Inside the ACE Score Strengths Limitations and Misapplications with Dr. Robert Anda

Dr. Robert Anda, Co-Principal Investigator and designer of the ACE Study, explains strengths and limitations of the ACE Score. He explains why the growing popular movement to use the ACE Score for screening patients, assigning risk, and making clinical decisions for individual patients is a misapplication of the ACE Study findings. 

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Why is the Adverse Childhood Experiences Study (ACEs Study) and building resilience important for communities?

In our neighborhoods, schools, grocery stores, and playgrounds, communities all matter in addressing Adverse Childhood Experiences (ACEs) and supporting individual and family resilience. Each person’s life history impacts who they are, how they develop relationships, and how they respond to opportunities. Follow the Roadmap to Resilience to see how communities are working to educate their neighbors and change attitudes!

What is the ACE Study?

In the Adverse Childhood Experiences study, the Kaiser-Permanente (KP) Health Maintenance Organization (HMO) and the US Centers for Disease Control and Prevention (CDCP) collaborated in surveying over 17,000 HMO members about their experience with a variety of adversities as 0-18 year olds, and their subsequent health histories. They found a strong relationship between the quantity of categories of adversities experienced (physical abuse, emotional abuse, sexual abuse, physical and emotional neglect and experience of parental domestic violence, substance abuse, incarceration, mental illness, and separation/ bereavement) and the risk of a variety of negative behavior and health outcomes. These included, “the leading causes of morbidity, mortality and disability in the USA: cardiovascular disease, chronic lung disease, chronic liver disease, depression and other forms of mental illness, obesity, smoking and alcohol and drug abuse.”

Initially eight and then ten categories of adversity were included in the study because of their high prevalence in the KP weight reduction program: five directed toward children (physical abuse, emotional abuse, sexual abuse, and, later, physical neglect, emotional neglect) and five household issues (domestic violence to mother, separation, substance abuse, incarceration, significant psychiatric illness). Although other risk factors such as poverty, political and cultural trauma, etc. also affect illness and wellness, they were not analyzed in the ACE Study of KP members.The number of adversity categories experienced in childhood significantly predicted negative health and behavior outcomes, but it did not appear to matter much which categories were involved. The number of experiences within categories was not counted.

What do communities have to do with ACEs?

Communities work together to develop a shared agenda to learn more about Adverse Childhood Experiences (ACEs) and how to build more resilience. When communities join the forces from the worlds of education, medicine, business, public safety, mental health, clergy and more, adversity and resilience can be helped at many levels. Working together means sharing resources, collaborating for funding, participating in the same training, and developing a shared vision for their community.

How Can Communities Help?

An example of community work related to Adverse Childhood Experiences (ACEs) could include networks of service providers, community members, clergy, law enforcement, and parent and public school educators collaborating to host a local conference with training sessions and a session to develop response plans.

Collaborative trainings can result in changes in attitudes and learning new ways to approach working with “at risk” families, students and individuals. A strength-based, or resilience-based approach looks for the ways that people and families have survived and even thrived, despite difficult circumstances. When communities work together to think about their neighbors in new resilience-based ways, new, healthier relationships are formed. Please contact the Maine Resilience Building Network  at for training information or questions.

What does community collaboration look like?

The Children’s Resilience Initiative in Washington State is an example of a community-based effort. Their website, “Resilience Trumps ACEs” is one place to visit to understand how to approach Adverse Childhood Experiences (ACEs) at the community level. Please contact the Maine Resilience Building Network  at for training information or questions.

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