Adverse Childhood Experiences (ACE)

Adverse Childhood Experiences (ACEs) is the term used to describe all types of abuse, neglect, and other potentially traumatic experiences that occur to people under the age of 18.

ACEs have been linked to risky health behaviors, chronic health conditions, and early death.

ACEs are common. Seven in ten individuals have at least one ACE.

Adverse Childhood Experiences inform who we become as adults.

STATE OF THE NATION’s characters, Dion, Luqman, Santos, Jonas…even Cheryl, and certainly the old homeless man from the Tuskegee Study, Flukey Luke, all have one or more of the markers from ACEs.

The information below was obtained from the following source:

Got Your ACE Score?

What’s Your ACE Score? (and, at the end, What’s Your Resilience Score?)

There are 10 types of childhood trauma measured in the ACE Study. Five are personal — physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to other family members: a parent who’s an alcoholic, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment. Each type of trauma counts as one. So a person who’s been physically abused, with one alcoholic parent, and a mother who was beaten up has an ACE score of three.

There are, of course, many other types of childhood trauma — racism, bullying, watching a sibling being abused, losing a caregiver (grandmother, mother, grandfather, etc.), homelessness, surviving and recovering from a severe accident, witnessing a father being abused by a mother, witnessing a grandmother abusing a father, involvement with the foster care system, involvement with the juvenile justice system, etc. The ACE Study included only those 10 childhood traumas because those were mentioned as most common by a group of about 300 Kaiser members; those traumas were also well studied individually in the research literature.

The most important thing to remember is that the ACE score is meant as a guideline: If you experienced other types of toxic stress over months or years, then those would likely increase your risk of health consequences.

Prior to your 18th birthday:

  1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
    No___If Yes, enter 1 __

  2. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
    No___If Yes, enter 1 __

  3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
    No___If Yes, enter 1 __

  4. Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
    No___If Yes, enter 1 __

  5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
    No___If Yes, enter 1 __

  6. Were your parents ever separated or divorced?
    No___If Yes, enter 1 __

  7. Was your mother or stepmother:
    Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
    No___If Yes, enter 1 __

  8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
    No___If Yes, enter 1 __

  9. Was a household member depressed or mentally ill, or did a household member attempt suicide? No___If Yes, enter 1 __

  10. Did a household member go to prison?
    No___If Yes, enter 1 __

Now add up your “Yes” answers: _ This is your ACE Score


Now that you’ve got your ACE score, what does it mean?

First….a tiny bit of background to help you figure this out…..(if you want the back story about the fascinating origins of the ACE Study, read The Adverse Childhood Experiences Study — the largest, most important public health study you never heard of — began in an obesity clinic.)

The CDC’s Adverse Childhood Experiences Study (ACE Studyuncovered a stunning link between childhood trauma and the chronic diseases people develop as adults, as well as social and emotional problems. This includes heart disease, lung cancer, diabetes and many autoimmune diseases, as well as depression, violence, being a victim of violence, and suicide.

The first research results were published in 1998, followed by more than 70 other publications through 2015. They showed that:

  • childhood trauma was very common, even in employed white middle-class, college-educated people with great health insurance;

  • there was a direct link between childhood trauma and adult onset of chronic disease, as well as depression, suicide, being violent and a victim of violence;

  • more types of trauma increased the risk of health, social and emotional problems.

  • people usually experience more than one type of trauma – rarely is it only sex abuse or only verbal abuse.

A whopping two thirds of the 17,000 people in the ACE Study had an ACE score of at least one — 87 percent of those had more than one. Thirty-six states and the District of Columbia have done their own ACE surveys; their results are similar to the CDC’s ACE Study.

The study’s researchers came up with an ACE score to explain a person’s risk for chronic disease. Think of it as a cholesterol score for childhood toxic stress. You get one point for each type of trauma. The higher your ACE score, the higher your risk of health and social problems. (Of course, other types of trauma exist that could contribute to an ACE score, so it is conceivable that people could have ACE scores higher than 10; however, the ACE Study measured only 10 types.)

As your ACE score increases, so does the risk of disease, social and emotional problems. With an ACE score of 4 or more, things start getting serious. The likelihood of chronic pulmonary lung disease increases 390 percent; hepatitis, 240 percent; depression 460 percent; attempted suicide, 1,220 percent.

(By the way, lest you think that the ACE Study was yet another involving inner-city poor people of color, take note: The study’s participants were 17,000 mostly white, middle and upper-middle class college-educated San Diegans with good jobs and great health care – they all belonged to the Kaiser Permanente health maintenance organization.)

Here are some specific graphic examples of how increasing ACE scores increase the risk of some diseases, social and emotional problems. All of these graphs come from “The relationship of adverse childhood experiences to adult health, well being, social function and health care”, a book chapter by Drs. Vincent Felitti and Robert Anda, co-founders of the ACE Study, in “The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease.”

What causes this?

At the same time that the ACE Study was being done, parallel research on kids’ brains found that toxic stress damages the structure and function of a child’s developing brain. This was determined by a group of neuroscientists and pediatricians, including neuroscientist Martin Teicher and pediatrician Jack Shonkoff, both at Harvard University, neuroscientist Bruce McEwen at Rockefeller University, and child psychiatrist Bruce Perry at the Child Trauma Academy.

When children are overloaded with stress hormones, they’re in flight, fright or freeze mode. They can’t learn in school. They often have difficulty trusting adults or developing healthy relationships with peers (i.e., they become loners). To relieve their anxiety, depression, guilt, shame, and/or inability to focus, they turn to easily available biochemical solutions — nicotine, alcohol, marijuana, methamphetamine — or activities in which they can escape their problems — high-risk sports, proliferation of sex partners, and work/over-achievement. (e.g. Nicotine reduces anger, increases focus and relieves depression. Alcohol relieves stress.)

Using drugs or overeating or engaging in risky behavior leads to consequences as a direct result of this behavior. For example, smoking can lead to COPD (chronic obstructive pulmonary disease) or lung cancer. Overeating can lead to obesity and diabetes. In addition, there is increasing research that shows that severe and chronic stress leads to bodily systems producing an inflammatory response that leads to disease.

In addition, toxic stress can be passed down from generation to generation. The field of epigenetics shows that we are born with a set of genes that can be turned on and off, depending on what’s happening in our environment. If a child grows up with an overload of toxic stress, their stress-response genes are likely to be activated so that they are easily triggered by stressful situations that don’t affect those who don’t grow up with toxic stress. They can pass that response onto their children.  

Fortunately, brains and lives are somewhat plastic. Resilience research shows that the appropriate integration of resilience factors — such as asking for help, developing trusting relationships, forming a positive attitude, listening to feelings — can help people improve their lives.

For more information about ACEs science and how it’s being used, go to: ACEs Science 101.

For more information about the ACE Study, check out the CDC’s ACE Study site.

Here’s a link to the long questionnaire (200+ questions).

For more information about ACEs science, go to ACEs Science 101.


What’s Your Resilience Score?

This questionnaire was developed by the early childhood service providers, pediatricians, psychologists, and health advocates of Southern Kennebec Healthy Start, Augusta, Maine, in 2006, and updated in February 2013. Two psychologists in the group, Mark Rains and Kate McClinn, came up with the 14 statements with editing suggestions by the other members of the group. The scoring system was modeled after the ACE Study questions. The content of the questions was based on a number of research studies from the literature over the past 40 years including that of Emmy Werner and others. Its purpose is limited to parenting education. It was not developed for research.

Rains wants everyone to know that the resilience questions are only meant to prompt reflection and conversation on experiences that may help protect most people (about three out of four) with four or more ACEs from developing negative outcomes. A secure early childhood is helpful, but not necessary. A higher number of positive experiences is not necessarily more protective. He regrets that the questions have taken on a life of their own and that people may have misinterpreted or misunderstood their experience of risk and resilience, based on the ACE or “Resilience” questionnaires. For more information, he suggests reading this article on ACEs Too High — Putting resilience and resilience surveys under the microscope.

RESILIENCE Questionnaire

Please circle the most accurate answer under each statement:

1.  I believe that my mother loved me when I was little.

Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True

2. I believe that my father loved me when I was little.

Definitely true Probably true Not sure Probably Not True Definitely Not True

3. When I was little, other people helped my mother and father take care of me and they seemed to love me.

Definitely true Probably true Not sure Probably Not True Definitely Not True

4. I’ve heard that when I was an infant someone in my family enjoyed playing with me, and I enjoyed it, too.

Definitely true Probably true Not sure Probably Not True Definitely Not True

5. When I was a child, there were relatives in my family who made me feel better if I was sad or worried.

Definitely true Probably true Not sure Probably Not True Definitely Not True

6. When I was a child, neighbors or my friends’ parents seemed to like me.

Definitely true Probably true Not sure Probably Not True Definitely Not True

7. When I was a child, teachers, coaches, youth leaders or ministers were there to help me.

Definitely true Probably true Not sure Probably Not True Definitely Not True

8. Someone in my family cared about how I was doing in school.

Definitely true Probably true Not sure Probably Not True Definitely Not True

9. My family, neighbors and friends talked often about making our lives better.

Definitely true Probably true Not sure Probably Not True Definitely Not True

10. We had rules in our house and were expected to keep them.

Definitely true Probably true Not sure Probably Not True Definitely Not True

11. When I felt really bad, I could almost always find someone I trusted to talk to.

Definitely true Probably true Not sure Probably Not True Definitely Not True

12. As a youth, people noticed that I was capable and could get things done.

Definitely true Probably true Not sure Probably Not True Definitely Not True

13. I was independent and a go-getter.

Definitely true Probably true Not sure Probably Not True Definitely Not True

14. I believed that life is what you make it.

Definitely true Probably true Not sure Probably Not True Definitely Not True

How many of these 14 protective factors did I have as a child and youth? (How many of the 14 were circled “Definitely True” or “Probably True”?) _______

Of these circled, how many are still true for me? _______

Ted Talk by Nadine Burke Harris: How Childhood Trauma Affects Health Across A Lifetime:

September 2019 Interview with Lambda Literary

O Freedom - Charles White

O Freedom - Charles White

Set in Philadelphia in the 1980s, David Jackson Ambrose’s State of the Nation (a 2019Lambda Literary Award Finalist for Gay Fiction) explores how the bodies of young gay black men are pursued in a racist world, and the fierce, funny sense they make of that horrific pursuit. As the Atlanta child murders unfold, five boys form a loosely-knit group that comes together and falls apart in the wake of the violence of the adults who exploit, pimp, narc, neglect, and abuse them. Yet these characters are jubilant, funny, and fun to follow as they roam the streets of greater Philly.

Particularly compelling is Ambrose’s portrayal of white, straight 80s male coming-of-age archetypes—the nerdy punk spouting philosophy beneath his Mohawk, the intellectually disabled but spiritually gifted seer—as black queer boys. With deft characterizations and some of the best dialogue I’ve ever read, Ambrose reframes the state of the nation as a force that makes and breaks black lives.

Your characters are just so rich, so complexly portrayed. I was particularly struck by how brilliantly you capture the voices of young black queer men. The dialogue is snappy, authentic, and hella funny. How did you approach the different voices?

I’ve had many distinctive friends over the years. We used to communicate with this amalgamation of vernacular, urban gay lexicon, and Standard English. I wanted to make the point that sometimes when we hear certain people using slang we make assumptions about their level of intellect. These people are very bright, and fully aware of what they are doing when they break from standard usage. It’s what Henry Louis Gates refers to as the signifying monkey. It’s a deliberate radical opposition to colonizing influences. I also wanted to show that white characters utilize code switching too; that was one of the primary reasons that I brought in the character of White Girl Toni. She does some major switching.

Horror is used as a method of critiquing racism throughout the novel. The Atlanta child murders suffuse the kids’ worlds, pursuing them. Their bodies are chased, exploited, feared. It reminded me of Jordan Peele’s use of horror in Get Out. What do you think of that comparison?

The horror works sort of as the backdrop, shaping the lives of these people as trauma. They are being victimized in their lives, but are almost unaware of it, because in comparison to the boys being murdered in Atlanta, they are at least still among the living.

I think the difference from Get Out is that there is more of an immersion into black lives and culture, and to black gay culture within that, whereas Get Out has the central character immersed in a white world.

Students who studied the book for a horror grad class did not see it as horror. I get that, in that it doesn’t include the traditional markers of the genre. Here, the horror is more like the ghosts of psychic trauma that Toni Morrison refers to as our ancestors from the middle passage.

Horror as the ghost of psychic trauma: that seems exactly right. While you use kaleidoscopic viewpoints, you center the story on a pair of brothers, Santos and Jonas, one of whom is intellectually disabled—but also a visionary. What informed that choice? What did you hope to accomplish with that portrayal?

Many times our public school systems diagnose behavioral issues that result from trauma—and the child’s inability to verbalize that trauma—as an intellectual deficit, and place them erroneously in special ed. Jonas is a representation of such children. He has been assumed to be developmentally delayed. He isn’t developmentally delayed, but he is indeed special. Through the course of the book, he is shown to be entirely different than the initial presentation. It takes Luqman, who does not see him through that prism, to communicate with him without those misconceptions, and demonstrate that he is maybe different than the other characters, but in no way less able.

Along with different kinds of ability, diverse sexualities and gender identities are explored, but with vintage 80s labels. What do you make of today’s more fluid terminology and how it might help—or hinder—these characters? How does the title play into the state of sexualities depicted in your novel?

I wanted to show that the identity spectrum was wide even then. I wanted to challenge assumptions. One of the characters only sleeps with men for money. Another sleeps with men because it is what he knows as normal because of being a victim of sexual predation. He doesn’t necessarily define himself as gay or straight. His best male friend identifies as femme, and has been acculturated into his best friend’s sensibilities.

Another character hasn’t given it much thought. That might be considered a cop-out, but I think back to my own sexuality at sixteen or seventeen, and it didn’t seem to be so cut and dried as to one label or the other. The 80’s was also a time when bisexuality for men was being depicted as this sort of glamorous way to be—Bowie, Boy George, Prince, Duran Duran, Michael Jackson, Adam Ant, Jagger—the whole gamut. So many male performers were claiming bisexuality, some perhaps just for effect. I wondered how that would personify for a character that was not yet sexually active, but still constantly surrounded by the “threat” of sex, particularly as he viewed the ways that sex was impacting his best friends.



Jennifer Natalya Fink is the author of Bhopal Dance, which was a Lambda Literary Award finalist and Doctorow Prize winner, and five other books. She is a professor of English at Georgetown University, where she co-founded the Program in Disability Studies. Queer hellraiser, birdwatcher, and unlikely mother, you can find out more about her here:


Honorable Mention: 2019 US Review of Books

State of the Nation, David Jackson Ambrose, The TMG Firm - Skillfully woven with multiple points of view and set against the backdrop of the Atlanta Child Murders of the late 70s, the book chronicles the lives of three poor, marginalized, young black men growing up in Atlanta. They are struggling to make ends meet and carve out a niche for their unique identities in the only world they know. Truly immersive and deftly researched, one can’t grasp the magnitude of this world until they’ve come out the other side. Violence, innocence, race, poverty, brotherhood, and the blurred lines of gender identity come together to create a time and place in history, which is both fantiastical, and at the same time, all too real.