The connection between childhood trauma and later in life outcomes is widely accepted today as a significant public health issue. Researchers Dr. Vincent Felitti and Dr. Robert Anda first established the relationship in their revolutionary 1995-1997 Adverse Childhood Experiences (ACEs) Study, which remains one of the largest investigations of childhood trauma and later-in-life health and well-being outcomes. Their study determined that ACEs are prevalent, cumulative, co-occurring. Among 17,337 participants, they found that 26% of participants had experienced one ACE, almost 40% reported two or more ACEs and 12.5% had experienced four or more ACEs. Respondents who reported having experienced one category of ACE exposure had an 85% chance of experiencing a second category of ACE exposure and a 70% chance of experiencing a third.

Twenty years later, the original ACE study continues to be replicated by institutions nationally (e.g. Robert Wood Johnson Foundation, Harvard University, Princeton University) to evaluate population health and predict health risk factors. The ACE questionnaire has been most widely implemented through the Behavioral Risk Factor Surveillance System (BRFSS), which is the country’s premier system of health-related telephone surveys that annually collects state data about U.S. residents regarding their health-related risk behaviors, chronic health conditions, and use of preventive services. Since 2009, 32 states have included ACE questions, adapted from the original ACE questionnaire, for at least one year of the BRFSS to collect data on the prevalence of child abuse and neglect within their borders. Data shows that, while ACEs are common in all states (nationally, 35% of children ages 0-17 report experiencing one or two ACEs and 11% report three or more ACEs), there are variations in ACE prevalence between states. Among of children ages 0-17 in New Jersey and Connecticut, 7% report three or more ACEs compared to 17% of kids in Montana.

The findings of the BRFSS and other recent ACE studies remain largely consistent with those of the original CDC-Kaiser Permanente study, thus confirming that early adversity shapes to health over the life course. BRFSS ACE data from participating states demonstrate a graded relation between ACE score and a range of physical health, mental health, behavioral, and socioeconomic outcomes (Table 1). Table .1 summarizes the BRFSS findings for 25 states. Included in the table are the prevalence rates of ACEs and correlated outcomes, as reported by the BRFSS. As Table 1 demonstrates, ACEs are common among population throughout the country and deleterious throughout the life course. Table 2. is a collective list of actions states recommend as best practices to reduce ACEs and related outcomes.

Table 1. ACE prevalence and outcomes among adults as reported by BRFSS (2009- 2016) in 25 states

Table 2. Recommended Actions to address ACEs in adult and youth populations

ACE studies, by illuminating the prevalence and long-term implications of childhood trauma, encourage greater investment in early intervention and trauma informed care practices. State and local level ACE data collected by the BRFSS is used to direct health policy, plan health programs and create strategies for early intervention and prevention programs. The recommended actions outlined in Table 2. can be organized into three broad categories: 1) Increasing awareness of ACEs and their impact on health and well-being, 2) increasing assessment of and response to ACEs in health care settings, and 3) enhancing the capacity of communities to prevent and respond to ACEs. The evidence created by state BRFSS has been fundamental in raising awareness and strengthening responses to childhood trauma and toxic stress. Thus, as we move forward, it is also vital that we continue to expand our understanding of childhood trauma and its effects on childhood development through continued scholarship and research.