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PACEs Connection Resource Center

PACEs Science: Research


Seminal resources below cover the ACE study and related publications as well as the five parts of PACEs science:

  1. The epidemiology of adverse childhood experiences;

  2. The neurobiology of toxic stress caused by ACEs (effects on the developing brain);

  3. The health (biomedical) consequences of toxic stress;

  4. The epigenetic consequences of toxic stress (how the effects of ACEs are passed on from generation to generation; and 

  5. The research on positive childhood experiences and resilience, which shows that the brain is plastic and the body wants to heal.

A list of category searches on PubMed for publications related to PACEs science:

ACE Study and Related Publications

  • CDC-Kaiser Permanente Adverse Childhood Experiences Study: Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults, 1998
    This is the original ACE study conducted by Drs. Vincent Felitti and Robert Ada.
    [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.]
  • CDC-Kaiser Permanente Adverse Childhood Experiences Study Journal Articles by Category, 1998- 2014
    This site provides journal articles produced by the CDC-Kaiser Permanente ACE Study cataloged by topic. The topics are: Commentary/Overview; Chronic Disease; Health Risk Behaviors; Mental Health; Methodological Issues; Reproductive Health/Sexual Behavior; Special Populations; Victimization and Perpetration; Other Health and Social Issues.

  • The Lifelong Effects of Early Childhood Adversity and Toxic Stress, 2012
    This report presents an ecobiodevelopmental framework that illustrates how early experiences and environmental influences can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health. The report also examines extensive evidence of the disruptive impacts of toxic stress, offering intriguing insights into causal mechanisms that link early adversity to later impairments in learning, behavior, and both physical and mental well-being. The implications of this framework for the practice of medicine, in general, and pediatrics, specifically, are potentially transformational. They suggest that many adult diseases should be viewed as developmental disorders that begin early in life and that persistent health disparities associated with poverty, discrimination, or maltreatment could be reduced by the alleviation of toxic stress in childhood. 
    [Shonkoff, J.P., Garner, A.S.; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; & Section on Developmental and Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246.]

  • Unpacking the Impact of Adverse Childhood Experiences on Adult Mental Health, 2017 
    Exposure to childhood adversity has an impact on adult mental health, increasing the risk for depression and suicide. Associations between Adverse Childhood Experiences (ACEs) and several adult mental and behavioral health outcomes are well documented in the literature, establishing the need for prevention. The current study analyzes the relationship between an expanded ACE score that includes being spanked as a child and adult mental health outcomes by examining each ACE separately to determine the contribution of each ACE. Data were drawn from Wave II of the CDC-Kaiser ACE Study, consisting of 7465 adult members of Kaiser Permanente in southern California. 
    [Merrick, M.T., Ports, K.A., Ford, D.C., Afifi, T.O., Gershoff, E.T., & Grogan-Kaylord, A. (2017). Unpacking the Impact of Adverse Childhood Experiences on Adult Mental Health. Child Abuse & Neglect, 69, 10-19.]

  • Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence, 2019 
    This resource from the Centers for Disease Control and Prevention (CDC) helps states and communities leverage the best available evidence to prevent ACEs from happening in the first place as well as lessen harms when ACEs do occur. It features six strategies drawn from the CDC Technical Packages to Prevent Violence.

  • Addressing Childhood Adversity in Violence Prevention Programs journal articles from American Journal of Preventative Medicine, 2022
    Volume 62, Issue 6, Supplement 1S1-S46, June 2022. Edited by Phyllis G. Ottley [Open access]


  • ACEs Surveys in States 2009-2020
    This blog post includes a series of a dozen maps that record the progress of states and the District of Columbia (DC) to include the ACEs module in the Behavioral Risk Factor Surveillance System (BRFSS) survey. Starting with six states in 2009, now all 50 states and DC include the module. Here is the link to CDC’s information on the Behavioral Risk Factor Surveillance System (BRFSS) ACEs module data.

  • Association of Childhood Adversity with Morbidity and Mortality in US Adults: A systematic review, 2021
    The results of this systematic review suggest that childhood adversity is a leading contributor to morbidity and mortality in the US and may be considered a preventable determinant of mortality. The prevention of CA and the intervention on pathways that link these experiences to elevated disease risk should be considered a critical public health priority.
    [Grummit, L.R., Kreski, N.T., Kim, S.G., et al., (2021). Association of Childhood Adversity with Morbidity and Mortality in US Adults: A systematic review. JAMA Pediatrics. doi:10.1001/jamapediatrics.2021.2320]

  • Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students — Adolescent Behaviors and Experiences Survey, United States, January–June 2021, 2022
    The prevalences of poor current mental health and past-year suicide attempts among adolescents reporting four or more ACEs during the COVID-19 pandemic were four and 25 times as high as those without ACEs, respectively. Exposure to specific ACE types (e.g., emotional abuse) were associated with higher prevalences of poor mental health and suicidal behaviors.
    [Anderson, K.N., Swedo, E.A., Trinh, E., et al. (2022). Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students — Adolescent Behaviors and Experiences Survey, United States, January–June 2021. MMWR Morb Mortal Wkly Rep, 71:1301–1305. DOI:]

  • Disparities in Adverse Childhood Experiences by Race/Ethnicity, Gender, and Economic Status: Intersectional Analysis of a Nationally Representative Sample, 2021
    This study analyzes data from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative sample in the U.S., to explore variation in ACEs by race/ethnicity, economic status, and gender. Descriptively, the authors found that ACEs are more prevalent overall among the poor than the non-poor, among most racial/ethnic minority groups than non-Hispanic Whites, and among females than males. However, multivariate regression results indicate that gender is not a robust correlate of cumulative adversity and that economic status moderates racial/ethnic differences. MAIHDA models further expose heterogeneity in aggregate ACE scores between intersectional strata representing unique combinations of gender, race/ethnicity, and economic status. The MAIHDA results confirm that conclusions based on unadjusted group differences may be spurious. While most variance in ACE scores is explained by additive main effects, accounting for intersections among social categories generates a more complex portrait of inequality. 
    [Mersky, J.P., Choi, C., Lee, C.P., Janczewski, C.E. (2021). Disparities in adverse childhood experiences by race/ethnicity, gender, and economic status: Intersectional analysis of a nationally representative sample. Child Abuse & Neglect, 117, 105066.]

  • Prevalence of Adverse Childhood Experiences (ACEs) among US Children, 2019
    Data from the nationally representative 2016 National Survey of Children's Health (NSCH). Parent-reported child ACE exposure was measured using counts of those reporting zero ACEs, one to three ACEs, and four or more ACEs. 
    [Crouch, E., Probst, J.C., Radcliff, E., Bennett, K.J., & McKinney, S.H. (2019). Prevalence of adverse childhood experiences (ACEs) among US children. Child Abuse Negl., 92, 209-218.]

  • The Prevalence of Adverse Childhood Experiences, Nationally, by State, and by Race or Ethnicity, 2018
    This brief uses data from the 2016 National Survey of Children’s Health (NSCH) to describe the prevalence of one or more ACEs among children from birth through age 17, as reported by a parent or guardian. The data are representative at national and state levels. The study team estimated the national prevalence of eight specific ACEs and compared the prevalence of these ACEs across states. To examine prevalence differences by race/ethnicity and geography, we used the nine geographic divisions used by the U.S. Census Bureau.
    [Sacks, V., Murphey, D.. (2018). The prevalence of adverse childhood experiences, nationally, by state, and by race or ethnicity. Child Trends,]

  • Racial/Ethnic Differences in Positive Childhood Experiences across a National Sample, 2021
    The information from this study highlights the negative disparities borne by racial/ethnic minority populations. Findings can be used to inform policymakers, program developers, and stakeholders on where to target interventions and how to bring together families and communities to not only confront adversity in childhood, but also to leverage community and family-level assets to create PCEs for all children. 
    [Crouch, E., Radcliff, E., Merrell, M.A., Brown, M.J., Ingram, L.A., & Probst, J. (2021). Racial/ethnic differences in positive childhood experiences across a national sample. Child Abuse Negl., 115, 105012.]

  • Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017 
    Adverse childhood experiences, such as violence victimization, substance misuse in the household, or witnessing intimate partner violence, have been linked to leading causes of adult morbidity and mortality. Therefore, reducing adverse childhood experiences is critical to avoiding multiple negative health and socioeconomic outcomes in adulthood. 
    [Merrick, M.T., Ford, D.C., Ports, K.A., Guinn, A.S., Chen, J., Klevens, J., Metzler, M., Jones, C.M., Simon, T.R., Daniel, V.M., Ottley, P., & Mercy, J.A. (2019). Vital signs: Estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention — 25 states, 2015–2017. MMWR Morb Mortal Wkly Rep, 68, 999-1005.]

Neurobiology and Biomedical Effects

  • Background

    • The Brain Story online learning modules, 2018
      This thorough set of modules from Alberta Family Wellness Initiative include text documents, presentations and videos. Each of these modules has several parts. The Alberta Family Wellness Initiative focuses on the Canadian community; the modules draw from contributions of experts in Canada and the U.S., and its content is applicable in any country. The modules include the following:

      • brain architecture and development; 

      • early experiences and gene expression; 

      • building cognitive, emotional and social capacities; 

      • positive, tolerable and toxic stress; 

      • brain plasticity and behavioural change; 

      • interventions and treatments in children's mental health; 

      • the development of addiction; 

      • different kinds of addiction; and

      • prevention, intervention and treatment of addiction; and policy implications.

    • Three Core Concepts in Early Development, 2018
      This three-part video series from the Harvard University's Center on the Developing Child and the National Scientific Council on the Developing Child depicts how advances in neuroscience, molecular biology, and genomics describe how early experiences are built into our bodies and brains.

  • Adverse Childhood Experiences, Allostasis, Allostatic Load, and Age-related Disease, 2012
    Research reviewed here suggests that adverse childhood experiences are associated with changes in biological systems responsible for maintaining physiological stability through environmental changes, or allostasis. 
    [Danese, A., & McEwen, B.S. (2012). Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiology & behavior, 106(1), 29-39.]

  • Adverse Childhood Experiences (ACEs) on Mental Disorders in Young Adulthood: Latent Classes and Community Violence Exposure, 2020 
    This study aims to (1) identify underlying ACE classes including exposure to community violence, and (2) investigate the associations of ACE classes with mental disorders in adulthood: depression, anxiety, and Post-Traumatic Stress Disorder (PTSD). Findings supported the differences in mental disorders in young adulthood by types of exposures to ACEs. The study highlights the importance of considering types of ACEs exposure for promoting mental health of young adults. 
    [Lee H., Kim Y., Terry J. (2020). Adverse childhood experiences (ACEs) on mental disorders in young adulthood: Latent classes and community violence exposure, Preventive Medicine, 134, 106039.]

  • The Enduring Effects of Abuse and Related Adverse Experiences in Childhood, 2006
    The authors found that a graded relationship of the ACE score to 18 different outcomes in multiple domains theoretically parallels the cumulative exposure of the developing brain to the stress response with resulting impairment in multiple brain structures and functions. 
    [Anda, R.F., Felitti, V.J., Bremner, J.D., Walker, J.D., Whitfield, C., Perry, B.D., Dube, S.R., & Giles, W.H. (2006). The enduring effects of abuse and related adverse experiences in childhood. European Archives of Psychiatry and Clinical Neuroscience, 256(3), 174-186.]

  • Exposure to Violence during Childhood is Associated with Telomere Erosion from 5 to 10 Years of Age: A Longitudinal Study, 2012
    Researchers examined telomere erosion in relation to children’s exposure to violence, which has known long-term consequences for well-being. 
    [Shalev, I., Moffitt, T.E., Sugden, K., Williams, B., Houts, R.M., Danese, A., Mill, J., Arseneault, L, & Caspi, A. (2013). Exposure to violence during childhood is associated with telomere erosion from 5 to 10 years of age: a longitudinal study. Molecular Psychiatry, 18(5), 576-581.]

  • Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health, 2020
    Roadmap for Resilience serves as a blueprint for how communities, states, and nations can recognize and effectively address Adverse Childhood Experiences (ACEs) and toxic stress as a root cause to some of the most harmful, persistent, and expensive societal and health challenges facing our world today. The report provides clear cross-sector and equitable response solutions, models, and best practices to be replicated or tailored to serve community needs. This comprehensive report brings together ​insights from global experts across sectors, specialties, and disciplines to promote science-based approaches to primary, secondary, and tertiary prevention strategies for ACEs and toxic stress. The report further specifies a sector-specific and cross-sector roadmap for addressing ACEs and toxic stress at the state level, prioritizing prevention, ​early detection, evidence-based interventions and equity in outcomes, ​highlighting the need for enhanced coordination across the following sectors: healthcare; public health; social services; early childhood; education; and justice.

  • Spanking and Adult Mental Health Impairment: The Case for the Designation of Spanking as an Adverse Childhood Experience, 2017
    Spanking currently is not considered an ACE, but the physical and emotional abuse shown in previous research to correlate highly with poor health outcomes may be similar in nature to spanking. This study proposes that spanking is empirically similar to physical and emotional abuse and including spanking with abuse adds to our understanding of mental health problems.
    [Afifi, T.O., Ford, D., Gershoff, E.T., Merrick, M., Grogan-Kaylor, A., Ports, K.A., MacMillan, H.L., Holden, G.W., Taylor, C.A., Lee, S.J., & Bennett, R.P. (2017). Spanking and adult mental health impairment: The case for the designation of spanking as an adverse childhood experience. Child Abuse & Neglect, 71, 24-31.]


Positive Childhood Experiences (PCEs) and Resilience

  • Adverse Childhood Experiences: Assessing the Impact on Health and School Engagement and the Mitigating Role of Resilience, 2014
    Bethell et al (2014) found that children with higher ACE scores were less likely to demonstrate resilience, live in a protective home environment, have a mother who was healthy, and live in safe and supportive neighborhoods. However, almost half of the children who had experienced ACEs also demonstrated resilience, and “resilience mitigated the impact of adverse childhood experiences on grade repetition and school engagement.” 
    [Bethell, C., Newacheck, P., Hawes, E., & Halfon, N. Adverse childhood experiences: Assessing the impact on health and school engagement and the mitigating role of resilience. Health Affairs, 33(12).]

  • Adverse Childhood Experiences, Resilience and Mindfulness-Based Approaches: Common Denominator Issues for Children with Emotional, Mental, or Behavioral Problems, 2016
    This study examined ACEs, resilience, family protective factors, and emotional, mental or behavioral conditions (EMB) in children and youth in the U.S. The authors found that children with ACEs had higher EMB than children without ACEs, but the presence of resilience was significantly associated with lower amounts of EMB for both children with and without ACEs. In addition, the prevalence of EMB was lower when family protective factors were present, even if the child had ACEs, although the presence of two or more ACEs decreased the effect. 
    [Bethell, C., Gombojav, N., Solloway, M., & Wissow, L. (2016). Adverse childhood experiences, resilience and mindfulness-based approaches: Common denominator issues for children with emotional, mental, or behavioral problems. Child Adolesc Psychiatr Clin N Am, 25(2), 139-156.]

  • Balancing Adverse Childhood Experiences with HOPE, 2017
    This report presents evidence for HOPE (Health Outcomes of Positive Experiences) based on newly released, compelling data that reinforce the need to promote positive experiences for children and families in order to foster healthy childhood development despite the adversity common in so many families... This report contributes to a growing body of work – the Science of Thriving – that encourages us to better understand and support optimal child health and development.

  • Childhood Family Connection and Adult Flourishing: Associations Across Levels of Childhood Adversity, 2021
    Greater childhood family connection was associated with greater flourishing in US adults across levels of childhood adversity. Supporting family connection in childhood may influence flourishing decades later, even with early adversity. 
    [Whitaker, R., Dearth-Wesley, T., & Herman, A. (2021). Childhood family connection and adult flourishing: Associations across levels of childhood adversity. Academic Pediatrics.]

  • Effects of Positive and Negative Childhood Experiences on Adult Family Health, 2021 
    Childhood experiences affect family health in adulthood in the expected direction. Even in the presence of early adversity, positive experiences in childhood can provide a foundation for creating better family health in adulthood. 
    [Daines, C.L., Hansen, D., Novilla, M.L.B. & Crandall, A. (2021). Effects of positive and negative childhood experiences on adult family health. BMC Public Health, 21, 651.]

  • Examining the influence of positive childhood experiences on childhood overweight and obesity using a national sample, 2022
    Compared to children who were underweight or had a healthy weight, children who were overweight or obese were less likely to: participate after school activities, volunteer in their community, school, or church, have a mentor they feel comfortable going to for guidance, live in a safe neighborhood, live in a supportive neighborhood, and to live with a resilient family. In adjusted analysis, among children exposed to two or more ACEs, children residing in a supportive neighborhood were less likely to be overweight or obese. Our findings suggest that certain PCEs may mitigate overweight and obesity when children have experienced at least some childhood trauma.[Crouch, E., Radcliff, E., Kelly, K., et al., (2022). Preventive Medicine.]

  • Family Resilience and Connection Promote Flourishing Among US Children, Even Amid Adversity, 2019
    The presence of flourishing increased in a graded fashion with increasing levels of family resilience and connection. 
    [Bethell, C., Gombojav, N., & Whitaker, R. (2019). Family resilience and connection promote flourishing among US children, even amid adversity. Health Affairs 38(5).]

  • Influence of Race/Ethnicity and Income on the Link between Adverse Childhood Experiences and Child Flourishing, 2021
    The researchers conducted a secondary data analysis using the 2016–17 National Survey of Children’s Health data reported by parents/guardians for 44,686 children age 6–17 years. The data showed that family resilience partially mediated the ACEs-flourishing association. Although White and socioeconomically advantaged families were more likely to maintain family resilience, their children functioned more poorly at high-risk levels relative to Black and Hispanic children and across income groups.
    [Goldstein, E., Topitzes, J., Miller-Cribbs, J. et al. (2021). Influence of race/ethnicity and income on the link between adverse childhood experiences and child flourishing. Pediatr Res 89, 1861–1869.]

  • Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample: Associations Across Adverse Childhood Experiences Levels, 2019 
    Positive childhood experiences (PCEs) show dose-response associations with adult depression and/or poor mental health (D/PMH) and adult-reported social and emotional support (ARSES) after accounting for exposure to ACEs. The proactive promotion of PCEs for children may reduce risk for adult D/PMH and promote adult relational health. Findings support prioritizing possibilities to foster safe, stable nurturing relationships for children that consider the health outcomes of positive experiences. 
    [Bethell, C., Jones J., Gombojav, N., Linkenbach, J., & Sege R. (2019). Positive childhood experiences and adult mental and relational health in a statewide sample: Associations across adverse childhood experiences levels. JAMA Pediatr., 173(11), e193007.]

  • Resilience, 2016
    Every child is a unique individual. This individuality is evident in children exposed to psychosocial trauma or adverse childhood experiences. There exists wide variation in the way children respond to toxic stressors in their lives. Some children appear to be relatively unaffected, while others develop a variety of psychological, behavioral, and physical consequences. What is the explanation for this phenomenon? Resiliency has been suggested to explain this variation in pathology expressions in trauma-exposed children. It is vital for pediatric nurse practitioners to understand the concept of resilience. This continuing education offering will define concepts of resilience and stress, explore the neurobiology of resilience, and examine interventions that promote resilience in children.
    [Hornor G. (2017). Resilience. J Pediatr Health Care, 31(3), 384-390.]

  • Resilience Resources from The Harvard University Center on the Developing Child
    Reducing the effects of significant adversity on young children’s healthy development is critical to the progress and prosperity of any society. Yet not all children experience lasting harm as a result of adverse early experiences. Some may demonstrate “resilience,” or an adaptive response to serious hardship. A better understanding of why some children do well despite early adversity is important because it can help us design policies and programs that help more children reach their full potential. The Harvard University Center on the Developing Child has developed many resources related to resilience: