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The adverse childhood experience (ACE) questionnaire has become a critical part of public health. It offers physicians a screening tool to evaluate patients, gaining valuable insights into their physical and mental well-being. This information guides the implementation of preventive measures like lifestyle counseling to reduce the risk of ACE-related chronic conditions like depression, obesity, asthma, diabetes, and cancer. The questionnaire also facilitates the adoption of trauma-informed care, enabling providers to sensitively address traumatic experiences, and more broadly is useful for research into the long-term effects of the ongoing gun violence epidemic.

However, the questionnaire is now outdated because it fails to ask about childhood exposure to gun violence. To ensure a comprehensive understanding of a patient’s past, it’s essential to include questions about experiences of gun violence during childhood.


Annually, in the United States, an estimated 3 million children bear witness to the scourge of gun violence. Firearms are the leading cause of death for individuals aged 1-19; 19,000 either suffer injury or lose their lives each year. Exposure to gun violence can lead to diminished academic performance and the development of chronic mental health conditions, including anxiety and depression.

Vincent Felitti and Robert Anda introduced the Adverse Childhood Experiences Questionnaire, a tool designed to assess and quantify ACEs, in 1980s. This questionnaire employs a 10-item scale to examine experiences related to abuse, violence, and neglect. Each type of adverse experience counts as one point toward the ACEs score, with a score ranging from zero to 10. The higher the ACEs score, the greater the risk of negative outcomes in adulthood, including physical and mental health issues, substance abuse, and social problems. Felitti began working on the concept of ACEs after becoming frustrated with the 50% dropout rate of patients with severe obesity from his weight loss program. Upon investigation, he realized that the majority of his patients had experienced some form of childhood sexual abuse. A significant number of the women in the program expressed the belief that their physical size served as a deterrent to unwanted sexual advances from men.

That led him and Anda to study ACEs. Initiated at Kaiser Permanente between 1995 and 1997, the original ACE study involved two waves of data collection. More than 17,000 people underwent physical exams and completed confidential surveys. With data on both childhood experiences and current health status, researchers were able to discover relationships between early-life adversity and conditions in adulthood. Research on ACEs has found that 1 in 6 adults experienced four or more types of ACEs. The toxic stress resulting from ACEs has the potential to alter brain development and influence the body’s stress response. These changes in the body can hurt children’s ability to focus, make decisions, and learn.


This questionnaire has allowed for important insights and allowed clinicians to provide tailored recommendations. However, it fails to ask whether someone experienced, witnessed, or was affected by gun violence as a child.

The risk outcomes associated with youth-related gun violence closely mirror those revealed in research pertaining to ACEs. Just as the currently recognized ACEs can have enduring health consequences, so can the effects of gun violence. Survivors of gun violence face an elevated risk of developing substance use disorders.

Research indicates a surge in antidepressant use among youth and an increased suicide risk in communities that have experienced school shootings.

That’s why researchers should include gun violence as a component of the ACEs questionnaire. Although the questionnaire already inquires about exposure to violence, it is essential to ask about gun violence in particular for specificity and precision in risk assessment. Gun violence represents a distinct form of violence with unique implications for individuals’ health and well-being. By asking about gun violence, researchers and health care providers can gather more detailed information about the nature and impact of the exposure. Understanding an individual’s exposure to gun violence allows for a precise assessment of community risk factors and resilience. While general inquiries about violence provide valuable insights, asking about gun violence specifically enables practitioners to tailor interventions and support services effectively.

The CDC plays a pivotal role in ACEs research, and it should lead the process of testing a new ACE questionnaire item on gun violence — ideally with some additional funding from Congress. Current studies published and funded by the CDC have detailed the relationship between ACEs and the current leading causes of death in adults. Despite the wealth of knowledge generated, the omission of gun violence in this research hinders a comprehensive understanding of its impact, thereby limiting our ability to develop targeted interventions and policies aimed at reducing its devastating effects on public health.

The inclusion of gun violence as a dimension within the ACEs framework would also provide a tool for public health researchers and psychologists to develop a deeper understanding of how gun violence, as a distinct form of trauma, impacts a child’s mental and emotional well-being.

With these insights, they can develop more targeted interventions, policies, and support systems to better safeguard the mental health and well-being of our youth.

Sydney Durrah is pursuing a Master of Public Health degree specializing in Maternal and Child Health at the Milken Institute School of Public Health. She holds a Bachelor of Science from West Virginia University and serves as a graduate research assistant at the GW Center for Excellence in Maternal and Child Health.

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