ACE
Adverse Childhood Experiences questionnaire
In this guide
Ten-item screen for childhood exposure to abuse, neglect, and household dysfunction — predicts adult health outcomes at the population level.
Ready to administer ACE?
Open interactive assessment →The ACE (Adverse Childhood Experiences) questionnaire comes from the CDC–Kaiser Permanente ACE Study (Felitti et al., 1998). It asks ten yes/no questions about abuse, neglect and household challenges before age 18. Each 'yes' adds one point.
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
ACE scores should be interpreted alongside the clinical interview, the client's context, and the measure's intended population. A cutoff suggests follow-up; it does not establish a diagnosis.
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
How to score the ACE questionnaire
Count the number of 'yes' answers for a score from 0 to 10. The score counts categories of adversity, not how often or how severely they happened, and it does not capture protective factors or other adversities such as community violence or discrimination.
What does an ACE score of 4 or more mean?
In the original study, people reporting four or more ACE categories had substantially higher rates of health problems such as depression, substance use and heart disease than people reporting none. These are population-level associations — an individual ACE score does not predict any one person's outcome and is not a diagnosis.
Using the ACE score in therapy
Use it as a conversation starter about history and as context for a trauma-informed treatment plan, not as a screening test for PTSD. Pair it with a symptom measure such as the PCL-5, and explore resilience and supports alongside adversity.
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.
Is a high ACE score a diagnosis?
No. The ACE score counts types of childhood adversity. It is linked with higher health risk in groups of people, but it does not diagnose any condition or predict an individual's future.
References
Scoring bands and cutoffs on this page come from these published sources. This guide is educational and does not replace clinical judgment.
- Felitti, V. J., Anda, R. F., Nordenberg, D., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258.Supports: Original ACE Study and the ≥4 risk association
- Centers for Disease Control and Prevention. About Adverse Childhood Experiences.Supports: Background on ACEs and prevention