We Are More Than Our Numbers: Understanding and Responding to Adverse Childhood Experience Scores (ACEs) - Expanded Course

A consensus of scientific research demonstrates that cumulative adversity, especially when experienced during childhood development, is a root cause of some of the most harmful, persistent, and expensive health challenges facing our nation. “Adverse Childhood Experiences,” or “ACEs,” comes from the landmark 1998 Adverse Childhood Experiences Study (ACE Study). The study, conducted by Kaiser Permanente and the US Centers for Disease Control and Prevention (CDC), is one of the largest investigations ever conducted to assess connections between early adversity and long-term health.1
The study examined exposure to childhood adversity, including abuse, neglect, and household dysfunction like domestic violence, parental mental illness, and parental substance abuse. Researchers assigned an “ACE score” to each participant by adding up the number of categories of adversities the participant reported. The study highlighted two things: ACEs are incredibly common and the higher the ACE score, the higher the risk for acute and chronic disease for both children and adults. While patients are more than their ACE scores, the number plays a role in assessing health risk mediated by the toxic stress physiology.  ACEs Aware and the California Surgeon General recommend the Roadmap to Resilience for ACE screening.  A complete ACE screen involves assessing for the triad of adversity (ACE score), clinical manifestations of toxic stress (ACE-Associated Health Conditions), and protective factors. The first two components are used in assessing clinical risk for toxic stress and all three help to guide effective responses.  ACEs and toxic stress are significant public health issues and family physicians/primary care physicians can play a major role in improving outcomes for patients by engaging in the screening and management of these areas.2
Trauma-informed care (TIC) is one part of the necessary response. It uses childhood trauma as a lens to understand the range of cognitive, emotional, physical, and behavioral symptoms and health risks seen when individuals enter and move through systems of care.
The ACEs Aware initiative uses the following definition of a trauma-informed approach and principles. The principles are based on the Substance Abuse and Mental Health Services Administration (SAMHSA) definition but vary slightly in that they incorporate the biological susceptibility to toxic stress.
Approach 3
     A trauma-informed approach to clinical care is defined as having these components:
  • A foundation grounded in trauma-informed principles and a team approach to care;
  • An environment that is calm, safe, and empowering for patients;
  • Education about the impacts of current and past trauma (and other adversities) on health; and
  • Inquiry about and response to recent and past trauma that includes onsite or community-based resources and treatments.
Principles 4
  • Establish the physical and emotional safety of patients and staff;
  • Build trust between providers and patients;
  • Recognize the signs and symptoms of trauma exposure on physical and mental health;
  • Promote patient-centered, evidence-based care;
  • Ensure provider and patient collaboration by bringing patients into the treatment process and discussing mutually agreed upon goals for treatment; and
  • Provide care that is sensitive to the patient’s racial, ethnic, and cultural background, and gender identity
Individuals who have experienced traumatic life events are often very sensitive to situations that remind them of the people, places or things involved in their traumatic event.


This activity is supported by an unrestricted grant from the California Department of Health Care Services.


There is no charge for this activity.


This activity will not include discussions of products or devices that are not currently approved for use by the Food and Drug Administration (FDA), and the curriculum clearly indicates this fact.


Learners must register to participate in and receive credit for this online educational activity.  Read the target audience, learning objectives, and author disclosures.  Study the educational content online and choose the best answers to each question.  For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.


CAFP policy and California state law requires that each learning activity have elements of cultural and linguistic proficiency included in the content. This activity includes discussions of special populations and tools to use for patient communications.


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For questions regarding the content of this activity or for technical assistance, contact cafp@familydocs.org.
The CAFP has made all reasonable efforts to ensure that information contained herein is accurate in accordance with the latest available scientific knowledge at the time of accreditation of this continuing education program. Information regarding drugs (e.g., their administration, dosages, contraindications, adverse reactions, interactions, special warnings, and precautions) and drug delivery systems is subject to change, however, and the learner is advised to check the manufacturer's package insert for information concerning recommended dosage and potential problems or cautions prior to dispensing or administering the drug or using the drug delivery systems.
Approval of credit for this continuing education program does not imply endorsement by CAFP of any product or manufacturer identified.
Any medications or treatment methods suggested in this CME activity should not be used by the practitioner without evaluation of their patient's condition(s) and possible contraindication(s) or danger(s) of use of any specific medication.


© 2021 California Academy of Family Physicians. All rights reserved. No part of this activity may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embedded in articles or reviews.


Target Audience

This educational activity, designed for family physicians and their health care team members, stresses the relationship between ACE scores and ACE-Associated Health Conditions, including non-communicable diseases, and provides information on screening, treatment, management of ACEs and toxic stress, and trauma-informed care.

Learning Objectives

After reading this publication, learners should be able to:

  1. Define Adverse Childhood Experiences (ACEs), their prevalence, and their effects on health, including ACE-Associated Health Conditions (https://www.acesaware.org/treat/the-science-of-aces-toxic-stress/ ).5
  2. Explain the role of trauma and ACEs in patients’ risk for toxic stress and associated health conditions.
  3. Engage in conversations with their health care team members and their patients about ACE  screening, the screening triad, and TIC.


Additional Information

PDF icon References and Resources.pdf782.54 KB
Course summary
Available credit: 
  • 3.50 AAFP Prescribed
  • 3.50 AOA Category 2-A
  • 3.50 CA Board of Registered Nursing
Course opens: 
Course expires: 


Conflict of Interest Statements:

The Committee on Continuing Professional Development and CME will be responsible for mitigating any relevant financial relationships disclosed by an individual who may have influence on content, who have served as faculty, or who may produce CME/CPD content for the CAFP. Mitigation may include learner notification, peer review of content before presentation, requirement of EB-CME, changing topics, or even dismissing a potential faculty member.

It is the policy of the CAFP to ensure independence, balance, objectivity, scientific rigor, and integrity in all continuing education activities. All individuals with potential to influence the content of this program have submitted Disclosure of Interest declarations that have been reviewed according to policy. Learner notification of declarations is below. All individuals with relevant financial relationships with ineligible companies have been contacted by CAFP staff or CCPD members, and issues of conflict have been discussed and mitigated.


Brent Sugimoto is founder and Chief Medical Officer of Decoded Health, a clinical automation software company. This relevant financial relationship has been mitigated.
All other individuals associated with this activity declare that they have no financial relationships with ineligible companies to disclose.





Brent Sugimoto, MD, MPH, FAAFP
Editor, California Family Physician magazine
Planner, Author and Editor
See above. Mitigated
Shelly Rodrigues, CAE, MS, FACEHP
CAFP, Deputy Executive Vice President
Planner, Author and Editor
Nothing to Disclose
Jessie Liu, MD
Contra Costa Regional Medical Center FMRP
Nothing to Disclose
Sway Wu, MD
John Muir FMRP
Nothing to Disclose
Adia Scrubb, MD, MPP
John Muir FMRP
Nothing to Disclose
Janani Sankara, MD, MPH
Scripps-Chula Vista FMRP
Nothing to Disclose
Serena Liu, MD
John Muir FMRP
Nothing to Disclose
Nadine Burke-Harris, MD, FAAP
State of California, Surgeon General
Nothing to Disclose
Devika Bhushan, MD, FAAPChief Health Officer, Office of the Surgeon GeneralReviewerNothing to Disclose
Tanya Schwartz, MSW, MPPAurrera ConsultingReviewerNothing to Disclose
Brigid McGaw, MD, MPH, FACPAurrera ConsultingReviewerNothing to Disclose
Matt SchuellerOffice of the Surgeon GeneralReviewerNothing to Disclose

3.50 AAFP Prescribed

This Enduring Material activity, We Are More Than Our Numbers: Understanding and Responding to Adverse Childhood Experience Scores (ACEs) - Expanded Course, has been reviewed and is acceptable for up to 3.50 Prescribed credit(s) by the American Academy of Family Physicians. AAFP certification begins 05/21/2021. Term of approval is for one year from this date.

AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 credit(s)™ toward the AMA Physician’s Recognition Award. When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed, not as Category 1.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

3.50 CA Board of Registered Nursing

The California Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The California Academy of Family Physicians is an approved provider through the California Board of Registered Nursing, number #1809. This activity is approved for 3.50 nursing credits.

Clinicians should only claim credit commensurate with the extent of their participation in the activity.

3.50 AOA Category 2-A

The California Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. This activity is approved for 3.50 AOA Category 2-A credits. 

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Available Credit

  • 3.50 AAFP Prescribed
  • 3.50 AOA Category 2-A
  • 3.50 CA Board of Registered Nursing
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