How the ACE Questionnaire Measures Childhood Trauma and Predicts Future Health

How the ACE Questionnaire Measures Childhood Trauma and Predicts Future Health

What we experience in childhood impacts us for the rest of our lives. Most of us know that firsthand, from our own personal history. But over decades of research, experts have come to understand that certain types of experiences during our formative years can have long-lasting effects on our health and well-being. And they’ve created a tool to measure the extent of those effects. It’s called the ACE questionnaire.

ACE stands for Adverse Childhood Experience. Also referred to as the ACE quiz or the ACE test, the questionnaire includes 10 questions that identify areas of childhood trauma. This information gives individuals and their healthcare providers insight into how the repercussions of such trauma may be permeating their adult lives.

Often people with a history of trauma—especially childhood trauma that happened before they could understand it—have the sense that there is something fundamentally wrong with them. The ACE questionnaire helps them understand that it’s not about what’s wrong with them, but rather what happened to them.

Jennifer B. Dragonette, PsyD, Newport Clinical Services Instructor

How Does the ACE Questionnaire Work?

The ACE questionnaire measures 10 types of childhood or teen trauma that occurred before age 18, including abuse, neglect, and household dysfunction:

  • Physical abuse
  • Verbal abuse
  • Sexual abuse
  • Emotional neglect
  • Physical neglect
  • Having a parent who was an alcoholic or used drugs
  • A mother or stepmother who was a victim of domestic violence
  • Family member in prison
  • Parent or parents with depression
  • Parents’ divorce.

Each “yes” answer to a question scores a 1. Hence, a person who has experienced emotional neglect, has a family member in prison, and was sexually abused would have an ACE score of 3.

“The higher an individual’s score is, the more likely it is that they will have challenges that affect their long-term health and life satisfaction,” says Dr. Dragonette. “This includes not only mental health, but also physical health.”

History of the ACE Study and ACE Test

The ACE test resulted from a study done in California by Dr. Vincent Felitti. Dr. Felitti worked with obese clients. In reviewing their histories, he noticed a link between weight gain and adverse childhood experiences. He proposed a theory that research later validated: that weight gain can be a conscious or unconscious way of protecting oneself against physical or sexual abuse.

Subsequently, the Centers for Disease Control and Prevention partnered with Kaiser Permanente to develop the ACE Study, led by Dr. Felitti. Over several years, researchers examined the physical and mental health of more than 17,000 adult participants. They also used the ACE test to determine how much childhood trauma or teen trauma they had experienced. Then they analyzed the links between participants’ experiences in the past and their current health.

First, the study revealed that adverse childhood experiences were more common that had previously been thought: Almost 40 percent of the participants scored a 2 or higher on the ACE test, and 12.5 percent scored a 4 or more.

What the ACE Test Means for Physical and Mental Health

Researchers found illuminating information on how adverse childhood experiences affect physical and mental health. People with higher ACES scores were at greater risk for a wide variety of diseases and negative life events, ranging from unintended pregnancy to diabetes to depression and anxiety. For example, compared to someone with a score of zero, a person with an ACE score of 4 or higher was

  • Twice as likely to smoke,
  • Twice as likely to have been diagnosed with cancer or heart disease
  • Seven times as likely to be alcoholics
  • Six times as likely to have had sex before the age of 15
  • Four times as likely to suffer from emphysema or chronic bronchitis
  • Nearly five times as likely to experience depression
  • 12 times as likely to have attempted suicide.

Furthermore, the life expectancy of an individual with an ACE score of 6 or more goes down by as much as 20 years. In addition, researchers found that even when individuals with high ACE scores did not have poor health behaviors (such as drinking and smoking), their risk for disease was still higher. Today, groundbreaking research in the field of epigenetics is revealing how childhood trauma can trigger genetic activity that increases the likelihood of disease.

“We are born with biological predeterminants, but our lives impact our genomes as we grow,” explains Dr. Dragonette. “Therefore, those genes will express themselves differently based on what we experience.”

How ACE Scores Predict Future Relationships

We know that chronic and relational trauma in the early years of life have an enormous influence on our ability to form authentic connections with others. Our first connection with our primary caregiver sets the stage for our relationships and interactions throughout our lifetime. When that relationship creates confusion, fear, shame, and an inability to depend on the other person, those feelings translate to all our other relationships—with friends, romantic partners, and even colleagues and authority figures. People who have undergone struggle with childhood trauma symptoms often have a very hard time trusting others and sharing their inner selves and emotions.

Recent research confirms the link between ACE scores and relationship dysfunction. In one study, women with higher ACE scores were more likely to have partners with high ACE scores. In a second study, researchers found that participants who had perpetrated or suffered violence in intimate relationships were more likely to have high ACE scores.

Who Uses the ACE Questionnaire?

Clinicians use the ACE test to learn how adverse childhood experiences may be contributing to an adult’s or young adult’s mental health, suicidal thoughtssubstance abuse, and other life challenges, such as domestic violence or relationship issues.

“For instance, if you had a family member who humiliated you during childhood, when you were setting up your expectations of how you were going to be treated in the world, it makes sense that you have trouble trusting others,” says Dr. Dragonette. “The ACE questionnaire can help people better understand what happened to them, and why their life has unfolded the way it has. I’ve had many older clients say to me, ‘I wish someone had asked me this earlier.’”

Moreover, caregivers and healthcare providers can administer the ACE quiz or people can take it on their own, as no particular experience or credentials are required.

Healing the Impact of Adverse Childhood Experiences

The important thing to know, says Dr. Dragonette, is that the impact of adverse childhood experiences can be mitigated. Hence, many trauma-informed treatment modalities can help heal the effects of ACEs. These include

  • Trauma-focused Cognitive Behavioral Therapy
  • Cognitive Processing Therapy
  • Dialectical Behavioral Therapy
  • Eye Movement Desensitization and Reprocessing (EMDR)
  • Somatic, or body-based, therapy
  • Comprehensive Resource Model: a new approach using elements of psychology, spirituality, neurobiology, and body-based (somatic) techniques.

The ACE questionnaire can mark the first step toward making positive change. When people understand how their past is affecting their present, they can seek the support they need to begin the healing process