Research Articles

Research, Publications and Applications of the Expanded ACE Survey

Published in the Children's Hospital Research Institute - Center for Injury and Prevention Website

"If only the original ACE measure were used, the rates of childhood adversity in our community would have been under-reported. Moreover, when looking at Expanded and Conventional ACEs, we found clear differences in ACE exposure based on demographic characteristics; gender, race, and poverty were associated with higher exposure to Expanded (community-level) ACEs but not Conventional (household-level) ACEs."

Author: Christine Forke-Young

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Published in Academic Pediatrics, Volume 17, Issue 7, Supplement


The Philadelphia ACE Task Force is a community based collaborative of health care providers, researchers, community-based organizations, funders, and public sector representatives. The mission of the task force is to provide a venue to address childhood adversity and its consequences in the Philadelphia metropolitan region. In this article we describe the origins and metamorphosis of the Philadelphia ACE Task Force, which initially was narrowly focused on screening for adverse childhood experiences (ACEs) in health care settings but expanded its focus to better represent a true community-based approach to sharing experiences with addressing childhood adversity in multiple sectors of the city and region. The task force has been successful in developing a research agenda and conducting research on ACEs in the urban context, and has identified foci of local activity in the areas of professional training and workforce development, community education, and local practical interventions around adversity, trauma, and resiliency. In this article we also address the lessons learned over the first 5 years of the task force's existence and offers recommendations for future efforts to build a local community-based ACEs collaborative.
Author(s): Lee M. Pachter, DO, Leslie Lieberman, MSW, Sandra L. Bloom, MD, Joel A. Fein, MD, MPH

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Published in Child Abuse & Neglect, Volume 52, February 2016,


Adverse Childhood Experiences (ACEs), which include family dysfunction and community-level stressors, negatively impact the health and well being of children throughout the life course. While several studies have examined the impact of these childhood exposures amongst racially and socially diverse populations, the contribution of ACEs in the persistence of socioeconomic disparities in health is poorly understood. To determine the association between ACEs and health outcomes amongst a sample of adults living in Philadelphia and examine the moderating effect of Socioeconomic Status (SES) on this association, we conducted a cross-sectional survey of 1,784 Philadelphia adults, ages 18 and older, using random digit dialing methodology to assess Conventional ACEs (experiences related to family dysfunction), Expanded ACEs (community-level stressors), and health outcomes. Using weighted, multivariable logistic regression analyses along with SES stratified models, we examined the relationship between ACEs and health outcomes as well as the modifying effect of current SES. High Conventional ACE scores were significantly associated with health risk behaviors, physical and mental illness, while elevated Expanded ACE scores were associated only with substance abuse history and sexually transmitted infections. ACEs did have some differential impacts on health outcomes based on SES. Given the robust impact of Conventional ACEs on health, our results support prior research highlighting the primacy of family relationships on a child's life course trajectory and the importance of interventions designed to support families. Our findings related to the modifying effect of SES may provide additional insight into the complex relationship between poverty and childhood adversity.

Authors: Roy Wade, Peter F Cronholm, Joel A Fein, Christine M Forke, Martha B Davis, Mary Harkins-Schwarz, Lee M Pachter, Megan H Bair-Merritt

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Published in the American Journal of Preventative Medicine


Introduction: Current knowledge of Adverse Childhood Experiences (ACEs) relies on data predominantly collected from white, middle- / upper-middle-class participants and focuses on experiences within the home. Using a more socioeconomically and racially diverse urban population, Conventional and Expanded (community-level) ACEs were measured to help understand whether Conventional ACEs alone can sufficiently measure adversity, particularly among various subgroups.

Methods: Participants from a previous large, representative, community-based health survey in Southeast Pennsylvania who were aged Z18 years were contacted between November 2012 and January 2013 to complete another phone survey measuring ACEs. Ordinal logistic regression models were used to test associations between Conventional and Expanded ACEs scores and demographic characteristics. Analysis was conducted in 2013 and 2014.

Results: Of 1,784 respondents, 72.9% had at least one Conventional ACE, 63.4% at least one Expanded ACE, and 49.3% experienced both. A total of 13.9% experienced only Expanded ACEs and would have gone unrecognized if only Conventional ACEs were assessed. Certain demographic characteristics were associated with higher risk for Conventional ACEs but were not predictive of Expanded ACEs, and vice versa. Few adversities were associated with both Conventional and Expanded ACEs.

Conclusions: To more accurately represent the level of adversity experienced across various sociodemographic groups, these data support extending the Conventional ACEs measure.

Authors: Peter F. Cronholm, MD, MSCE, Christine M. Forke, MSN, CRNP, Roy Wade, MD, PhD, MPH, Megan H. Bair-Merritt, MD, MSCE, Martha Davis, MSS, Mary Harkins-Schwarz, MPH, Lee M. Pachter, DO, Joel A. Fein, MD, MPH

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