Research Article| Volume 49, ISSUE 3, P354-361, September 2015

Adverse Childhood Experiences

Expanding the Concept of Adversity


      Current knowledge of Adverse Childhood Experiences (ACEs) relies on data predominantly collected from white, middle- / upper-middle-class participants and focuses on experiences within the home. Using a more socioeconomically and racially diverse urban population, Conventional and Expanded (community-level) ACEs were measured to help understand whether Conventional ACEs alone can sufficiently measure adversity, particularly among various subgroups.


      Participants from a previous large, representative, community-based health survey in Southeast Pennsylvania who were aged ≥18 years were contacted between November 2012 and January 2013 to complete another phone survey measuring ACEs. Ordinal logistic regression models were used to test associations between Conventional and Expanded ACEs scores and demographic characteristics. Analysis was conducted in 2013 and 2014.


      Of 1,784 respondents, 72.9% had at least one Conventional ACE, 63.4% at least one Expanded ACE, and 49.3% experienced both. A total of 13.9% experienced only Expanded ACEs and would have gone unrecognized if only Conventional ACEs were assessed. Certain demographic characteristics were associated with higher risk for Conventional ACEs but were not predictive of Expanded ACEs, and vice versa. Few adversities were associated with both Conventional and Expanded ACEs.


      To more accurately represent the level of adversity experienced across various sociodemographic groups, these data support extending the Conventional ACEs measure.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Felitti V.J.
        • Anda R.F.
        • Nordenberg D.
        • et al.
        Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACEs) Study.
        Am J Prev Med. 1998; 14: 245-258
      1. CDC. Adverse Childhood Experiences (ACEs) Study—major findings. Accessed May 2, 2014.

        • Hillis S.D.
        • Anda R.F.
        • Felitti V.J.
        • Marchbanks P.A.
        Adverse childhood experiences and sexual risk behaviors in women: a retrospective cohort study.
        Fam Plann Perspect. 2001; 33: 206-211
        • Anda R.F.
        • Whitfield C.L.
        • Felitti V.J.
        • et al.
        Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression.
        Psychiatr Serv. 2002; 53: 1001-1009
        • Dong M.
        • Giles W.H.
        • Felitti V.J.
        • et al.
        Insights into causal pathways for ischemic heart disease: adverse childhood experiences study.
        Circulation. 2004; 110: 1761-1766
        • Anda R.F.
        • Brown D.W.
        • Dube S.R.
        • Bremner J.D.
        • Felitti V.J.
        • Giles W.H.
        Adverse childhood experiences and chronic obstructive pulmonary disease in adults.
        Am J Prev Med. 2008; 34: 396-403
        • Brown D.
        • Anda R.
        • Felitti V.
        • et al.
        Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study.
        BMC Public Health. 2010; 10: 20
        • O’Connor C.
        • Finkbiner C.
        • Watson L.
        Adverse Childhood Experiences in Wisconsin: Findings From the 2010 Behavioral Risk Factor Survey.
        Wisconsin Children’s Trust Fund and Child Abuse Prevention Fund of Children’s Hospital & Health System, Madison, WI2012
        • Anda R.
        • Brown D.
        Adverse childhood Experiences & Population Health in Washington: The Face of a Chronic Public Health Disaster.
        State Family Policy Council, Olympia, WA2010
        • Austin A.E.
        • Herrick H.
        The Effect of Adverse Childhood Experiences on Adult Health: 2012 North Carolina Behavioral Risk Factor Surveillance System Survey.
        State of North Carolina’s Department of Health and Human Services, Division of Public Health’s State Center for health Statistics, Raleigh, NC2014
      2. Adverse Childhood Experiences in Iowa: a new way of understanding lifelong health—findings from the 2012 Behavioral Risk Factor Surveillance System. Central Iowa ACEs 360 Steering Committee.

      3. U.S. Census Bureau. State & County QuickFacts. Accessed November 11, 2014.

      4. CDC. Behavioral Risk Factor Surveillance System—prevalence and trends data: all states—2013. Accessed November 11, 2014.

        • Smedley B.D.
        • Stith A.Y.
        • Nelson A.R.
        Institute of Medicine (U.S.). Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care.
        Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press, Washington, DC2003
        • Wade Jr, R.
        • Shea J.A.
        • Rubin D.
        • Wood J.
        Adverse childhood experiences of low-income urban youth.
        Pediatrics. 2014; 134: e13-e20
      5. Pachter LM, Bahora Y, Witherspoon M, Davis M, Smith-Brown C, Bernstein BA. Adverse childhood experiences (ACEs) in an urban Latino community: a qualitative study. Paper presented at the 2014 Pediatric Academic Societies Meeting; Vancouver, BC.

        • Finkelhor D.
        • Shattuck A.
        • Turner H.
        • Hamby S.
        Improving the adverse childhood experiences study scale.
        JAMA Pediatr. 2013; 167: 70-75
      6. UCLA Center for Health Policy Research. CHIS Questionnaires. Accessed June 10, 2014.

      7. World Health Organization. Adverse Childhood Experiences International Questionnaire (ACEs-IQ). Accessed June 10, 2014.

      8. Office of Juvenile Justice and Delinquency Prevention. Accessed June 10, 2014.

      9. CDC. Injury prevention & control: Adverse Childhood Experiences (ACEs) Study—family health history and health appraisal questionnaires. Accessed June 10, 2014.

        • Pachter L.M.
        • Szalacha L.A.
        • Bernstein B.A.
        • Coll C.G.
        Perceptions of Racism in Children and Youth (PRaCY): properties of a self-report instrument for research on children’s health and development.
        Ethn Health. 2010; 15: 33-46
      10. U.S. Census Bureau. Philadelphia Region. Accessed June 10, 2014.

        • American Association for Public Opinion Research (AAPOR)
        Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Survey.
        4th ed. AAPOR, Lenexa, KS2006
        • Cabrera N.J.
        • The SRCD Ethnic and Racial Issues Committee
        Social policy report: positive development of minority children.
        Sharing Child Youth Dev Knowledge. 2013; 27: 1-30
        • Winslow E.B.
        • Shaw D.S.
        Impact of neighborhood disadvantage on overt behavior problems during early childhood.
        Aggress Behav. 2007; 33: 207-219
        • Heberle A.E.
        • Thomas Y.M.
        • Wagmiller R.L.
        • Briggs-Gowan M.J.
        • Carter A.S.
        The impact of neighborhood, family, and individual risk factors on toddlers’ disruptive behavior.
        Child Dev. 2014; 85: 2046-2061
        • DuMont K.A.
        • Widom C.S.
        • Czaja S.J.
        Predictors of resilience in abused and neglected children grown-up: the role of individual and neighborhood characteristics.
        Child Abuse Neglect. 2007; 31: 255-274
        • Kohen D.E.
        • Leventhal T.
        • Dahinten V.S.
        • McIntosh C.N.
        Neighborhood disadvantage: pathways of effects for young children.
        Child Dev. 2008; 79: 156-169
        • Odgers C.L.
        • Jaffee S.R.
        Routine versus catastrophic influences on the developing child.
        Annu Rev Public Health. 2013; 34: 29-48
        • Wright E.M.
        • Fagan A.A.
        • Pinchevsky G.M.
        The effects of exposure to violence and victimization across life domains on adolescent substance use.
        Child Abuse Neglect. 2013; 37: 899-909
        • Wilson H.W.
        • Pettineo L.
        • Edmonds A.
        • Goodman E.A.
        • Emerson E.
        • Donenberg G.R.
        From violence exposure to development of sexual risk in low-income urban girls: the role of psychopathology.
        Child Psychiatry Hum Dev. 2014;
        • Pachter L.M.
        • Coll C.G.
        Racism and child health: a review of the literature and future directions.
        J Dev Behav Pediatr. 2009; 30: 255-263
        • Kumar M.
        • Fonagy P.
        Differential effects of exposure to social violence and natural disaster on children’s mental health.
        J Trauma Stress. 2013; 26: 695-702
        • McEwen B.S.
        Protective and damaging effects of stress mediators.
        N Engl J Med. 1998; 338: 171-179
        • Gustafsson P.E.
        • San Sebastian M.
        • Janlert U.
        • Theorell T.
        • Westerlund H.
        • Hammarstrom A.
        Life-course accumulation of neighborhood disadvantage and allostatic load: empirical integration of three social determinants of health frameworks.
        Am J Public Health. 2014; 104: 904-910
        • Kawachi I.
        • Berkman L.F.
        Neighborhoods and Health.
        Oxford University Press, Oxford2003
        • Nandi A.
        • Sweet E.
        • Kawachi I.
        • Heymann J.
        • Galea S.
        Associations between macrolevel economic factors and weight distributions in low- and middle-income countries: a multilevel analysis of 200,000 adults in 40 countries.
        Am J Public Health. 2014; 104: e162-e171
        • Hicken M.T.
        • Lee H.
        • Morenoff J.
        • House J.S.
        • Williams D.R.
        Racial/ethnic disparities in hypertension prevalence: reconsidering the role of chronic stress.
        Am J Public Health. 2014; 104: 117-123
        • Williams D.R.
        • Neighbors H.W.
        • Jackson J.S.
        Racial/ethnic discrimination and health: findings from community studies.
        Am J Public Health. 2003; 93: 200-208
        • Hunte H.E.
        • Barry A.E.
        Perceived discrimination and DSM-IV-based alcohol and illicit drug use disorders.
        Am J Public Health. 2012; 102: e111-e117
        • Ko S.J.
        • Ford J.D.
        • Kassam-Adams N.
        • et al.
        Creating trauma-informed systems: child welfare, education, first responders, health care, juvenile justice.
        Prof Psychol Res Pract. 2008; 39: 396-404
        • Krieger N.
        Methods for the scientific study of discrimination and health: an ecosocial approach.
        Am J Public Health. 2012; 102: 936-944