Health Risks Associated with Adverse Childhood Experiences (ACEs)
Adverse childhood experiences (ACEs) significantly increase the risk for multiple serious health conditions including cardiovascular disease, lung disease, liver disease, mental illness, and cancer through toxic stress responses that alter biological systems and promote maladaptive coping behaviors. 1
What Are ACEs?
ACEs encompass a spectrum of childhood adversities that include:
- Abuse: Physical, emotional, and sexual abuse
- Neglect: Physical and emotional neglect
- Household dysfunction: Parental substance misuse, mental illness, separation/divorce, intimate partner violence, and incarcerated household member 1
Dose-Dependent Health Risks
The relationship between ACEs and negative health outcomes follows a dose-dependent pattern, with higher ACE scores correlating with greater health risks:
Physical Health Outcomes
- Cardiovascular disease
- Lung disease
- Liver disease
- Cancer
- Premature death 1
Mental Health Outcomes
- Depression and anxiety disorders
- Suicide attempts (individuals with ≥4 ACEs have nearly 18 times higher odds compared to those with no ACEs) 2
- Mental health treatment needs (individuals with ≥4 ACEs have significantly higher rates of therapy utilization) 2, 3
Behavioral Health Outcomes
- Substance use disorders:
- Risky sexual behaviors
- Obesity 1
Justice System Involvement
- Higher rates of delinquency
- Increased risk for recidivism
- Greater need for behavioral health interventions 1
Biological Mechanisms
ACEs impact health through toxic stress responses that alter multiple biological systems:
- Genomic function
- Brain structure and connectivity
- Metabolism
- Neuroendocrine-immune function
- Inflammatory cascade
- Microbiome 1
These alterations can "get under the skin" and negatively impact life-course trajectories, influencing the adoption of maladaptive coping behaviors decades later.
Mediating Factors
The pathway from ACEs to negative health outcomes is often mediated by:
Mood and anxiety disorders - These typically develop approximately 3 years before substance dependence diagnoses and partially mediate the effect of ACEs on substance dependence risk 4
Maladaptive coping behaviors - Including substance use and risky behaviors that develop in response to trauma 5
Protective Factors
Supportive childhood relationships can moderate the risks associated with ACEs:
- In individuals with ≥4 ACEs, supportive childhood relationships reduced suicide attempt rates from 23% to 13% 2
- Similar protective effects were observed for therapy utilization (25% to 20%), problem drinking (23% to 17%), and smoking (34% to 32%) 2
Clinical Implications
Healthcare providers should:
Screen for ACEs - Implement routine screening in pediatric and adult primary care settings 1
Recognize differential impacts - Consider how ACEs may manifest differently based on gender, race, and ethnicity 1
Address mental health early - Early identification and treatment of mood and anxiety disorders associated with ACEs could reduce the risk of developing substance dependence 4
Promote resilience factors - Support interventions that enhance supportive relationships and other protective factors 2
Implement trauma-informed care - Train healthcare providers in trauma-responsive practices 1
Pitfalls and Caveats
- Screening without adequate follow-up resources may be problematic
- Referral decisions after positive screens can be difficult, especially in the absence of current symptoms
- There may be inadequate referral sources for behavioral health care
- Screening could potentially increase stigma or negative expectancies for patients with high ACEs 1
The evidence clearly demonstrates that ACEs have profound, long-lasting effects on health outcomes across multiple domains, making prevention, early identification, and intervention critical priorities for reducing morbidity and mortality.