Health and Well-Being

How High ACE Scores Can Impact Adult Health

The adult who painted this picture has an ACE score of 7 and suffers with chronic PTSD caused by childhood trauma and abuse.

By Juliet Bonnay

Updated 28 November 2019

High ACE scores can impact adult health as risk factors for the leading mental and physical health problems that currently afflict western societies. For example, there is a 5,000 percent increased likelihood of suicide attempts with an ACE score of six from a score of zero, and a 15 percent or greater chance of suffering from any of the leading causes of death in the United States: chronic obstructive pulmonary disease (COPD), ischemic heart disease, and liver disease. ACEs are the “gravest and most costly public health issue in the United States,” said Dr Robert Anda, who worked on what is known as the ACE or Adverse Childhood Experiences Study with Dr. Vincent Felitti, from Kaiser Permanente.

However, we are not addressing the urgency that this problem demands because within society and the medical professions there is a general disconnect between ACEs and their ripple effects in families, schools, and communities. Too often they are swept under the urgent-to-deal-with radar because most people who are in a position to affect change are either ignorant of the long term damage ACEs can cause, deny there is a grave problem to address, and/or lack the courage to acknowledge the presence of painful ACEs in their own lives, thereby turning a blind eye to, or dismissing, the impact they have on their patients, clients, or people who otherwise rely on them for help or assistance.

Exactly What Are ACEs?

ACEs are Adverse Childhood Experiences that can negatively impact a person’s health and well-being – even as much as fifty years later. ACEs include physical, sexual, and emotional abuse. Emotional and physical neglect are also ACEs that can leave long-lasting psychological scars. In fact physical neglect among boys is a high risk factor for developing post-traumatic stress disorder (PTSD), as is sexual and physical abuse.

Other ACEs that can cause long-lasting negative outcomes for children are living with a caregiver who has a drinking problem, takes drugs, is depressed, or has a mental illness (and even a chronic physical illness); experiencing parental divorce; having an incarcerated parent; being permanently separated from one or both parents; and, living with domestic violence. These adverse childhood experiences can be ongoing, as in the case of a child living with chronic domestic violence, or a single traumatic incident such as rape, kidnapping, or abandonment. Children forcibly removed from loving parents and placed in foster care or adopted out, as is currently happening in Britain, will suffer well into adulthood from this heart wrenching ACE.

The ACE Study

The ACE Study was a large-scale study conducted from 1995 to 1997 involving 17,421 people – mostly white, middle class, middle aged, well educated and financially secure. It was conducted by Vincent Felitti, MD (left), chief of Kaiser Permanente’s Department of Preventative Medicine in San Diego in collaboration with Robert Anda, MD, from the Centers for Disease Control and Prevention (CDC).

Interestingly, the study came about as a result of an intrigue. Why had a woman in Dr Vincent Felitti’s weight loss program begin piling on weight again after losing 276 pounds?

Well, when her newly trim body attracted unwanted sexual attention, she went home and started stuffing herself with food. Why? Felitti was shocked to discover that the underlying cause was a lengthy history of incest with her grandfather. As another woman in the weight loss program stated, “Overweight is overlooked.”

Ten days later, when Felitti heard a similar story, he and his team took a closer look at their patients’ histories. Their shocking discovery was that most of their morbidly obese patients had been sexually abused as children. Not only that, but they also uncovered a host of other family problems. And this is what led to the ACE Study, where Dr Felitti was able to start connecting dots between adverse childhood experiences and many challenging and intractable health problems in adulthood – even fifty years later.  He found that the higher an ACE score, the greater the negative impact on adult health.

The Alarming Results of the ACE Study

Only one-third in this study reported no adverse childhood experiences. Of the two-thirds of respondents who reported an adverse experience, 87 percent scored two or more. One in six of all respondents had an ACE score of four or higher.

These scores were then correlated with each participant’s health problems, revealing the urgency with which we need to act to create safe, respectful, and loving homes in which everyone can thrive.

  • More than half of those with ACE scores of 4 or higher reported having learning or behavioral problems at school.
  • High ACE scores correlated with high workplace absenteeism, financial problems, and lower lifetime income.
  • For those with an ACE score of 4 or more, depression was prevalent in 66 percent of women and 35 percent of men (compared with an overall rate of 12 percent with an ACE score of zero).
  • There is a 5,000 percent increased likelihood of suicide attempts from zero to an ACE score of 6.
  • Adults with an ACE score of 4 were seven times more likely to be an alcoholic.
  • With an ACE score of 6 or more, the likelihood of IV drug use was 4,600 percent greater than for those with a score of zero.
  • The prevalence of rape went from 5 percent with a ACE score of zero to 33 percent at a score of 4 or more.
  • High risk behaviors predicted by the ACE score included smoking, obesity, unintended pregnancies, multiple sexual partners, and STDs.
  • An ACE score of 6 or more produced a 15 percent or greater chance than those with a score of zero, of a person currently suffering from any of the leading causes of death in the United States: chronic obstructive pulmonary disease (COPD), ischemic heart disease, and liver disease. They were twice as likely to suffer from cancer, and 4 times as likely to have emphysema.

Source: Bessel van der Kolk, M.D. (2014), The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, pp. 148-149.

A drawing by artist, Jackson Pollock, who suffered with depression and alcoholism until his death at the age of 44 in a car accident. It is very likely that Pollock had more than four ACEs as the drawing reveals a troubled early childhood, to which his brother, Sanford, alludes in a letter: “As you know troubles such as his are very deep rooted, in childhood usually, and it takes a long while to get them ironed out.”

Dr Bessel van der Kolk, who wrote comprehensively about PTSD in The Body Keeps the Score, noted the following about Robert Anda’s experience of the ACE study:

The first time I heard Robert Anda present the results of the ACE study, he could not hold back his tears. In his career at the CDC he had previously worked in several major risk areas, including tobacco research and cardiovascular death. But when the ACE study began to appear on his computer screen, he realized that they had stumbled upon the gravest and most costly public health issue in the United States: child abuse. He had calculated that its overall costs exceeded those of cancer or heart disease and that eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters. It would have a dramatic effect on workplace performance and vastly decrease the need for incarceration. (p. 150, italics, mine.)

What Is Your ACE Score?

Felitti and Anda devised the following ten categories for the study to ascertain a person’s ACE score. Answering “yes” to one of the questions in a category equals one point. Or you can do the online test with the same questions as below.

  1. Before your 18th birthday, 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?
  2. Before your 18th birthday, 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?
  3. Before your 18th birthday, did an adult or person at least five 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?
  4. Before your eighteenth birthday, 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?
  5. Before your 18th birthday, 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?
  6. Before your 18th birthday, was a biological parent ever lost to you through divorce, abandonment, or other reason?
  7. Before your 18th birthday, 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?
  8. Before your 18th birthday, did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
  9. Before your 18th birthday, was a household member depressed or mentally ill, or did a household member attempt suicide?
  10. Before your 18th birthday, did a household member go to prison?

In the video below, Dr Felitti gives a talk about the ACE study and what he found. Or watch on YouTube.

Let’s Update The ACE Study

Not included in this study are John Briere’s later findings (Auckland Seminar, 2009) that early emotional neglect and sexual abuse before the age of five, feature in the histories of people diagnosed with borderline personality disorder (BPD), who are known for having much difficulty in interpersonal relationships.

Neither does does the study include the findings that rape, sexual abuse, neglect, and physical abuse in childhood are risk factors for developing post-traumatic stress disorder (PTSD). In an article I wrote, PTSD And It’s Damaging Impact on Individuals, Families and Communities, I noted that:

Many studies now reveal that PTSD is a significant risk factor for domestic violence, child abuse, problems in interpersonal relationships, violent crimes, incarceration and problems with the judicial system, depression, other anxiety disorders, substance abuse/disorders, suicide, smoking, high risk behavior, teenage pregnancies, eating disorders, obesity, diabetes, ischemic heart disease, cancer, lung disease, asthma, poor educational outcomes, unemployment, benefit dependency, and homelessness.

But the most shocking fact about developing PTSD is the possibility that it can be handed down from one generation to the next epigenetically. This means that the impact of one person’s trauma can become inter-generational – along with all the correlated negative health, social, interpersonal, and work outcomes.

ACEs and Toxic Shame

John Bradshaw, a well-known American family therapist, causes us to pause and reflect on the deep and often crippling injury of sexually abusing a child for an adult’s gratification by describing such acts as “soul murder.” It creates a wound that cannot heal because it is filled with toxic shame that leaves a child feeling bad, dirty, defective, and undeserving of love and the good things life can offer. A person may never recover from ACEs to integrate their true self, but remain a lifelong captive of a false self or persona that not only hides their wounds, but impoverishes their life on many levels.

Marlene Pania, during an interview about New Zealand gang girls (below), shows the hurt she still feels after she was sexually abused by uncles as a child, and why she sought refuge within the gang community.

A drawing by Craig, a man in his early thirties who was so full of toxic shame that his eyes remained glued to the floor during his initial counseling session with me. He is a faint blue ghost-like figure trying start a new life (motorbike) so he can reach someone in the distance (his future) who loves him. But as you can see, he is tied to the dominating mother of his past who is locked in grief over her husband’s death, and expects her son to run the family farm just like his father did. Craig grew up believing that no one loved him because his mother constantly told him he was “no good.”

“Oh, I had a happy childhood,” was the frequent automatic response when I began digging in to a person’s history during our first counseling session which, more often than not, was to discuss a relationship problem. Yet a gentle exploration often revealed abuse of the vilest nature.

For example, ‘Simon’ sought my advice on how to help his girlfriend deal with a newly revealed history of sexual abuse. However he was so distraught and fidgety that we decided it was more appropriate to explore his own childhood using a simple regression technique that went straight to the cause of his agitation. And it was this: When Simon was three-years-old, his father anally raped him during an access visit after his parents separated.

Underneath ‘Simon’s’ agitation was anger that wanted to “erupt through the pores of his skin like it had nowhere to hide.” Underneath that anger was toxic shame that contained such deep self-loathing that he wanted to fail his final year at university. That was when I became an intimate witness not only to the damage caused by such a vile sexual act on a child, but also the excruciating emotional and physical nature of the traumatic experience that had to hide the memory of it within toxic shame.

Unfortunately, my files were full of similar stories.

In this drawing Craig ‘killed’ the ‘bad’ and unacceptable self he imagined that others saw him as. However, he has no feet on the ground and is still ghost-like. If he had been able to love himself then, just as he was, knowing that he wasn’t ‘defective’ but that his parents lacked the ability to love him unconditionally as a child, he would have instead embraced his rejected self and re-parented him through self-love, which is a very powerful way to heal childhood wounds. Unfortunately it can take years, if not a lifetime, to learn to love oneself after a childhood of toxic shaming.

The Ripple Effect of ACEs in the Classroom

Seemingly at the other end of the scale of adverse childhood experiences are the children who are called names by their caregivers. A friend of mine had a saying, “Tell a child something three times and it becomes a truth.” It might not seem much to you, but calling a child names can tear big holes in their self-esteem. Moreover, name calling is emotional abuse and can also turn into toxic shame, where doing something ‘wrong’ is translated in a child’s mind as “I am bad.” It took a class of restless and often agitated eleven-year-olds to teach me the adverse effect of name calling.

When my class of 28 students would not settle one morning – despite exercises and our run around the oval to let off steam – almost in exasperation I asked, “What happened before you arrived at school today?” Their replies shocked me.

‘Jack’ said his mother called him a “fat slob” which made him angry because he was doing his best to find a way to lose weight, and even went to Weight Watcher’s of his own accord. His frustration and anger caused him to hit out at other students, upsetting them and causing retaliatory actions.

‘Lucy’s’ father had called her a “clumsy oaf,” and possibly many other names besides because I noticed that she often tuned out of lessons to draw horse pictures instead. This was having a serious impact on her ability to do well in class, and it was sad to see the sullen look that remained glued most days, mask-like to her face.

An ongoing problem for the boys was ‘Stacy,’ who kept getting out of her seat to pinch them as if it was an uncontrollable compulsion. Later in private she was able to tell me that her stepfather teased her about wearing her first bra, and frequently pulled the elastic to sting her back. I suspected that he was also doing more than that, for I often caught a knowing look of lost innocence on her face that blended into shame. This negatively affected her schoolwork, too.

The Transformative Impact of the Creative Arts

Not long after this, my students revealed a more concerning cause for their unrest. A full third of the class came from broken homes where many were stuck in grief over being separated from a loved parent. This was revealed during a Maths class in which they were designing their dream home. When one boy asked why people had to sell their home after a divorce, a girl interrupted my answer to say they also had custody cases to decide which parent has the children. A chorus of voices immediately erupted with, “That happened to me, too.” Their voices then became a babble filled with urgency, begging me to allow them to re-enact a custody case in their next creative drama class.

I instantly recoiled, seeing my own childhood in their faces. But they were most insistent. This was to become one of many instances where my students became my teacher.

Children in a creative drama class exploring their inner feelings by acting out images that came to them while previously in a relaxed state listening to music.

What I discovered, after a little guidance from me, was that they were able to confront what was perhaps secret or hushed up, and bring it out into the open for a close inspection. The therapeutic effect was instant. The experience empowered many of them then to confront their ‘bogey man’ by writing stories, or plays to perform in front of the class. Their writing was powerful because the acting out had reconnected them to feelings many had anesthetized during their parents’ breakup.

After making it clear that their stories were private and they did not have to hand them in for assessment, I said they could share them with me if they wished. One girl, Jackie, came shyly to my desk and asked if she could read her story to me. It described the day her parents separated, and was beautifully written. And then came a confession: she had cried herself to sleep every night for over a year because her father “won’t let Mum see me.” I had met her father, and it became clear to me that this was an act of revenge against his ex-wife. So focused on getting back at her, he unable to consider the serious impact on his daughter that would haunt her for years to come.

As painful as this situation was, there were a couple of mitigating factors present: one, Jackie had a teacher who cared and validated her experience; two, she learned that writing a story about her unhappy experience and sharing it with someone who listened, helped her to release some of her grief to someone who could contain it.

Social support is a critical mitigating factor in the aftermath of any type of trauma or adverse experience.

Allowing my students to act out a custody case in creative drama was proof to them that they had been heard, and enabled some integration of their adverse experience to occur. As a class they became calmer and settled more readily to their school work each day. But now to my mind, however, their plays and stories was their real work.

Alice Miller, a Swiss psychotherapist, wrote that as soon as you put a paintbrush into a child’s hand they will paint what underlies their problems. This is also true for adults. At left is one of my own paintings (done in 1980) that marked the beginning of my own journey to heal childhood wounds. The painting clearly shows how living with fighting parents impacted me (dark green horse at bottom). Looking back, it was like living in a war zone, and contributed to the post-traumatic stress disorder (PTSD) that I live with today as a constant reminder of my past.

The adverse experiences I have outlined above, not only negatively impact a child’s self-esteem and self-confidence, but at a future date could negatively impact their health as well. Often it is unresolved painful childhood experiences that underlie teenage depression, suicide, binge drinking, drug addiction, risk taking behaviors, and teenage pregnancies.

Much is done in therapy to help children integrate trauma through play. However writing, drawing, painting and other artistic expressions are also powerful ways to integrate adverse experiences. In this way children learn to tolerate what was once so painful to them and, as they do, traumatic experiences lessen their negative grip to allow for new learning and ways of seeing. Eventually this can bring peace of being where ACEs are no longer risk factors for negative adult health outcomes.

The last drawing Craig did reflects much inner healing. He has torn the wall apart and his feet are firmly planted on the ground. He looks strong, finally grounded in self-love.

We Have Urgent Work To Do

It is now 2019 and far too little has been done to address this urgent issue of reducing child abuse here in New Zealand. Before the 2005 election, then Prime Minister Helen Clark said in reference to the harsh social welfare policies of the nineties that:

…we are overcoming the impacts of a generation or two having been pretty battered. We experience the impact of that in regions where there’ve been very high unemployment, and where getting people back to work was actually quite a major rehab job, because there were many people who had simply become — with second-or third-generation unemployment – too alcoholic, drug-dependent, overweight and just plain sick to work. Now, if you then say, “Well, what kind of families come from that?”, it isn’t good. I think we’ve got long-term repair work to do there, none of which is helped by a return to the excesses of neo-liberalism. 

However, the specter of neo-liberalism still haunts us to this day. Poverty, which translates into child poverty, has its own way of further entrenching and exacerbating social problems. The Child Poverty Action Group (CPAG) has for many years played a huge role in highlighting the damage caused by poverty and exclusion in social welfare policies, and has campaigned tirelessly to fix issues adversely impacting people on welfare. In 2008, the National Party Government created greater awareness of the damage caused by domestic violence through their “White Ribbon” and “It’s not OK” campaigns, and offending men were sent to anger management programs. However, the 2009 Leitner Center Study of domestic violence in New Zealand found that this fell short of what was needed, and that some programs were dropped once started through lack of funding. It stated:

The prevalence of violence against women persists despite New Zealand’s commitments under international law to secure equality for women, act with due diligence to prevent, investigate or punish acts of domestic violence and provide for effective remedies to the victims of domestic violence.

However the study noted that the domestic violence “prevalence rates within Maori communities are even higher than the rates for the general population.” What has been of great concern this year (2019) is the policy of the Social Welfare Ministry to uplift babies at birth (predominately Maori) who are born into ‘potentially harmful’ family situations. A very disturbing film was made during one of these attempted uplifts, which can be viewed within this article: NZ’s own ‘taken generation’ . Babies are removed and either placed into foster care, or are adopted out. Not only is this a disturbing practice because of a baby’s broken attachment with their birth mother, but a placement into foster care is no guarantee that a child will be ‘safe’ from abuse.

It seems that we would prefer to bear the financial and societal burden of ongoing domestic violence and child abuse than investigate the causes of it, then set in place measures to reduce it – along with changes in government policies, the education necessary to understand its impact, and learning how to treat each other with compassion and respect.

Shirley Julich, who wrote her Ph.D. thesis on the price the government is paying for New Zealand’s high rate of sexual abuse (25 percent of girls and 9 percent of boys are sexually abused in some way by the time they reach 16), estimated the cost in 2002 at $2.4 billion a year, taking into account the “cost of lost earnings, extra health bills and the unmet potential of adult survivors of childhood sexual abuse” (Western Leader, 05 August 2002). However, this figure does not take into account the extra cost of incarceration and loss of income of those found guilty of sexually abusing children.

Another huge loss caused by child abuse is what Vincent Felitti called turning “gold into lead.” This is the extent to which each abused child loses their ability to realize their potential, and all the good feelings and rewards that come with this. After Buckminster Fuller’s death, Robert T. Kiyosaki recalled Bucky’s poignant words:

Look into the eyes of a newborn baby and you will see the spark and the soul of a genius.

Distraught over his death, Kiyosaki decided to find out what caused this genius to hide – both in himself and other people. His study took him all over the world to work with thousands of people. He wrote:

“My findings were not pretty. I discovered that the genius born in every child is greatly diminished before the child even begins school. Sadly, our teachers hardly have a chance to restore and ignite the flame.” (p. 316, If You Want to be Rich and Happy Don’t Go to School?)

What happens to destroy this “genius” or “turn gold into lead”? John Bradshaw maintained that this is the result of child abuse. More specifically, he said that child abuse creates toxic shame. And it is toxic shame that sends the genius within a child into hiding. Toxic shame is a belief that says, “I am bad,” “I am a mistake,” “I am a failure,” and “I can never do anything right.” Therefore, “I am not worthy of love.”

This is how the seed of self-hate is sown.

When this precious child grows up, he or she can often look for love in all the wrong places, become a caretaker in an unconscious effort to “fix” an abusive parent, or become an abuser and perpetuate this negative cycle.

Is There A Way to Revive This Lost ‘Genius’?

There is a ray of hope to revive this lost genius, as Kiyosaki also tracked down people who were considered geniuses in their fields, people who not only pushed the known boundaries in their fields, but pushed themselves “beyond personal beliefs and paradigms.” He discovered that the secret to expressing their genius was this:

They used what they LOVED to solve the problems they HATED.

Each person was using his or her gift – that which came naturally to them – to solve problems that bothered them deeply or in some way totally captured their attention.

(p. 317, If You Want to be Rich and Happy Don’t Go to School?)

Such a desire, I have personally found, acts as a powerful antidote to the poisonous toxicity of shame created by child abuse. Not only can it imbue one’s life with a sense of purpose, thus preventing a major fall into despair, depression, or suicidal thoughts, but it gives a sense of hope that one can leave the world a better place for having found their gift, and shared it. No matter what the odds.

This surely, then, is the Hero’s Journey, where a person can evolve by overcoming the obstacles in their path. It is also a chance to find one’s Golden Fleece.

In the following informative TED talk, Nadine Burke Harris shares her experience as a practicing pediatrician after discovering the ACE Study, and why we are not acting on this most important and vital information.


Prevalence of ACEs by Category for CDC-Kaiser ACE Study Participants by Sex, Waves 1 and 2.

ACE CategoryWomenMenTotal
Percent (N = 9,367)Percent (N = 7,970)Percent (N = 17,337)
Emotional Abuse13.1%7.6%10.6%
Physical Abuse27%29.9%28.3%
Sexual Abuse24.7%16%20.7%
Mother Treated Violently13.7%11.5%12.7%
Household Substance Abuse29.5%23.8%26.9%
Household Mental Illness23.3%14.8%19.4%
Parental Separation or Divorce24.5%21.8%23.3%
Incarcerated Household Member5.2%4.1%4.7%
Emotional Neglect316.7%12.4%14.8%
Physical Neglect39.2%10.7%9.9%

Note: 3Collected during Wave 2 only (N=8,629). Research papers that use Wave 1 and/or Wave 2 data may contain slightly different prevalence estimates.

ACE Score Prevalence for CDC-Kaiser ACE Study Participants by Sex, Waves 1 and 2.

Number of Adverse Childhood Experiences (ACE Score)Women
Percent(N = 9,367)
Percent (N = 7,970)
Percent (N = 17,337)
4 or more15.2%9.2%12.5%

Note: Research papers that use Wave 1 and/or Wave 2 data may contain slightly different prevalence estimates.

Source: Centers for Disease Control and Prevention, Kaiser Permanente. The ACE Study Survey Data [Unpublished Data]. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2016.

Find out more about the ACE Study