Adverse Childhood Experiences Questionnaire (ACE-Q)

1. Abuse / Neglect – measures exposure to emotional, physical, and sexual abuse and experiences of emotional and physical neglect during childhood. 
2. Household Dysfunction – evaluates various forms of family dysfunction including domestic violence, parental separation/divorce, and household members with substance abuse problems, mental illness, or involvement in the criminal justice system.

Given the potentially triggering nature of the questions for trauma survivors, some clinicians choose to administer the questionnaire collaboratively rather than having clients complete it independently (McLennan et al., 2020).

Sample Items from the ACE-Q:

For clinicians, the ACE-Q offers several distinct advantages, particularly in settings where understanding developmental trauma is critical to effective intervention planning. The measure is especially valuable for working with individuals presenting with complex symptomatology, as it provides a systematic framework for quantifying childhood adversity and understanding its potential contribution to current difficulties (Hughes et al., 2017).

The ACE-Q aides in clinical formulation, treatment planning, and therapy. As a formulation tool, it helps clinicians identify potential developmental origins of presenting problems, facilitating a trauma-informed approach to case conceptualisation. This can be particularly valuable in understanding the aetiology of conditions such as depression, anxiety, substance use disorders, and personality disorders, all of which have demonstrated associations with adverse childhood experiences (Merrick et al., 2017).

In treatment planning, higher ACE-Q scores may indicate the need for trauma-focused interventions or approaches that specifically address the neurobiological and psychological impacts of developmental trauma. Research suggests that individuals with higher ACE scores often require longer courses of treatment and may benefit from approaches that specifically target affect regulation, attachment disruptions, and maladaptive beliefs stemming from early adversity (Oral et al., 2016).

During therapy, understanding a client’s ACE-Q score can inform the pacing and focus of interventions. For example, higher scores potentially indicate a need for greater emphasis on establishing safety and stabilisation before addressing traumatic material. The ACE-Q can also facilitate exploration of and psychoeducation about the impact of early adversity on current functioning, helping to normalise symptoms, reduce self-blame, and validate the client’s experience (Felitti, 2009). Meta-analytic evidence demonstrates a strong association between caregiver and child ACE scores, highlighting the intergenerational transmission of adversity and underscoring the importance of trauma-informed approaches that address both caregiver and child experiences when using the ACE-Q in clinical settings (Zhu et al., 2025).

When using the ACE-Q in clinical practice, consider the following:

• Contextual interpretation: ACE-Q scores should be interpreted in the context of the individual’s full clinical presentation, including current symptoms, life circumstances, and protective factors.
• Dose-response relationship: Research consistently demonstrates a dose-response relationship between ACE scores and health outcomes, with higher scores associated with increased risk across multiple domains (Merrick et al., 2017). However, more recent research has highlighted that not all ACEs contribute equally to risk outcomes (Briggs et al., 2021) with certain pairs of ACEs potentially interacting to significantly increase overall risk beyond the sum of their individual contributions. Sexual abuse (Item 3 in the ACE-Q) has been identified as the most reactive ACE, combining with other adverse experiences to potentially create disproportionate impacts (Briggs et al., 2021)
• Resilience factors: While the ACE-Q focuses on adversity, clinicians should also assess protective factors that may have buffered against adversity. Complementary measures such as the Benevolent Childhood Experiences (BCEs) scale and the Positive Childhood Experiences (PCEs) scale can provide a more balanced assessment (Narayan et al., 2018).

The ACE-Q uses a dichotomous (Yes/No) response format, with “Yes” responses summed to create a total score ranging from 0 to 10. Higher scores indicate exposure to a greater number of adverse childhood experiences, with each point representing a different type of adversity rather than the frequency or severity of any single experience.

The ACE-Q items can be conceptually grouped into two categories: 

1. Abuse / Neglect (Items 1-5): Emotional, physical, and sexual abuse and emotional and physical neglect;
2. Household Dysfunction (Items 6-10): Household substance abuse, mental illness, incarceration, domestic violence, and parental separation/divorce

Clinicians may find it valuable to note patterns across these domains in addition to the total score. For example, a client with a score of 4 concentrated in the abuse/neglect domain may present differently than a client with a score of 4 distributed across both domains.

For clinical interpretation, ACE-Q scores are categorised as follows, with corresponding qualitative descriptors:

• 0 ACEs (No Reported Adversity): Indicates no exposure to the measured adverse childhood experiences. Individuals in this category typically show the lowest risk for negative health outcomes.
• 1-3 ACEs (Low to Moderate Adversity): Indicates exposure to one or more types of adversity. Research demonstrates a modest but statistically significant elevation in risk for various health and social problems compared to individuals with no ACEs.
• 4+ ACEs (High Adversity): Represents a clinically significant threshold where risk for negative outcomes increases substantially. This category is associated with significantly elevated risk across multiple domains of functioning and should prompt thorough clinical attention.
• 6+ ACEs (Very High Adversity): Although not a formal categorisation in all ACE literature, scores of 6 or higher represent exposure to multiple forms of serious adversity and are associated with the highest risk for severe and complex health problems.

The ACE-Q demonstrates a robust dose-response relationship with health outcomes, meaning that each incremental increase in ACE score is associated with progressively higher risk for negative health outcomes. This graded relationship holds across physical health, mental health, and social functioning domains.

When interpreting ACE-Q scores in clinical settings, consider the following guidance:

• Context matters: ACE scores should be interpreted within the context of the individual’s current functioning, symptom presentation, and available protective factors. Some individuals with high ACE scores demonstrate remarkable resilience and may not exhibit significant impairment.
• Types of adversity: Consider not only the number but also the types of adversities experienced. Different types of adversity may have different mechanisms of impact and may require different intervention approaches.
• Timing and chronicity: Although the ACE-Q does not capture information about the timing, duration, or severity of adverse experiences, these factors are relevant to clinical formulation. When appropriate, gathering additional information about these aspects can enhance understanding of their impact.
• Cultural considerations: Cultural factors may influence both the prevalence of specific ACEs and their psychological impact. Interpretation should be sensitive to cultural context and should avoid pathologising cultural differences.
• Resilience and protective factors: ACE scores provide information about risk but do not capture protective factors or resilience. Comprehensive assessment should include attention to strengths and resources that may buffer against the impact of adversity.

When communicating ACE scores to clients, a trauma-informed approach is essential. This includes:

• Normalising the prevalence of ACEs in the general population
• Emphasising that ACEs are risk factors, not deterministic predictors
• Highlighting the role of protective factors and the potential for resilience
• Focusing on the relevance of ACEs to current symptoms and treatment rather than simply labelling the client as “traumatised”
• Using psychoeducation about the neurobiology of trauma to reduce shame and self-blame
• Checking readiness and attention to stabilisation and pacing

For clients with clinically significant ACE-Q scores (4+), evidence-based trauma-focused interventions such as Trauma-Focused Cognitive Behavioural Therapy (TF-CBT), Eye Movement Desensitisation and Reprocessing (EMDR), or Sensorimotor Psychotherapy may be indicated. However, the selection of intervention should be guided by the client’s specific symptoms, needs, and preferences rather than by the ACE score alone.

Upon the first administration of the ACE-Q a plot is presented showing the ACE-Q total score with the subscale contribution to this score visible. The descriptors are shaded in the background of the plot to aid in interpretation of the ACE-Q total score. In subsequent administrations, a plot of the total score over time is also presented. 

The ACE-Q consists of 10 dichotomous (Yes/No) items that assess exposure to adverse childhood experiences across two domains: abuse / neglect (5 items) and household dysfunction (5 items). The questionnaire was originally developed for the landmark ACE Study conducted by Kaiser Permanente and the Centers for Disease Control and Prevention (CDC) from 1995 to 1997 (Felitti et al., 1998).

The internal consistency of the ACE-Q has been demonstrated, with Cronbach’s alpha coefficients typically ranging from 0.70 to 0.76 (Olah et al., 2023; Wingenfeld et al., 2010). While the original ACE-Q did not undergo formal psychometric validation prior to its implementation, subsequent research has established its reliability and validity across diverse populations (Bethell et al., 2017; Ports et al., 2019). Factor analytic studies have supported the two-domain structure of the ACE-Q (Mersky et al., 2017; Michael et al., 2025).

Construct validity of the ACE-Q is supported by its ability to predict health outcomes in the directions hypothesised by developmental traumatology models. The scale demonstrates expected relationships with measures of depression, anxiety, substance use disorders, and physical health conditions (Hughes et al., 2017). 

Convergent validity has been established through correlations with other measures of childhood trauma and adversity. The ACE-Q shows moderate correlations with measures such as the Childhood Trauma Questionnaire (Karatekin & Hill, 2019; Wingenfeld et al., 2010). Discriminant validity is supported by lower correlations with measures of positive childhood experiences (r = -0.33 with the Benevolent Childhood Experiences scale), indicating that these constructs are related but distinct (Narayan et al., 2018).

Predictive validity of the ACE-Q is a particular strength, with numerous longitudinal studies demonstrating its ability to predict future health outcomes. Higher ACE scores consistently predict increased risk for mental health disorders, substance use problems, chronic physical health conditions, and premature mortality, even after controlling for demographic factors and other potential confounders (Campbell et al., 2016; Felitti et al., 1998; Hughes et al., 2017). Research by Reavis et al. (2013) provides compelling evidence for the predictive validity of the ACE-Q by demonstrating its ability to distinguish between criminal and non-criminal populations. In their study of criminal offenders, subjects reported nearly four times as many adverse childhood experiences than adults in the normative sample. Eight of ten ACE categories were found at significantly higher levels among criminal populations, with particularly dramatic differences for psychological abuse (52.3% vs 7.6%), parental criminality (20.5% vs 4.1%), and parental divorce (53.6% vs 21.8%). This research extends the ACE-Q’s predictive validity beyond health outcomes to include antisocial behavior and criminality.

Research suggests that not all ACEs contribute equally to risk outcomes, challenging the notion of a simple cumulative score. Briggs et al. (2021) found that certain pairs of ACEs interact to significantly increase overall risk beyond the sum of their individual contributions. In their research with both a general population adult sample and a mixed trauma youth sample, approximately 30-40% of the variance in outcomes was accounted for by additive interactions between specific pairs of ACEs. Sexual abuse was consistently identified as the most reactive ACE, combining with other adverse experiences to create disproportionate impacts.

Compared to individuals with an ACE score of 0, research indicates the following risk elevations for individuals with an ACE score of 4 or higher (Felitti et al., 1998; Hughes et al., 2017; Merrick et al., 2017):

• 1.2-2.2 times higher risk for ischaemic heart disease
• 1.4-1.6 times higher risk for cancer
• 2.1-2.4 times higher risk for smoking
• 4.2-4.7 times higher risk for depression
• 7.2-7.4 times higher risk for alcoholism
• 10.3-11.1 times higher risk for injection drug use
• 12.2-15.8 times higher risk for suicide attempt

Particularly alarming is the finding that people with 6 or more ACEs have a life expectancy that is approximately 19-20 years shorter than those with no ACEs (Brown et al., 2009).

For clinical interpretation, ACE-Q scores are typically categorised as follows, with corresponding qualitative descriptors (Hughes et al., 2017; Felitti et al., 1998):

• 0 ACEs (No Reported Adversity): Indicates no exposure to the measured adverse childhood experiences. Individuals in this category typically show the lowest risk for negative health outcomes.
• 1-3 ACEs (Low to Moderate Adversity): Indicates exposure to one or more types of adversity. Research demonstrates a modest but statistically significant elevation in risk for various health and social problems compared to individuals with no ACEs.
• 4+ ACEs (High Adversity): Represents a clinically significant threshold where risk for negative outcomes increases substantially. This category is associated with significantly elevated risk across multiple domains of functioning and should prompt thorough clinical attention.
• 6+ ACEs (Very High Adversity): Although not a formal categorisation in all ACE literature, scores of 6 or higher represent exposure to multiple forms of serious adversity and are associated with the highest risk for severe and complex health problems (Anda et al., 2006).

The threshold of 4 or more ACEs is particularly meaningful in clinical contexts, as it represents a statistical inflection point at which risk for negative health outcomes increases substantially (Felitti et al., 1998; Hughes et al., 2017).

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