> ## Documentation Index > Fetch the complete documentation index at: https://docs.getrivet.ca/llms.txt > Use this file to discover all available pages before exploring further. # ACE — Adverse Childhood Experiences > The ten-item retrospective childhood adversity screener — administered with trauma-informed care. The ACE questionnaire is the original Kaiser Permanente / CDC instrument from Felitti's 1998 study — the work that established the dose-response relationship between childhood adversity and adult health outcomes including depression, substance use, suicide attempts, heart disease, and early mortality. Ten items, retrospective (before age 18), one total score. ACE is unusual on this list because every single item asks about childhood abuse or household dysfunction. The administration matters as much as the score. **Every item on the ACE is sensitive.** Don't drop this into an intake battery without preparation. The trauma-informed administration sequence below isn't optional — it's how this instrument is used responsibly. Practitioner judgement about whether ACE is appropriate for a specific client at a specific moment overrides any general "intake screener" reflex. ## What it measures Ten yes/no questions covering childhood maltreatment and household dysfunction before age 18, in two categories of five: **Childhood maltreatment (5 items)** * Emotional abuse * Physical abuse * Sexual abuse * Emotional neglect * Physical neglect **Household dysfunction (5 items)** * Domestic violence witnessed * Household substance use * Household mental illness or suicidal household member * Parental separation or divorce * Household member incarcerated ## When to use it * **Adult clients only.** ACE is retrospective and validated in adult samples. * **Intake in trauma-informed practices** where childhood adversity history is relevant to formulation. * **Complex trauma and CPTSD work** as context alongside the ITQ. * **Somatic and physical-health-related presentations** where the dose-response link to adult health is part of the case formulation. * **Addictions work** where the ACE literature is part of the evidence base. Re-administration is rarely meaningful — ACE is retrospective and the score doesn't change with treatment. It's an intake instrument, not a tracking measure. ## How clients fill it out Ten yes/no items, three to five minutes. Reading level grade 6-7. ## Trauma-informed administration Use this sequence — it comes from SAMHSA trauma-informed care guidelines and is the standard expectation for any clinician administering ACE: Tell the client this is a questionnaire about childhood experiences before age 18, that some questions ask about abuse or household dysfunction, and why you're asking (case formulation, treatment planning, understanding how their history shapes the present). The client may decline any single item or the whole questionnaire without consequence. Say this out loud — not just in a consent form they signed at intake. After administration, you discuss the *total score* and what it implies clinically. You don't walk through each item asking "tell me about this one." If the client volunteers detail about a specific item, follow their lead. "A score of \{n} puts you in the \{band} range. Research links higher scores with \{clinical implication relevant to this client}." Avoid implying the score predicts their individual future — it describes population-level risk, not a personal prognosis. ## Scoring and severity cutoffs Sum of all ten yes-scored items. Range 0-10. ### Bands | Total | Band | | ----- | ---------------------------------------- | | 0 | No ACEs reported | | 1-3 | Low-to-moderate ACE exposure | | 4-10 | Clinically significant ACE exposure (≥4) | A score of **4 or higher** is the Felitti 1998 cutoff for elevated risk of multiple adult health outcomes — respondents at ≥4 had a 4-12 fold increase in alcoholism, drug abuse, suicide attempts, and depression in the original Kaiser cohort. ≥4 is the dominant clinical-significance threshold across the ACE literature. ## Risk flagging ACE doesn't include a current-suicide item, but the dose-response link between ACE score and lifetime suicide attempt is one of the strongest findings in the literature. At ACE ≥4, pair with current-risk assessment (C-SSRS) at intake regardless of presenting concern. ## ACE vs PCL-5 They are often mentioned together and they measure different things. The ACE counts how many categories of childhood adversity a person was exposed to before eighteen. The [PCL-5](/clinical-templates/screening/pcl-5) measures how much they are struggling with trauma symptoms right now. Two consequences follow. First, a high ACE score is not a PTSD score and should never be read as one — exposure is not the same as symptoms, and plenty of people with an ACE of 5 have none. Second, the ACE is retrospective, so re-administering it is not meaningful; it will not move. The PCL-5 is designed to be repeated and is what shows whether treatment is working. If you want the trauma history and the current symptom picture, those are two instruments, not one. ## Is it free to use? **Yes — it is public domain.** The ACE module is distributed by the CDC as part of the BRFSS. ## Citation Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). "Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study." *American Journal of Preventive Medicine,* 14(4): 245-258. US CDC / public domain. Verbatim canonical wording. Distributed by the CDC as the BRFSS ACE Module. ## When not to use it * **The client is under 18.** ACE is retrospective and validated in adults; pediatric adversity assessment is a different instrument space. * **You don't have time to administer in a trauma-informed way.** ACE in a rushed intake is more harmful than not administering it at all. Defer to a session where you have space. * **The clinical frame doesn't need a childhood adversity score.** ACE is a useful instrument when childhood history shapes formulation. It's not a universal intake measure. * **Re-administration during treatment.** The score doesn't change; re-administering implies it should and can be confusing for the client. ## Related articles The ICD-11 Complex PTSD measure — the symptom-side counterpart to ACE's history-side context. DSM-5 PTSD severity for current symptoms. How a template flows from picker to session note — and the extra care ACE warrants.