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Adverse childhood experiences (ACEs) are a significant risk factor for substance use disorders and can impact
prevention efforts.
Adverse childhood experiences (ACEs) are stressful or traumatic events, including abuse and neglect. They
may also include household dysfunction such as witnessing domestic violence or growing up with family
members who have substance use disorders. ACEs are strongly related to the development and prevalence of a
wide range of health problems throughout a person’s lifespan, including those associated with substance
ACEs include:
• Physical abuse
• Sexual abuse
• Emotional abuse
• Physical neglect
• Emotional neglect
• Intimate partner violence
• Mother treated violently
• Substance misuse within a household
• Household mental illness
• Parental separation or divorce
• Incarcerated household member

ACEs are a good example of the types of complex issues that the prevention workforce often faces. The
negative effects of ACEs are felt throughout the nation and can affect people of all backgrounds. Successfully
addressing their impact requires:
• Assessing prevention needs and gathering data
• Effective and sustainable prevention approaches guided by applying the Strategic Prevention Framework
• Prevention efforts aligned with the widespread occurrence of ACEs
• Building relationships with appropriate community partners through strong collaboration

Many studies have examined the relationship between ACEs and a variety of known risk factors for disease,
disability, and early mortality. The Division of Violence Prevention at the Centers for Disease Control and
Prevention (CDC), in partnership with Kaiser Permanente, conducted a landmark ACE study from 1995 to
1997 with more than 17,000 participants. The study found:
• ACEs are common. For example, 28% of study participants reported physical abuse and 21% reported
sexual abuse. Many also reported experiencing a divorce or parental separation, or having a parent with a
mental and/or substance use disorder.
• ACEs cluster. Almost 40% of the Kaiser sample reported two or more ACEs and 12.5% experienced
four or more. Because ACEs cluster, many subsequent studies now look at the cumulative effects of
ACEs rather than the individual effects of each.
• ACEs have a dose-response relationship with many health problems. As researchers followed
participants over time, they discovered that a person’s cumulative ACEs score has a strong, graded
relationship to numerous health, social, and behavioral problems throughout their lifespan, including
substance use disorders. Furthermore, many problems related to ACEs tend to be comorbid or cooccurring.
ACEs and Prevention Efforts
Preventing ACEs and engaging in early identification of people who have experienced them could have a
significant impact on a range of critical health problems. You can strengthen your substance misuse prevention
efforts by:
• Informing local decision-making by collecting state- and county-level ACEs data
• Increasing awareness of ACEs among state- and community-level substance misuse prevention
professionals, emphasizing the relevance of ACEs to behavioral health disciplines
• Including ACEs among the primary risk and protective factors when engaging in prevention planning
• Selecting and implementing programs, policies, and strategies designed to address ACEs, including
efforts focusing on reducing intergenerational transmission of ACEs
• Using ACEs research and local ACEs data to identify groups of people who may be at higher risk for
substance use disorders and to conduct targeted prevention
ACEs Research and Behavioral Health
Research has demonstrated a strong relationship between ACEs, substance use disorders, and behavioral
problems. When children are exposed to chronic stressful events, their neurodevelopment can be disrupted. As
a result, the child’s cognitive functioning or ability to cope with negative or disruptive emotions may be
impaired. Over time, and often during adolescence, the child may adopt negative coping mechanisms, such as
substance use or self-harm. Eventually, these unhealthy coping mechanisms can contribute to disease,
disability, and social problems, as well as premature mortality.
ACEs and Substance Use
• Early initiation of alcohol use. Efforts to prevent underage drinking may not be effective unless ACEs
are addressed as a contributing factor. Underage drinking prevention programs may not work as intended
unless they help youth recognize and cope with stressors of abuse, household dysfunction, and other
adverse experiences. Learn more from a 2008 study on how ACEs can predict earlier age of drinking
onset.(link is external)
• Higher risk of mental and substance use disorders as an older adult (50+ years). ACEs such as
childhood abuse (physical, sexual, psychological) and parental substance abuse are associated with a
higher risk of developing a substance use disorder. Learn more from a 2017 study on adverse childhood
experiences and mental and substance use disorders as an adult(link is external).
• Continued tobacco use during adulthood. Prevalence ratios for current and ever smoking increased as
ACEs scores increased, according to a 2011 study on ACEs and smoking status.
• Prescription drug use. For every additional ACE score, the rate of number of prescription drugs used
increased by 62%, according to a 2017 study of adverse childhood experiences and adolescent
prescription drug use.(link is external)
• Lifetime illicit drug use, drug dependency, and self-reported addiction. Each ACE increased the
likelihood of early initiation into illicit drug use by 2- to 4-fold, according to a 2003 study on childhood
abuse, neglect, and household dysfunction and the risk of illicit drug use.
ACEs and Behavioral Problems
• Suicide attempts. ACEs in any category increased the risk of attempted suicide by 2- to 5-fold
throughout a person’s lifespan, according to 2001 study. According to a recent 2017 article(link is
external), individuals who reported 6 or more ACEs had 24.36 times increased odds of attempting
• Lifetime depressive episodes. Exposure to ACEs may increase the risk of experiencing depressive
disorders well into adulthood—sometimes decades after ACEs occur. Learn more from a 2015 study on
ACEs and the risk of geriatric depressive disorders.
• Sleep disturbances in adults. People with a history of ACEs have a higher likelihood of experiencing
self-reported sleep disorders, according to a 2015 systematic review of research studies on ACEs and
sleep disturbances in adults.
• High-risk sexual behaviors. Women with ACEs have reported risky sexual behaviors, including early
intercourse, having had 30 or more sexual partners, and perceiving themselves to be at risk for
HIV/AIDS. Learn more from a 2001 study on ACEs and sexual risk behaviors in women. Sexual
minorities who experience ACEs also demonstrate earlier sexual debut according to a 2015 study.
• Fetal mortality. Fetal deaths attributed to adolescent pregnancy may result from underlying ACEs rather
than adolescent pregnancy, according to a 2004 study of the association between ACEs and adolescent
• Pregnancy outcomes. Each additional ACE a mother experienced during early childhood is associated
with decreased birth weight and gestational age of her infant at birth, according to a 2016 study on the
association between ACEs and pregnancy outcomes
• Negative physical health outcomes. Experiencing adverse childhood family experiences may increase
the risk for long-term physical health problems (e.g., diabetes, heart attack) in adults. Learn more from
a 2015 study on long-term physical health consequences of adverse childhood experiences.
• Poor dental health. Children who have experienced at least one ACE are more likely to have poor dental
health. Learn more from a 2015 study on the association between ACEs and dental health in children and
adolescents(link is external).
Publications and Resources
• Archived Webinar: Trauma & Adverse Childhood Experiences: Implications for Preventing Substance
• The Role of Adverse Childhood Experiences in Substance Abuse and Related Behavioral Health
• Adverse Childhood Experiences: Risk Factors for Substance Abuse and Mental Health Video – 2012
• Adverse Childhood Experiences: Implications for Transforming Our Systems of Care Video – 2012
Access more CAPT tools and other learning resources.
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