A Clinician’s Guide to Adverse Childhood Experiences
If you’ve spent any time reading about trauma, resilience, or mental health in the last few years, you’ve probably run into the term “ACE score.” Maybe a therapist mentioned it. Maybe you took an online quiz that gave you a number between 0 and 10 and didn’t tell you much else. Maybe you’ve wondered whether a number from a questionnaire can really say anything true about a whole human life.
I understand the skepticism, because I’ve spent my career on both sides of that question, first as the clinician sitting across from patients whose charts told one story while their bodies told another, and later as someone who did the harder work of applying what I’d learned in the clinic to my own healing.
A Number With a Real Research History
I had the opportunity to work directly with Dr. Vincent Felitti, whose research at Kaiser Permanente in the late 1990s became the foundation of what we now call the ACE STUDY (adverse childhood experience), one of the largest investigations ever conducted into how childhood adversity shapes adult health. Results from the ACE study have influenced my patient care and teaching experiences in the classroom. Combined with my personal life experiences the results also contributed to the discovery of seven healing practices. These practices are built on a foundation of research and reflections shared in Between Wounded and Well: Lessons in Healing.
The ACE Study asked a large group of adults a simple set of questions about their childhoods, then tracked those answers against decades of health outcomes. What it found reshaped the conversation: adversity in childhood doesn’t just leave emotional marks. It shows up in adults’ rates of heart disease, autoimmune disorders, depression, anxiety and many other conditions we used to treat as unrelated to mental health.
The 10 ACE Categories, in Plain Language
An ACE score is simply a count — out of 10 — of how many categories of adversity someone experienced before the age of 18. The original categories are:
- Physical abuse
- Emotional abuse
- Sexual abuse
- Physical neglect
- Emotional neglect
- A household member with a mental illness
- A household member with a substance use disorder
- Witnessing a parent being treated violently
- Parental separation or divorce
- A household member who was incarcerated
You don’t need every detail of your childhood to have been difficult to end up with a score above zero. Many people are surprised to learn that something they’d never labeled as “trauma” like a parent’s divorce or a household touched by addiction, counts as an adverse or traumatic experience.
What a High Score Means (and What It Doesn’t)
Here is where I want to be careful, because this is where most conversations about ACE scores go wrong. A high ACE score is not a diagnosis. It is not a prediction of who you will become. It is not a life sentence, and it is not an excuse. What it is, is a research-backed way of naming a pattern of exposure. It’s a starting point for understanding why certain things might feel harder for you than they seem to for other people, and why some symptoms in your body and your relationships might have roots further back than you’ve been taught to look.
The most common misconception I hear is some version of, “If my score is high, doesn’t that mean I’m damaged?” I understand exactly why that fear shows up. But the research the ACE Study opened the door to, the study of resilience and of what helps people heal, tells a different story. A score describes exposure, not destiny. What happens after you learn your score and how you heal is within your control.
Why Your ACE Score Is a Beginning, Not an Ending
I wrote Between Wounded and Well to share what the ACE Study doesn’t measure, which is what a person does with what happened to them. In my clinical and personal life, I came to believe that healing from adversity follows practices, not just time. The seven healing practices derived from experiences described in the book are Defined Purpose, Self-Care Practices, Partnerships, Pardons, Persistent curiosity followed by lifelong learning, Boundaries, and Gratitude.
If you’ve just learned your ACE score, or you’ve been carrying it quietly for years, I want you to hear this clearly: the number is data, not a verdict, it describes relationships not a cause and affect. What matters far more is what you after learning your score.