Regional prevalence of adverse childhood experiences in the United States using a nationally representative school-based sample


Yau, Margaret Y.; Ge, Shaokui; Moss, Howard B.; Cooper, Takesha; Osei, Adwoa; Ijeaku, Ijeoma; & Deas, Deborah (2022). Regional prevalence of adverse childhood experiences in the United States using a nationally representative school-based sample. SSM - Population Health. , PMCID: PMC9218229


Adverse childhood experiences (ACEs) are potentially traumatic experiences during childhood and youth. They have been shown to be strong risk factors for chronic diseases, substance use disorders, and mental health conditions (Anda et al., 2002; Gilbert et al., 2015; Moss et al., 2020; Sonu et al., 2019). Leading public health organizations, including the U.S. Centers for Disease Control and Prevention (CDC; CDC, 2019), the American Academy of Pediatrics (Garner et al., 2021), and the Departments of Health of California, Tennessee, North Carolina, and Oregon (Cooper & Hanlon, 2020) recommend routine screening for ACEs because this clinical information can assist health care providers in offering more effective and equitable health care, as well as steering appropriate patients towards targeted trauma-based clinical interventions that may enhance healing and long-term health (Purewal Boparai et al., 2018). Consequently, screening for ACEs has been successfully integrated into a wide range of clinical settings, including pediatric/adult primary care, behavioral health, women's health, and medical school curriculum (Osei et al., 2022; Pletcher et al., 2019; Rariden et al., 2021).

Understanding the geographic distribution of ACEs is important to health policy because it guides regional resource allocation for prevention, professional training about ACEs, screening methodology, and the implementation of trauma-informed programs of care in various care settings. ​​However, there is limited availability of nationally representative data on regional variations in ACE prevalence in the U.S., and different limitations exist in the datasets used for regional prevalence estimations in previous studies (Bethell et al., 2017b; Giano et al., 2020; Merrick et al., 2018). For example, the National Survey of Children's Health (NSCH) assesses ACEs in a nationally representative sample of U.S. children, but its surveys are conducted with parents and guardians of children ages varying from 0 to 17, resulting in underestimation of lifetime prevalence of ACEs, especially for vulnerable populations such as those with foster care experience and unreported childhood abuse or neglect (Child and Adolescent Health Measurement Initiative, 2022; Turney & Wildeman, 2017). Another commonly used ACE data source, the Behavioral Risk Factor Surveillance System (BRFSS) ACE module provides community-based samples obtained in only a subset of U.S. states in any given survey year and therefore are not ideal for national prevalence estimates of ACEs (CDC, 2022).

In this study, we explored the regional differences in the prevalence of nine ACEs defined by the original CDC-Kaiser ACE Study (Felitti et al., 1998) using a nationally representative school-based sample from the National Longitudinal Study of Adolescents to Adult Health (Add Health; Add Health; Harris, 2009). Add Health is a longitudinal study that used systematic sampling methods and implicit stratification to create a sample of middle and high schools representative of U.S. schools with respect to region of country, urbanity, school size, school type, and ethnicity (Chen & Chantala, 2014). As opposed to the NSCH and BRFSS ACE data, Add Health provides nationally representative data for all U.S. states on ACEs that were self-reported by the young adults who experienced them before age 18, thus allowing better lifetime prevalence estimations.



adverse childhood experiences

Reference Type

Journal Article

Journal Title

SSM - Population Health


Yau, Margaret Y.
Ge, Shaokui
Moss, Howard B.
Cooper, Takesha
Osei, Adwoa
Ijeaku, Ijeoma
Deas, Deborah

Year Published



June 11, 2022







Reference ID