Prevalence of Adverse Childhood Experiences Among U.S. Adults — Behavioral Risk Factor Surveillance System, 2011–2020

Abstract

Adverse childhood experiences (ACEs) are defined as preventable, potentially traumatic events that occur among persons aged <18 years and are associated with numerous negative outcomes; data from 25 states indicate that ACEs are common among U.S. adults (1). Disparities in ACEs are often attributable to social and economic environments in which some families live (2,3). Understanding the prevalence of ACEs, stratified by sociodemographic characteristics, is essential to addressing and preventing ACEs and eliminating disparities, but population-level ACEs data collection has been sporadic (1). Using 2011-2020 Behavioral Risk Factor Surveillance System (BRFSS) data, CDC provides estimates of ACEs prevalence among U.S. adults in all 50 states and the District of Columbia, and by key sociodemographic characteristics. Overall, 63.9% of U.S. adults reported at least one ACE; 17.3% reported four or more ACEs. Experiencing four or more ACEs was most common among females (19.2%), adults aged 25-34 years (25.2%), non-Hispanic American Indian or Alaska Native (AI/AN) adults (32.4%), non-Hispanic multiracial adults (31.5%), adults with less than a high school education (20.5%), and those who were unemployed (25.8%) or unable to work (28.8%). Prevalence of experiencing four or more ACEs varied substantially across jurisdictions, from 11.9% (New Jersey) to 22.7% (Oregon). Patterns in prevalence of individual and total number of ACEs varied by jurisdiction and sociodemographic characteristics, reinforcing the importance of jurisdiction and local collection of ACEs data to guide targeted prevention and decrease inequities. CDC has released prevention resources, including Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence, to help provide jurisdictions and communities with the best available strategies to prevent violence and other ACEs, including guidance on how to implement those strategies for maximum impact (4-6). BRFSS is an annual survey of health-related risk behaviors and chronic health conditions representative of noninstitu-tionalized adults collected from all 50 states, the District of Columbia, and three U.S. territories (7). In addition to core questions administered annually to all participants, jurisdictions and territories can include jurisdiction-approved optional modules, as well as jurisdiction-added questions.* From 2011 * https://www.cdc.gov/violenceprevention/communicationresources/pub/ technical-packages.html to 2020, ACEs questions were included in the BRFSS questionnaire at least once by all 50 states and the District of Columbia as either an optional module (2011-2012 and 2019-2020) or jurisdiction-added questions (2013-2018). For jurisdictions that included ACEs questions in more than 1 year, the most recent year was included. The optional ACEs module includes 11 questions to determine exposure to eight types of ACEs: physical abuse, emotional abuse, sexual abuse, witnessing intimate partner violence, household substance abuse, household mental illness, parental separation or divorce, and incarcerated household member † (1). The Arkansas and New Hampshire questionnaires differed from the optional ACEs module. Arkansas collapsed three sexual abuse questions into a single question, and New Hampshire omitted two of the three sexual abuse questions. § The Arkansas questionnaire also combined household drug abuse and alcohol abuse questions into a single household substance abuse question. ¶ Responses to all ACE types were dichotomized ** ; ACE scores were calculated for participants † https://www.cdc.gov/brfss/questionnaires/index.htm § Arkansas' sexual abuse question was worded, "How often did anyone at least 5 years older than you or an adult ever touch you sexually, try to make you touch them sexually, or force you to have sex?" New Hampshire only included one of the three sexual abuse questions, "How often did anyone at least 5 years older than you or an adult ever touch you sexually?" ¶ Arkansas' substance abuse question was worded, "Did you live with anyone who was a problem drinker or alcoholic, or who used illegal street drugs or abused prescription medications?" ** Generally, for ACE questions with response options of "Yes/No/Don't know," "Yes" was coded as experiencing the ACE, "No" was coded as not experiencing the ACE, and "Don't know" was coded as missing. For ACEs questions with response options of "Never/Once/More than once/Don't know," "Never" was coded as not experiencing the ACE, "Once" or "More than once" was coded as experiencing the ACE, and "Don't know" was coded as missing. For the substance use ACE, a "Yes" response to either the alcohol use or illegal drug or prescription drug misuse questions was coded as experiencing the substance use ACE. If the response to either alcohol use or illegal drug or prescription drug misuse questions was "No" and the other question response was missing, the substance use ACE was coded as missing. For the divorce or separation ACE, "Yes" was coded as experiencing the ACE, "No" was coded as not experiencing the ACE, and responses of "Parents not married" or "Don't know" were coded as missing. For the sexual abuse ACE, three individual sexual abuse questions were combined to form a composite, dichotomous sexual abuse ACE. If answers to any of the sexual abuse questions was "Once" or "More than once," the composite sexual abuse ACE was coded as experiencing the ACE. If answers to all of the sexual abuse questions was "Never," the composite sexual abuse ACE was coded as not experiencing the ACE. If the respondent answered "Never" to one or more questions but was missing responses for one or more of the other sexual abuse questions, the response was coded as missing.