Childhood Trauma Test (ACE Score)
The ACE questionnaire (Adverse Childhood Experiences questionnaire) is a 10-item self-report questionnaire that counts exposure to 10 categories of abuse, neglect and household dysfunction before age 18. In the original ACE Study, four or more categories were associated with markedly elevated risk for depression, alcoholism, drug abuse and suicide attempt, and the number of categories showed a graded relationship with chronic disease.
For professional reference, research, and education only. Not for diagnosis or medical advice.
ACE Score Risk Reference
Enter a total score to see its range.
One point per category of adversity endorsed before age 18. The score measures exposure, not symptoms, and describes group-level risk, not an individual prognosis.
ACE score Interpretation 4+ Four or more categoriesIn the original ACE Study, adults with four or more categories had 4- to 12-fold increased risk for alcoholism, drug abuse, depression and suicide attempt compared with those reporting none. 1–3 One to three categoriesRisk rises in a graded fashion with each additional category (Felitti et al., 1998). 0 No categories endorsedThe reference group in the original ACE Study. Felitti et al. (1998), ACE Study (original seven categories, range 0–7; four or more vs none).
The ACE questionnaire (Adverse Childhood Experiences questionnaire) is a self-report screener that counts exposure to 10 categories of childhood adversity, including abuse, neglect and household dysfunction, for a score from 0 to 10. Four or more categories were associated with markedly elevated risk for depression, alcoholism, drug abuse and suicide attempt in the original ACE Study [1], and a graded dose-response relationship has been found across many outcomes [2].
What does the ACE questionnaire measure?
A childhood trauma test screens for adverse childhood experiences (ACEs), traumatic events or chronic stressors occurring before age 18 that are associated with lasting physical and mental health consequences. In the landmark ACE Study, conducted at Kaiser Permanente, 9,508 adults responded, and the number of adversity categories showed a graded relationship with adult health risk behaviours and disease [1].
The current CDC-Kaiser ACE questionnaire assesses 10 categories across three domains: abuse (emotional, physical, sexual), neglect (emotional, physical), and household dysfunction (domestic violence, substance abuse, mental illness, parental separation/divorce, incarcerated household member). It measures cumulative exposure to adversity, not current symptom severity.
The ACE score is a group-level risk indicator, not a personal prognosis. Adults with a score of 4 or more show markedly elevated risk for a range of mental and physical health conditions [1], but the score does not predict what will happen to any one person.
ACE categories (10 total)
The 10-item CDC-Kaiser ACE questionnaire covers adversity across three domains. One point is assigned if any item in a category was present before age 18.
Abuse (3 categories)
| # | Category | Example experiences covered |
|---|---|---|
| 1 | Emotional abuse | Repeated humiliation, threats, or belittling by an adult in the household |
| 2 | Physical abuse | Being hit, beaten, or kicked hard enough to leave marks |
| 3 | Sexual abuse | Sexual contact or behaviour by an adult or person ≥5 years older |
Neglect (2 categories)
| # | Category | Example experiences covered |
|---|---|---|
| 4 | Emotional neglect | Not feeling loved, important, or protected by family |
| 5 | Physical neglect | Lack of sufficient food, clothing, medical care, or supervision |
Household dysfunction (5 categories)
| # | Category | Example experiences covered |
|---|---|---|
| 6 | Domestic violence | Witnessing a mother or stepmother being physically hurt by a partner |
| 7 | Household substance abuse | Living with someone who was a problem drinker, used street drugs, or was alcoholic |
| 8 | Household mental illness | Living with someone who was depressed, mentally ill, or attempted suicide |
| 9 | Parental separation or divorce | Parents ever separated or divorced |
| 10 | Incarcerated household member | A household member ever sent to prison |
Note: the original 1998 paper used seven categories (range 0–7) [1]. The 10-category version is the expanded CDC-Kaiser standard that became the widely used public-health tool.
How do you give the ACE questionnaire?
The standard ACE questionnaire is a self-report tool designed for large-scale epidemiological surveys. A trauma-informed clinician is needed to contextualize results, explore individual history, and guide treatment decisions.
This screener is for educational awareness only and does not constitute clinical assessment. If childhood trauma is affecting your wellbeing, speak with a trauma-informed therapist.
Crisis support: 988 Suicide & Crisis Lifeline.
How do you score and interpret the ACE questionnaire?
The interpretation below comes from the ACE Study [1] and later research. ACE scores are a group-level risk indicator; resilience, support systems, and treatment can modify individual outcomes.
Score interpretation
The ACE questionnaire yields a score from 0 to 10, with each endorsed category counting as 1 point.
The original 1998 study found a graded relationship between ACE score and adult risk outcomes: higher scores corresponded to increasingly elevated risk across multiple health domains. The widely cited ≥4 threshold is the comparison the original study reported (four or more categories versus none) for depression, alcoholism, drug abuse, and suicide attempt [1].
| ACE Score | Group Risk Profile |
|---|---|
| 0 | Baseline reference group in the original ACE Study |
| 1–3 | Graded elevation in risk begins; each additional point increases likelihood of adverse health outcomes [1] |
| ≥4 | 4- to 12-fold increased risk for alcoholism, drug abuse, depression, and suicide attempt; 2- to 4-fold for smoking and poor self-rated health; graded relationship with ischemic heart disease, cancer, and other chronic diseases [1] |
Important: These figures are derived from epidemiological cohort studies and represent group-level probabilities. They do not predict outcomes for any individual. Many people with high ACE scores live healthy, fulfilling lives.
Health outcomes by ACE score
Cumulative risk across domains from the original ACE Study and later research.
| Outcome Domain | ACE Score ≥4 vs score 0 | Source |
|---|---|---|
| Alcoholism, drug abuse, depression, suicide attempt (group) | 4- to 12-fold increased risk | [1] |
| Smoking, poor self-rated health, ≥50 sexual partners, sexually transmitted disease (group) | 2- to 4-fold increased risk | [1] |
| Physical inactivity, severe obesity (group) | 1.4- to 1.6-fold increased risk | [1] |
| Ischemic heart disease, cancer, chronic lung disease, skeletal fractures, liver disease | Graded relationship; no summary multiplier reported in abstract | [1] |
| Multimorbidity (two or more chronic conditions) | Each additional ACE associated with ~13% increased odds | [4] |
| 18 health/behavioural outcomes across multiple domains | Dose-response graded relationship; mean comorbidity count tripled across ACE score range | [2] |
The dose-response relationship holds across mental health, substance use, sexual health, and chronic physical disease domains. A later ACE Study analysis of 17,337 HMO members, using eight adversity categories, confirmed this pattern across 18 outcomes; the mean number of co-occurring outcomes tripled across the ACE score range [2].
Psychometric properties
- Predictive validity: the original ACE Study (9,508 respondents, 70.5% response rate) found a graded relationship between the number of adversity categories and each adult health risk behaviour and disease studied [1]. The same graded pattern was found across 18 outcomes in 17,337 adults [2].
- Mental health: in 8,667 adults, mental health scores fell as the number of maltreatment types rose, a dose-response relation, and an emotionally abusive family environment deepened the drop [3].
- Internal consistency: in 240 adolescents in the Hungarian child welfare system, the 10-item version showed acceptable internal consistency (α = 0.701), with strong associations between the cumulative score and emotional and behavioural symptoms supporting concurrent validity [5].
- Item structure: the adversity categories are strongly interrelated [1]; in the child welfare sample, the parental separation/divorce item correlated weakly with the rest of the questionnaire [5].
Limitations
- Exposure, not diagnosis. The ACE score counts categories of adversity; it does not measure current symptoms or diagnose PTSD, depression or any other condition.
- Group-level risk. Risk estimates come from cohort studies and do not predict outcomes for any individual.
- Retrospective self-report. Adults recall childhood events, so reports depend on memory and willingness to disclose.
- Counts, not severity. Each category scores one point regardless of frequency, duration or severity; the original study used seven categories (range 0–7), and the ≥4 threshold comes from that version.
- Narrow coverage. Adversities outside the 10 categories (for example, community violence or discrimination) are not captured.
Which other measures assess childhood trauma?
ACE scores measure exposure, not destiny. Trauma-focused therapies such as EMDR, CPT and TF-CBT, stable supportive relationships, and community connection are all part of recovery from childhood adversity. If you recognize these experiences in yourself, connecting with a trauma-informed therapist is a practical next step.
Beyond the ACE questionnaire, clinicians use a range of validated measures to assess specific trauma-related outcomes:
- PCL-5 (PTSD Checklist for DSM-5): 20-item self-report screen for PTSD symptom severity
- PHQ-9: depression severity monitoring commonly paired with ACE-informed care
- GAD-7 (Generalized Anxiety Disorder-7): anxiety severity screen frequently used alongside trauma assessment
- AUDIT (Alcohol Use Disorders Identification Test): substance use screening, relevant given the elevated risk at ACE ≥4
- CTQ (Childhood Trauma Questionnaire): a retrospective self-report assessing several types of childhood maltreatment with more dimensional detail than the ACE screener
For individuals: This page is a clinical reference, not a diagnostic tool. If you have concerns about your own symptoms, bring this information to a qualified mental health professional.
Related
Billing
In the US, the Childhood Trauma Test (ACE Score) is usually billed under these CPT codes. Payer rules vary.
Assessments
- ACE Score
- CDC Scoring · Child Dissociative Checklist (Version 3)
- DES-B Scoring · Brief Dissociative Experiences Scale (8-Item)
- Bipolar Test (MDQ)
- MDQ: Mood Disorder Questionnaire
- Young Mania Rating Scale (YMRS): Scoring and Cutoffs
Dot size shows how strongly each scale's condition is linked to this one in HiBoop's co-occurrence map.
FAQ
What does an ACE score of 4 or higher mean?
An ACE score of 4 or more indicates exposure to four or more categories of adverse childhood experience. In the original ACE Study, adults at this threshold had 4- to 12-fold increased risk for alcoholism, drug abuse, depression, and suicide attempt compared to those with a score of 0. The score is a group-level risk indicator, not a personal diagnosis or prognosis: it does not predict any individual's outcome.
Is the ACE questionnaire self-report or clinician-administered?
The standard ACE questionnaire is a self-report tool. It was designed for large-scale epidemiological surveys. It is not a clinical diagnostic tool; a trauma-informed clinician is needed to contextualize results, explore individual history, and guide treatment decisions.
Can the ACE score diagnose PTSD or depression?
No. The ACE score measures cumulative exposure to adversity categories, not current symptom severity. PTSD, depression, and other trauma-related conditions require separate validated diagnostic tools (such as the PCL-5 for PTSD or the PHQ-9 for depression) and clinical assessment. A high ACE score warrants further evaluation, not a diagnosis.
How many items are on the ACE questionnaire and what does it cover?
The current CDC-Kaiser 10-item ACE questionnaire assigns one point for each category of adversity experienced before age 18, across three domains: abuse (emotional, physical, sexual), neglect (emotional, physical), and household dysfunction (domestic violence, substance abuse, mental illness, parental separation or incarceration). The score ranges from 0 to 10. The original 1998 study by Felitti and colleagues used seven categories; the questionnaire was later expanded to ten.
References
- 1.Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-58.
- 2.Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD, Dube SR, Giles WH. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):174-86.
- 3.Edwards VJ, Holden GW, Felitti VJ, Anda RF. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study. Am J Psychiatry. 2003;160(8):1453-60.
- 4.Senaratne DNS, Thakkar B, Smith BH, Hales TG, Marryat L, Colvin LA. The impact of adverse childhood experiences on multimorbidity: a systematic review and meta-analysis. BMC Med. 2024;22(1):315.
- 5.Oláh B, Fekete Z, Kuritárné Szabó I, Kovács-Tóth B. Validity and reliability of the 10-Item Adverse Childhood Experiences Questionnaire (ACE-10) among adolescents in the child welfare system. Front Public Health. 2023;11:1258798.
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