Adverse childhood experiences (ACEs) are the traumatic experiences in a person’s life occurring before the age of 18 years that the person remembers as an adult and that have consequences on a diverse set of outcomes. ACEs include physical abuse, sexual abuse, emotional abuse, mental illness of a household member, problematic drinking or alcoholism of a household member, illegal street or prescription drug use by a household member, divorce or separation of a parent, domestic violence toward a parent, and incarceration of a household member. Each of these experiences before the age of 18 years increases the likelihood of not only adulthood depression, suicide, and substance use disorders, but also a range of nonpsychiatric outcomes such as heart disease and chronic lung disease.

Case summary

Ellie is a 16-year-old girl with a past history of ADHD and oppositionality who arrives on her own in a walk-in clinic to be seen for a sports physical. Ellie has been generally healthy and was previously on a stable medical regimen of methylphenidate but has not been taking it for about 1 year. The oppositionality that she previously experienced in her early school-age years has slowly decreased. She generally does well in school and is in several clubs. In the course of the history, Ellie reveals that her mother’s depression has been worse lately to the point where her mother has resumed her drinking and illegal opiate use. You discuss safety with Ellie, and she reveals that, while she has never been threatened or injured, there has been domestic violence in the home that Ellie felt responsible to try to stop by calling the police. This led to the one and only time that Ellie was physically struck. Her father is now incarcerated, and Ellie feels guilty. After a discussion with Ellie, you report this situation to social services, who already has the case on file. Ellie’s mental status exam, including a thorough examination of symptoms of mood disorders, anxiety, substance use, and PTSD, is within normal limits.

Case discussion

Ellie has suffered a set of ACEs. Specifically, her mother has a mental illness, has a drinking problem, and uses illegal drugs; Ellie has witnessed domestic violence toward her mother, has a family member who is incarcerated, and has suffered from physical abuse. This ACEs score of 6 puts her at markedly increased risk for multiple psychiatric and nonpsychiatric medical outcomes. Individuals with scores of 4 or above on the simple ACEs questionnaire have demonstrated a 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempts. Further, studies have shown a twofold to fourfold increase in smoking, poor self-rated health, increased numbers of sexual partners and sexually transmitted disease, and 1.4- to 1.6-fold increase in physical inactivity and severe obesity ( Am J Prev Med. 1998 May;14[4]:245-58 ). In Ellie’s case, her history of ADHD and family history of substance use puts her at even further increased risk for later substance use disorders.

While there is no pharmacotherapy or psychotherapy specific to the treatment of having suffered adversity, it is critical for the clinician to note her increased risk. Ellie would be an individual for whom health promotion and prevention would be critical. It is excellent that she is exercising and participating in sports, which appear to be protective. Careful counseling and follow-up with regard to her increased risk for psychiatric and nonpsychiatric disorders is paramount.

Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at


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