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ACE Awareness – Good, Bad, Both?

If you’re not familiar with the now somewhat famous ACE studies, what we are talking about here are studies that seemed to show that the more Adverse Childhood Experiences you had, the more likely it is that you will deal with bad outcomes in adulthood. The original studies got a lot of media attention, deservedly, but also because the numbers, as reported, made for really great headlines.

As subjects filled out the questionnaire, reporting on how many of the listed experiences they had, child abuse, domestic violence, mental illness in the house, death of a parent, incarceration of a parent, divorce, etc.

What they studies showed was that if your score was 4 or higher, the prevalence of bad outcomes went up exponentially.

Twice as many smokers, 4.5 times as many struggled with depression, seven times as likely to be alcoholic, ten times as likely to have injected illicit drugs, and over 12 times as likely to have attempted suicide.

Those numbers got the headlines. That’s actually fair. The numbers are shocking. But, as much as those numbers got attention, there have also been a few articles that critique the entire subject of ACEs.

So, who’s correct? I decided, the best way to get an answer for myself was to go look at the actual numbers from the original study. Sure enough, it’s clear the reports were accurate about the increases:
These numbers show us how, for each category, as you start with zero ACEs and go up to four or more, the percentage of people reporting these various “bad outcomes”, go up, some WAY up. This is exciting news. We can see a pattern of childhood trauma and stress creating health and well-being issues in adulthood. There are also charts that show increases in physical health issues. We’ve been seeking ways to lower the number of smokers, addicts, people with depression and anxiety, etc., and here we have a sign that childhood trauma prevention and early intervention and support for the adverse experiences we are unable to prevent could put quite a dent in the numbers of adults struggling with these things. For advocates of child abuse prevention, and early childhood treatment, this, and further studies that have confirmed the corollary, give us something to point out the need for these resources and programs and a way to measure the success of those programs.

This is, in my opinion, a fantastic thing. So, why the criticism?

Well, actually, again, in my opinion, that has less to do with the study than it does our inability to fully understand statistics and probability.

The increased risk is there. I don’t question that. But, it’s not the whole story. Let’s go take a closer look at the numbers around depression as an example:
Look at that increase, 4.6 times as many people who had 4 or more ACEs are possibly dealing with depression than those with zero. A full 50.7% of the people with 4 or more report struggling in this area.

Those were the headlines. What wasn’t in the headlines?

  • That 50.7% was only based on surveys of 542 people.
    • I’m actually willing to overlook this, because while that number may not be exact, we’ve seen similar increases in other studies, so yes, it’s a small sample size, but we haven’t seen anything that strongly contradicts the results since then. Only confirmation.
  • That 14.2% of people reporting zero ACE scores still appear to be struggling with depression.
    • This is where we’ve started to go wrong. ACEs appear to be a risk factor for depression, but they are not the end-all be-all of depression and mental health treatments. Even this study shows that there is a significant percentage of the population who may be dealing with depression that has nothing to do with adverse childhoods.
  • We’ve also overlooked the 49.3% of people with scores of 4 or more, who aren’t depressed. Or, the 81.7% who haven’t attempted suicide, the 71.6% who have not used illicit drugs, or 83.9% who don’t consider themselves alcoholic.
    • Too many people saw those numbers and made an all-too common mistake. They assumed large increased risks = fate. This is, clearly, not true.

When I stop to consider those final two points, I understand why there is criticism. It’s not so much about the study, or subsequent studies, it’s what we do with those numbers. When we advocate for resources, and policy decisions, to assist with ACE prevention and treatment, we cannot forget the people who are struggling for entirely different reasons. We do not need one treatment and support option, we need a buffet table full of options. Looking seriously at childhood stress and trauma should be one thing on that buffet. So should a number of other things to treat a number of different mental health conditions that are not even dealt with in this study. We also need to stop and consider the ramifications of classifying the results as fate. Yes, childhood can set us up for an increased risk statistically. But we need to be careful how we interpret that and treat people. Our ability to get life or health insurance should not be based on this, for example. We shouldn’t assume someone with a high score is an addict, or is at risk for obesity.

That’s the thing about statistics and percentages. They can help guide us to ways to help more people, and recognize risk factors. But if I point you to one individual, they don’t really tell us much about that person.

Is that one person with a high score part of the 50.7% who may be dealing with depression, or the 49.3% that isn’t? Is the person who scores a zero at no risk for suicide attempt or addiction? Obviously, no. There are an infinite number of possibilities when it comes to one person. The statistics don’t mean much. We’d do well to remember that as we start building AI and big data risk models.

Just to give you an example. My ACE score would be in the 4 or more category. I would answer in the positive to 2 of the 10 “bad outcome” categories above. Even before I spent time in therapy and got help with my trauma, I would have only answered in the positive to 3. (I haven’t been depressed this year, I would have been that year.)

This doesn’t represent my individual fate. It doesn’t represent yours.

It does, however, represent a chance to help lower the prevalence of these things across an entire population. For that, we need to use them to encourage more resources for prevention, right alongside more resources for research and treatment options that have nothing to do with ACEs. We can do a lot more, for everyone.

For more reading and alternative views that I’ve seen recently:

Good intentions but the right approach? The case of ACEs

Why you need to remain critical of ACEs (Adverse Childhood Experiences)

Adverse childhood experiences and how to recover from ACEs

Also, I highly recommend this episode of Dak Shepard’s podcast Armchair Expert with Johan Hari, where they discuss many things about addiction, childhood trauma, mental health treatments, etc. It’s lengthy but worth it: (I may have a few other posts based on that discussion, after I give it a second listen)


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