🚧 Website Maintenance in Progress: Thank you for visiting! We are currently in the process of enhancing our website to serve you better. Please check back soon for our new and improved website.

According to the U.S. Centers for Disease Control and Prevention (CDC), one in six adults has reported at least one adverse childhood experience (ACE) with approximately 16% of the population endorsing four or more ACEs (2019). ACEs are associated with negative physical and psychological health issues, including early death, chronic disease, loneliness, revictimization, substance use, and both depressive and anxiety symptoms (Bryant et al., 2020; Hatton-Bowers et al., 2021; Kendall-Tackett, 2022; Kim et al., 2022; Thompson & Kingree, 2022). The risks associated with ACEs carry significant implications for health practitioners and emphasize the need for accurate screening and treatment. One such tool, the ACE screener, is among the most frequently used measures of the presence of ACEs (McLennan et al., 2020). Items are categorized according to three domains of adversity, namely: childhood abuse, neglect, and household dysfunction (Holden et al., 2020; Felitti et al., 1998). 

The ACE screener remains a widely used tool in clinical psychology to determine prevalence rates and correlations between childhood adversity and other latent constructs (McLaughlin et al., 2012). Additionally, it can be used as a screening tool for psychologists and psychiatrists to determine a lifetime history of trauma or adversity (National Child Traumatic Stress Network [NCTSN], 2021). Clinicians often include the ACE screener in case conceptualization and treatment decisions, underscoring the role of this questionnaire in developing trauma-informed interventions. 

Previous studies have found that a history of ACEs increases the risk of developing PTSD and more severe symptomatology (Brockie et al., 2015; Herzog & Schmahl, 2018). For example, Brockie et al. (2015) found that 21% of people who reported ACEs and a subsequent Criterion A event endorsed PTSD symptoms. Research suggests that high ACEs predispose individuals to other psychological disorders, such as depressive disorders, anxiety disorders, substance use disorders, and PTSD (Chapman et al., 2004; Gardner 2019 et al., 2019; LeTendre and Reed 2017). Risk for suicide also becomes significant for those with histories of ACEs. For example, the CDC reports that individuals with four or more ACEs are 30 times more likely to have a lifetime suicide attempt (2022). Considering the impact of childhood adversity on overall well-being, practitioners require malleable tools that identify applicable traumatic events. 

Numerous adaptations of this tool exist, including but not limited to the two-item ACE screener (Wade et al., 2017), ACE-R (Finkelhor et al., 2015), ACE-Q (Tranter et al., 2021), and the ACE-IQ (World Health Organization [WHO], 2012). Some revised versions of the ACE screener are limited to questions regarding childhood abuse and neglect, while others refer to exposure to non-violent familial violence, low socioeconomic status, and peer victimization. Researchers and clinicians have speculated that beyond the original ten items, there may be other potential ACEs. For example, Finkelhor et al. (2015) included an additional four items such as community violence exposure, peer bullying, peer isolation, and poverty. Additionally, a history of ACEs may exacerbate physical and psychological health consequences experienced from the COVID-19 pandemic (Browne et al., 2022). However, many traumatic childhood experiences are not found in the ACE screener and most adaptations refer to limited domains (see Table 1). 

Grief experienced in childhood is another potential ACE that deserves attention due to its impact on development, adult functioning, and treatment outcome. Recent devastating events have increased public awareness of traumatic loss, such as mass shootings, pandemic-related deaths, police-community violence, and suicides. Statistics have soared, as the CDC reported that more than one in seven people die a violent death each hour (CDC, 2019). These include death by firearm, assault, suicide, or other violent means. Moreover, research suggests a dose-effect for multiple losses, similar to the increased risk of negative outcomes for those endorsing more than one ACE (Hamai & Felitti, 2022). This article outlines the detrimental impact of loss during childhood, accentuating its need to be included in future iterations of the ACE screener. 

Death in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association; DSM)

Contrary to most diagnoses in the fifth edition of the DSM (American Psychiatric Association, 2022), trauma-related disorders require specific experiences of adversity for individuals to meet diagnostic criteria. Although widely debated (Holmes et al., 2016; Stein et al., 2016; Weathers & Keane, 2007), Criterion A of PTSD recognizes death as a qualifying traumatic experience to meet diagnostic criteria. More specifically, diagnostic criteria refer to learning that an accidental or violent death happened to a close friend or family member. Nevertheless, learning of or witnessing the death of a loved one has not been included in the ACE screener. Adjusting the ACE screener to include loss or grief may increase its clinical utility, as this could indicate essential points of intervention. 

Prolonged Grief Disorder (PGD), recently added to the DSM-5-TR, further highlights the long-lasting effects of grief on well-being (American Psychiatric Association,2022). An estimated 16% of individuals with PGD experience clinical impairment (Rosner et al., 2021). Other research examining the association between characteristics of the death event and the development of PGD found that recent deaths, accidental deaths, death of siblings, and the death of a spouse from unnatural causes are positively associated with a greater potential risk of developing PGD (Gang et al., 2022). If the ACE screener does not evolve with the field, this tool will become outdated and impede trauma-informed care. 

Loss of Family and Friends 

Loss experienced before the age of 18 increases the risk of pathological grief reactions as subsequent developmental barriers prevent adaptive coping (Crehan, 2004). According to the World Health Organization, there are over six million confirmed deaths linked to the COVID-19 pandemic to date. Arguably, children and adolescents have been disproportionately affected by these unprecedented periods of loss, as many grieve one or more primary caregivers. With over 140,000 children orphaned in the United States, insufficient research regarding the impact of caregiver loss on adult functioning is problematic (CDC, 2021). Loss of primary caregivers has been linked to substantial health and psychological consequences, including premature death, suicidal ideation, and depressive episodes (Brent et al., 2009; Keyes et al., 2014; Oosterhoff et al., 2018). Referred to as the ‘silent epidemic’ (Layne & Kaplow, 2020), longitudinal studies have found the loss of a caregiver to be the most frequently reported adverse experience during childhood (Keyes et al., 2014). 
Loss, however, is not limited to caregiver death. According to Fletcher et al. (2013), almost 10% of individuals report the death of a sibling before the age of 25. The effects of sibling death reach beyond childhood grief, as this event could trigger other adversities such as parental bereavement, lack of social support and family conflict (Crehan, 2004). Additionally, loss of friends prior to age 18 may also result in significant distress, especially when considering limited developmental capacity of understanding death among young children (Cowan, 2010). As an estimated 2.2 million youth die each year, death of friends and the effects thereof on children and adolescents require clinical attention (You, 2015). 

Furthermore, research has suggested that multiple losses lead to more severe maladaptive grief reactions (Neimeyer, 2016). Previous literature has associated bereavement overload with increased feelings of hopelessness, guilt, and existential crises (Corr, 2003). Despite the prevalence of loss during childhood, as well as the profound impact into adulthood, this adverse experience is not currently included in any adaptations of the ACE screener. 

Conclusion: A Call to Action

Taken together, research and current events reflect the concrete need for loss to be considered a profound adverse experience. As a cost-effective and convenient screener, including grief-related experiences in the ACEs will address the needs of a clinical population disregarded by past research. The legitimacy and effectiveness of mental health professionals rely on evidence-based practice and practitioners informed by science. Therefore, a screener for ACEs that excludes a prevalent form of adversity so deleterious for children and adults is a serious limitation to the field.

About the Authors

Luca Hartman, BA (she/her) is a second-year clinical psychology student at Nova Southeastern University. Her research and clinical interests are in childhood adversity, racial trauma and adult survivors of trauma. She is completing her first practicum at the Child and Adolescent Traumatic Stress Program in addition to working as a research co-coordinator of the Trauma Resolution and Integration Program. 

Brianna Domaceti, BA (she/her) is a second-year clinical psychology student at Nova Southeastern University. Her research and clinical interests are in complex trauma and the therapeutic alliance. She is completing her first practicum at the Anxiety Treatment Center. She is also a member of two trauma-based research groups.

Amy E. Ellis, PhD (she/her) is an assistant professor and the director of the Trauma Resolution and Integration Program at Nova Southeastern University. Her research and clinical work focus on complex trauma and increasing treatment engagement and enhancing treatment services for LGBTQ+ individuals.

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision [DSM-5-TR]. 

Brent, D., Melhem, N., Donohoe, M. B., & Walker, M. (2009). The incidence and course of depression in bereaved youth 21 months after the loss of a parent to suicide, accident, or sudden natural death. American Journal of Psychiatry, 166(7), 786-794.

Brockie, T. N., Dana-Sacco, G., Wallen, G. R., Wilcox, H. C., & Campbell, J. C. (2015). The relationship of adverse childhood experiences to PTSD, depression, poly-drug use and suicide attempt in reservation-based Native American adolescents and young adults. American Journal of Community Psychology, 55(3-4), 411–421.

Browne, A., Stafford, O., Berry, A., Murphy, E., Taylor, L. K., Shevlin, M., . . . Burke, T. (2022). Psychological flexibility mediates wellbeing for people with adverse childhood experiences during COVID-19. Journal of Clinical Medicine, 11(2)

Bryant, D. J., Oo, M., & Damian, A. J. (2020). The rise of adverse childhood experiences during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12, S193-S194.
 
 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control Web‐Based Injury Statistics Query and Reporting System (WISQARS), (2019).

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control Web‐Based Injury Statistics Query and Reporting System (WISQARS), (2021).

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control Web‐Based Injury (2022). Adverse childhood experiences, overdose, and suicide.

Corr, C. A. (2003). Loss, grief, and trauma in public tragedy. In M. Lattanzi-Licht, & K. J. Doka (Eds.), Living with grief: Coping with public tragedy; living with grief: Coping with public tragedy (pp. 63-76, Chapter vi, 314 Pages). New York, NY: Brunner-Routledge.

Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R., Edwards, V. J., & Anda, R. F. (2004). Adverse childhood experiences and the risk of depressive disorders in adulthood. Journal of Affective Disorders, 82(2), 217-225.

Crehan, G. (2004). The surviving sibling: The effects of sibling death in childhood. Psychoanalytic Psychotherapy, 18(2), 202-219.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., 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 Preventative Medicine, 14(4), 245–58.

Finkelhor D., Shattuck A., Turner H., & Hamby S. (2015). A revised inventory of adverse childhood experiences. Child Abuse & Neglect, 48, 13-21.  

Fletcher, J., Mailick, M., Song, J., & Wolfe, B. (2013). A sibling death in the family: Common and consequential. Demography, 50(3), 803-826. doi: 10.1007/s13524-012-0162-4

Cowan, D. S. (2010). Death of a friend during childhood. In C. A. Corr, & D. E. Balk (Eds.), Children's encounters with death, bereavement, and coping; children's encounters with death, bereavement, and coping (pp. 219-236, Chapter xxv, 488 Pages). New York, NY: Springer Publishing Company.

Gang, J., Falzarano, F., She, W. J., Winokur, H., & Prigerson, H. G. (2022). Are deaths from covid-19 associated with higher rates of prolonged grief disorder (PGD) than deaths from other causes? Death Studies,46(6), 1287-1296.

Gardner, M. J., Thomas, H. J., & Erskine, H. E. (2019). The association between five forms of child maltreatment and depressive and anxiety disorders: A systematic review and meta-analysis. Child Abuse & Neglect, 96, 19.

Hamai, T. A., & Felitti, V. J. (2022). Adverse childhood experiences: Past, present, and future. In R. Geffner, J. W. White, L. K. Hamberger, A. Rosenbaum, V. Vaughan-Eden & V. I. Vieth (Eds.), Handbook of interpersonal violence and abuse across the lifespan: A project of the national partnership to end interpersonal violence across the lifespan (NPEIV); handbook of interpersonal violence and abuse across the lifespan: A project of the national partnership to end interpersonal violence across the lifespan (NPEIV) (pp. 97-120, Chapter lxix, 4956 Pages). Cham: Springer Nature Switzerland AG.

Hatton-Bowers, H., Lombardi, C. M., Kemp, B., Decker, K. B., Virmani, E. A., Brophy-Herb, H., & Vallotton, C. D. (2021). Risks and resources for college students’ mental health: ACEs, attachment, and mindfulness. Journal of American College Health, 9, 1-12.

Herzog, J. I., & Schmahl, C. (2018). Adverse childhood experiences and the consequences on neurobiological, psychosocial, and somatic conditions across the lifespan. Frontiers in Psychiatry, 9, 420.

Holden, G. W., Gower, T., & Chmielewski, M. (2020). Methodological considerations in ACEs research. In G. J. G. Asmundson, & T. O. Afifi (Eds.), Adverse childhood experiences: Using evidence to advance research, practice, policy, and prevention; adverse childhood experiences: Using evidence to advance research, practice, policy, and prevention (pp. 161-182, Chapter xix, 364 Pages). San Diego, CA: Elsevier Academic Press.

Holmes, S. C., Facemire, V. C., & DaFonseca, A. M. (2016). Expanding criterion A for Posttraumatic Stress Disorder: Considering the deleterious impact of oppression. Traumatology, 22(4), 314.

Kendall-Tackett, K. (2022). The health effects of childhood abuse and adversity: Mechanisms, consequences, and trauma-informed care. In R. Geffner, J. W. White, L. K. Hamberger, A. Rosenbaum, V. Vaughan-Eden & V. I. Vieth (Eds.), Handbook of interpersonal violence and abuse across the lifespan: A project of the national partnership to end interpersonal violence across the lifespan (NPEIV); handbook of interpersonal violence and abuse across the lifespan: A project of the national partnership to end interpersonal violence across the lifespan (NPEIV) (pp. 4409-4424, Chapter lxix, 4956 Pages). Cham: Springer Nature

Keyes, K. M., Pratt, C., Galea, S., McLaughlin, K. A., Koenen, K. C., & Shear, M. K. (2014). The burden of loss: unexpected death of a loved one and psychiatric disorders across the life course in a national study. American Journal of Psychiatry, 171(8), 864-871.

Kim, Y., Lee, H., & Aely, P. (2022). Patterns of adverse childhood experiences and depressive symptoms: Self-esteem as a mediating mechanism. Social Psychiatry and Psychiatric Epidemiology, 57(2), 331-341.

Layne, C. M., & Kaplow, J. B. (2020). Assessing bereavement and grief disorders. In E. A. Youngstrom, M. J. Prinstein, E. J. Mash, & R. A. Barkley (Eds.), Assessment of disorders in childhood and adolescence (pp. 471–508). The Guilford Press.

LeTendre, M. L., & Reed, M. B. (2017). The effect of adverse childhood experience on clinical diagnosis of a substance use disorder: Results of a nationally representative study. Substance use & Misuse, 52(6), 689-697.

McLaughlin, K. A., Green, J. G., Gruber, M. J., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2012). Childhood adversities and first onset of psychiatric disorders in a national sample of US adolescents. JAMA Psychiatry, 69(11), 1151-1160. doi: 10.1001/archgenpsychiatry.2011.2277.

McLennan, J. D., MacMillan, H. L., & Afifi, T. O. (2020). Questioning the use of adverse childhood experiences (ACEs) questionnaires. Child Abuse & Neglect, 101, 4.

National Child Traumatic Stress Network. (2021). Beyond the ACE Score: Perspectives from the NCTSN on Child Trauma and Adversity Screening and Impact. Retrieved June 20, 2022, from https://www.nctsn.org/resources/beyond-the-ace-score-perspectives-from-the-nctsn-on-child-trauma-and-adversity-screening-and-impact

Neimeyer, R. A. (2016). Disentangling multiple loss. In R. A. Neimeyer (Ed.), Techniques of grief therapy: Assessment and intervention; techniques of grief therapy: Assessment and intervention (pp. 153-156, Chapter xxiii, 352 Pages). New York, NY: Routledge/Taylor & Francis Group. Retrieved from https://ezproxylocal.library.nova.edu/login

Oosterhoff, B., Kaplow, J. B., & Layne, C. M. (2018). Links between bereavement due to sudden death and academic functioning: Results from a nationally representative sample of adolescents. School Psychology Quarterly, 33, 372-380.

Rosner, R., Comtesse, H., Vogel, A., & Doering, B. K. (2021). Prevalence of prolonged grief disorder. Journal of Affective Disorders, 287, 301-307.

Stein, J. Y., Wilmot, D. V., & Solomon, Z. (2016). Does one size fit all? Nosological, clinical, and scientific implications of variations in PTSD Criterion A. Journal of Anxiety Disorders, 43, 106-117.

Thompson, M. P., & Kingree, J. B. (2022). Adverse childhood experiences, sexual victimization, and suicide ideation and attempts: A longitudinal path analysis spanning 22 years. American Journal of Orthopsychiatry, 92(3), 302.

Tranter, H., Brooks, M., & Khan, R. (2021). Adverse childhood experiences questionnaire--amended version 

Wade, R., Jr., Becker, B. D., Bevans, K. B., Ford, D. C., & Forrest, C. B. (2017). Development and evaluation of a short adverse childhood experiences measure.American Journal of Preventive Medicine, 52(2), 163-172.

Weathers, F. W., & Keane, T. M. (2007). The Criterion A problem revisited: Controversies and challenges in defining and measuring psychological trauma. Journal of Traumatic Stress, 20(2), 107-121.

World Health Organization. (2012). Adverse childhood experiences international questionnaire (ACE-IQ) – rationale for ACE-IQ.

You, D., Hug, L., Ejdemyr, S., Idele, P., Hogan, D., Mathers, C., Gerland, P., New, J. R., Alkema, L., & United Nations Interagency Group for Child Mortality Estimation (UN IGME) (2015). Global, regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation. Lancet (London, England), 386(10010), 2275–2286.

Table 1.
Items across ACE measures.

Items ACE
(Felitti et al., 1998)
ACE-2
(Smith et al., 2020)
ACE-R
(Finkelhor et al., 2015)
ACE-Q
(Tranter et al., 2021)
ACE-IQ
(WHO, 2012)
Emotional abuse X X X X X
Physical abuse X X X X
Sexual abuse X X X X
Neglect  X   X X X
Household dysfunction X X X X X
Exposure to non-familial violence         X
Low socioeconomic status     X    
Community violence exposure      X   X
Peer victimization     X   X
Peer isolation/
rejection
    X    
Collective violence         X