What it measures?
- The Adverse Childhood Experiences Questionnaire (ACE-Q) is a widely used tool for assessing childhood adversity (Atzl et al., 2019). It involves tallying adverse childhood experiences (ACEs) to measure various types of maltreatment and adversity that individuals may have experienced during their childhood, including emotional, physical and sexual abuse, emotional and physical neglect, and five household dysfunctions: parental separation/divorce, household physical violence, household substance abuse, household mental illness or suicide attempt, and the incarceration of a household member.
Who is it for?
Adults aged 18 years +
Instrument Quality
- In general, the ACE-Q has been acknowledged as a well-validated scale for assessing exposure to adversity before the age of 18 and correlates with later health outcomes (Hantsoo et al., 2019). However, limitations of the ACE-Q have been noted (Anda et al., 2020; Lacey & Minnis, 2019): For example, ACE-Q questions are limited in their ability to comprehensively capture the frequency, intensity, and chronicity of adverse childhood experiences, as well as to consider sex differences and variations in the timing of exposure. For instance, two individuals with the same ACE score of 4 may have distinct lifetime exposures, exposure timings (especially during critical developmental stages), or contrasting positive experiences and protective factors that influence their stress biology. While one person with an ACE score of 1 might have undergone intense, persistent, and continuous exposure to a single form of abuse, another individual with multiple low-level exposures (in terms of intensity, frequency, and chronicity) to various adversities could end up with a higher ACE score. Consequently, relying solely on an individual's ACE score to predict health or social outcomes based on grouped or average risks from epidemiological studies can result in significant underestimation or overestimation of the actual risk. Over-reliance on ACE scores in clinical practice can also contribute to over-simplistic communication of risk/causality, determinism and stigma. Therefore, exclusive recourse to the ACE score for screening individuals and determining their risk for making decisions regarding the necessity for services or treatment is not advisable.
Structure
- The ACE-Q consists of 10 categories/items (e.g. ‘Did you live with anyone who went to jail or prison’). The respondent is asked to place a check mark next to the items that they experienced prior to their 18th birthday. A final supplementary question asks the respondent whether they believe the experiences they endorsed have affected their health.
- Items are summed to derive a full-scale score.
Scoring instructions
Sum item responses (one point per item) to derive a full-scale score.
| Subscale | Item number |
|---|---|
Full-scale (ACE-Q) | 1,2,3,4,5,6,7,8,9,10 |
Score Interpretation
What higher scores mean?
- Higher scores on the Adverse Childhood Experiences Questionnaire (ACE-Q) typically indicate a greater exposure to adverse childhood experiences (ACEs; Halpin et al., 2021). Only about 5–10% of the general population obtain a score 4 or more, for which the general long-term health consequences become most pronounced. Research suggests that higher ACE scores are associated with an increased risk of various negative outcomes in adulthood, including mental health issues, behavioral problems, substance use disorders, and physical health concerns (Merrick et al., 2017; Tsehay et al., 2020). Studies have shown that individuals with higher ACE scores are more likely to experience cognitive dysfunction, depressive symptoms, and suicidal behavior (Reuben et al., 2016; Merrick et al., 2017). Moreover, higher ACE scores have been linked to a higher prevalence and severity of mental health disorders, indicating a dose-response relationship between childhood adversity and adult mental health outcomes (Merrick et al., 2017; Tsehay et al., 2020). Additionally, higher ACE scores have been associated with a greater likelihood of engaging in risky behaviors, such as substance abuse and intimate partner violence (Kidman et al., 2023; Novick et al., 2023). Research has also highlighted the intergenerational transmission of ACEs, with parents' ACE scores being correlated with their children's ACE scores, underscoring the long-term impact of childhood adversity across generations (Schickedanz et al., 2021). The cumulative effect of ACEs, as reflected in higher ACE scores, has been shown to have a significant influence on individuals' well-being, emphasizing the importance of addressing childhood adversity to prevent adverse outcomes in adulthood (Merrick et al., 2017; Tsehay et al., 2020). In summary, higher scores on the ACE-Q indicate a greater exposure to adverse childhood experiences, which can have profound implications for individuals' mental, behavioural, and physical health outcomes in adulthood.
How to assess symptom severity & change?
- Full-scale (ACE-Q)
| Description | Score Range | |
|---|---|---|
| Low Toxic Stress Risk | 0 | |
| Intermediate Toxic Stress Risk | 1 | |
| High Toxic Stress Risk | 4 | |
| Maximum (High Toxic Stress Risk) | 10 |
Severity ranges
* Numerous scientific studies have shown that significant exposure to chronic stress during crucial stages of early childhood, in the absence of supportive and caring relationships with reliable caregivers and secure surroundings, can result in enduring impairments in brain growth and the functioning of immune, hormonal, and metabolic systems, mediated by genetic regulatory processes. This phenomenon has been identified as the toxic stress response. Individuals with six or more ACEs exhibit a life expectancy that is 19 years lower compared to those with no ACEs. Moreover, adverse Childhood Experiences (ACEs) and toxic stress have been linked to heightened susceptibility to various health issues across age groups, referred to as ACE-Associated Health Conditions, including (but not limited to) Diabetes, Chronic obstructive pulmonary disease (COPD), Cardiovascular disease, Stroke, Cancer, Depression, Anxiety, Substance use, Chronic pain, Post-Traumatic Stress Disorder. The cut-off scores we have adopted indicating risk of toxic stress derive from the The ACEs Aware initiative in California, based on the original research of Felitti and colleagues (1998).
Reliable change and clinically significant improvement
Wampold et al (2001) conducted a meta analysis of psychotherapy outcome studies and noted that the average improvement was reflected in an effect size (ES) of .80. Because a change of 1 SD corresponds to an ES of 1.0, and .80 is considered to be a large ES, Wise (2004) concludes that a change of 1 SD is a defensible indicator of clinically significant change.
Mean
| Sample | Mean | Comments |
|---|---|---|
| Clinical | 2.26 | Sample consisted of Italian university students (N = 121) who had approached counselling services and attended one clinical interview prior to treatment (Craig et al., 2023). |
| Normative | 1.57 | Sample included Italian university students with no past experience of counselling (N = 255; Craig et al., 2023). |
Standard Deviation
| Sample | Mean | Comments |
|---|---|---|
| Clinical | 1.74 | Sample consisted of Italian university students (N = 121) who had approached counselling services and attended one clinical interview prior to treatment (Craig et al., 2023). |
| Normative | 1.67 | Sample included Italian university students with no past experience of counselling (N = 255; Craig et al., 2023). |
Reliability
| Value | Comments |
|---|---|
| 0.91 | * Sample consisted of 284 Canadians attending primary care clinics (mean age = 40.96 years; sd = 16.05), who completed the ACE-Q twice during a 3-month interval (Frampton et al., 2018). |
Instrument developers
- Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F.,Spitz, A. M., Edwards, V., … Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258.
Refrences
* Atzl, V. M., Narayan, A. J., Rivera, L. M., & Lieberman, A. F. (2019). Adverse childhood experiences and prenatal mental health: type of aces and age of maltreatment onset.. Journal of Family Psychology, 33(3), 304-314. https://doi.org/10.1037/fam0000510. * Drevin, J., Stern, J., Annerbäck, E., Peterson, M., Butler, S. D., Tydén, T., … & Kristiansson, P. (2016). Adverse childhood experiences influence development of pain during pregnancy. Obstetric Anesthesia Digest, 36(2), 78-79. https://doi.org/10.1097/01.aoa.0000482612.79796.c7 * Halpin, A., MacAulay, R. K., Boeve, A., D'Errico, L., & Michaud, S. (2021). Are adverse childhood experiences associated with worse cognitive function in older adults?. Journal of the International Neuropsychological Society, 28(10), 1029-1038. https://doi.org/10.1017/s1355617721001272. * Hughes, K., Bellis, M. A., Hardcastle, K. A., Sethi, D., Butchart, A., Mikton, C., ... & Dunne, M. P. (2017). The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. The Lancet public health, 2(8), e356-e366. * Kaloeti, D. V. S., Rahmandani, A., Sakti, H., Salma, S., Suparno, S., & Hanafi, S. P. (2018). Effect of childhood adversity experiences, psychological distress, and resilience on depressive symptoms among indonesian university students. International Journal of Adolescence and Youth, 24(2), 177-184. https://doi.org/10.1080/02673843.2018.1485584. * Kidman, R., Breton, E., Behrman, J. R., Zulu, A., & Kohler, H. (2023). Longitudinal associations between childhood adversity and adolescent intimate partner violence in malawi. Journal of Interpersonal Violence, 38(11-12), 7335-7354. https://doi.org/10.1177/08862605221145720. * Holden, R., Stables, I., Brown, P., & Fotiadou, M. (2021). Adverse childhood experiences and adult self-harm in a female forensic population. BJPsych Bulletin, 46(3), 148-152. https://doi.org/10.1192/bjb.2021.34. * Hantsoo, L., Jašarević, E., Criniti, S., McGeehan, B., Tanes, C., Sammel, M. D., … & Epperson, C. N. (2019). Childhood adversity impact on gut microbiota and inflammatory response to stress during pregnancy. Brain, Behavior, and Immunity, 75, 240-250. https://doi.org/10.1016/j.bbi.2018.11.005. * Lacey, R. and Minnis, H. (2019). Practitioner review: twenty years of research with adverse childhood experience scores – advantages, disadvantages and applications to practice. Journal of Child Psychology and Psychiatry, 61(2), 116-130. https://doi.org/10.1111/jcpp.13135 * Merrick, M. T., Ports, K. A., Ford, D. C., Afifi, T. O., Gershoff, E. T., & Grogan‐Kaylor, A. (2017). Unpacking the impact of adverse childhood experiences on adult mental health. Child Abuse &Amp; Neglect, 69, 10-19. https://doi.org/10.1016/j.chiabu.2017.03.016. * Narayan, A. J., Kalstabakken, A. W., Labella, M. H., Nerenberg, L. S., Monn, A. R., & Masten, A. S. (2017). Intergenerational continuity of adverse childhood experiences in homeless families: unpacking exposure to maltreatment versus family dysfunction.. American Journal of Orthopsychiatry, 87(1), 3-14. https://doi.org/10.1037/ort0000133. * Novick, A. M., Stoddard, J., Johnson, R. L., Duffy, K. A., Berkowitz, L., Costa, V. D., … & Epperson, C. N. (2023). Adverse childhood experiences and hormonal contraception: interactive impact on sexual reward function. Plos One, 18(1), e0279764. https://doi.org/10.1371/journal.pone.0279764. * Petersen, J., Schulz, A., Brähler, E., Sachser, C., Fegert, J. M., & Beutel, M. E. (2022). Childhood maltreatment, depression and their link to adult economic burdens. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.908422. * Racine, N., Killam, T., & Madigan, S. (2020). Trauma-informed care as a universal precaution. JAMA Pediatrics, 174(1), 5. https://doi.org/10.1001/jamapediatrics.2019.3866 * Reuben, A., Moffitt, T. E., Caspi, A., Belsky, D. W., Harrington, H., Schroeder, F., … & Danese, A. (2016). Lest we forget: comparing retrospective and prospective assessments of adverse childhood experiences in the prediction of adult health. Journal of Child Psychology and Psychiatry, 57(10), 1103-1112. https://doi.org/10.1111/jcpp.12621 * Schickedanz, A., Escarce, J. J., Halfon, N., & Sastry, N. (2021). Intergenerational associations between parents’ and children’s adverse childhood experience scores. Children, 8(9), 747. https://doi.org/10.3390/children8090747 * Tsehay, M., Necho, M., & Mekonnen, W. (2020). The role of adverse childhood experience on depression symptom, prevalence, and severity among school going adolescents. Depression Research and Treatment, 2020, 1-9. https://doi.org/10.1155/2020/5951792. * Yousef, A. M., Mohamed, A. E., Eldeeb, S. M., & Mahdy, R. S. (2022). 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