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  2. Adverse Childhood Experiences (ACE) Questionnaire

Adverse Childhood Experiences (ACE) Questionnaire

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Purpose

The ACE (Adverse Childhood Experiences) Questionnaire is a standardized tool used to assess and measure a person's exposure to adverse childhood experiences. It consists of a series of 10 questions, inquiring about various traumatic events and stressful situations that an individual may have experienced during their childhood. 

Link to Instrument

Acronym ACE-Q, ACE-10

Area of Assessment

Stress & Coping

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

CDE Status

Not a CDE -- last searched 8/11/2023

Populations

Pediatric Disorders
Mixed Populations
Mental Health

Key Descriptions

  • The ACE questionnaire is a self-reported survey designed to assess an individual's exposure to adverse childhood experiences. It consists of 10 questions, each addressing different types of traumatic events that may have occurred during childhood. A graded dose-response association between ACEs questionnaire scores and adverse adult physical and behavioral health outcomes has been indicated in the literature. Within the questionnaire, there are five questions pertaining to abuse and five that address household dysfunction.
  • Minimum Score: 0 (indicating no reported adverse childhood experiences)
  • Maximum Score: 10 (indicating exposure to all types of adverse childhood experiences)
  • Item Scoring: Each question in the ACE questionnaire is scored with one point for every ‘yes’ response, indicating the presence of a particular adverse experience. The scores are then summed to provide an overall ACE score ranging from 0 to 10.
  • Administration: The ACE questionnaire is either administered by a clinician with adult clients or self-administered. It involves providing "yes" or "no" responses to specific questions about childhood experiences.
  • Important Note: The ACE questionnaire is widely used in various research and public health settings to assess the association between childhood trauma and adult physical and behavioral health outcomes. The questionnaire focuses on specific types of adverse childhood experiences and may not encompass the full range of traumatic events an individual may have faced during childhood.

Number of Items

10

Time to Administer

5-10 minutes

Required Training

No Training

Age Ranges

Adolescent

13 - 17

years

Adult

18 - 64

years

Instrument Reviewers

Lenny Weld, Randy Woychuk, Rob Austria, and Caitlin Heermans (Master of Occupational Therapy Students) and Danbi Lee, PhD, OTD, OTR/L (Faculty Mentor), Division of Occupational Therapy, Department of Rehabilitation Medicine, University of Washington, Seattle

ICF Domain

Activity
Participation

Measurement Domain

General Health

Professional Association Recommendation

None found -- last searched 8/11/2023

Considerations

  • When using the ACE-10 questionnaire, it is suggested that cultural differences and norms that may influence the perception and understanding of certain experiences be taken into account.
  • Notably, there are alternatives to the original ACE questionnaire which seek to address cultural differences - including the ACE-IQ (international questionnaire) that was developed by the World Health Organization, the ACE-I (which includes adversities that may be more relevant to immigrant populations) as well as translated versions of ACEs outside of majority English speaking nations. 
  • Shortened versions of the questionnaire are available: the ACE-ASF focuses on abuse more broadly, not just household dysfunction. The two-item ACE screener is designed for rapid identification of adults impacted by childhood adversity.
  • The subject matter of the questions, and the direct manner in which they are asked could cause distress by requiring clients to engage in trauma recall.

Mental Health

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Cut-Off Scores

Adults: (Meehan et al., 2022; n = 8506 adults; mean age = 56.1 years; female = 52.1%; reanalysis of original ACE study data where subjects retrospectively reported ACEs following medical evaluation)

  • Recommended high-risk cut-off of ≥ 4 ACEs yielded low sensitivity across outcomes (mean = 0.14, range = 0.07-0.34)

Normative Data

Adults with history of overdose: (Asheh et al., 2023; n = 115; mean age = 40.6 (14.4) years; male = 61 (53%))

  • The mean ACE score for participants with an overdose (OD) history, as compared to those with no history of OD, was 4.0 (2.7) vs 2.3 (2.2). 

 

Emerging Adults (ages 18-25): (Babad et al., 2022; n = 436; mean age = 19.73 (1.83) years; age range = 18-25 years; Female = 278 (63.8%))

  • Mean cumulative ACEs = 1.52 (1.70) 

 

Women seeking substance use disorder treatment: (Cockroft et al., 2020; n = 301; median age = 32 years (interquartile range [IQR] 27, 39; age range = 18-61); female = 300 (one subject did not identify gender); median days since admission = 5 (IQR = 4,6; range = 0-7); treatment at community-based treatment center)

  • The mean number of prior ACEs reported was 5.3 (2.8), covering the entire range of possible scores (min 0, max 10).

     

Nursing students reporting burnout and depression: (McKee-Lopez et al., 2019; n = 179; mean age = 24.67 (5.915) years; female = 72%; Hispanic or Latino = 89%)

Childhood adversity percentages among participating cohorts

ACE score

Cohort 1

Cohort 2

Cohort 3

Total

n

31

85

63

179

0

26%

29%

29%

28%

1

35%

26%

17%

25%

2

0%

13%

22%

14%

3

10%

8%

16%

11%

4

10%

11%

6%

9%

5

10%

7%

5%

7%

6

6%

2%

3%

3%

7

0%

0%

2%

1%

8

3%

2%

0%

2%

9

0%

1%

0%

1%

10

0%

0%

0%

0%

ACE Score (>4)

29%

24%

16%

23%

 

Treatment-seeking veterans of the Canadian Armed Forces: (Plouffe et al., 2023; n = 192; mean age = 44.80 (11.56) years, age range = 22-65 years; mean time of military service = 13.54 (10.24) years; male = 83.9%)

  • Mean ACE score (n = 166) = 2.83 (2.50)

 

Women who experienced betrayal trauma (Vogeler et al., 2020; n = 192; female = 100%; age 18-24: 6.8%, 25-34: 24.5%, 35-44: 30.7%, 45-54: 24.0%, 55-64: 10.9%, 65-74: 3.0%)

  • Mean ACE score = 7.40 (2.46)

Internal Consistency

Adults with history of overdose: (Asheh et al., 2023)

  • Adequate: Cronbach’s alpha = 0.76

     

Women seeking substance use disorder treatment: (Cockroft et al., 2020)

  • Adequate: Cronbach’s alpha = 0.79

     

Women who experienced betrayal trauma: (Vogeler et al., 2020)

  • Adequate: Cronbach’s alpha for ACE-Total = 0.75

     

Treatment-seeking veterans of the Canadian Armed Forces: (Plouffe et al., 2023)

  • Adequate: Cronbach’s alpha (n = 166) = 0.78

Criterion Validity (Predictive/Concurrent)

Predictive Validity:

Emerging Adults (ages 18-25): (Babad et al. 2021)

  • Poor predictive validity of emotional abuse at predicting greater behavioral inhibition (β = 0.28, p < .001)
  • Poor predictive validity of growing up with a mentally ill family member (β = -0.12, p < .05) and emotional neglect (β = -0.13, p < .05) at predicting less motivation to pursue one’s goals 
  • Poor predictive validity of emotional neglect (β = -0.12, p < .05) and witnessing domestic violence (β = -0.10, p < .05) at predicting reward responsiveness

Construct Validity

Convergent validity:

Adults with history of overdose: (Asheh et al., 2023)

  • Adequate convergent validity between higher ACE scores and having a reported OD (B = 0.20, adjusted odds ratio = 1.23 (1.00 – 1.50), p = 0.045)

 

Women seeking substance use disorder treatment: (Cockroft et al., 2020)

  • Poor negative convergent validity between ACE scores and scores on the Rotter Interpersonal Trust Scale (r = -0.14, p = 0.019)

     

Nursing students reporting burnout and depression: (McKee-Lopez et al., 2019)

  • Significant positive association of ACE scores with Maslach's Burnout Inventory (MBI) subscale “Burnout A” (a measure of emotional exhaustion) (p?<?0.001)
    • There was a strong gender effect (p < 0.05), with females having higher ACE scores more likely to report higher Burnout A compared to males.

  • Significant positive association of ACE scores with depression on the Patient Health Questionnaire (PHQ-9) (p?<?0.01)

     

Treatment-seeking veterans of the Canadian Armed Forces: (Plouffe et al., 2023, n = 166)

  • Poor convergent validity with other scales:
    • Mortal Injury Event Scale (r = 0.14)
    • PTSD (r = 0.06)
    • Anxiety (r = 0.14)
    • Depression (r = 0.14)
    • Death/suicide ideation (r = 0.15)
    • Combat experience (r = -0.01)
    • Anger (r = 0.13)

 

Discriminant validity:

Adults: (Meehan et al., 2022)

  • Adequate discriminate validity of overall ACE scores in identifying specified health outcomes:
    • Suicide attempt (AUC = 0.76)
    • Drug injection (AUC = 0.74)
  • Poor discriminate validity of overall ACE scores in identifying specified health outcomes:
    • Alcoholism (AUC = 0.68)
    • Depressed mood ≥ 2 weeks (AUC = 0.65)
    • Chronic bronchitis/emphysema (AUC = 0.60)
    • Current smoker (AUC = 0.59)
    • Severe obesity (AUC = 0.58)
    • Illicit drug use (AUC = 0.67)
    • No leisure-time physical activity (AUC = 0.54)
    • Any health risk factor (AUC = 0.63)
    • Hepatitis/jaundice (AUC = 0.57)
    • Poor/fair self-rated health (AUC = 0.55)
    • Ischemic heart disease (AUC = 0.52)
    • Skeletal fracture (AUC = 0.52)
    • Stroke (AUC = 0.51)
    • Diabetes (AUC = 0.51)
    • Cancer (AUC = 0.50)

 

Women who experienced betrayal trauma: (Vogeler et al., 2020)

  • Excellent discriminate validity of ACE-Total scores with Trauma Index for Partners of Sex Addicts (TIPSA) (r = 0.244)
  • Adequate discriminant validity of ACE-Total scores with PTSD Checklist for DSM-5 (PCL-5) (r = 0.308)

Responsiveness

ACEs and Self-esteem: (Babad et al., 2022)

  • Moderate negative changes for emotional abuse (β = -0.20, p < 0.01), emotional neglect (β = -0.21, p < 0.001), and having a substance using family member (β = -0.12, p < 0.05)
  • No significant changes for cumulative ACEs (β = -0.03, p > 0.05)

 

ACEs and Loneliness: (Babad et al., 2022)

  • Small positive changes for emotional neglect (β = 0.16, p < 0.01)
  • Moderate positive changes for cumulative ACEs (β = 0.29, p < 0.01)

 

ACEs and Negotiation in Intimate Partner Relationship: (Babad et al., 2022)

  • Small positive changes for family member in prison (β = 0.12, p < 0.05)

Pediatric Disorders

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Standard Error of Measurement (SEM)

Justice involved youth: (Bergquist, 2024; n = 519; mean age = 15.12 (1.37) years, age range = 10-18 years; male = 433 (83.3%))

  • SEM (calculated) for entire group (n = 519): 1.27

Minimal Detectable Change (MDC)

Justice involved youth: (Bergquist, 2024)

  • MDC (calculated) for entire group (n = 519): 3.52

Normative Data

Adolescents in residential treatment program: (Schauss et al., 2021; n = 20; age 11-14: 40%, 15-17: 60%; substance use history = 70%, no substance use history = 30%; justice involvement history = 50%, no justice involvement history = 50%)

  • Mean ACE score = 4.6 (2.78)

 

Youth: (Kova?cs-To?th et al., 2023; n = 792; mean age = 14.98 (1.19) years; Hungarian sample)

 

ACE characteristics of the total sample (n = 792)

ACE score

n (%)

0

418 (52.77)

1

172 (21.71)

2

88 (11.11)

3

37 (4.67)

≥4

49 (6.18)

ACE categories

Exposure n (%) 

Emotional abuse

106 (13.38)

Physical abuse

54 (6.81)

Sexual abuse

29 (3.66)

Emotional neglect

108 (13.63)

Physical neglect

22 (2.77)

Parental separation/divorce

196 (24.74)

Household physical violence

28 (3.53)

Household substance abuse

66 (8.33)

Household mental illness

61 (7.70)

Incarcerated household member

41 (5.17)

 

 

Justice-Involved Youth: (Bergquist et al., 2024; n = 519)

  • Mean ACE score = 3.49 (2.06)

Test/Retest Reliability

Adolescents in Residential Treatment Program (Schauss et al., 2021)

  • Excellent test-retest reliability (r = 0.913)

Internal Consistency

Youth: (Kova?cs-To?th et al., 2023)

  • Adequate: Cronbach’s alpha = 0.64
  • Excellent: theta reliability coefficient based on component analysis = 0.86

Criterion Validity (Predictive/Concurrent)

Predictive validity:

Justice Involved Youth: (Bergquist et al., 2022)

  • A greater accumulation of ACEs was a significant predictor of higher offense history scores (β = 0.10, p = 0.03) and greater psychopathology symptoms (β = 0.11, p = 0.03)

 

Concurrent validity:

Youth: (Kova?cs-To?th et al., 2023; subsample n = 677; mean age = 14.95 (1.76) years, Hungarian sample)

  • Higher ACE scores were significantly associated with more social, emotional, and behavioral symptoms (as measured by Strengths and Difficulties Questionnaire) (p < 0.001)
    • Compared to reporting no ACEs, reporting two, three, and four or more ACEs was significantly associated with more difficulties (p < 0.001)
  • ACE accumulation significantly predicted several times higher odds for experiencing each subjective health complaint (including headache, stomachache, backache, and feeling low as measured by the Hungarian Questionnaire of the Health Behaviors in School-Aged Children) 

Construct Validity

Convergent validity:

Justice Involved Youth: (Bergquist et al., 2022)

  • Poor negative convergent validity between ACEs and protective variables (all p < 0.01): future aspirations (r = -0.25), positive self-concept (r = -0.27), empathy (r = -0.21), prosocial peers (r = -0.24), encouraging school environment (r = -0.25), and prosocial community (r = -0.16)
  • Adequate negative convergent validity between ACEs and protective variables (all p < 0.01): emotional insight (r = -0.30), family support network (r = -0.32), family involvement (r = -0.37)
  • Poor convergent validity between ACEs and offense history (r = 0.19, p < 0.01)
  • Poor convergent validity between ACEs and psychopathology (r = 0.23, p < 0.01) and ACEs and gender (r = 0.19, p < 0.01)
  • Significant changes of offense history negatively associated with ACE scores (p < 0.05 for steps 2 and 3)
  • Significant changes of psychopathology positively associated with ACE scores (p < 0.05 for steps 2 and 3)
  • The internal protective factor of positive self-concept significantly interacted with ACEs to negatively associate with offense history (β = -0.17, p = 0.001)
    • The effect of ACEs on offense history was moderated by positive self-concept: it was insignificant when positive self-concept was 1 standard deviation below the mean (β = -0.08, p = 0.36), but was significant when positive self-concept was 1 standard deviation above the mean (β = 0.34, p < 0.001)
  • The internal protective factor of positive emotional insight significantly interacted with ACEs to positively associate with psychopathology symptoms (β = 0.13, p = 0.004)
    • The effect of ACEs on psychopathology symptoms  was moderated by emotional insight: it was significant when positive emotional insight was 1 standard deviation below the mean (β = 0.25, p < 0.001), but was insignificant when emotional insight  was 1 standard deviation above the mean (β = -0.03, p = 0.52)
  • Significant changes of psychopathology positively associated with ACEs and emotional insight internal protective factor interactions (p < 0.01)

Mixed Populations

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Normative Data

Non-institutionalized (NI) adults: (Ford et al. 2014; n = 85,248 (27,545 NI adult respondents surveyed for the 2009 Behavioral Risk Factor Surveillance System (BRFSS) with mean age = 47.1 (0.18) and 57,703 surveyed for the 2010 BRFSS with mean age = 47.5 (0.18); age range = 18-98 for both samples)

 

Descriptive statistics for the composite scores of the 2010 BRFSS ACE Module

Scale

# Items

Mean

Std. Dev.

Household dysfunction

5

0.77

1.12

Emotional/physical abuse

3

0.67

0.94

Sexual abuse

3

0.21

0.64

Overall ACE

11

1.61

2.07

 

Internal Consistency

Non-Institutionalized Adults: (Ford et al. 2014, 2010 BRFSS ACE data)

  • Poor: Cronbach’s alpha for household dysfunction subscale = 0.61
  • Adequate: Cronbach’s alpha for emotional/physical abuse subscale = 0.70
  • Excellent: Cronbach’s alpha for sexual abuse subscale = 0.80
  • Adequate: Cronbach’s alpha for the overall ACE scale = 0.78

Construct Validity

Convergent validity:

Non-institutionalized Adults: (Ford et al. 2014, 2009 BRFSS ACE data)

  • Confirmatory factor analysis specified a 3-factor model with factor loadings > 0.40 for all items in each factor:
    • Household dysfunction (5 items, factor loadings = 0.41-0.86)
    • Emotional/physical abuse (3 items, factor loadings = 0.57-0.93)
    • Sexual abuse (3 items, factor loadings = 0.85-0.97)

Bibliography

Asheh AM, Courchesne-Krak N, Kepner W, Marienfeld C. (2023, May-Jun). Adverse childhood experiences are associated with history of overdose among patients presenting for outpatient addiction care. J Addict Med., 17(3):333-338. doi: 10.1097/ADM.0000000000001126. Epub 2023 Jan 17. PMID: 37267182; PMCID: PMC10241414

Babad, S., Zwilling, A., Carson, K. W., Fairchild, V., Razak, S., Robinson, G., & Nikulina, V. (2021). Risk-taking propensity and sensation seeking in survivors of adverse childhood experiences. Journal of Interpersonal Violence, 36(19–20). https://doi.org/10.1177/0886260519876035 

Babad, S., Zwilling, A., Carson, K. W., Fairchild, V., & Nikulina, V. (2022). Childhood environmental instability and social-emotional outcomes in emerging adults. Journal of Interpersonal Violence, 37(7-8), 1-27. https://doi.org/10.1177/0886260520948147

Bergquist, B., Schmidt, A., & Thomas, A. (2024). Adverse childhood experiences and negative outcomes among justice-involved youth: Moderating effects of protective factors. Crime & Delinquency, 70(4), 1274-1303. https://doi.org/10.1177/00111287221122756

Cockroft JD, Adams SM, Matlock D, Dietrich MS. (2020). Reliability and construct validity of 3 psychometric trust scales for women seeking substance abuse treatment in a community setting. Substance Abuse. 2020;41(3):391-399. doi:10.1080/08897077.2019.1635967

Ford, D. C., Merrick, M. T., Parks, S. E., Breiding, M. J., Gilbert, L. K., Edwards, V. J., ... & Thompson, W. W. (2014). Examination of the factorial structure of adverse childhood experiences and recommendations for three subscale scores. Psychology of Violence, 4(4), 432. https://pubmed.ncbi.nlm.nih.gov/26430532/

Kova?cs-To?th B, Ola?h B, Kurita?rne? Szabo? I and Fekete (2023). Psychometric properties of the Adverse Childhood Experiences Questionnaire 10 item version (ACE-10) among Hungarian adolescents. Front. Psychol. 14:1161620.

McKee-Lopez, G., Robbins, L., Provencio-Vasquez, E., & Olvera, H. (2019). The relationship of childhood adversity on burnout and depression among BSN students. Journal of Professional Nursing35, 112–119.&苍产蝉辫;

Meehan, A. J., Baldwin, J. R., Lewis, S. J., MacLeod, J. G., & Danese, A. (2022). Poor individual risk classification from adverse childhood experiences screening. American Journal of Preventive Medicine, 62(3), 427–432. https://doi.org/10.1016/j.amepre.2021.08.008 

Plouffe, R. A., Easterbrook, B., Liu, A., McKinnon, M. C., Richardson, J. D., & Nazarov, A. (2023). Psychometric evaluation of the moral injury events scale in two Canadian armed forces samples. Assessment, 30(1), 111-123. https://pubmed.ncbi.nlm.nih.gov/34515535/ 

Schauss, E., Zettler, H., Patel, M., Hawes, K., Dixon, P., Bartelli, D., ... & West, S. (2021). Exploring the test-retest differences of self-reported adverse childhood experiences among adolescents in residential treatment. Journal of Family Trauma, Child Custody & Child Development, 18(3), 263-278

Vogeler, H. A., Fischer, L., Bingham, J. L., Hansen, K. S., Heath, M. A., Jackson, A. P., & Skinner, K. B. (2020). Assessing the validity of the trauma inventory for partners of sex addicts (TIPSA). Sexual Addiction & Compulsivity, 27(1-2), 90-111. https://doi.org/10.1080/10720162.2020.1772158

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