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Adverse Childhood Experiences

Epidemiology of ACEs

The first large scale population study to link Adverse Childhood Experiences, commonly called ACEs, to poor adult health outcomes was completed by a partnership between the CDC and Kaiser Permanente in the mid-1990s. This study identified 10 specific childhood experiences linked to a long list of chronic health conditions including heart disease, cancer diabetes, and even depression.*

10 ACEs


  1. Physical
  2. Emotional
  3. Sexual


  1. Physical 
  2. Emotional

Household dysfunction 

  1. Parental divorce or separation
  2. Witnessing household violence
  3. Incarcerated household member
  4. Household substance abuse
  5. Household mental illness

From a sample size of approximately 17,000 insured adults living in Southern California the study revealed that ACEs are incredibly common, with 64% of the population having experienced at least 1 ACE. The study also discoved that the more ACEs a person had the higher their risk for severe obesity, alcoholism, or depression 

*The 10 ACEs originally studied do not account for all possible types of childhood adversity. 

Helpful Visuals 

How toxic stress harms developing brains

How does childhood adversity lead to poor adult health outcomes? The evidence points to toxic stress. Toxic stress occurs when a child experiences strong, frequent, and/or prolonged adversity, such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship-without adequate adult support. During a child’s sensitive developmental years, exposure to toxic stress leads to structural changes in the brain. Due to these changes in the brain, the child over-develops physiological and behavioral coping strategies meant for survival in dangerous environments.  The child perceives danger and instability in everyday circumstances and responds with a toxic stress coping strategy, such as hyper-vigilance or aggression. Adults who witness these coping behaviors often misinterpret them as behavioral problems or learning difficulties exclusively.  As a result, children exhibiting toxic stress coping behaviors are often considered disruptive in common social environments, such as school.

Helpful Videos:

Consequences of toxic stress on the body

Short Term 

The consequences of ACEs are not limited to chronic health conditions seen later in life. Health and behavioral outcomes in children experiencing adversity may manifest as developmental delay, failure to thrive, or sleep disruption in infants; asthma, learning difficulties, or behavioral problems in school-age children; and obesity, frequent headaches, or engaging in risky behavior as adolescents. If adversity is addressed early enough in life children have the opportunity to counter the negative effects of exposure to adversity by developing resilience and healthy coping mechanisms with the support of safe, stable, and nurturing relationships. 

Long Term

The original ACE Study identified linkages between ACEs and a long list of poor outcomes. The CDC currently recognizes over 40 outcomes relating to ACEs in a dose-response relationship, meaning the more ACEs a person has the higher their risk for any number of poor health, behavior, or life potential indicators. 

Poor health outcomes identified in the ACE Study:

  • Chronic obstructive pulmonary disease
  • Depression
  • Fetal death
  • Health-related quality of life
  • Illicit drug use
  • Ischemic heart disease
  • Liver disease
  • Poor work performance
  • Financial stress 
  • Risk for intimate partner violence
  • Multiple sexual partners
  • Sexually transmitted diseases
  • Early initiation of smoking
  • Smoking
  • Suicide attempts
  • Unintended pregnancies
  • Early initiation of sexual activity
  • Risk for sexual violence 

Those who have experienced 4 or more ACEs were 2.2 times more likely to smoke than someone with an ACE score of 0. They were also 7.4 times as likely to consider themselves an alcoholic, 4.7 times as likely to have used illicit drugs, 1.6 times as likely to have diabetes, 1.9 times as likely to have had cancer, and 12.2 times as likely to have attempted suicide. 

ACEs in Snohomish County 

Resilience is HOPE

Resilience is the ability to adjust or "bounce back" after something bad has happened. It is the buffer to life's adversity. It can be developed and strengthened throughout life. 

Building resilience in children

Children begin developing resilience from the moment they are born. The infant learns to trust in the first year of life, and the toddler begins to test her or his independence, developing self-regulation skills and initiative. What children learn related to relationships, self-regulation, and initiative can impact their ability to function as adults. Trusted caregivers can foster resilience during these critical stages of development by providing safe, stable, and nurturing environments for children to build their skills and thrive. 


Strong relationships and healthy attachment leads an infant to understand that their world is safe and builds their confidence for exploration. There are many ways to support healthy attachment. Some of these strategies include recognizing cues and responding or hugging and cuddling together. Kindness and patience can be modeled by using a calm and gentle voice. Ultimately, healthy attachment is built upon the feeling of safety and security.


Self-regulation is the precursor to adult self-control. It is the child’s evolving ability to show and successfully manage their feelings. A caring adult can support a child’s development of self-regulation by developing and maintaining routines, naming and discussing feelings, offering choices, or accepting mistakes and talking about ways to problem solve.


As children begin to think and act independently or try to do things for themselves they develop initiative. Children who have strong initiative will try new things or show persistence after an unsuccessful attempt at trying something new. Support a child developing initiative by playing simple games, setting up family routines, showing joy at a child’s accomplishments, or encouraging persistence.


Sesame Street addresses trauma and resilience!

The Everett Public Library has compiled a children’s book list of 31 titles that demonstrate resilience. Organized by age group—Babies, Toddlers and Preschoolers—the list provides a brief description to help you and your child find the right fit.

 (click to enlarge and print)

Reading to your child can support a nurturing relationship that can last a lifetime, and the books provide the opportunity to teach children how to talk about and manage their emotions to develop resiliency.

Building resilience as an adult


Healthy relationships should help us in laughing more, having fun, feeling healthy, and feeling supported. Do you have good friends who support you in making good decisions? Do you provide support to others? Do you trust your family or close friends?

Internal Beliefs

Internal beliefs are the feelings and thoughts we have about ourselves and how effective we think we are at taking action in life. When internal beliefs about yourself are positive you are more able to shrug off a negative environment. What are some of your personal strengths? How do you describe yourself? What are you grateful for? What were some values or beliefs your family had when you were growing up? How do you feel about those values today? What values do you want your children to learn from you?


If you have the ability to make choices and decisions and act upon them then you are able to demonstrate initiative. There are a number of ways we can build initiative as adults. We can attempt to improve our communication skills, try different ways to solve problems, engage in an enjoyable hobby, pursue new knowledge, or even practice the ability to say ‘no’.


The ability to experience a range of feelings and express those feelings using words and actions that society considers appropriate describes self-control. The first step to self-control is recognizing how you are feeling. If you are able to name your feelings, are you able to express your emotions in a safe way? Sometimes it helps to set personal limits, priorities, or even take time to reflect on the successes of the day.


For more detailed strategies on building resilience in both children and adults visit: Devereux Advanced Behavioral Health: Center for Resilient Children

Alberta Family Wellness Initiative -- Brains: Journey to Resilience 

TED 2017 -- The science of cells that never get old. By: Elizabeth Blackburn

For more books, reports, scholarly articles, movies & webinars on ACEs and resilience, try Johns Hopkins published ACEs Resource Packet (PDF).

Seeking additional support?

If you have Medicaid, try calling the Washington Mental Health Access Line at 1 (888) 693-7200. 

For any other insurance carrier try calling the number on the back of the insurance card or log onto their website and search for provider coverage. 

Public Documentary Screenings & Other Events

Scheduled public screenings of the documentary (click the link to be directed to the documentary trailer) Resilience: The Biology of Stress and the Science of Hope, can be found below:

Date/Time Location
October 24th, 2018
3:00 PM - 4:30 PM

Snohomish Health District, Auditorium
3020 Rucker Ave, Everett, WA 98201

Register to attend here

Contact if you are interested in organizing a community or professional screening of the documentary Resilience: The Biology of Stress and the Science of Hope.


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