Skip to main content Accessibility help

A Critique of the Adverse Childhood Experiences Framework in Epidemiology and Public Health: Uses and Misuses

  • Michelle Kelly-Irving (a1) and Cyrille Delpierre (a2)


Adverse childhood experiences (ACEs) have emerged as a major research theme. They make reference to an array of potentially harmful exposures occurring from birth to eighteen years of age and may be involved in the construction of health inequalities over the lifecourse. As with many simplified concepts, ACEs present limitations. They include diverse types of exposures, are often considered cumulatively, can be identified using prospective and retrospective approaches, and their multidimensional nature may lead to greater measurement error. From a public health perspective, ACEs are useful for describing the need to act upon complex social environments to prevent health inequalities at a population level. As the ACEs concept becomes popular in the context of policy interventions, concerns have emerged. As a probabilistic and population-level tool, it is not adapted to diagnose individual-level vulnerabilities, an approach which could ultimately exacerbate inequalities. Here, we present a critique of the ACEs framework, discussing its strengths and limits.



Hide All
Appleton, A. A., Holdsworth, E., Ryan, M. and Tracy, M. (2017) ‘Measuring childhood adversity in life course cardiovascular research: a systematic review’, Psychosomatic Medicine, 79, 4, 434–40.
Barker, D. J. P. and Osmond, C. (1986) ‘Infant mortality, chidhood nutrition, and ischaemic heart disease in England and Wales’, The Lancet, 1, 1077–81.
Brown, D. W., Anda, R. F., Felitti, V. J., Edwards, V. J., Malarcher, A. M., Croft, J. B. and Giles, W. H. (2010) ‘Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study’, BMC Public Health, 10, 20.
Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R., Edwards, V. J. and Anda, R. F. (2004) ‘Adverse childhood experiences and the risk of depressive disorders in adulthood’, Journal of Affective Disorders, 82, 2, 217–25.
Clark, C., Caldwell, T., Power, C. and Stansfeld, S. A. (2010) ‘Does the influence of childhood adversity on psychopathology persist across the lifecourse? A 45-year prospective epidemiologic study’, Annals of Epidemiology, 20, 5, 385–94.
Danese, A., Moffitt, T. E., Harrington, H., Milne, B. J., Polanczyk, G., Pariante, C. M., Poulton, R. and Caspi, A. (2009) ‘Adverse childhood experiences and adult risk factors for age-related disease depression, inflammation, and clustering of metabolic risk markers’, Archives of Pediatrics and Adolescent Medicine, 163, 12, 1135–43.
Dong, M., Giles, W. H., Felitti, V. J., Dube, S. R., Williams, J. E., Chapman, D. P. and Anda, R. F. (2004) ‘Insights into causal pathways for ischemic heart disease: adverse childhood experiences study’, Circulation, 110, 13, 1761–6.
Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P., Williamson, D. F. and Giles, W. H. (2001) ‘Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study’, JAMA, 286, 24, 3089–96.
Dube, S. R., Felitti, V. J., Dong, M., Giles, W. H. and Anda, R. F. (2003) ‘The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900’, Preventive Medicine, 37, 3, 268–77.
Engels, F. (1987) ‘The condition of the working class in England’, American Journal of Public Health, 93, 8, 171–84.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P. and 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, 245–58.
Finkelhor, D. (2018) ‘Screening for adverse childhood experiences (ACEs): cautions and suggestions’, Child Abuse and Neglect, 85, 174–9.
Francis, D., Diorio, J., Liu, D. and Meaney, M. J. (1999) ‘Nongenomic transmission across generations of maternal behavior and stress responses in the rat’, Science, 286, 5442, 1155–8.
Hardt, J. and Rutter, M. (2004) ‘Validity of adult retrospective reports of adverse childhood experiences: review of the evidence’, Journal of Child Psychology and Psychiatry and Allied Disciplines, 45, 2, 260–73.
Hartas, D. (2019) ‘Assessing the foundational studies on adverse childhood experiences’, Social Policy and Society, doi: 10.1017/S1474746419000034.
Hill, A. B. (1965) ‘The environment and disease: association or causation?’, Proceedings of the Royal Society of Medicine, 58, 5, 295300.
Holman, D. M., Ports, K. A., Buchanan, N. D., Hawkins, N. A., Merrick, M. T., Metzler, M. and Trivers, K. F. (2016) ‘The association between adverse childhood experiences and risk of cancer in adulthood: a systematic review of the literature’, Pediatrics, 138, Supplement 1, S81–91.
Houtepen, L., Heron, J., Suderman, M., Tilling, K. and Howe, L. (2018) ‘Adverse childhood experiences in the children of the Avon Longitudinal Study of Parents and Children (ALSPAC) [version 1; referees: 1 approved]’, Wellcome Open Research, 3, 106.
Hughes, K., Bellis, M. A., Hardcastle, K. A., Sethi, D., Butchart, A., Mikton, C., Jones, L. and Dunne, M. P. (2017) ‘The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis’, The Lancet Public Health, 2, 8, e356–66.
Kelly-Irving, M., Lepage, B., Dedieu, D., Bartley, M., Blane, D., Grosclaude, P., Lang, T. and Delpierre, C. (2013a) ‘Adverse childhood experiences and premature all-cause mortality’, European Journal of Epidemiology, 28, 9, 721734.
Kelly-Irving, M., Lepage, B., Dedieu, D., Lacey, R., Cable, N., Bartley, M., Blane, D., Grosclaude, P., Lang, T. and Delpierre, C. (2013b) ‘Childhood adversity as a risk for cancer: findings from the 1958 British birth cohort study’, BMC Public Health, 13, 1, 767.
Krieger, N. (1994) ‘Epidemiology and the web of causation: has anyone seen the spider?’, Social Science and Medicine, 39, 7, 887903.
Kuh, D., Power, C., Blane, D. and Bartley, M. (1997) Social pathways between childhood and adult health, in Kuh, D. and Ben-Shlomo, Y. (eds.), A Life Course Approach to Chronic Disease Epidemiology, Oxford: Oxford University Press.
Liu, D., Diorio, J., Tannenbaum, B., Caldji, C., Francis, D., Freedman, A., Sharma, S., Pearson, D., Plotsky, P. M. and Meaney, M. J. (1997) ‘Maternal care, hippocampal glucocorticoid receptors, and hypothalamic-pituitary-adrenal responses to stress’, Science, 277, 5332, 1659–62.
Lupien, S. J., McEwen, B. S., Gunnar, M. R. and Heim, C. (2009) ‘Effects of stress throughout the lifespan on the brain, behaviour and cognition’, Nature Reviews Neuroscience, 10, 6, 434–45.
Lynch, J. W., Davey Smith, G., Kaplan, G. A. and House, J. S. (2000) ‘Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions’, British Medical Journal, 320, 1200–04.
Marmot, M. and Wilkinson, R. G. (2001) ‘Psychosocial and material pathways in the relation between income and health: a response to Lynch et al.’, British Medical Journal, 322, 1233–36.
Metzler, M., Merrick, M. T., Klevens, J., Ports, K. A. and Ford, D. C. (2017) ‘Adverse childhood experiences and life opportunities: shifting the narrative’, Children and Youth Services Review, 72, 141–9.
Poulter, M. O., Du, L., Weaver, I. C. G., Palkovits, M., Faludi, G., Merali, Z., Szyf, M. and Anisman, H. (2008) ‘GABAA receptor promoter hypermethylation in suicide brain: implications for the involvement of epigenetic processes’, Biological Psychiatry, 64, 8, 645–52.
Public Health Wales (2015) Welsh Adverse Childhood Experiences Study, Wales: Public Health Wales NHS Trust.
Ridout, K. K., Khan, M. and Ridout, S. J. (2018) ‘Adverse childhood experiences run deep: toxic early life stress, telomeres, and mitochondrial dna copy number, the biological markers of cumulative stress’, Bioessays, 40, 9, e1800077.
Rutter, M. (1980) ‘The long-term effects of early experience’, Developmental Medicine and Child Neurology, 22, 6, 800–15.
Shonkoff, J. P. and Philips, D. A. (2000) From Neurons to Neighborhoods: The Science of Early Childhood Development, Washington: National Academy Press.
Solis, C. B., Kelly-Irving, M., Fantin, R., Darnaudery, M., Torrisani, J., Lang, T. and Delpierre, C. (2015) ‘Adverse childhood experiences and physiological wear- and-tear in midlife: findings from the 1958 British birth cohort’, Proceedings of the National Academy of Sciences of the United States of America, 112, 7, E738–46.
Susser, M. and Susser, E. (1996) ‘Choosing a future for epidemiology: I. Eras and paradigms’, American Journal of Public Health, 86, 5, 668–73.
Townsend, P. and Davidson, N. (1982) Inequalities in Health: the Black Report, Middlesex: Penguin.


A Critique of the Adverse Childhood Experiences Framework in Epidemiology and Public Health: Uses and Misuses

  • Michelle Kelly-Irving (a1) and Cyrille Delpierre (a2)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed