How High ACE Scores Can Impact Adult Health

Vincent Felitti, MD

Updated: 27 November 2017

Adverse Childhood Experiences (ACEs) can turn “gold into lead,” maintains Vincent Felitti, MD. Adverse experiences include emotional abuse, neglect, sexual abuse, physical abuse, having a caregiver who has a drinking problem, takes drugs, is depressed, or has a mental illness. Experiencing parental divorce, having a parent incarcerated, or being permanently separated from one or both parents are also adverse experiences for a child – ones that can include violence and much heartache.

Dr Felitti found that the higher an ACE score, the greater the negative impact on adult health – even fifty years later. These findings were the result of a large-scale study from 1995 to 1997 involving 17,421 people – mostly white, middle class, middle aged, well educated and financially secure. The study (known as the ACE study) was a collaboration between Vincent Felitti, MD, chief of Kaiser Permanente’s Department of Preventative Medicine in San Diego and Robert Anda, MD, from the Centers for Disease Control and Prevention (CDC).

The study came into being from a question that set off a ripple effect. Why did a woman who had lost 276 pounds in Felitti’s weight loss program suddenly start piling on weight again? The woman revealed that when her newly trim body attracted unwanted sexual attention she went home and started stuffing herself with food. Shocked by this extreme reaction, Felitti began probing to find its underlying cause, which turned out to be a lengthy history of incest with her grandfather. As another woman in the weight loss program stated, “Overweight is overlooked.”

Ten days later, when Felitti heard a similar story, he and his team took a closer look at their patients’ histories. Their shocking discovery was that most of their morbidly obese patients had been sexually abused as children. Not only that, but they also uncovered a host of other family problems. And this finally led to the ACE Study.

Felitti and Anda devised the following ten categories for the study to ascertain a person’s ACE score. Answering “yes” to one of the questions in a category equals one point.

Find your ACE score out of ten.
  1. Before your 18th birthday, did a parent or other adult in the household often or very often…swear at you, insult you, put you down, or humiliate you?oract in a way that made you afraid that you might be physically hurt?
  2. Before your 18th birthday, did a parent or other adult in the household often or very often…push, grab, slap, or throw something at you?orever hit you so hard that you had marks or were injured?
  3. Before your 18th birthday, did an adult or person at least five years older than you ever…touch or fondle you or have you touch their body in a sexual way?orattempt or actually have oral, anal, or vaginal intercourse with you?
  4. Before your eighteenth birthday, did you often or very often feel that…no one in your family loved you or thought you were important or special?oryour family didn’t look out for each other, feel close to each other, or support each other?
  5. Before your 18th birthday, did you often or very often feel that…you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?oryour parents were too drunk or high to take care of you or take you to the doctor if you needed it?
  6. Before your 18th birthday, was a biological parent ever lost to you through divorce, abandonment, or other reason?
  7. Before your 18th birthday, was your mother or stepmother:often or very often pushed, grabbed, slapped, or had something thrown at her?orsometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard?orever repeatedly hit over at least a few minutes or threatened with a gun or knife?
  8. Before your 18th birthday, did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
  9. Before your 18th birthday, was a household member depressed or mentally ill, or did a household member attempt suicide?
  10. Before your 18th birthday, did a household member go to prison?


Only one-third in this study reported no adverse childhood experiences. Of the two-thirds of respondents who reported an adverse experience, 87 percent scored two or more. One in six of all respondents had an ACE score of four or higher.

These scores were then correlated with each participant’s health problems, revealing the urgency with which we need to act to create safe, respectful, and loving homes in which everyone can thrive.

  • More than half of those with ACE scores of 4 or higher reported having learning or behavioral problems at school.
  • High ACE scores correlated with high workplace absenteeism, financial problems, and lower lifetime income.
  • For those with an ACE score of 4 or more, depression was prevalent in 66 percent of women and 35 percent of men (compared with an overall rate of 12 percent with an ACE score of zero).
  • There is a 5,000 percent increased likelihood of suicide attempts from zero to an ACE score of 6.
  • Adults with an ACE score of 4 were seven times more likely to be an alcoholic.
  • With an ACE score of 6 or more, the likelihood of IV drug use was 4,600 percent greater than for those with a score of zero.
  • The prevalence of rape went from 5 percent with a ACE score of zero to 33 percent at a score of 4 or more.
  • High risk behaviors predicted by the ACE score included smoking, obesity, unintended pregnancies, multiple sexual partners, and STDs.
  • An ACE score of 6 or more produced a 15 percent or greater chance than those with a score of zero, of a person currently suffering from any of the leading causes of death in the United States: chronic obstructive pulmonary disease (COPD), ischemic heart disease, and liver disease. They were twice as likely to suffer from cancer, and 4 times as likely to have emphysema.

Source: pp. 148-149, Bessel van der Kolk, M.D. (2014) The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

Not included in this study are John Briere’s later findings (Auckland Seminar, 2009) that early emotional neglect and sexual abuse before the age of five, feature in the histories of people diagnosed with borderline personality disorder (BPD).

Neither does does the study include the findings that rape, sexual abuse, neglect, and physical abuse in childhood are risk factors for developing post-traumatic stress disorder (PTSD). In an article I wrote on PTSD a few years ago, I noted that:

Many studies now reveal that PTSD is a significant risk factor for domestic violence, child abuse, problems in interpersonal relationships, violent crimes, incarceration and problems with the judicial system, depression, other anxiety disorders, substance abuse/disorders, suicide, smoking, high risk behaviour, teenage pregnancies, eating disorders, obesity, diabetes, ischemic heart disease, cancer, lung disease, asthma, poor educational outcomes, unemployment, benefit dependency, and homelessness.

But the most shocking fact about developing PTSD is the possibility that it can be handed down from one generation to the next epigenetically. This means that the impact of one person’s trauma can become inter-generational – along with all the correlated negative health, social, interpersonal, and work outcomes.

Bessel van der Kolk, M.D. who wrote comprehensively about PTSD in his book The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, noted the following about his experience of the ACE study:

The first time I heard Robert Anda present the results of the ACE study, he could not hold back his tears. In his career at the CDC he had previously worked in several major risk areas, including tobacco research and cardiovascular death. But when the ACE study began to appear on his computer screen, he realized that they had stumbled upon the gravest and most costly public health issue in the United States: child abuse. He had calculated that its overall costs exceeded those of cancer or heart disease and that eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters. It would have a dramatic effect on workplace performance and vastly decrease the need for incarceration. (p. 150)

And now it is 2017 and nothing whatsoever has been done to address this urgent issue of reducing child abuse. It seems that we would prefer to bear the financial burden of ongoing child abuse than set in place preventative measures to reduce it.

Shirley Julich, who wrote her Ph.D. thesis on the price the government is paying for New Zealand’s high rate of sexual abuse (25 percent of girls and 9 percent of boys are sexually abused in some way by the time they reach 16), estimated the cost at $2.4 billion a year, taking into account the “cost of lost earnings, extra health bills and the unmet potential of adult survivors of childhood sexual abuse (Western Leader, 05 August 2002). However, this figure does not take into account the extra cost of incarceration and loss of income of those found guilty of sexually abusing children.

Perhaps the most horrifying loss caused by child abuse is what Vincent Felitti called turning “gold into lead.” This describes the extent to which each abused child loses their ability to realize their potential, and all the good feelings and rewards that come with this. After Buckinster Fuller’s death, Robert T. Kiyosaki recalled Bucky’s poignant words:

Look into the eyes of a newborn baby and you will see the spark and the soul of a genius.

Distraught over his death, Kiyosaki decided to find out what caused this genius to hide – both in himself and other people. His study took him all over the world to work with thousands of people. He wrote:

My findings were not pretty. I discovered that the genius born in every child is greatly diminished before the child even begins school. Sadly, our teachers hardly have a chance to restore and ignite the flame. (p. 316, If You Want to be Rich and Happy Don’t Go to School?)

What happens to destroy this “genius” or “turn gold into lead”? John Bradshaw maintained that this is the result of child abuse. More specifically, he said that child abuse creates toxic shame. And it is toxic shame that sends the genius within a child into hiding. Toxic shame is a belief that says, “I am bad,” “I am a mistake,” “I am a failure,” and “I can never do anything right.” Therefore, “I am not worthy of love.”

This is how the seed of self-hate is sown.

When this precious child grows up, he or she can often look for love in all the wrong places, become a caretaker in an unconscious effort to “fix” an abusive parent, or become an abuser and perpetuate this negative cycle of abuse.

But there is a ray of hope to revive this lost genius. During his study, Kiyosaki also tracked down people who were considered geniuses in their fields, people who not only pushed the known boundaries in their fields, but pushed themselves “beyond personal beliefs and paradigms.” He discovered that the secret to expressing their genius was this:

They used what they LOVED to solve the problems they HATED.

Each person was using his or her gift – that which came naturally to them – to solve problems that bothered them deeply or in some way totally captured their attention. (p. 317, If You Want to be Rich and Happy Don’t Go to School?)

Such a desire, I have personally found, acts as a powerful antidote to the poisonous toxicity of shame created by child abuse. Not only can it imbue one’s life with a sense of purpose, thus preventing a major fall into despair, depression, or suicidal thoughts, but it gives a sense of hope that one can leave the world a better place for having found their gift, and shared it. No matter what the odds.

This surely, then, is the Hero’s Journey, and a chance to find one’s Golden Fleece.

In the following informative TED talk, Nadine Burke Harris shares her experience as a practicing pediatrician after discovering the ACE Study, and why we are not acting on this most important and vital information.

Find out more about the ACE study.

Prevalence of ACEs by Category for CDC-Kaiser ACE Study Participants by Sex, Waves 1 and 2.

ACE Category Women Men Total
Percent (N = 9,367) Percent (N = 7,970) Percent (N = 17,337)
Emotional Abuse 13.1% 7.6% 10.6%
Physical Abuse 27% 29.9% 28.3%
Sexual Abuse 24.7% 16% 20.7%
Mother Treated Violently 13.7% 11.5% 12.7%
Household Substance Abuse 29.5% 23.8% 26.9%
Household Mental Illness 23.3% 14.8% 19.4%
Parental Separation or Divorce 24.5% 21.8% 23.3%
Incarcerated Household Member 5.2% 4.1% 4.7%
Emotional Neglect3 16.7% 12.4% 14.8%
Physical Neglect3 9.2% 10.7% 9.9%

Note: 3Collected during Wave 2 only (N=8,629). Research papers that use Wave 1 and/or Wave 2 data may contain slightly different prevalence estimates.


ACE Score Prevalence for CDC-Kaiser ACE Study Participants by Sex, Waves 1 and 2.

Number of Adverse Childhood Experiences (ACE Score) Women
Percent(N = 9,367)
Percent (N = 7,970)
Percent (N = 17,337)
0 34.5% 38.0% 36.1%
1 24.5% 27.9% 26.0%
2 15.5% 16.4% 15.9%
3 10.3% 8.5% 9.5%
4 or more 15.2% 9.2% 12.5%

Note: Research papers that use Wave 1 and/or Wave 2 data may contain slightly different prevalence estimates.

Source: Centers for Disease Control and Prevention, Kaiser Permanente. The ACE Study Survey Data [Unpublished Data]. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2016.

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