirety of for further research into how different adversities co-
maltreatment’ (McGuire et al., 2018: p. 18). Examin- occur, which measurement methods to use in which
ing individual types of maltreatment, their severity, contexts, and how more nuanced findings can be
timing and frequency, as well as exploring maltreat- translated meaningfully into clinical practice and
ment as a unitary concept encompassing any/all public health/policy initiatives, both to prevent
types of maltreatment the child has experienced can ACEs in the first place and to prevent their potential
be informative (McGuire et al., 2018; Nemeroff & impact across the lifecourse.
Binder, 2014). This work suggests that, if knowledge Our recommendations for researchers are:
about ACEs is to inform treatment plans for children
and adolescents, careful, sensitive enquiry about 1. To be clearer in their definitions of adversity when
exactly what happened, how severe it was and at reporting research. What definitions were applied
what developmental stage is going to be needed. This in this particular study? What ACEs were
is what clinicians have been doing for decades – included and not included and why?
sometimes in liaison with social work colleagues and/ 2. To move beyond the 10 ACEs from the Kaiser
or with the help of existing data contained in casefiles Permanente study and take context into
or administrative databases. Emerging research sug- account when deciding which additional ACEs
gests that careful integration of existing data, clinical to include.
interviewing and observation in a multi-agency 3. To consider alternative approaches to opera-
framework can be beneficial in reducing ACEs tionalising adversity beyond ACE scores: to con-
(Dubowitz, Lane, Semiatin, & Magder, 2012) and this sider weighting, clustering and recording of
will be an important area for future research. severity, frequency and developmental period.

© 2019 Association for Child and Adolescent Mental Health

 ACE scores: pros, cons and applications to practice 11

This will help elucidate the life course mecha- Adverse childhood experience scores have been
nisms leading to poorer outcomes, and guide instrumental in stimulating an explosion of trans-
intervention developments. formative research into childhood adversity. Inno-
4. Longitudinal studies, recording high quality vations in practice are multiplying based on these
prospective ACEs data, are crucial to ACEs findings. The challenge now is to find more
research, particularly those in which the severity, nuanced ways of measuring and conceptualising
duration, frequency, timing and patterning of ACEs that are still easily usable so that detailed
adversities can be taken into account, as well as models of development can better inform practice
the direction of associations. and policy.
5. Rigorous intervention studies are needed to
examine the cost-effectiveness and safety of pro-
grammes such as routine enquiry and trauma Acknowledgements
informed initiatives. R.L. was funded by the UK’s ESRC (grant number ES/
P010229/1). The authors are grateful to the following
Our recommendations for practitioners are: people for reading a draft of this review – Philip Worsfold
(Population Health Directorate, Department of Health
1. To be more cautious and sensitive in translating and Social Care); Christine Garrington (Economic and
evidence from population research to individual Social Research Council’s (ESRC) International Centre
risk in order to reduce stigma and avoid deter- for Lifecourse Studies in Society and Health, University
ministic messages from being propagated. College London); Ross McQueenie (General Practice and
2. Give careful thought to how and when to appro- Primary Care, Institute of Health and Wellbeing,
priately record ACEs in different practice settings. University of Glasgow); Ann Hagell (Association for
Young People’s Health); Sara Dodds (Directorate for
In some situations, e.g. in therapeutic settings,
Children and Families, Scottish Government); Steven
detailed information on specific adversities might
Beeston (Shenley Academy School, Birmingham);
be useful but it needs to be recognised that ACEs Michael Smith (NHS Greater Glasgow and Clyde); Lucy
do not necessarily result in poor outcomes. Thompson (Institute of Health and Wellbeing, Univer-
3. Consider whether evidence is available on the sity of Glasgow). Their feedback has been immensely
effectiveness and acceptability of programmes helpful in shaping this review. The authors have
such as routine enquiry and trauma informed declared that they have no competing or potential
initiatives before implementation. conflicts of interest.
4. Only routinely enquire about ACEs where the
benefit outweighs any potential harm, and where
evidence-based interventions exist and are read- Correspondence
ily available. Rebecca E. Lacey, Research Department of Epidemiol-
5. Look beyond individuals and families to the broader ogy and Public Health, University College London, 1-19
structural ‘causes’ of ACEs, such as poverty – Torrington Place, London WC1E 6BT, UK; Email:
[email protected]
especially when developing policy initiatives.

Key points

Areas for future research

Researchers need to be clearer about their definitions of adversity – what constitutes an adversity and what
does not?

Researchers should consider including additional ACEs other than the 10 frequently investigated ACEs from
the Kaiser Permanente Study and justify these clearly.

Researchers should explore the different ways in which ACEs tend to cluster cluster and, individually and
together, predict outcomes

Longitudinal studies are required, particularly those which are able to consider the co-occurrence, timing,
frequency, duration and severity of ACEs, and which have high quality prospective ACEs data.

Key practitioner messages

Twenty years of adverse childhood experiences (ACEs) research has shown a graded relationship between the
number of adversities (ACE score) and health and other outcomes in many different populations, with
important implications about the potential impact of ACEs in clinical practice, public policy and public health
initiatives.

© 2019 Association for Child and Adolescent Mental Health

12 Rebecca E. Lacey and Helen Minnis

In all clinical, public policy and public health uses of ACE scores, appropriate and sensitive communication of
messages about risk/resilience and causation versus correlation is crucial in order to avoid detrimental and
deterministic messages being propagated. More sophisticated recording of ACEs (e.g. all ACEs experienced
rather than just reason for coming into care) will allow development of practice and research understanding
of the way ACEs cluster and of their individual and combined impact.

Before implementing routine enquiry about ACEs, careful considerations are required, including how data
are used, availability of evidence-based interventions, determinism and stigma

A broader focus on the structural ‘causes’ of ACEs is also warranted, especially a focus on issues such as
poverty and inequality

Note unpredictability as determinants of parenting and early

life history strategy. Developmental Psychology, 48, 662–
673.
1. Family social support (father absent), family size Bennett, E.L., Rosenzweig, M.R., Diamond, M.C., Morimoto,
(4 + children), stressful life events (25% most), eth- H., & Hebert, M. (1974). Effects of successive environments
nic minority group (non-white), occupation of the on brain measures. Physiology and Behavior, 12, 621–631.
head of household (semi- or unskilled), chronicity of Berliner, L., & Kolko, D.J. (2016). Trauma Informed Care.
maternal psychopathology (≥1 contact), maternal Child Maltreatment, 21, 168–172.
Bethell, C.D., Carle, A., Hudziak, J., Gombojav, N., Powers, K.,
anxiety (25% most anxious), parental perspectives Wade, R., & Braveman, P. (2017). Methods to assess adverse
(25% lowest), maternal interactive behaviours (25% childhood experiences of children and families: toward
least), and maternal education (no high school). approaches to promote child well-being in policy and prac-
tice. Academic Pediatrics, 17, S51–S69.
Bj€
orkenstam, E., Hjern, A., & Vinnerljung, B. (2017). Adverse
childhood experiences and disability pension in early
References midlife: results from a Swedish National Cohort Study. The
ACE Aware Scotland (2018). Conference - ACE Aware Scotland. European Journal of Public Health, 27, 472–477.
Available from: http://aceawarescotland.com/conference/ Bronfenbrenner, U. (1979). The ecology of human development.
[last accessed 15 October 2018]. Cambridge, MA: Harvard University Press.
ACE Aware Wales (2019). ACE Aware Wales. Available from: Brown, S., Rienks, S., McCrae, J., & Watamura, S. (2017). The
https://www.aceawarewales.com/about [last accessed 8 co-occurrence of adverse childhood experiences among
March 2019]. children investigated for child maltreatment: A latent class
Alastalo, H., R€ aikk€onen, K., Pesonen, A.K., Osmond, C., analysis. Child Abuse and Neglect, 87, 18–27.
Barker, D.J.P., Heinonen, K., . . . & Eriksson, J.G. (2013). Brumley, L.D., Brumley, B.P., & Jaffee, S.R. (2018). Compar-
Early life stress and blood pressure levels in late adulthood. ing cumulative index and factor analytic approaches to
Journal of Human Hypertension, 27, 90–94. measuring maltreatment in the National Longitudinal Study
Alcala, H.E., Mitchell, E.M., & Keim-Malpass, J. (2018). Hetero- of Adolescent to Adult Health. Child Abuse and Neglect, 87,
geneous impacts: Adverse childhood experiences and cancer 65–76.
screening. Cancer Causes and Control, 29, 343–351. Bucci, M., Gutierrez Wang, L., Koita, K., Purewal, S., Silverio
Allnock, D., & Miller, P. (2013). No one noticed, no one heard: A Marques, S., & Burke Harris, N. (2015). Center for Youth
study of disclosures of childhood abuse. Available from: Wellness ACE-Questionnaire User Guide. San Francisco.
https://learning.nspcc.org.uk/media/1052/no-one-noticed- Available from: http://centerforyouthwellness.org/wp-
no-one-heard-report.pdf [last accessed 15 October 2018]. content/uploads/2018/06/CYW-ACE-Q-USer-Guide-copy.
Anda, R., Croft, J., Felitti, V., Nordenberg, D., Giles, W., pdf [last accessed 27 September 2018].
Williamson, D., & Giovino, G. (1999). Adverse childhood Busso, D.S., McLaughlin, K.A., & Sheridan, M.A. (2016).
experiences and smoking during adolescence and adult- Dimensions of adversity, physiological reactivity, and exter-
hood. JAMA, 282, 1652–1658. nalizing psychopathology in adolescence: Deprivation and
Andermann, A., Blancquaert, I., Beauchamp, S., & D ery, V. threat. Psychosomatic Medicine, 79, 162–171.
(2008). Revisiting Wilson and Jungner in the genomic age: a Caleyachetty, R., Hardy, R., Cooper, R., Richards, M., Howe,
review of screening criteria over the past 40 years. Bulletin of L.D., Anderson, E., . . . & Stafford, M. (2018). Modeling
the World Health Organization, 86, 317–319. exposure to multiple childhood social risk factors and
Andrews, S.J., Lamb, M.E., & Lyon, T.D. (2015). The effects of physical capability and common affective symptoms in later
question repetition on responses when prosecutors and life. Journal of Aging and Health, 30, 386–407.
defense attorneys question children alleging sexual abuse in Caleyachetty, R., Khaw, K.-T., Surtees, P.G., Wainwright,
court. Law and Human Behavior, 39, 559–570. N.W.J., Wareham, N., & Griffin, S.J. (2016). Cumulative
Appleton, A., Holdsworth, E., Ryan, M., & Tracy, M. (2017). social risk exposure in childhood and smoking and excessive
Measuring childhood adversity in life course cardiovascular alcohol use in adulthood. European Journal of Public Health,
research: a systematic review. Psychosomatic Medicine, 79, 26, 575–581.
434–440. Center for Youth Wellness (2017). Applying universal ACEs
Baldwin, J.R., Reuben, A., Newbury, J.B., & Danese, A. (2019). screening in the pediatric clinic. Available from: https://ce
Agreement between prospective and retrospective measures nterforyouthwellness.org/advancing-clinical-practice/ [last
of childhood maltreatment. JAMA Psychiatry, 76, 584–593. accessed 26 September 2018].
Barrett, W. (2018). Childhood trauma: Why I worry about the Chapman, D., Whitfield, C., Felitti, V., Dube, S., Edwards, V.,
ACE-aware movement’s impact | Tes News. Available from: & Anda, R. (2004). Adverse childhood experiences and the
https://www.tes.com/news/why-i-worry-about-ace-aware- risk of depressive disorders in adulthood. Journal of Affec-
movements-impact [last accessed 15 October 2018]. tive Disorders, 82, 217–225.
Belsky, J., Schlomer, G.L., & Ellis, B.J. (2012). Beyond Children1st (2018). Poverty and Adverse Childhood Experi-
cumulative risk: Distinguishing harshness and ences (ACEs). Available from: https://www.children1st.org.

© 2019 Association for Child and Adolescent Mental Health

 ACE scores: pros, cons and applications to practice 13

uk/who-we-are/news/blog/poverty-and-adverse-child initiating alcohol use during adolescence. The Journal of

hood-experiences-aces/ [last accessed 28 August 2019]. Adolescent Health: Official Publication of the Society for
Cohen, J.A., & Mannarino, A.P. (2008). Trauma-focused cog- Adolescent Medicine, 38, 444, e1–10.
nitive behavioural therapy for children and parents. Child Dubowitz, H., Lane, W.G., Semiatin, J.N., & Magder, L.S.
and Adolescent Mental Health, 13, 158–162. (2012). The SEEK model of pediatric primary care: Can child
Couper, S., & Mackie, P. (2016). Scottish Public Health Network maltreatment be prevented in a low-risk population? Aca-
(ScotPHN) “Polishing the Diamonds” Addressing Adverse Child- demic Pediatrics, 12, 259–268.
hood Experiences in Scotland. Available from: https://www.sc Edwards, R., Gillies, V., Lee, E., Macvarish, J., White, S., &
otphn.net/wp-content/uploads/2016/06/2016_05_26- Wastell, D. (2017). Written evidence submitted by Universi-
ACE-Report-Final-AF.pdf [last accessed 4 January 2018]. ties of Kent, Southampton, Sheffield, Westminster and Not-
Croen, L.A., Zerbo, O., Qian, Y., Massolo, M.L., Rich, S., tingham. Available from: http://data.parliament.uk/writte
Sidney, S., & Kripke, C. (2015). The health status of adults nevidence/committeeevidence.svc/evidencedocument/scie
on the autism spectrum. Autism, 19, 814–23. nce-and-technology-committee/evidencebased-early-years-
Cronholm, P.F., Forke, C.M., Wade, R., Bair-Merritt, M.H., Davis, intervention/written/75249.html [last accessed 3 July
M., Harkins-Schwarz, M., . . . & Fein, J.A. (2015). Adverse 2019].
Childhood Experiences: expanding the concept of adversity. Ellis, B.J., Figueredo, A.J., Brumbach, B.H., & Schlomer, G.L.
American Journal of Preventive Medicine, 49, 354–361. (2009). Fundamental dimensions of environmental risk.
Crowell, J.A., Davis, C.R., Joung, K.E., Usher, N., McCormick, Human Nature, 20, 204–268.
S.P., Dearing, E., & Mantzoros, C.S. (2016). Metabolic Evans, G.W., Li, D., & Whipple, S.S. (2013). Cumulative risk
pathways link childhood adversity to elevated blood pres- and child development. Psychological Bulletin, 139, 1342–
sure in midlife adults. Obesity Research and Clinical Prac- 1396.
tice, 10, 580–588. Felitti, V., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz,
Dalsgaard, S., Ostergaard, S.D., Leckman, J.F., Mortensen, A.M., Edwards, V., . . . & Marks, J.S. (1998). Relationship of
P.B., & Pedersen, M.G. (2015). Mortality in children, ado- childhood abuse and household dysfunction to many of the
lescents, and adults with attention deficit hyperactivity leading causes of death in adults. American Journal of
disorder: A nationwide cohort study. The Lancet, 385, Preventive Medicine, 14, 245–258.
2190–6. Finkelhor, D. (2018). Screening for adverse childhood experi-
Danese, A., Moffitt, T.E., Arseneault, L., Bleiberg, B.A., ences (ACEs): Cautions and suggestions. Child Abuse and
Dinardo, P.B., Gandelman, S.B., . . . & Caspi, A. (2017). Neglect, 85, 174–179.
The origins of cognitive deficits in victimized children: Finkelhor, D., Ormrod, R.K., & Turner, H.A. (2007). Polyvic-
Implications for neuroscientists and clinicians. American timization and trauma in a national longitudinal cohort.
Journal of Psychiatry, 174, 349–361. Development and Psychopathology, 19, 149–166.
Davis, C.R., Dearing, E., Usher, N., Trifiletti, S., Zaichenko, L., Finkelhor, D., Shattuck, A., Turner, H., & Hamby, S. (2013).
Ollen, E., . . . & Crowell, J.A. (2014). Detailed assessments of Improving the adverse childhood experiences study scale.
childhood adversity enhance prediction of central obesity JAMA Pediatrics, 167, 70–75.
independent of gender, race, adult psychosocial risk and Fletcher, S., Elklit, A., Shevlin, M., & Armour, C. (2017).
health behaviors. Metabolism: Clinical and Experimental, 63, Predictors of PTSD treatment response trajectories in a
199–206. sample of childhood sexual abuse survivors: The roles of
Debowska, A., Willmott, D., Boduszek, D., & Jones, A. (2017). social support, coping, and PTSD symptom clusters. Journal
What do we know about child abuse and neglect patterns of of Interpersonal Violence. https://doi.org/10.1177/
co-occurrence? A systematic review of profiling studies and 0886260517741212
recommendations for future research. Child Abuse and Fond, M., Haydon, A., & Kendall-Taylor, N. (2015). Communi-
Neglect, 70, 100–111. cating connections: Framing the relationship between social
Denholm, R., Power, C., Thomas, C., & Li, L. (2013). Child drivers, early adversity, and child neglect. Retrieved
maltreatment and household dysfunction in a British birth from: http://frameworksinstitute.org/assets/files/ECD/so
cohort. Child Abuse Review, 22, 340–353. cial_determinants_ecd_messagebrief_final.pdf [last accessed
Dennison, M.J., Rosen, M.L., Sambrook, K.A., Jenness, J.L., 20 February 2019].
Sheridan, M.A., & McLaughlin, K.A. (2017). Differential Ford, K.,Butler, N., Hughes, K., Quigg, Z., Bellis, M.A., Barker,
associations of distinct forms of childhood adversity with P., . . . & Paterson, B. (2016). Adverse childhood experiences
neurobehavioral measures of reward processing: A develop- (ACEs) in hertfordshire, Luton and northamptonshire adverse
mental pathway to depression. Child Development, 90, e96– childhood experiences (ACEs) in hertfordshire, Luton and
e113. Northamptonshire contributorship. Liverpool.
Diamond, M.C., Rosenzweig, M.R., Bennett, E.L., Lindner, B., Ford, K., Hughes, K., Hardcastle, K., Di Lemma, L.C.G., Davies,
& Lyon, L. (1972). Effects of environmental enrichment and A.R., Edwards, S., & Bellis, M.A. (2019). The evidence base for
impoverishment on rat cerebral cortex. Journal of Neurobi- routine enquiry into adverse childhood experiences: A scoping
ology, 3, 47–64. review. Child Abuse and Neglect, 91, 131–146.
Dinkler, L., Lundstr€ om, S., Gajwani, R., Lichtenstein, P., Ford, S., Merrick, M.T., Parks, S.E., Breiding, M.J., Gilbert,
Gillberg, C., & Minnis, H. (2017). Maltreatment-associated L.K., Edwards, V.J., . . . & Thompson, W.W. (2014). Exam-
neurodevelopmental disorders: A co-twin control analysis. ination of the factorial structure of adverse childhood
Journal of Child Psychology and Psychiatry, 58, 691–701. experiences and recommendations for three subscale
Dong, M., Anda, R.F., Felitti, V.J., Dube, S.R., Williamson, scores. Psychology of Violence, 4, 432–444.
D.F., Thompson, T.J., . . . & Giles, W.H. (2004). The interre- Friedman, E.M., Montez, J.K., Sheehan, C.M., Guenewald, T.L., &
latedness of multiple forms of childhood abuse, neglect, and Seeman, T.E. (2015). Childhood adversities and adult car-
household dysfunction consequences of a specific ACE. diometabolic health: Does the quantity, timing, and type of
Assessment of multiple ACEs allows for the potential adversity matter? Journal of Aging and Health, 27, 1311–1338.
assessment of a graded relationship between these child- Green, J.G., McLaughlin, K.A., Berglund, P.A., Gruber, M.J.,
hood exposures and he. Child Abuse and Neglect, 28, 771– Sampson, N.A., Zaslavsky, A.M., & Kessler, R.C. (2010).
784. Childhood adversities and adult psychiatric disorders in the
Dube, S.R., Miller, J.W., Brown, D.W., Giles, W.H., Felitti, V.J., national comorbidity survey replication I: Associations with
Dong, M., & Anda, R.F. (2006). Adverse childhood experi- first onset of DSM-IV disorders. Archives of General Psychi-
ences and the association with ever using alcohol and atry, 67, 113–123.

© 2019 Association for Child and Adolescent Mental Health

14 Rebecca E. Lacey and Helen Minnis

Hamby, S., & Grych, J. (2013). The web of violence: Exploring and threat as distinct dimensions of early experience.
connections among different forms of interpersonal violence Neuroscience and Biobehavioral Reviews, 47, 578–591.
and abuse. Dordrecht, the Netherlands. Springer. Merrick, M., Ports, K., Ford, D., Afifi, T., Gershoff, E., &
Hartas, D. (2019). Assessing the foundational studies on Grogan-Kaylor, A. (2017). Unpacking the impact of adverse
adverse childhood experiences. Social Policy and Society, childhood experiences on adult mental health. Child Abuse
18, 435–443. and Neglect, 69, 10–19.
Hirvikoski, T., Mittendorfer-Rutz, E., Boman, M., Larsson, H., Mersky, J.P., Janczewski, C.E., & Topitzes, J. (2017). Rethink-
Lichtenstein, P., & B€ olte, S. (2016). Premature mortality in ing the measurement of adversity. Child Maltreatment, 22,
autism spectrum disorder. British Journal of Psychiatry, 58–68.
208, 232–238. Miller, A.B., Sheridan, M.A., Hanson, J.L., McLaughlin, K.A.,
Holmes, T.H., & Rahe, R.H. (1967). The social readjustment Bates, J.E., Lansford, J.E., . . . & Dodge, K.A. (2018).
rating scale. Journal of Psychosomatic Research, 11, 213–218. Dimensions of deprivation and threat, psychopathology,
Howard, L.M. (2017). Routine enquiry about violence and and potential mediators: A multi-year longitudinal analysis.
abuse is needed for all mental health patients. British Journal of Abnormal Psychology, 127, 160–170.
Journal of Psychiatry, 210, 298. Nemeroff, C.B., & Binder, E. (2014). The preeminent role of
Howe, L.D., Tilling, K., & Lawlor, D.A. (2015). Studying the life childhood abuse and neglect in vulnerability to major
course health consequences of childhood adversity: Chal- psychiatric disorders: toward elucidating the underlying
lenges and opportunities. Circulation, 136(12), 1645–1647. neurobiological mechanisms. Journal of the American Acad-
Hughes, K., Bellis, M.A., Hardcastle, K.A., Sethi, D., Butchart, emy of Child and Adolescent Psychiatry, 53, 395–397.
A., Mikton, C., . . . & Dunne, M.P. (2017). The effect of Newbury, J., Arseneault, L., Moffitt, T., Caspi, A., Danese, A.,
multiple adverse childhood experiences on health: A sys- Baldwin, J., & Fisher, H. (2018). Measuring childhood
tematic review and meta-analysis. The Lancet Public Health, maltreatment to predict early-adult psychopathology: Com-
2, e356–e366. parison of prospective informant-reports and retrospective
Isohookana, R., Marttunen, M., Hakko, H., Riipinen, P., & self-reports. Journal of Psychiatric Research, 96, 57–64.
Riala, K. (2016). The impact of adverse childhood experi- NHS Highlands (2018). Adverse Childhood Experiences, Resi-
ences on obesity and unhealthy weight control behaviors lience and Trauma Informed Care: A Public Health Approach
among adolescents. Comprehensive Psychiatry, 71, 17–24. to Understanding and Responding to Adversity. Available
Kajeepeta, S., Gelaye, B., Jackson, C.L., & Williams, M.A. from: https://www.nhshighland.scot.nhs.uk/Publications/
(2015). Adverse childhood experiences are associated with Documents/DPH-Annual-Report-2018_(web-version).pdf [last
adult sleep disorders: A systematic review. Sleep Medicine, accessed 20 February 2019].
16, 320–330. PublicHealthWales (n.d.). Adverse childhood experiences video.
Kelly-Irving, M., & Delpierre, C. (2019). A critique of the Available from: http://www.aces.me.uk/in-wales/ [last
adverse childhood experiences framework in epidemiology accessed 20 February 2019].
and public health: Uses and misuses. Social Policy and Purewal, S., Bucci, M., Wang, L., Koita, K., Marques, S., Oh,
Society, 18, 445–456. D., & Burke Harris, N. (2016). Screening for Adverse
Kelly-Irving, M., Lepage, B., Dedieu, D., Bartley, M., Blane, D., Childhood Experiences (ACEs) in an integrated pediatric
Grosclaude, P., . . . & Delpierre, C. (2013). Adverse childhood care model. Zero to Three, 37, 10–17.
experiences and premature all-cause mortality. European Read, J., Harper, D., Tucker, I., & Kennedy, A. (2018). Do adult
Journal of Epidemiology, 28, 721–734. mental health services identify child abuse and neglect? A
Ko, S.J., Ford, J.D., Kassam-Adams, N., Berkowitz, S.J., systematic review. International Journal of Mental Health
Wilson, C., Wong, M., . . . & Layne, C.M. (2008). Creating Nursing, 27, 7–19.
trauma-informed systems: Child welfare, education, first RealLifeResearch (2015). An Evaluation of REACh: Routine
responders, health care, juvenile justice. Professional Psy- enquiry into adversity in childhood. Available from: https://
chology: Research and Practice, 39, 396–404. warrenlarkinassociates.co.uk/media/1261/july29-final-full-
Lanier, P., Maguire-Jack, K., Lombardi, B., Frey, J., & Rose, R.A. evaluation-report-for-reach-1.pdf [last accessed 20 February
(2018). Adverse childhood experiences and child health out- 2019].
comes: Comparing cumulative risk and latent class Reuben, A., Moffitt, T.E., Caspi, A., Belsky, D.W., Harrington, H.,
approaches. Maternal and Child Health Journal, 22, 288–297. Schroeder, F., . . . & Danese, A. (2016). Lest we forget: compar-
Liming, K.W. (2018). Examining the differing effects of eco- ing retrospective and prospective assessments of adverse
nomic hardship and poor maternal wellbeing on cumulative childhood experiences in the prediction of adult health. Journal
exposure to adverse childhood experiences. Journal of Child of Child Psychology and Psychiatry, 57, 1103–1112.
and Adolescent Trauma, 12, 307–321. Ross, C.E., & Mirowsky, J. (1979). A comparison of life-event-
Maclean, M., Sims, S., Hansen, M., Leonard, H., Bourke, J., weighting schemes: Change, undesirability, and effect-pro-
Bower, C., & O’Donnell, M. (2017). Abuse and neglect in portional indices. Journal of Health and Social Behavior, 20
children with disabilities: Risk varies by type of disability. (2), 166.
International Journal of Population Data Science, 1, 177. Rutter, M. (1978). Family, area and school influences in the
McEwen, C.A., & Gregerson, S.F. (2019). A Critical assessment genesis of conduct disorders. In L.A. Hersov, & M. Berger
of the adverse childhood experiences study at 20 years. (Eds.), Aggression and anti-social behavior in childhood and
American Journal of Preventive Medicine, 56, 790–794. adolescence (pp. 95–113). Oxford, UK: Pergamon.
McGuire, A., Cho, B., Huffhines, L., Gusler, S., Brown, S., & Sameroff, A.J., Seifer, R., Zax, M., & Barocas, R. (1987). Early
Jackson, Y. (2018). The relation between dimensions of mal- indicators of developmental risk: Rochester longitudinal
treatment, placement instability, and mental health among study. Schizophrenia Bulletin, 13, 383–394.
youth in foster care. Child Abuse and Neglect, 86, 10–21. Schooling, C.M., Jiang, C., Lam, T.H., Zhang, W., Cheng, K.K.,
McLaughlin, K.A. (2016). Future directions in childhood & Leung, G.M. (2011). Parental death during childhood and
adversity and youth psychopathology. Journal of Clinical adult cardiovascular risk in a developing country: The
Child and Adolescent Psychology, 45, 361–382. Guangzhou Biobank Cohort study. PLoS ONE, 6, e19675.
McLaughlin, K.A., & Sheridan, M.A. (2016). Beyond cumula- Slopen, N., Koenen, K.C., & Kubzansky, L.D. (2014). Cumulative
tive risk: A dimensional approach to childhood adversity. adversity in childhood and emergent risk factors for long-term
Current Directions in Psychological Science, 25, 239–245. health. The Journal of Pediatrics, 164, 631–638. e2.
McLaughlin, K.A., Sheridan, M.A., & Lambert, H.K. (2014). Slopen, N., Loucks, E.B., Appleton, A.A., Kawachi, I., Kubzan-
Childhood adversity and neural development: Deprivation sky, L.D., Non, A.L., . . . & Gilman, S.E. (2015). Early origins

© 2019 Association for Child and Adolescent Mental Health

 ACE scores: pros, cons and applications to practice 15

of inflammation: An examination of prenatal and childhood affects amygdala processing of biologically salient stimuli.
social adversity in a prospective cohort study. Psychoneu- Biological Psychiatry, 66, 649–655.
roendocrinology, 51, 403–413. Werner, E., & Smith, R. (1982). Vulnerable but invincible: A
Stern, A., Agnew-Blais, J., Danese, A., Fisher, H.L., Jaffee, longitudinal study of resilient children and youth. New York:
S.R., Matthews, T., . . . & Arseneault, L. (2018). Associations McGraw Hil.
between abuse/neglect and ADHD from childhood to young Westermair, A.L., Stoll, A.M., Greggersen, W., Kahl, K.G.,
adulthood: A prospective nationally-representative twin H€uppe, M., & Schweiger, U. (2018). All unhappy childhoods
study. Child Abuse and Neglect, 81, 274–285. are unhappy in their own way – Differential impact of
Sullivan, K.M., Murray, K.J., & Ake, G.S. (2016). Trauma- dimensions of adverse childhood experiences on adult
informed care for children in the child welfare system. Child mental health and health behavior. Frontiers in Psychiatry,
Maltreatment, 21, 147–155. 9, 198.
Sumner, J.A., Colich, N.L., Uddin, M., Armstrong, D., & WHO (2018). Adverse Childhood Experiences International
McLaughlin, K.A. (2018). Early experiences of threat, but Questionnaire (ACE-IQ). Available from: http://www.who.
not deprivation, are associated with accelerated biological int/violence_injury_prevention/violence/activities/adve
aging in children and adolescents. Biological Psychiatry, 85, rse_childhood_experiences/en/ [last accessed 4 February
268–278. 2015].
Taket, A., Wathen, C.N., & MacMillan, H. (2004). Should Wilson, J.M.G., & Jungner, G. (1968). Principles and practice of
health professionals screen all women for domestic violence? screening for disease. Geneva. Available from: https://apps.
PLoS Med, 1, e4. who.int/iris/bitstream/handle/10665/37650/WHO_PHP_
van der Kolk, B.A. (2005). Developmental trauma disorder: 34.pdf?sequence=17&isAllowed=y [last accessed 22 Febru-
Toward a rational diagnosis for children with complex ary 2018].
trauma histories. Psychiatric Annals, 35, 401–408.
van Marle, H.J.F., Hermans, E.J., Qin, S., & Fern andez, G. Accepted for publication: 12 September 2019
(2009). From specificity to sensitivity: how acute stress

© 2019 Association for Child and Adolescent Mental Health