ACE
Adverse Childhood Experiences questionnaire
Ten-item screen for childhood exposure to abuse, neglect, and household dysfunction — predicts adult health outcomes at the population level.
When to use the ACE
Use the ACE questionnaire when you are formulating developmental context — not as a routine screener and never early in a first session. It tells you about cumulative childhood adversity, which shapes risk, not about current symptoms.
What the ACE measures
Yes/no items across three domains: abuse (emotional, physical, sexual), neglect (emotional, physical), and household dysfunction (domestic violence, substance use, mental illness, parental separation, incarcerated household member). Score is the count.
Use the ACE when
- Case formulation once the alliance is established and stabilization skills exist
- Explaining to a client why chronic stress responses make sense given their history
- Prevention and health-education conversations about long-term risk
- Population-level or program-level needs assessment
Why use the ACE instead of another measure
The ACE score is the most widely replicated dose-response link between childhood adversity and adult health outcomes, which makes it a powerful psychoeducational and formulation tool. It is short, free, and instantly understandable to clients.
When not to use the ACE
- It is the first session, or you cannot contain what disclosure may open
- You want a symptom or severity measure — the ACE score is exposure, not distress
- You would use the score to predict this individual's outcome; it is an epidemiological risk index, not a prognosis
- Protective factors and resilience are not also being assessed
Scoring and bands
Cutoffs
A score of ≥4 is the most-cited threshold for elevated risk, drawn from the original Felitti studies. Risk is dose-response — higher scores correlate with more outcomes — and the ACE was designed as a population measure, not an individual prognostic tool.
What ACE results mean — and what to do next
No reported adverse childhood experiences on this list.
Next stepRemember the list is not exhaustive — bullying, poverty, racism, and medical trauma are not included.
Moderate adversity exposure.
Next stepExplore which experiences remain active in the present and link them to current coping patterns.
High adversity exposure — the threshold associated with markedly elevated health and mental-health risk.
Next stepPrioritize trauma-informed pacing, nervous-system regulation, and screen for PTSD with the PCL-5.
How often to re-administer
Once. This is a historical measure — re-administration adds nothing and risks re-exposure.
What to pair it with
PCL-5 (current trauma symptoms) and a resilience or protective-factors conversation to balance the picture.
How to talk about the score
Pre-frame the questions before administering. 'These are sensitive questions about childhood. You don't have to share details — just yes/no — and we can talk about what comes up.' Hold space after, regardless of score.
Limitations
- Designed for population research, not individual prediction
- Treats categories as equivalent (one yes = one yes regardless of severity, frequency, or duration)
- Omits significant adversities (community violence, racism, poverty, foster-care experiences)
- Can re-traumatize if administered without care
- Resilience and protective factors not captured
Best used for
- Trauma-informed intake when administered with care
- Psychoeducation about adversity-health links
- Opening a conversation, not closing one
Frequently asked questions about the ACE
Should I use the ACE on intake?
Only with informed consent and a clinical follow-through plan. Many clinicians prefer to defer the ACE until alliance is established and the client opts in.
Is a high ACE score deterministic?
No. It's a population-level risk indicator, not an individual prognosis. Many people with high ACE scores live well; protective factors and adult resources matter enormously.