Adverse Childhood Events (ACE)


  See ACE brochure

1. What are ACES

a. Stress and Early Brain Growth

ACEs stand for Adverse Childhood Events. This can include experiences such as abuse (physical, emotional and sexual), neglect (physical and emotional), household dysfunction (parental mental illness, incarcerated family member, substance abuse in the home, domestic abuse and loss of parent), serious accident or illness, community violence or bullying. These experiences can be influenced and compounded by financial hardship.

These experiences shape the development of the child, making some children and adults more vulnerable to poor physical health and mental health, as well as substance misuse. This happens as a result of prolonged toxic stress on early brain growth. This leads to a number of consequences, such as:

  • The brain, specifically the hippocampus which processes emotion and manages stress, is reduced in size
  • Increased stress hormone present in the body affects the immune system and can result in a number of diseases
  • Lowers future tolerance for stressful situations, which increases likelihood of risky behaviour in order to calm the feelings of stress in the body
  • Difficulties in school due to increased problems with memory and learning
  • Difficulties in building future relationships

2. How prevalent are ACES

ACES are common in the population, a study in Wales has found that 50% have at least one, with 14% having four or more (Bellis et al. 2016).

However, having four or more is notable and may require trauma informed care.

Sample Graphic:

Image Source

3. What Impact Do ACEs Have

As the number of ACEs increase, so does the risk for negative health outcomes. This can mean the adoption of risky health behaviours, such as poor diet, smoking, dangerous sexual behaviour and alcohol and drug abuse.

This leads to a shorten life span, with six or more ACES linked to having a lifespan shortened by 20 years. ACEs contribute to health problems in adulthood, such as heart disease, cancer and diabetes.

ACE Pyramid:

Image from CDC (2016)

Graphic: 4 or More Aces

  • 12.2 times as likely to attempt suicide
  • 10.3 times as likely to use injection drugs
  • 4.7 times as likely to use illicit drugs
  • 7.4 times as likely to be an alcoholic

Graphic from Felitti et al. (1998)

4. What is an ACE Aware Approach?

ACEs represent the complex issues that service workers face when working with service users. Being ACE aware can be beneficial in order to combat the effects of trauma in adulthood.

SAMHSA’s 4 R’s

To be ACE aware, we must

  1. REALISE the impact of Trauma and how this relates to recovery
  2. RECOGNISE the symptoms of trauma and better understand behaviour as survival strategies
  3. RESPOND with Trauma-Informed Care
  4. RESIST re-traumatising both service users and service workers

Principles of Trauma Informed Care

More information can be found here

5. Acceptability

Learning about ACEs can help people better understand their own story.

The inclusion of questions regarding ACEs can lead to questions regarding whether it is acceptable to ask someone such personal questions. However, a pilot study aimed at investigating ACES of new mothers during routine health visits has found that 90% of mothers considered it acceptable to answer ACE screenings (Hardcastle & Bellis, 2019).

6. Trauma Resilience

ACEs do not mean destiny, research has shown that we can tackle previous trauma by building resilience, or the ability to “bounce back” after negative experiences.

Supportive factors include social connections and community ties, knowledge of parenting skills and child development, and awareness of emotions.

7. Window of Tolerance

Understanding the window of tolerance can be helpful in working with individuals who have experienced a number of ACEs.

Image Source

More information is available here


Bellis, M. A., Ashton, K., Hughes, K., Ford, K., Bishop, J., & Paranjothy, S. (2016). Adverse
Childhood Experiences (ACEs) in Wales and their Impact on Health in the Adult Population: Mariana Dyakova. European Journal of Public Health, 26(1).

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.

Hardcastle, K. and Bellis, M. (2019). Asking about adverse childhood experiences (ACEs) in
health visiting Findings from a pilot study. [online] Public Health Wales NHS Trust.

Additional Materials:


ACE study and ACE pyramid (Voiceover)
American (McMaster University)/Good overview. (Graphics)
Welsh ACEs (Graphics)
NHS Scotland (Graphics)
UCLA Health (Person)
Good for last line (Person)
Sharon Lambert Cork Simon (Person)


Hardcastle, K. and Bellis, M. (2019). Asking about adverse childhood experiences (ACEs) in health visiting Findings from a pilot study.

The Relation Between Adverse Childhood Experiences and Adult Health: Turning Gold into Lead (Felitti, 2002) [Healthcare focused]

Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study (Dube et al, 2003)

Women and Addiction: A Trauma-Informed Approach (Covington, 2008)


Wales: Adverse childhood experiences (ACEs) and resilience: risk and protective factors for mental illness throughout life

NHS Scotland – Overview plus key facts clickable

General overview 

CDC USA/Great graphics 

7 ways ACES changes the brain

Cork Simon – Presentation of ACES with Cork Simon

Principles of Trauma Informed Care

Center for Evidence Based Practices:


DHS Wisconsin

SAMHSA Materials:

4 Page PDF on The Role of Adverse Childhood Experiences in Substance Misuse and Related Behavioral Health Problems:

SAMHSA Risk Factor Video (3 mins)

SAMHSA Transforming Systems of Care (3 mins)

SAMHSA – Trauma & Adverse Childhood Experiences: Implications for Preventing Substance Misuse

SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach 27 page pdf