Adverse Childhood Experiences in United States

United States

Adverse childhood experiences (ACEs) are stressful or traumatic events that can impact children’s health and well-being throughout their lifespan. Early experiences have a broad and profound impact on an individual’s development and subsequent emotional, cognitive, social and biological functioning. The relationship between ACEs and health was first described in a 1998 study, which found that individuals with more ACEs had much higher rates of behaviors and diseases that are risk factors for the leading causes of death in adults. A more recent study found that having four or more ACEs increased the risk of a adverse health outcomes in adulthood, including:

• Drug and alcohol abuse and smoking.
• Interpersonal and self-directed violence.
• Sexual risk-taking behaviors.
• Poor mental health.
• Poor self-rated health.
• Cancer, heart disease and respiratory disease.

Another survey also found that having more ACEs was associated with a higher prevalence of poor mental health, persistent feelings of sadness and suicidal behaviors among adolescents. These issues often persist into adulthood, as ACEs are strongly linked to poor adult mental health outcomes, including psychiatric problems such as post-traumatic stress disorder (PTSD) and self-harm.

In the United States, the annual economic burden of ACE-associated health conditions among adults is $14.1 trillion ($183 billion in direct medical spending and $13.9 trillion in healthy life-years lost).

According to data from the National Survey of Children’s Health, the prevalence of two or more ACEs is higher among:

• Children living in poverty. 
• Non-Hispanic Black children and children who identify as other race compared with Asian children, who have the lowest prevalence. Hispanic children also have a high prevalence of ACEs. 
• Children living in English-speaking households compared with those in households where English is not the primary language.

Prevention strategies to address ACEs may focus on:

• Improving economic support for children and families.
• Promoting violence prevention.
• Providing high-quality child care to ensure children have a strong start in life.
• Teaching social-emotional and healthy relationship skills.
• Connecting youth with supportive adults through mentoring or after-school programs. 
• Intervening with services necessary to reduce short- and long-term harms of ACEs (e.g., routine screening for ACEs, support groups or cognitive-behavioral therapy). 
• Offering parenting education to help caregivers develop positive parenting practices.

Large-scale policy recommendations to address ACEs include: 

• Promoting public awareness of ACEs and their impact on health.
• Increasing the capacity of health care providers to assess the presence of ACEs and provide appropriate treatment options.
• Training health care providers in trauma-informed care.
• Improving access to needed mental health and substance abuse services.
• Encouraging nurturing home and classroom environments.
• Implementing family-friendly workplace policies that support paid leave and access to quality child care.

The Centers for Disease Control and Prevention offers free online training modules on ACEs prevention. The introductory module is appropriate for anyone interested in learning about ACEs and is designed to help users understand, recognize and prevent ACEs. Additional modules are also available for professionals working directly with and on behalf of children and families.

Healthy People 2030 has a developmental objective to reduce the number of young adults who report three or more ACEs.

Altman, Lara, and Madison Hamett. “Policy Approaches to Addressing Childhood Adversity: Findings from a Policy Scan of 2019 State-Level Legislation.” The Illinois ACEs Response Collaborative, Health & Medicine Policy Research Group, August 5, 2020. https://hmprg.org/wp-content/uploads/2020/08/Policy_Approaches_to_Addressing_Childhood_Adversity.pdf.

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Hughes, Karen, Mark A. Bellis, Katherine A. Hardcastle, Dinesh Sethi, Alexander Butchart, Christopher Mikton, Lisa Jones, and Michael P. Dunne. “The Effect of Multiple Adverse Childhood Experiences on Health: A Systematic Review and Meta-Analysis.” The Lancet Public Health 2, no. 8 (August 2017): e356–66. https://doi.org/10.1016/s2468-2667(17)30118-4.

Murphey, David, and Jessica Dym Bartlett. “Childhood Adversity Screenings Are Just One Part of an Effective Policy Response to Childhood Trauma.” Research Brief. Child Trends, July 2019. https://www.childtrends.org/publications/childhood-adversity-screenings-are-just-one-part-of-an-effective-policy-response-to-childhood-trauma-2.

Peterson, Cora, Maria V. Aslam, Phyllis H. Niolon, Sarah Bacon, Mark A. Bellis, James A. Mercy, and Curtis Florence. “Economic Burden of Health Conditions Associated With Adverse Childhood Experiences Among US Adults.” JAMA Network Open 6, no. 12 (December 6, 2023): e2346323. https://doi.org/10.1001/jamanetworkopen.2023.46323.

Thurston, Christina, Aja Louise Murray, Hannabeth Franchino-Olsen, and Franziska Meinck. “Prospective Longitudinal Associations between Adverse Childhood Experiences and Adult Mental Health Outcomes: A Protocol for a Systematic Review and Meta-Analysis.” Systematic Reviews 12, no. 1 (September 30, 2023): 181. https://doi.org/10.1186/s13643-023-02330-1.