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The ACE effect

A case study of adverse childhood experiences

Zarnello, Lisa BSN, RN

doi: 10.1097/01.NURSE.0000530408.46074.64

Exposure to traumatic events and adversity in childhood can shape lifestyle risk factors and trigger chronic diseases later in life. Follow the advice presented in this case study to help affected patients of all ages.

Lisa Zarnello is an RN in the ED at Highland Hospital in Rochester, N.Y.

The author has disclosed no financial relationships related to this article.



MS. J, 59, PRESENTED to the ED in acute respiratory distress. Ms. J was well known to the ED staff due to her multiple chronic diseases that often required emergency medical treatment. She also had a history of depression with multiple suicide attempts.

Recovering from alcohol and opiate addiction, she was 3 years sober. As Ms. J's clinical status began to improve, she was able to talk with her nurse. “Did you miss me, honey? I thought I was goner this time!” In her gravelly voice, she told it like it was: “You know, I watched my mom die just like this. She did it to herself, too, just like I'm doing it to myself. She smoked and drank, but she lived just how she wanted.”

After many years of working in the community ED, I'd gotten to know Ms. J, but this was the first time she'd ever brought up her mother. Out of curiosity, I asked her, “What was your mom like?” She sighed, shifted her gaze to the side, and said as she exhaled, “She really loved all us kids. I watched my father beat her almost every Friday and Saturday night until she finally kicked him to the curb.”

During her frequent visits, Ms. J had never spoken about her childhood, but I sensed that she wanted to talk about it today. I pulled up a chair and asked her, “What was it like for you when you were a kid?”

She responded, “You know what? I never want to think about it, but I still think about it all the time.” She then began to share her heartbreaking story of poverty, abuse, neglect, sexual molestation, parental alcoholism, and despair.

After hearing her talk, I began to wonder, is Ms. J's poor physical health in any way related to the burden of her emotional pain from the traumatic events she endured as a child? How are her chronic diseases related to her harrowing childhood experiences?

Answers to these questions can be found by examining the Adverse Childhood Experiences (ACE) study.1 This study and the relationship ACE have to the accumulation of risky lifestyle behaviors and the development of chronic diseases are described in this article. Nurses can follow the advice found here to help patients like Ms. J, starting in childhood.

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Risk clusters

Chronic diseases, according to the CDC, account for 7 out of 10 deaths per year.2 Treating them accounts for 86% of healthcare costs in the United States. Many leading causes of chronic disease are connected to lifestyle-related risk factors, such as smoking, obesity, alcohol abuse, substance abuse, and risky sexual behaviors.2

These risk factors have been found to cluster in certain population groups and aren't randomly distributed.3 In other words, if a person has one lifestyle risk factor, the likelihood is strong that he or she will have other risk factors too. This suggests that some exposure influences the predisposition to engage in these lifestyle risks and for chronic disease to develop.

Ms. J's history included a cluster of lifestyle risk factors: cigarette smoking, drug and alcohol abuse, and obesity. Some may look at these lifestyle choices as the sole contributing factors leading to her chronic diseases. However, an increasing body of research and evidence suggests that these lifestyle choices may be a sign of an even earlier and more insidious exposure correlate—exposure to ACE.4

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Childhood exposure to adverse experiences

A major epidemiologic and public health research project called the ACE study has discovered that exposure to traumatic events and adversity in childhood is a significant determinant in lifestyle risk factors and chronic diseases.5 The ACE study, originally published in 1998, is an ongoing collaborative research study of the CDC and Kaiser Permanente. The study includes over 17,000 participants from a primary care setting. Both prospective and retrospective, it describes the prevalence of ACE, along with correlating the effect ACE have on medical, behavioral, psychosocial, and public health problems.1,5

The ACE screening questionnaire is used to generate an ACE score. It assesses an individual's childhood exposure to psychological, physical, and sexual abuse; household dysfunction; substance abuse; and mental illness; and to witnessing domestic violence and/or criminal behavior in the household. Each positive answer in the survey is counted as an exposure and is given one point.1,4 For the ACE test, go to

An individual's ACE score (the total number of points) can range from 0 to 10.5 ACE scores of 4 or greater are strongly linked to multiple risk factors, including smoking, severe obesity, sedentary lifestyle, depressed mood, suicide attempts, alcoholism, drug abuse, multiple sexual partners, sexually transmitted diseases, and various chronic diseases.4

Ms. J has an ACE score of 7. Based on the data from the ACE study research, Ms. J's ACE score of 7 makes her significantly more likely to develop hepatitis and chronic obstructive pulmonary disease, engage in substance abuse, and have triple the risk of developing ischemic heart disease (IHD). She's 4.5 times more likely to have depression and is 12 times more likely to attempt suicide than an individual with an ACE score of 0.6

Exposure to ACE is a major preventable conduit to the development of substance abuse, mental illness, and chronic diseases.5 The ACE study found a strong dose–response relationship with ACE, lifestyle risk factors, and chronic diseases.6 The higher an individual's ACE score, the greater the chance the person will engage in risky behavior and develop chronic diseases, leading to an increased risk of premature death. Study participants who had an ACE score of 6 or more died 20 years earlier on average than those with a score of 0.4

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Lifestyle versus biology

Because research has shown a strong correlation between exposure to ACE and risky lifestyle choices, some might assume that the choice to engage in risky behaviors causes chronic disease development associated with ACE. For example, Ms. J assumed she was solely responsible for her lifestyle choices and resulting health outcomes because she “did it to myself.”

Although poor health and lifestyle activities contribute to chronic disease development, research shows that children who've been exposed to childhood adversity and toxic stress have biologically embedded changes. Alterations to physiologic systems can impact lifestyle choices, alter coping mechanisms, and change stress responses well into adulthood.7 (See Effects of ACE.) ACE have been implicated in changes to the neurobiologic, epigenetic, and adaptive stress hormonal response mechanisms in the developing brain.4

Evidence from epidemiology and neurobiology research shows that early childhood stress and exposure to adversity can create lasting biologically imprinted changes and brain dysfunction that can contribute to poor health outcomes and substance abuse later in life.4 Frequent activation of a child's stress response system from repeated exposure to traumatic events can initiate a prolonged stress reaction that can progress to allostatic overload of the nervous system.7

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Physiologic response

Allostatic load is the physiologic response to stress accumulation within an individual. During conditions of allostatic overload, the parasympathetic nervous system is less able to balance or limit sympathetic nervous system activity, causing prolonged or exaggerated inflammatory responses.8

Constant stimulation of the hypothalamic-pituitary-adrenal axis due to stressful events in childhood can cause lasting physiologic changes well into adulthood that affect the nervous, endocrine, and immune systems. These physiologic alterations can increase the affected adult's risk of developing age-related chronic diseases.7

Recent epigenetic research suggests that repeated childhood traumatic exposure can even change DNA. Some of these changes include a shortening of the telomere segment of DNA strands, the part of DNA that helps to hold the strands together, as well as changes to the DNA's methylation.9

These DNA changes can alter gene expression within the trauma-affected individual.4 Many of the genes that showed DNA alterations in relation to child maltreatment were associated with the development of cancer and previously identified ACE-related diseases.9

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Brain changes

Trauma or neglect can also trigger changes to a child's brain structure. Magnetic resonance imaging scans of adults and children with an ACE score of 4 or greater have shown volume reductions in the prefrontal cortex, with considerable gray matter volume reduction in the amygdala, cerebellum, hippocampus, and the parahippocampal and fusiform gyri.7,10

In one study of substance abusers, the anatomic brain changes associated with a history of childhood exposure to maltreatment were related to an increased likelihood that the affected person would relapse into substance abuse.10 This held true even when the trauma was no longer occurring.

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Other health risks

Exposure to ACE is considered an independent risk factor for developing cardiovascular disease.11 Exposure to stressors early in childhood is strongly correlated with IHD in adulthood.11 Depression, inflammation, and a clustering of metabolic risk markers associated with ACE are theorized to contribute to the development of IHD.12

The evidence of trauma-induced biologic changes leads to this question: Do people like Ms. J simply “choose” to engage in unhealthy lifestyle choices and coping mechanisms? And is it simply these lifestyle choices that lead to the development of chronic diseases? Or, did Ms. J's childhood exposure to trauma and adversity biologically and genetically imprint alterations affecting her brain, hormonal regulations, and gene expression, thus predisposing her to illness and participation in unhealthy lifestyle activities?

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Nursing implications

Once we recognized the profound impact Ms. J's traumatic experiences had on her health status, we understood that her treatment required more than just symptom management. Ms. J was referred to a caseworker and a mental health professional, initiating care coordination that integrated a trauma-informed approach to her care plan.

The effect of ACE spirals across all disciplines of healthcare and requires a dynamic multidisciplinary approach.13 Because nurses are accustomed to interdisciplinary collaboration in care provision, they're well equipped to intercede and lead efforts to combat this public health issue. Nursing interventions should include providing ACE education, increasing professional knowledge of trauma-informed care modalities, increasing community awareness, providing appropriate mental health referrals, engaging in research, disseminating research findings and translation into practice, initiating screening protocols for children and parents, and providing resources for care with a trauma-informed approach.13 (See What's a trauma-informed approach?)

In addition, due to the pervasive intergenerational transmission of ACE from parent to child, an initial and annual psychosocial history and trauma screen are suggested for children and adolescents at routine well visits in the primary care setting.14

Encouraging and building resiliency factors is another important consideration when addressing exposure to ACE. This includes building supportive parent-child relationships and educating parents about the effects of toxic stress and ACE on the child's current and future well-being. Be prepared to refer families to available community resources.14

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Effects of ACE



The ACE pyramid shows the mechanism by which ACE influence health and well-being throughout the lifespan.

Source: Adverse Childhood Experiences Presentation Graphics. The ACE pyramid. 2016.

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What's a trauma-informed approach?

According to the Substance Abuse and Mental Health Services Administration, “A program, organization, or system that's trauma-informed:

  • realizes the widespread impact of trauma and understands potential paths for recovery
  • recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system
  • responds by fully integrating knowledge about trauma into policies, procedures, and practices
  • seeks to actively resist re-traumatization.”

A trauma-informed approach reflects adherence to these six key principles:

  1. Safety
  2. Trustworthiness and transparency
  3. Peer support
  4. Collaboration and mutuality
  5. Empowerment, voice, and choice
  6. Cultural, historical, and gender issues.

Source: Substance Abuse and Mental Health Services Administration. Trauma-informed approach and trauma-specific interventions. 2015.

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1. Felitti VJ, Anda RF, 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 (ACE) Study. Am J Prev Med. 1998;14(4):245–258.

2. Centers for Disease Control and Prevention. Chronic disease prevention and health promotion. 2015.

3. Centers for Disease Control and Prevention. The ACE pyramid.

4. Anda R. The progressive nature of adverse childhood experiences: building self-healing communities. [video file]. 2014.

5. Anda R, Felitti VJ. Adverse childhood experiences and long-term health. Academy on Violence and Abuse. 2015.

6. Corwin DL (producer). ACE study, the adverse childhood experiences study: background, findings, and paradigm shift. [video recording]. Shakopee, MN: Academy on Violence and Abuse; 2011.

7. Danese A, McEwen BS. Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiol Behav. 2012;106(1):29–39.

8. McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. 7th ed. St. Louis, MO: Mosby; 2014.

9. Yang BZ, Zhang H, Ge W, et al Child abuse and epigenetic mechanisms of disease risk. Am J Prev Med. 2013;44(2):101–107.

10. Van Dam NT, Rando K, Potenza MN, Tuit K, Sinha R. Childhood maltreatment, altered limbic neurobiology, and substance use relapse severity via trauma-specific reductions in limbic gray matter volume. JAMA Psychiatry. 2014;71(8):917–925.

11. Loria AS, Ho DH, Pollock JS. A mechanistic look at the effects of adversity early in life on cardiovascular disease risk during adulthood. ACTA Physiol (Oxf). 2014;210:277–287.

12. Danese A, Moffitt TE, Harrington H, et al Adverse childhood experiences and adult risk factors for age related disease depression, inflammation, and clustering of metabolic risk markers. JAMA Pediatr. 2009;163(12):1135–1143.

13. Madsen Thompson M, Klika B. Increasing resilience: primary healthcare providers' opportunities to promote protective factors before and after childhood trauma. Academy on Violence and Abuse. 2015.

14. Hornor G. Childhood trauma exposure and toxic stress: what the PNP needs to know. J Pediatr Health Care. 2015;29(2):191–198.

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ACE Response.

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