Got Your ACE, Resilience Scores?

What's Your ACE Score? (and Your Resilience Score?)

There are 10 types of childhood trauma measured in the ACE Study. Five are personal -- physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to other family members: a parent who's an alcoholic, a mother who's a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment. Each type of trauma counts as one. So a person who's been physically abused, with one alcoholic parent, and a mother who was beaten up has an ACE score of three.

But there are many other types of childhood trauma -- watching a sibling being abused, losing a caregiver (grandmother, mother, grandfather, etc.), homelessness, surviving and recovering from a severe accident, witnessing a father being abused by a mother, witnessing a grandmother abusing a father, etc. The ACE Study included only those 10 childhood traumas because those were mentioned as most common by a group of about 300 Kaiser members; those traumas were also well studied individually in the research literature.

The most important thing to remember is that the ACE score is meant as a guideline: If you experienced other types of toxic stress over months or years, then those would likely increase your risk of health consequences.

For more information about different types of ACE surveys, go to this section of the ACEsConnection.com Resources Center. 

Prior to your 18th birthday:

  1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
    No___If Yes, enter 1 __
  2. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
    No___If Yes, enter 1 __
  3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
    No___If Yes, enter 1 __
  4. Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
    No___If Yes, enter 1 __
  5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
    No___If Yes, enter 1 __
  6. Were your parents ever separated or divorced?
    No___If Yes, enter 1 __
  7. Was your mother or stepmother:
    Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
    No___If Yes, enter 1 __
  8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
    No___If Yes, enter 1 __
  9. Was a household member depressed or mentally ill, or did a household member attempt suicide?                        No___If Yes, enter 1 __
  10. Did a household member go to prison?
    No___If Yes, enter 1 __

Now add up your “Yes” answers: _ This is your ACE Score

__________________________

Now that you've got your ACE score, what does it mean?

First....a tiny bit of background to help you figure this out.....(if you want the back story about the fascinating origins of the ACE Study, read The Adverse Childhood Experiences Study -- the largest, most important public health study you never heard of -- began in an obesity clinic.)

The CDC's Adverse Childhood Experiences Study (ACE Studyuncovered a stunning link between childhood trauma and the chronic diseases people develop as adults, as well as social and emotional problems. This includes heart disease, lung cancer, diabetes and many autoimmune diseases, as well as depression, violence, being a victim of violence, and suicide.

The first research results were published in 1998, followed by nearly 70 other  publications through 2015. They showed that:

  • childhood trauma was very common, even in employed white middle-class, college-educated people with great health insurance;
  • there was a direct link between childhood trauma and adult onset of chronic disease, as well as depression, suicide, being violent and a victim of violence;
  • more types of trauma increased the risk of health, social and emotional problems.
  • people usually experience more than one type of trauma – rarely is it only sex abuse or only verbal abuse.

A whopping two thirds of the 17,000 people in the ACE Study had an ACE score of at least one -- 87 percent of those had more than one. Thirty-six states and the District of Columbia have done their own ACE surveys; their results are similar to the CDC's ACE Study.

acescores

The study's researchers came up with an ACE score to explain a person's risk for chronic disease. Think of it as a cholesterol score for childhood toxic stress. You get one point for each type of trauma. The higher your ACE score, the higher your risk of health and social problems. (Of course, other types of trauma exist that could contribute to an ACE score, so it is conceivable that people could have ACE scores higher than 10; however, the ACE Study measured only 10 types.)

As your ACE score increases, so does the risk of disease, social and emotional problems. With an ACE score of 4 or more, things start getting serious. The likelihood of chronic pulmonary lung disease increases 390 percent; hepatitis, 240 percent; depression 460 percent; suicide, 1,220 percent.

(By the way, lest you think that the ACE Study was yet another involving inner-city poor people of color, take note: The study's participants were 17,000 mostly white, middle and upper-middle class college-educated San Diegans with good jobs and great health care - they all belonged to the Kaiser Permanente health maintenance organization.)

Here are some specific graphic examples of how increasing ACE scores increase the risk of some diseases, social and emotional problems. All of these graphs come from "The relationship of adverse childhood experiences to adult health, well being, social function and health care", a book chapter by Drs. Vincent Felitti and Robert Anda, co-founders of the ACE Study, in "The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease."

 

 

 

 

 

 

What causes this?

At the same time that the ACE Study was being done, parallel research on kids’ brains found that toxic stress physically damages a child’s developing brain. This was determined by a group of neuroscientists and pediatricians, including neuroscientist Martin Teicher and pediatrician Jack Shonkoff, both at Harvard University, neuroscientist Bruce McEwen at Rockefeller University, and child psychiatrist Bruce Perry at the Child Trauma Academy.

When children are overloaded with stress hormones, they’re in flight, fright or freeze mode. They can’t learn in school. They often have difficulty trusting adults or developing healthy relationships with peers (i.e., they become loners). To relieve their anxiety, depression, guilt, shame, and/or inability to focus, they turn to easily available biochemical solutions — nicotine, alcohol, marijuana, methamphetamine — or activities in which they can escape their problems — high-risk sports, proliferation of sex partners, and work/over-achievement. (e.g. Nicotine reduces anger, increases focus and relieves depression. Alcohol relieves stress.)

Using drugs or overeating or engaging in risky behavior leads to consequences as a direct result of this behavior. For example, smoking can lead to COPD (chronic obstructive pulmonary disease) or lung cancer. Overeating can lead to obesity and diabetes. In addition, there is increasing research that shows that severe and chronic stress leads to bodily systems producing an inflammatory response that leads to disease.
 
Fortunately, brains and lives are somewhat plastic. The appropriate integration of resilience factors born out of ACE concepts — such as asking for help, developing trusting relationships, forming a positive attitude, listening to feelings — can help people improve their lives.
For more information about the ACE Study, check out the CDC's ACE Study site.

Here's a link to the long questionnaire (200+ questions).

To cite the original ACE study/questionnaire, please link to the article published online in American Journal of Preventive Medicine: https://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext#Defining%20Childhood%20Exposures

_______________________

What's Your Resilience Score?

This questionnaire was developed by the early childhood service providers, pediatricians, psychologists, and health advocates of Southern Kennebec Healthy Start, Augusta, Maine, in 2006, and updated in February 2013. Two psychologists in the group, Mark Rains and Kate McClinn, came up with the 14 statements with editing suggestions by the other members of the group. The scoring system was modeled after the ACE Study questions. The content of the questions was based on a number of research studies from the literature over the past 40 years including that of Dr. Emmy Werner and others. Its purpose is limited to parenting education. It was not developed for research.

Rains wants everyone to know that the resilience questions are only meant to prompt reflection and conversation on experiences that may help protect most people (about three out of four) with four or more ACEs from developing negative outcomes. A secure early childhood is helpful, but not necessary. A higher number of positive experiences is not necessarily more protective. He regrets that the questions have taken on a life of their own and that people may have misinterpretted or misunderstood their experience of risk and resilience, based on the ACE or “Resilience” questionnaires. For more information, he suggests reading this article on ACEs Too High -- Putting resilience and resilience surveys under the microscope.

RESILIENCE Questionnaire

Please circle the most accurate answer undereach statement:

1.  I believe that my mother loved me when I was little.

Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True

 
2.  I believe that my father loved me when I was little.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
3.  When I was little, other people helped my mother and father take care of me and they seemed to love me.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
4.   I’ve heard that when I was an infant someone in my family enjoyed playing with me, and I enjoyed it, too.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
5.  When I was a child, there were relatives in my family who made me feel better if I was sad or worried.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
6.   When I was a child, neighbors or my friends’ parents seemed to like me.
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
7.  When I was a child, teachers, coaches, youth leaders or ministers were there to help me.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
8.  Someone in my family cared about how I was doing in school.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
9.  My family, neighbors and friends talked often about making our lives better.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
10.  We had rules in our house and were expected to keep them.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
11. When I felt really bad, I could almost always find someone I trusted to talk to.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
12.  As a youth, people noticed that I was capable and could get things done.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
13.  I was independent and a go-getter.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True
 
14.  I believed that life is what you make it.
 
Definitely true         Probably true         Not sure         Probably Not True        Definitely Not True

 

How many of these 14 protective factors did I have as a child and youth? (How many of the 14 were circled "Definitely True" or "Probably True"?)   _______
 
Of these circled, how many are still true for me? _______
 
 

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Comments (18)

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Know Jessica... If you are going to figure it out and then heal, you are going to have to be a scientist.  You are going to have to be a voyager and you are going to have to figure out what to do for yourself. Yes, biology determines response. Psychiatry and most of psychology will not be able to guide you.  Guide yourself. It's tough and scary.... but you get to be the captain and as long as you always look for truth... you will find it... and if you want to get out of Missouri... come find me in Asheville.. I will be working on the brain. 

Last edited by Tina Cain

Kathy Brous is a person who had serious early trauma and wrote about her healing journey.  has a lot of very good info synthesizing much of this research.  She summarizes a lot of the relevant researchers and various aspects of the problem really well.   She writes about Peter Levine, Allan Schore, etc, and also child development people Fonagy, Bowlby, etc.

I also strongly recommend the book by Laurence Heller, "Healing Developmental Trauma."  It really puts the somatic element in, and illustrates how emotional flashbacks work.  His method for healing is to help people re-enter their somatic awareness in small pieces in a safe situation, say just focusing on the tight neck, or the jumpy stomach int he presence of a therapist that keeps the client at the EDGE of the feeling without letting it take over.  And it is healing to have the horrible feeling in the presence of a safe person and help place its origins in the past.

The tricky part is 0-3 rejection/ injury leaves its traces in the Right brain.  The right brain is not the part of the brain reachable by CBT, etc.   The R brain learns a lot 0-3 via IMPLICIT learning.  Explicit learning is what you are taught overtly, like manners or math.  Implicit learning is what you ABSORB from environment and the facts of life.  So your worldview (life is good/ life is bad) and other assumptions about the way things are mostly live in the R brain. 

One of the best ways of thinking about the R brain is "the right brain drives the car."  You could not possibly use the L brain to logically assess oncoming traffic, the yellow light, the guy tailgating you, and pedestrians stepping close to the curb, all at once.  It's the R brain that can do all this calculation, in concert, and tell you to hit the brakes...  The R brain is so fast it takes over. 

Well, the injured R brain must assess/take over too.  Only it has learned about how things "are" in a state of danger, of pain, of not being wanted, of being told 'you are no good,' etc.  So what the R brain KNOWS is now based on false information, leads it to false conclusions about 'dangers' and hostilities lurking.

Where the body comes in:   the emotional state of not being wanted or being hurt by people supposed to love you is so painful it is blocked as much as possible by the child.  That remembered state can be triggered in the here an now and feel like it is actually happening in the here and now.  It might be a noise, smell, or other small thing, but suddenly your R brain is "driving the car" to get you the hell out of there to avoid the horrible feeling or the sense of grave danger that happened long ago.  And it happens in a microsecond.  The person might run, hide, rage, freeze, dissociate, or whatever the old pattern of avoidance might be.  

 

 

Jessica Blankly posted:

WOW! 

This is hardcore. Is there a more in-depth version of this questionnaire? The responses for this one leave me with an ACE's score of 10 and a Resiliency score of 2. Seems dismal at best.

J.

Jessica - The "resiliency" score is basically an attachment scale and attachment, especially a secure attachment in infancy is the greatest protection against accruing these Adverse Childhood Experiences from the ACEstudy later in childhood.  This "resilience" questionnaire is not standardized and the ACE questions are not the only childhood stressors nor are they necessarily the most important - they just happen to be the factors included in the Adverse Childhood Experiences study.  

Yeah,  having an ACE score of 10 and a "resiliency" score of 2 is pretty bad.  It means you had lots of hard things happen to you and you didn't really have anyone there protecting you as a kid. 

You probably have a lot of anxiety, maybe panic, confusion.   Resilience is built in our biology according to everything I have read over this last year --- by a secure attachment with a parent who loves and protects you in infancy from the ages of zero to three.   

This early toxic stress - is pretty resistant to Cognitive Behavioral Therapy and Psychiatic drugs. Psychiatric drugs basically numb, deaden, take away feelings.   CBT isn't really useful for memories that were never verbal.  There is a lot of feelings in the body for many people that are Implicit Memory.  We don't have any verbal recall because the experiences were preverbal.    These can be really strong emotions in the body as an example a feeling like the gut is gonna explode or the chest is going to explode but having no idea where this is coming from.   It is a body memory that doesn't have words because the memories (neurons wired and firing together) were laid down before we were verbal.  Also the two hemispheres of the brain have different functions and the "personality" can be kind of all over the place because segments of memory are kind of activated in different ways by different things that we see, hear, sense in the environment and there are like walls between sets of memories to help us survive chaos, terror---- I didn't explain this very well because it is hard to find a book that gives the straight answer to this kind of thing.  I have been looking since I was 25 years old some 25 years ago.   Hope that helps.  

 

Last edited by Tina Cain
Chris Jarko posted:

I'm looking for a revised ACE's questionnaire. I need a shorter, simple, quick questionnaire to complete in a clinic based service. Is any one aware of a revised version?  Is this even allowed to maintain the fidelity of the original questionnaire. 

Hi Chris, I wrote a story a while back about the work of Dr. Kathryn Erickson-Ridout at Kaiser Medical Center in San Jose, Calif. who was testing out a shorter 4 question ACEs questionnaire. Here's a link to that story. I suggest you reach out to her.  Here's a link to her bio. I'm happy to introduce you. Please write me at: ludesky@acesconnection if you would like me to do an introductory email.  I would also suggest that you check out the ACEs Connection resource center

If you grew up feeling people care about you, you learned (a) "people are safe and will help me" and (b) "I am interesting/lovable."  When you get these experiences 0-3, they embed in the right brain, via implicit learning, and become a part of how you see 'reality.'  Obviously these go-to thoughts will buoy you up in moments of crisis and lead you to getting support/help.

This “resilience” questionnaire is basically an attachment questionnaire.  The first 4 questions are about attachment in infancy.  If you reverse questions 10 and 11, the first 10 questions are all about interpersonal relationships in childhood.  You could learn a lot from a large data set with a corresponding ACE Score - and a longitudinal study.   I envy RJ Gillespie. 

However it is really a misnomer to call this a resilience score, as it implies that one is resilient if one has many instances of adults who cared about you as a child and one is not resilient if you had no one.  These questions are more like a tally of questions about childhood relationships that can lead to adult resilience.  And though it is true, life will be a lot easier if you had a lot of people who cared and loved you as a child, especially a mother in infancy, that says nothing about one’s own drive to overcome the developmental deficits that are inevitable when a child did not have critical social experiences that are essential for sound development.   Basically what I am trying to say is the child who is developing in a social environment that creates disorganization cannot expect to develop the kind of brain that would develop in a secure social environment.    It is not possible for a child to develop a secure brain in a disorganizing environment. Any secure child placed in a disorganizing environment would quickly experience developmental forces pushing brain development towards disorganization. The adult resilience is a result of the secure foundation.

We are all social creatures and every pediatrician should know that emotionally neglected infants can die and many will have serious social emotional delays that look like autism; these delays cannot all be reversed  Think feral child or Spitz’s orphans.  When you have these kinds of social delays as a social creature in a social world and you don’t have the skills to navigate your developmental deficits, life is going to be hard. 

However, children are incredibly malleable. They will develop around whatever environment is presented to them to survive and I think that is pretty resilient even if the score on this set of 14 questions happens to be zero. 

Infancy is an incredibly important period to prevent childhood trauma and adversity and irreversible developmental deviation.  I hope we don’t overlook this.

Last edited by Tina Cain

When it comes to ACES and resiliency, would it be true to say that "HOPE" is more prevalent than resiliency? Also, I am struggling with the ideal that poly-victimization is more prevalent than ACES. Would love to hear some feedback as I work with victims of violence of all ages and have implemented ACES inside of Juvenile Halls and other areas. Although I agree ACES is significant, some of the youth I work with are not even 10 years of age and have faced many victimizations already in their young lives. I also feel many survivors and others I know were resilient, however it wasn't resilience that moved them forward. It was "Hope" that moved them forward. There is actually a study on Hope and it can be measured. I would love to hear from others on this.

Scrolling through the comments on this post, it inspired some compassionate and profoundly well rounded reflection upon my own experiences spanning abuse/neglect/under guardianship of the minister until 18. Grandparents raised one of my btothers and i from ages 7 & 9 after witnessing a heartbreaking and unstable sequence of events all our young lives.

My ACES score is 9. Resilience score is 12. Have good days & bad

I had all 14 resilience factors. 

 

I think my experience may be somewhat common....  My parents were VERY limited in their ability to deal with OLDER children but they did very well while we still deified them....  I think the break point is about age 9, when a kid begins to form their own opinions on things they have not questioned before.  I recall noticing gaps in the logic of my parents and beginning to disagree or express a divergent point of view about that age.  

In the case of my parents, this threatened them a lot, when I stopped always echoing them.  They needed/wanted too much control, from their own trauma histories.  Controlling was the one way they knew to "raise" kids... making us do what they said and echo their positions on things, making sure we walked the exact right path.

However, the resilience part is incredibly important, because though I have 5 ACES, I also have never suffered from depression, nor let dangerous people into my life, nor viciously turned against myself internally.   I am nice to myself.   I had my own trances due to parental narcissism that I had to wake up from in adulthood, and some authoritarian parenting tendencies I had to unlearn, but I was able to do that without fear once I figured it out.

10 sounds like a good even number, yet I would add an 11th question to the ACE test.

It would be about serious physical illnesses in the childhood.

At the age of 8, I spent 3 days dehydrated with an untreated gastrointestinal infection (similar to but not dysentery) in a hospital in Russia. My mother rescued me after 3 days when she heard the rumors that I am not getting better from another mother. This in turn predetermined my life for many years, mental health including.

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