Adverse Childhood Experiences (ACEs)

Adverse Childhood Experiences or ACEs are categorized as abuse, neglect, and household challenges experienced during childhood.

These include:

  • Emotional, physical, and sexual abuse;
  • Emotional and physical neglect; and
  • Household challenges that include exposure to domestic violence, a family member with household substance abuse, a family member with mental illness, an incarcerated household member, or parental separation or divorce.
Three Types of ACEs

Screening for ACEs with evidence-based tools helps clinical teams move toward prevention and also identify individuals at high risk who may benefit from additional assessment and interventions. On a population level, the higher the ACEs score, the greater the likelihood of poor health outcomes or high-risk behavior as an adult. ACEs scores do not predict individual outcomes, but screening provides the opportunity to intervene earlier to foster resiliency.

Positive Childhood Experiences (PCEs) are protective factors and can mitigate the adverse effect of ACEs . A critically important component of screening includes promoting resiliency through conversations with youth and caregivers in identifying PCEs and referrals to resources that foster resiliency. Safe, stable, and nurturing relationships build resiliency. Understanding the context and lived experiences of patients and their families is an important step toward providing trauma-informed care.

"Understanding Adverse Childhood Experiences (ACEs)" was published by NYS and has been translated into multiple languages. Also available is the ACEs webpage, which can be found here.

The original ACE study by Dr. Vincent Felitti and others in 1998 was the first epidemiologic study of adults to demonstrate that reported exposures to childhood abuse, neglect, and family dysfunction are common, and highly interrelated. They also noted that the effects of the ACEs were cumulative. See graph with examples of higher ACE scores associated with greater prevalence of poor health outcomes or high-risk behavior as an adult.

Dose Response - Exposure to Abuse/Household Dysfunction in Childhood and Risk for Leading Causes Death in Adults - Felitti et al, 1998

Adverse Childhood Experiences (ACEs) can have significant long-term impacts on both physical and behavioral health as adults. Adults with a history of ACEs are at increased risk for a wide range of chronic conditions and behavioral health challenges including:

  • heart disease,
  • diabetes,
  • and other long term chronic health conditions.
  • depression, anxiety,
  • substance use disorders,
  • and difficulties in maintaining healthy relationships.
  • Adults who have experienced multiple ACEs are more likely to smoke, and have excessive alcohol use.

Additionally, ACEs are strongly correlated with reduced socioeconomic stability, as they can contribute to challenges in education and employment over time. Understanding these risk factors is crucial for providers, enabling them to offer trauma-informed care that addresses both physical and behavioral health needs.

ACEs Increase Health Risks

NYS Department of Health Commissioner highlights the Medicaid benefit for Adverse Childhood Experiences screening in primary care practices - (Web) - (PDF) - 2.5.2025

Basics of Trauma-Informed Care and ACEs Screening:

ACEs screening should ideally take place in the context of trauma-informed care to ensure a safe, empowering environment for the child and family. Trauma-informed care is an approach that health care teams take to acknowledge a patient's life situation, both past and present. ACEs screening enables the team to be responsive to the adverse experiences of a child, be increasingly aware of the signs and symptoms of trauma, and actively avoid re-traumatization. The enhanced relationship between the health care team, patients and their families are guided by a set of core principles in a trauma-informed approach that includes: Safety; Trustworthiness and Transparency; Peer Support; Collaboration; Empowerment; and Humility and Responsiveness. To learn more visit: Trauma-Informed Care Implementation Resource Center by the Center Health Care Strategies site. Screening for ACEs is always voluntary and identifying individual ACEs is not required. Parents/caregivers should complete the ACEs screening on behalf of children who are unable to complete it on their own.

Toolkits

  • Toolkit from Coordinated Care Services, Inc. - Trauma-Informed Organizations Implementation Roadmap, 2023.
  • Toolkit from ACEs Aware and Center for Health Care Strategies - Integrating Adverse Childhood Experiences Screening into Clinical Practice: Insights from California Providers, March 2022

Resiliency Building and Provider Role in Anticipatory Guidance:

  • The most important protective factor for children to help them thrive is having at least one consistent, supportive relationship with a parent, caregiver or other adult.
  • Safe, stable and nurturing relationships are the building blocks of positive childhood experiences and contribute to the skills needed for children to thrive and flourish, and offset the potential health harms of childhood adversity.
  • Involving caregivers, including those who may be struggling, is a critical part of the solution and can be an empowering experience. There is no benefit to blame or shame.
  • Building resilience buffers against exposures to stress and trauma.
  • Other Positive Childhood Experiences that predict support of children's lifelong health include:
    • Feeling safe talking about their feelings,
    • Having a sense of belonging at school; and
    • Feeling supported when things are tough.

Protective Factors for Adults with ACEs and Provider Role: Screening for ACES can also help patients mitigate intergenerational transmission of trauma.

Research indicates that trauma experienced by one generation can influence the gene expression of subsequent generations through epigenetic mechanisms. For example, studies have shown that individuals affected by significant trauma display genetic changes that impact stress regulation and mental health. This phenomenon occurs because trauma can alter how genes are expressed without changing the underlying DNA, leading to increased vulnerability to conditions like post-traumatic stress disorder, anxiety, and depression in future generations. These findings highlight the importance of addressing trauma in healthcare settings, and educating patients about how to break cycles of adversity and promote healing.

By fostering protective factors, adults who have experienced ACEs can build resilience and improve their overall health and quality of life. Providers can play a crucial role by supporting these factors in their care plans and interventions. Some examples of protective factors for adults include:

  • Positive Personal Relationships: Forming and maintaining healthy, trusting relationships in adulthood (family, romantic partners, mentors, close friends) can counterbalance the negative effects of early-life adversity. These relationships can promote self-esteem, emotional regulation, and social support.
  • Stable and Safe Living Environment: Adults who live in stable, and safe environments have a better chance of recovering from the effects of ACEs. Housing stability, financial security, and a sense of safety can prevent further stress and provide a foundation for recovery.
  • Education and Employment Opportunities: Access to education, job training, and stable employment improves self-efficacy, provides individuals with a sense of purpose and economic stability, and may reduce stressors associated with ACEs.
  • Healthy Coping Mechanisms: Engaging in regular physical activity, mindfulness practices, or other stress-management techniques (e.g., meditation or getting out in nature) can help adults manage the physiological and emotional effects of ACEs. Building positive coping mechanisms supports overall well-being and reduces reliance on unhealthy behaviors like substance use.
  • Access to Mental Health Services: Adults with ACEs who receive mental health support such as therapy, counseling, or trauma-informed care are better equipped to process their past experiences and develop healthy coping strategies. Access to care is critical for addressing trauma, managing symptoms of depression or anxiety, and preventing further emotional or behavioral challenges.
  • Access to Healthcare: Regular healthcare access, especially to primary care providers who understand the long-term effects of ACEs, is a crucial protective factor. Early identification and treatment of ACE-related conditions, whether physical or mental, can prevent chronic issues from worsening.

NYS Medicaid is expanding previously issued coverage for Adverse Childhood Experiences (ACEs) screening conducted in primary care settings for children and adolescents up to 21 years of age. This expansion includes adults, 21 years of age to 65 years of age. For adults, 21 years of age to 65 years of age, the screening is limited to once per lifetime. Please note: An annual ACEs screening will continue to be covered for children and adolescents up to 21 years of age, as determined appropriate and medically necessary.

Medicaid Update Article: New York State Medicaid Update - September Volume 40 - Number 10

Project TEACH Referral Resources:

  • Project TEACH is a statewide program that supports reproductive, primary care, and pediatric clinicians to deliver quality mental health care in NYS.
  • Project TEACH services are available at no cost.
  • The program strives to strengthen and support the delivery of care to children, families, and individuals who experience mental health concerns.
  • Education, resources, and primary care provider consultations with child, adolescent, and maternal psychiatrists are available.
  • For consultations with a child, adolescent, or perinatal psychiatrist, contact (855) 227-7272.
  • Visit the Project TEACH website.
  • Websites and Articles:

ACEs Screening Tool Examples

Use of a research-based tool is required when screening for ACEs to be eligible for NYS Medicaid reimbursement. Health care practices should adopt the tool that meets the needs of their population and clinical workflow. Examples of recommended screening tools include:

References:

  1. Screening for Adverse Childhood Experiences and Trauma document
  2. ACEs Aware "Screening Tools" web page
  3. CDC Adverse Childhood Experiences
  4. ACES Aware
  5. Minnesota State ACES Protective Factors

Additional Resources