ACE score meaning: what your result can and can’t tell you

An ACE score is a count from 0 to 10 of how many of ten kinds of difficult experience happened before you turned 18, such as being hurt or not cared for, losing a parent, or living with someone who drank heavily or was very unwell. Sprout reads it in three groups: none of the ten, one to three, and four or more. It counts what happened, not how often, how badly or how much it affected you, so it describes your past rather than predicting your future, and it is never a diagnosis.

What is an adverse childhood experiences score?

It’s the number of “yes” answers on a short questionnaire about ten kinds of hardship in childhood. The idea comes from the Adverse Childhood Experiences study, led by Vincent Felitti at Kaiser Permanente in San Diego and Robert Anda at the American Centers for Disease Control and Prevention, and published in 1998 in the American Journal of Preventive Medicine.

More than 9,000 adults who had come in for routine health check-ups answered questions about their childhoods, and the researchers compared those answers with their health as adults. The people taking part were members of a health plan, mostly middle-aged, not a group anyone would have singled out as having had unusually hard lives. The study showed that difficult childhoods were common and connected to adult health in ways doctors hadn’t been looking at.

The 1998 paper looked at seven categories. Later work by the same team added three more, emotional neglect, physical neglect and parents separating or divorcing, which gave the ten-item list most people know today.

The version on Sprout is the Adverse Childhood Experience Questionnaire for Adults, prepared in 2020 by an advisory committee of doctors for California’s Surgeon General as part of the state’s ACEs Aware programme. It asks the ten questions in plain language and takes about three minutes. If you’d like to see your own count, you can take the ACE questionnaire at your own pace, and stop at any point if it becomes too much. Taking the test is free; results need Sprout Plus (7 days free).

Which ten experiences does the questionnaire ask about?

The ten questions fall into three groups. Each asks whether something happened before your 18th birthday, and each “yes” adds one point, however many times it happened and however long it went on.

Being harmed

• A parent or another adult at home swearing at you, insulting you or putting you down.
• A parent or another adult at home hitting you or physically hurting you.
• Anyone touching you sexually, making you touch them sexually, or trying to have sex with you when you didn’t want it.

Not being cared for

• Not having enough to eat, having to wear dirty clothes, or having no one to protect or look after you.
• Feeling that no one in your family loved you or thought you were special.

Difficulties in the household

• Losing a parent through divorce, being abandoned, death or another reason.
• Living with someone who was depressed, had a mental illness or attempted suicide.
• Living with someone who had a problem with drinking or using drugs.
• Adults at home hitting or threatening to harm each other.
• Living with someone who went to prison.

Half of the list isn’t about what was done to you at all. It’s about the home you grew up in. That surprises some people, who expect the questionnaire to be only about abuse. The original researchers found that household difficulties mattered too, and that the categories tended to come together: people who had one kind of experience often had others.

Sprout’s version adds one more question for anyone who answered yes at least once: whether you think these experiences have affected your health. It isn’t part of the score. It’s there because how you see the effect matters, and it’s a useful thing to mention to a doctor.

What does my ACE score mean?

Your ACE score tells you how many of the ten categories were part of your childhood, and nothing more. Sprout places it in one of three groups. The table also shows the tiers used by ACEs Aware, the California programme behind this version. Those tiers help doctors decide how much attention to pay; they describe likelihood across many people, not anything certain about you.

A score of 0: none of the ten

You didn’t report any of these ten kinds of experience before the age of 18. The list is limited, though, and it doesn’t cover everything that can make a childhood hard. If something else from your past still affects you, it matters just as much, and it’s always fine to talk about it with someone you trust or a professional.

A score of 1 to 3: one to three

A few of these hard experiences were part of your childhood. Difficult childhood experiences are very common, and they are one part of your life story, not the whole of it. They were not your fault.

Experiences like these can sometimes affect health and wellbeing later on, especially during stressful periods. Supportive relationships, enough sleep, regular movement and time outdoors all help, and a doctor can talk things through with you if you’d like.

A score of 4 or more: four or more

You went through several of these experiences growing up. That’s a lot to have carried, and none of it was your fault. The number describes what happened to you, not who you are.

Experiences like these can affect health and wellbeing in adulthood, and doctors now take them seriously. It could help to talk with a doctor or therapist about how they may be affecting you, whenever you feel ready. There are many ways to heal throughout life, and support can make a real difference.

Why does an ACE score of 4 matter?

An ACE score of 4 matters mostly because of how the original study was reported. Felitti, Anda and colleagues compared people who had four or more categories with people who had none, and that comparison showed the clearest differences in health. Since then, four has become the number at which many doctors and programmes take a closer look.

It isn’t a cliff edge, though. The study found what researchers call a graded relationship: the more categories people reported, the more common, as a group, were health risks such as smoking, heavy drinking and depression, and some of the leading causes of death in adults, including heart disease, cancer, chronic lung disease and liver disease. The risk rose step by step rather than switching on at one number.

So someone with three hasn’t escaped anything, and someone with six isn’t destined for illness. If your score is four or more, the honest reading is this: you went through a lot, your health deserves some extra care and attention, and it’s worth telling a doctor. That’s all the number can say on its own.

What did the 1998 study find, and what didn’t it?

Two findings made the study famous. First, hard childhoods were common: more than half of the people who answered reported at least one of the categories. Second, the more categories someone reported, the more likely they were to have health problems decades later.

The researchers suggested part of the reason. Some ways of coping with a painful childhood, such as smoking, drinking or eating for comfort, make sense at the time and harm health over the years. Later research has also looked at how long-lasting stress in childhood affects the developing body and the way it responds to pressure. Neither explanation is about anyone being weak or to blame.

What the study couldn’t do is predict what happens to a particular person. Its findings are averages across thousands of people. Many people with high ACE scores live long, healthy lives, and some people with a score of 0 struggle a great deal. That’s why the score is used to guide care, not to label people.

The questions also rely on memory, and the original group was drawn from one health plan in one American city. The pattern has been found again in many later studies in different places, but any single number is a rough summary of something far more complicated.

What can’t an ACE score tell you?

An ACE score can’t tell you how much your childhood affected you. It’s a checklist of categories, and many of the things that shape a person’s life sit outside it.

• How often or how long. Something that happened once and something that happened every week for years both count as one point.
• How old you were. The questionnaire treats a difficult year at 4 and a difficult year at 16 the same way.
• Who was there for you. A grandparent, teacher, neighbour or older sibling who made you feel safe doesn’t show up in the score, yet research suggests people like that matter a great deal.
• What isn’t on the list. Bullying, poverty, discrimination, serious illness, growing up in care, living through war or disaster, or losing a brother, sister or close friend aren’t among the ten questions, and they can be just as hard.
• How you are now. The score is fixed in the past. It says nothing about the support, healing and change that may have happened since.
• Whether you have any condition. It isn’t a diagnosis of depression, post-traumatic stress or anything else. Only a professional can assess that.

If memories of something that happened keep coming back uninvited, or you feel on guard much of the time, that is worth talking to a doctor about whatever your ACE score. The short trauma screening check asks about those after-effects directly, which the ACE questionnaire doesn’t.

What helps people after a difficult childhood?

Relationships help most. The people who do well after a hard start very often had, or later found, someone steady: an adult who listened, a friend who stayed, a teacher who noticed, a partner or community where they felt they belonged.

Research on positive childhood experiences has looked at this directly. A 2019 study led by Christina Bethell, published in JAMA Pediatrics, found that adults who remembered more good experiences growing up, such as feeling able to talk to family about feelings, feeling supported by friends and feeling they belonged at school, had better mental health as adults, even when they had also had adverse experiences. Good experiences don’t cancel the hard ones, but they count too.

Protection doesn’t only come from childhood. Much of what helps can be built at any age:

• Steady relationships. People who are consistent, kind and honest give the nervous system a chance to learn that closeness can be safe. Childhood experiences often shape how safe closeness feels later, and reading attachment test results can help you understand how that shows up in two simple scores.
• A kinder inner voice. Many people who grew up with criticism carry a harsh voice in their own head. Learning to speak to yourself with more self-compassion is a skill, and it can be practised.
• A steadier sense of worth. Feeling unloved or put down as a child can leave a lasting sense of not being good enough. The ideas in building self-esteem slowly are a place to start.
• Looking after the body. Sleep, movement, time outdoors and regular meals sound basic, but stress shows up in the body, and these are among the most reliable ways to ease it.
• Professional support. Talking therapies can help with the after-effects of a hard childhood, and therapists who work with trauma are trained to go at your pace.

How can you talk to a GP or therapist about your score?

You can share the number without sharing the details. Saying “I did the ACE questionnaire and scored five, and I’d like to talk about whether it might be affecting my health” is enough to start. A good doctor won’t ask you to describe what happened before you’re ready, and you can say that you’d rather not go into it today.

Some things that make the conversation easier:

• Write down a few lines beforehand. Your score, anything that has been bothering you lately (sleep, mood, worry, pain, drinking), and one or two questions you’d like answered.
• Ask what to keep an eye on. Because ACEs are linked with some health risks, your doctor may want to check things like blood pressure, sleep or mood more regularly.
• Ask about talking therapy. A doctor can explain the treatment options where you live, including therapies designed for the after-effects of trauma.
• Bring someone if it helps. A friend or family member can come along, sit in the waiting room, or simply know you’re going.
• Take breaks. If an appointment brings up more than you expected, it’s fine to stop and come back to it another time.

Some people feel they shouldn’t make a fuss about things that happened long ago. Doctors don’t see it that way any more. Childhood experiences are now a recognised part of understanding someone’s health, and raising them is a reasonable thing to do.

What if answering the questions stirred things up?

That’s a common and understandable reaction. Reading questions about painful parts of childhood can bring back memories or feelings you haven’t thought about for a while. It doesn’t mean something is wrong with you, and the feelings usually settle with time.

A few things can help in the moment. Slow breathing with a longer out-breath tells your body it’s safe enough to calm down, and the guided breathing practice takes a couple of minutes. Noticing five things you can see and a few you can hear brings your attention back to the present. A three-minute self-compassion pause can soften the harsh thoughts that sometimes follow. Talking to someone you trust, even without telling them why, can help you feel less alone.

If you feel unsafe or might hurt yourself, call your local emergency number now. You can find free, confidential helplines in your country at findahelpline.com.

Does an ACE score ever change?

The count itself stays the same, because it’s about things that happened before you were 18, so there’s no need to retake the questionnaire. Some people do find that their answers shift a little over the years, as they remember more or come to see something differently, and that’s normal too.

What changes is everything around the number: the support you have, how much the past weighs on you, and how you look after yourself now. That’s also where effort pays off. It isn’t a score to improve. It’s a description of where you started.

What should you do with your ACE result?

Use your ACE result to decide what support you might want now, rather than as a prediction. None, one to three, or four or more: whatever your count, it describes hard things that happened when you had little control over them, not who you are or what will happen next. The 1998 Felitti and Anda study showed these experiences are common and linked with health across large groups of people, which is why doctors take them seriously and why it’s worth mentioning yours.

If you haven’t counted yet and feel ready to, the ten-question ACE check takes about three minutes. Take it when it feels right, and treat the result as a starting point for looking after yourself, perhaps with a doctor or therapist alongside you.