We encourage community organizations, shelters, food pantries, churches, first responders, clinics, mentors, tutors, and other public-serving organizations to register now to receive our technology-enabled solution (coming soon). To learn more about how our technology can help you and your clients, contact us at wmag@middlelayers.org.

Collect ACE Data & Identify Solutions

  • Collect annual data on the prevalence of ACEs
  • Develop a thorough inventory of existing agency and community efforts to reduce ACEs and support resilience
  • Support efforts to identify evidence-based practices and tools to identify and respond to ACEs

The seminal CDC-Kaiser Permanente ACE study uncovered an alarmingly pervasive, yet hidden public health crisis and, in doing so, inspired a generation of ACE research. To replicate and expand the reach of the original study, researchers continue to adapt and administer the original ACE questionnaire in communities across the country. The ACE prevalence data collected from such surveys is utilized to estimate the magnitude of the public health crisis and, according to the Center for Youth Wellness, “craft effective strategies and policies to address the impact of ACEs on local communities.”

On the county and state levels, ACE data is collected through the Behavioral Risk Factor Surveillance Survey’s (BRFSS) ACE module. Since the module was first included in the BRFSS in 2009, over 32 states and the District of Columbia have administered the ACE questionnaire to adults 18 years and older. On the national level, ACE data has been collected through AFE (Adverse Family Experiences) modules of the 2011/2012 and 2016 National Surveys on Children’s Health (NSCH). Sponsored by the Maternal and Child Health Bureau of the Health Resources and Services Administration, an Agency in the U.S. Department of Health and Human Services, the NSCH examines the physical and emotional health of U.S. youth ages 0-17.

In recent years, researchers have increasing prioritized the surveying of demographically diverse populations to identify groups with greater risks of early trauma exposure. A key limitation of the CDC-Kaiser study is the homogeneity of the surveyed population. The population was primarily white (75 percent), middle-class, and highly educated (36 percent had completed some college and 39 percent were college graduates). As a result, the groups that experience the highest rates of ACEs – low-income, low educated, and non- White groups— were largely overlooked. To overcome this limitation, researchers are making efforts to administer ACE questionnaires using updated methodologies to assess broader forms of trauma among more diverse populations.

In 2012, the Institute for Safe Families created the Philadelphia ACE Task Force to develop policies, practices, and research in pediatric setting that mitigate the conditions arising from toxic stress and ACEs. One of the Task Force’s first initiatives was to conduct an ACE survey among Philadelphia residents to “measure the scope and nature of ACEs and toxic stressors that exist in the city.” The Philadelphia Urban ACE study was conducted between November 2012 and January 2013 and administered an Urban ACE Questionnaire to 1,784 Philadelphia adults age 18 and older. The Urban ACE Questionnaire included the original 10 questions used in the CDC-Kaiser study and added questions about urban ace indicators, or stressors often present in low SES urban environment. Indicators included neighborhood safety and trust, bullying, witnessing violence, racism, and experience with the foster care system.

When considering only the original 10 ACE questions, researchers discovered higher rates of ACEs in the urban, predominately low-income Philadelphia population than among the the original CDC-Kaiser study population (Table 1). This disparity in ACE score is most pronounced among individuals with four or more ACEs: over 3x more Philadelphia adults experienced 4+ ACEs than adults included in the CDC-Kaiser study. This gap grew even larger when the urban indicators were included. The percentage of adults who experienced at least one ACE increased by 19 percent (from 69.9 percent to 83.2 percent) when the urban indicators were considered. Overall, approximately 63 percent of Philadelphia adults had higher rates of ACEs when the urban indicators were included.

Table 1. ACE score comparisons CDC-Kaiser Permanente ACE Study vs. Philadelphia Urban ACE Study

ACE ScoreCDC-Kaiser Permanente ACE study (%)Philadelphia Urban ACE study (%)
1- 345.348.4

The findings of the Philadelphia Urban ACE study, when compared to the CDC-Kaiser Permanente ACE study, emphasize the need to survey diverse populations with differential ACE risks. ACE surveys that exclude low income, low educated, non-White populations produce ineffective, unresponsive policies.

In pursuit of this objective, the Middlelayers CSapplication prioritizes the widespread, inclusive administration of our adapted ACE questionnaire. The ACE questionnaire is integrated in all user profiles. It is easily navigable, quick to complete, and thus accessible to any user regardless of their prior knowledge of trauma and toxic stress. Furthermore, the Middlelayers platform, as a mobile application, can penetrate more communities, faster than traditional surveying methods. By facilitating access to and encouraging diverse, often marginalized populations to complete our questionnaire, the Middlelayers CSplatform aims to collect comprehensive ACE data and promote representative policies and responsive interventions.