Adverse childhood experiences (ACEs) are preventable, potentially traumatic events with lifelong negative impacts. Population-level data on ACEs among adolescents have historically relied on parent reports and excluded abuse-related ACEs. We present the self-reported prevalence of ACEs among a large population-based sample of US high school students.
Using cross-sectional, state-representative data from 16 states that included core ACE questions on their 2021 Youth Risk Behavior Survey, we estimate the prevalence of 8 individual (lifetime emotional, physical, or sexual abuse, physical neglect, witnessed intimate partner violence, household substance use, household poor mental health, incarcerated parent or guardian) and cumulative ACEs (0, 1, 2–3, ≥4) among a large population-based sample of adolescents, overall and by demographic characteristics (sex, race and ethnicity, age, sexual orientation).
Emotional abuse (65.8%), household poor mental health (36.1%), and physical abuse (32.5%) had the highest prevalence. ACEs were very common, with 80.5% of adolescents experiencing at least 1 ACE and 22.4% experiencing ≥4 ACEs. Experiencing ≥4 ACEs was highest among adolescents who were female (27.7%), non-Hispanic multiracial (33.7%), non-Hispanic American Indian or Alaska Native (27.1%), gay or lesbian (36.5%), bisexual (42.1%), or who described their sexual identity some other way or were not sure of their sexual identity (questioning) (36.5%).
Self-reported ACE estimates among adolescents exceed previously published parent-reported estimates. ACEs are not equally distributed, with important differences in individual and cumulative ACEs by demographic characteristics. Collecting ACE data directly from adolescents at the state level provides actionable data for prevention and mitigation.
ACEs are associated with negative outcomes. Although parent-reported data on adolescents indicate that ACEs are common in the United States, self-reported, population-based data on adolescents have not been published, particularly those related to abuse.
Four in 5 adolescents (80.5%) have experienced ≥1 ACE, and 1 in 5 (22.4%) have experienced ≥4 ACEs. Abuse-related ACEs were common. Prevalence of individual and cumulative ACEs varied by sociodemographic characteristics and exceeded previously published parent-reported adolescent estimates.
Adverse childhood experiences (ACEs) are preventable, potentially traumatic events occurring before age 18 that are associated with numerous negative health outcomes and diminished life opportunities.1 Most ACE research has occurred in the context of retrospective, self-reported data from adults reflecting on their experiences before the age of 18 years. Such research indicates that ACEs are common among adults; 63.9% of US adults reported at least 1 ACE, and 17.3% reported exposure to 4 or more ACEs before the age of 18 years.2 The lifetime prevalence of abuse-related ACEs among adults range from 12.6% for sexual abuse to 23.3% for physical abuse and 34.0% for emotional abuse.2
Self-reported lifetime prevalence estimates for physical, sexual, and emotional abuse among US adolescents were last collected in 2014 via telephone interview in the National Survey of Children’s Exposure to Violence (NatSCEV).3 Among 14- to 17-year-olds, the lifetime prevalence of physical abuse was 18.1%, emotional abuse was 23.9%, and sexual abuse was 0.2%.3 Although valuable, NatSCEV estimates are now more than a decade old and do not include household challenge ACEs. Conversely, more recent population-level data on ACEs among adolescents from the National Survey of Children’s Health have only been parent-reported and have not included important abuse-related ACEs, including physical, sexual, and emotional abuse.4,5 The parent-reported lifetime prevalence of ACEs from the 2022 National Survey of Children’s Health estimate is that 39.7% of US youth aged 12 to 17 years have experienced 1 or more ACE; 17.8% have experienced 2 or more ACEs; 7.2% have witnessed domestic violence; 8.5% have a parent or guardian who has been incarcerated; 11.8% have lived with someone who was mentally ill, suicidal, or severely depressed; and 12.2% have lived with someone who had a problem with alcohol or drugs.4
Comprehensive self-reported, population-based data from adolescents on abuse, neglect, and household challenge ACEs are needed to better characterize the scope of the problem, understand disparities in exposure to ACEs, and promote and evaluate ACE prevention and mitigation efforts. Collecting public health surveillance data on a host of ACEs, particularly abuse-related ACEs, is important because of differing phenotypes of outcomes associated with different types of adversity.6 In addition, gathering ACE data from adolescents themselves, rather than through parental proxy or adult retrospection, decreases the likelihood of recall bias and ensures that data are more accurate and timely to inform prevention and evaluation efforts.5
Improving ACE surveillance at the state and national levels is possible through the adaptation of youth-based surveillance systems. The Centers for Disease Control and Prevention’s (CDC) Youth Risk Behavior Surveillance System is a set of national, state, and local surveys that track behaviors that can lead to poor health in US high school students.7 In 2021, the CDC began bolstering the youth-based surveillance of ACEs and positive childhood experiences (PCEs) through the addition of 16 ACE and PCE questions to the Youth Risk Behavior Surveillance System optional question list. The CDC provided additional funding to jurisdictions that added either 8 “core” ACEs that mapped onto measures included in the original CDC-Kaiser ACEs study8 or 16 “core and expanded” ACEs and PCEs questions on their jurisdiction’s Youth Risk Behavior Survey (YRBS).5,9 This study reveals the first self-reported lifetime prevalence of individual and cumulative ACEs, including abuse-related ACEs, among a large population-based sample of US high school students.
Methods
We analyzed cross-sectional, state-representative 2021 YRBS data among 33 204 US public high school students aged <18 years from 16 states (Alabama, Arizona, Connecticut, Georgia, Iowa, Indiana, Kentucky, Nebraska, New Hampshire, Nevada, Ohio, Oklahoma, Pennsylvania, Texas, Virginia, South Carolina) that included all 8 “core” CDC Division of Violence Prevention-developed ACEs questions on their survey.7 In keeping with American Statistical Association recommendations on reporting meaningful results,10 all results are presented as point estimates (weighted lifetime prevalence) and level of certainty (95% confidence intervals). Differences between groups were assessed on the basis of magnitude of difference, not P value. The prevalence of dichotomized individual ACEs (emotional, physical, or sexual abuse, physical neglect, witnessed intimate partner violence, household substance use, household poor mental health, incarcerated parent or guardian) and cumulative ACEs (0, 1, 2–3, ≥4) was calculated.9 Cumulative ACEs were calculated for respondents with ≥5 non-missing responses to ACE questions (n = 27 785).4 The previous literature documents substantial health disparities by race and ethnicity stemming from differences in historical, political, and cultural context; social and environmental determinants; and access to health care.11,12 For this reason, we included the social constructs of race and ethnicity to better understand inequities in experiences of ACEs, particularly given that other determinants of inequities are not directly measured by YRBS. The race and ethnicity measure was self-reported and categorized as non-Hispanic American Indian or Alaska Native, non-Hispanic Asian, non-Hispanic Black or African American, non-Hispanic Native Hawaiian or other Pacific Islander, non-Hispanic white, non-Hispanic multiracial, or Hispanic or Latino (Hispanic). Other demographics included sex (female, male), age (≤14, 15, 16, 17), and sexual identity (heterosexual, lesbian or gay, bisexual, not sure of sexual identity [questioning] or describing sexual identity some other way). Participation in the survey was voluntary; local parental permission procedures were followed. State institutional review boards approved survey protocols; the secondary analysis was exempt from the CDC Institutional Review Board. All analyses accounted for a complex survey design and were conducted in SAS-callable SUDAAN (version 11.0.3; RTI International).
Results
Table 1 reveals the lifetime prevalence of individual types of ACEs among US adolescents overall and by demographic characteristics. Emotional abuse was the most reported (65.8%), followed by household poor mental health (36.1%) and physical abuse (32.5%). Patterns in individual ACEs varied by demographics. Female students had a higher prevalence of all individual ACEs compared with male students, apart from physical neglect. Notably, 13.1% of female students experienced sexual abuse, compared with 3.0% of male students. The experiences of individual ACEs varied by race and ethnicity; for example, non-Hispanic American Indian or Alaska Native adolescents most commonly reported household substance use (44.0%) but least commonly reported physical abuse (23.7%). Non-Hispanic Asian adolescents had a low prevalence of incarcerated parents or guardians (4.7%) but one of the highest prevalence rates of physical abuse (36.6%). Non-Hispanic white students reported the lowest prevalence of physical neglect (6.4%) but the second highest prevalence of emotional abuse (69.1%) and household poor mental health (41.7%). Students identifying as a sexual minority (lesbian or gay, bisexual, not sure of sexual identity [questioning] or describing sexual identity some other way) reported a higher prevalence of all individual ACEs compared with heterosexual students, particularly bisexual students; for example, 85.0% of bisexual students reported experiencing emotional abuse, compared with 63.2% of heterosexual students.
Lifetime Prevalence of Individual Types of ACEs Among US Adolescents in 16 Statesa by Sociodemographic Characteristic, YRBS 2021
| . | . | . | ACE Category, Weighted % (95% CI) . | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Characteristics | Total N (unweigh-ted) | Weighted %b (95% CI) | Emotional abusec | Physical abused | Sexual abusee | Physical neglectf | Witnessed intimate partner violenceg | Household substance useh | Household poor mental healthi | Incarcerated parent or guardianj |
| Total | 33 204 | NA | 65.8 (64.1 − 67.4) | 32.5 (30.9 − 34.1) | 8.1 (7.3 − 9.0) | 8.9 (8.2 − 9.7) | 19.1 (18.2 − 20.1) | 30.2 (28.6 − 31.9) | 36.1 (34.4 − 37.8) | 16.4 (15.0 − 18.0) |
| Sex | ||||||||||
| Male | 16 311 | 50.3 (48.4 − 52.1) | 59.5 (57.6 − 61.4) | 30.0 (28.1 − 31.9) | 3.0 (2.5 − 3.7) | 10.6 (9.4 − 11.9) | 15.9 (14.6 − 17.2) | 26.0 (24.1 − 27.9) | 27.8 (26.1 − 29.6) | 16.1 (14.6 − 17.8) |
| Female | 16 498 | 49.7 (47.9 − 51.6) | 72.0 (70.0 − 73.8) | 34.9 (32.9 − 37.0) | 13.1 (11.5 − 14.9) | 7.1 (6.3 − 8.1) | 22.2 (20.8 − 23.7) | 34.2 (31.8 − 36.7) | 44.1 (41.9 − 46.2) | 16.8 (14.8 − 19.0) |
| Race and ethnicity | ||||||||||
| American Indian or Alaska Native, NH | 427 | 1.2 (0.9 − 1.5) | 64.0 (54.2 − 72.8) | 23.7 (16.5 − 32.7) | 11.7 (6.7 − 19.7) | 15.8 (9.5 − 24.9) | 24.2 (16.3 − 34.4) | 44.0 (35.9 − 52.4) | 39.6 (31.2 − 48.7) | 26.9 (19.5 − 35.8) |
| Asian, NH | 1168 | 3.3 (2.6 − 4.4) | 66.8 (59.8 − 73.1) | 36.6 (31.2 − 42.5) | 5.3 (3.3 − 8.4) | 8.1 (6.2 − 10.6) | 16.1 (12.8 − 20.0) | 18.7 (15.7 − 22.1) | 23.1 (19.9 − 26.6) | 4.7 (3.1 − 6.9) |
| Black, NH | 3258 | 15.6 (12.9 − 18.7) | 60.4 (57.0 − 63.8) | 40.2 (36.4 − 44.0) | 8.8 (6.9 − 11.0) | 12.8 (10.4 − 15.6) | 19.5 (16.9 − 22.3) | 22.1 (18.3 − 26.4) | 25.3 (22.1 − 28.8) | 21.0 (16.7 − 26.2) |
| Native Hawaiian or Pacific Islander, NH | 120 | 0.4 (0.2 − 0.6) | 64.4 (42.2 − 81.7) | 27.7 (19.6 − 37.5) | 8.0 (3.4 − 17.8) | 17.3 (9.4 − 29.5) | 28.4 (20.7 − 37.6) | 27.1 (16.8 − 40.7) | 22.1 (9.4 − 43.7) | k |
| White, NH | 19 880 | 46.9 (42.9 − 50.8) | 69.1 (67.4 − 70.8) | 27.9 (26.4 − 39.4) | 6.8 (5.7 − 8.1) | 6.4 (5.6 − 7.4) | 17.3 (16.2 − 18.4) | 32.3 (30.3 − 34.2) | 41.7 (39.3 − 44.1) | 14.1 (12.7 − 15.6) |
| Hispanic or Latino | 5942 | 27.4 (24.4 − 30.5) | 61.9 (58.5 − 65.2) | 34.5 (32.1 − 37.0) | 10.0 (9.0 − 11.2) | 10.5 (9.0 − 12.1) | 20.8 (18.8 − 22.9) | 30.8 (28.3 − 33.5) | 32.0 (28.8 − 35.4) | 17.8 (15.3 − 20.6) |
| Multiracial, NH | 1714 | 5.3 (4.7 − 6.0) | 76.1 (71.5 − 80.2) | 39.4 (35.4 − 43.5) | 7.9 (5.7 − 11.0) | 7.9 (5.9 − 10.4) | 25.0 (21.6 − 28.9) | 38.3 (34.2 − 42.7) | 48.8 (43.8 − 53.9) | 22.7 (18.1 − 28.0) |
| Age group | ||||||||||
| ≤14 y | 7735 | 19.9 (17.2 − 22.9) | 64.5 (62.1 − 66.8) | 31.3 (28.4 − 34.3) | 7.5 (6.4 − 8.7) | 9.7 (8.0 − 11.8) | 18.8 (16.8 − 21.1) | 28.0 (26.0 − 30.1) | 32.6 (30.2 − 35.0) | 15.9 (13.7 − 18.3) |
| 15 y | 9631 | 27.4 (25.8 − 29.0) | 66.5 (64.2 − 68.8) | 31.8 (30.0 − 33.7) | 8.2 (7.0 − 9.7) | 9.4 (8.2 − 10.8) | 18.0 (16.1 − 20.0) | 29.2 (27.1 − 31.3) | 35.0 (32.4 − 37.8) | 16.9 (14.4 − 19.6) |
| 16 y | 8690 | 27.4 (25.1 − 29.9) | 64.4 (61.3 − 67.4) | 33.1 (30.9 − 35.4) | 7.3 (6.0 − 9.0) | 8.3 (7.0 − 9.8) | 19.2 (17.4 − 21.1) | 31.6 (28.8 − 34.6) | 37.7 (35.1 − 40.3) | 17.5 (15.5 − 19.8) |
| 17 y | 7148 | 25.4 (22.8 − 28.1) | 67.4 (64.6 − 70.1) | 33.5 (30.9 − 36.2) | 9.3 (7.6 − 11.4) | 8.5 (7.3 − 9.8) | 20.5 (18.4 − 32.7) | 31.4 (28.6 − 34.4) | 38.0 (34.9 − 41.2) | 15.2 (13.4 − 17.2) |
| Sexual orientation | ||||||||||
| Heterosexual | 21 532 | 76.1 (74.7 − 77.5) | 63.2 (61.0 − 65.3) | 28.0 (26.2 − 29.9) | 5.3 (4.7 − 6.0) | 8.0 (7.3 − 8.8) | 16.0 (15.2 − 16.9) | 27.4 (25.7 − 29.0) | 30.3 (28.5 − 32.1) | 15.7 (14.3 − 17.3) |
| Gay/lesbian | 1088 | 3.4 (3.0 − 3.8) | 78.6 (72.1 − 83.9) | 45.8 (40.5 − 51.2) | 13.5 (10.4 − 17.4) | 9.3 (6.6 − 12.9) | 33.6 (26.8 − 41.2) | 40.5 (35.2 − 46.1) | 54.6 (47.4 − 61.6) | 18.5 (14.3 − 23.6) |
| Bisexual | 3726 | 11.5 (10.7 − 12.3) | 85.0 (83.0 − 86.7) | 49.3 (46.1 − 52.5) | 19.1 (15.7 − 23.0) | 7.0 (5.6 − 8.7) | 30.8 (27.7 − 34.2) | 48.4 (44.3 − 52.4) | 61.9 (58.0 − 65.7) | 23.3 (20.3 − 26.5) |
| Describe sexual identity some other way/questioning | 2885 | 9.0 (8.3 − 9.8) | 81.0 (77.9 − 83.7) | 46.7 (42.4 − 51.1) | 17.5 (13.7 − 22.1) | 7.7 (5.5 − 10.7) | 27.9 (24.9 − 31.2) | 42.0 (36.4 − 47.7) | 56.0 (52.2 − 59.6) | 16.8 (13.8 − 20.4) |
| . | . | . | ACE Category, Weighted % (95% CI) . | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Characteristics | Total N (unweigh-ted) | Weighted %b (95% CI) | Emotional abusec | Physical abused | Sexual abusee | Physical neglectf | Witnessed intimate partner violenceg | Household substance useh | Household poor mental healthi | Incarcerated parent or guardianj |
| Total | 33 204 | NA | 65.8 (64.1 − 67.4) | 32.5 (30.9 − 34.1) | 8.1 (7.3 − 9.0) | 8.9 (8.2 − 9.7) | 19.1 (18.2 − 20.1) | 30.2 (28.6 − 31.9) | 36.1 (34.4 − 37.8) | 16.4 (15.0 − 18.0) |
| Sex | ||||||||||
| Male | 16 311 | 50.3 (48.4 − 52.1) | 59.5 (57.6 − 61.4) | 30.0 (28.1 − 31.9) | 3.0 (2.5 − 3.7) | 10.6 (9.4 − 11.9) | 15.9 (14.6 − 17.2) | 26.0 (24.1 − 27.9) | 27.8 (26.1 − 29.6) | 16.1 (14.6 − 17.8) |
| Female | 16 498 | 49.7 (47.9 − 51.6) | 72.0 (70.0 − 73.8) | 34.9 (32.9 − 37.0) | 13.1 (11.5 − 14.9) | 7.1 (6.3 − 8.1) | 22.2 (20.8 − 23.7) | 34.2 (31.8 − 36.7) | 44.1 (41.9 − 46.2) | 16.8 (14.8 − 19.0) |
| Race and ethnicity | ||||||||||
| American Indian or Alaska Native, NH | 427 | 1.2 (0.9 − 1.5) | 64.0 (54.2 − 72.8) | 23.7 (16.5 − 32.7) | 11.7 (6.7 − 19.7) | 15.8 (9.5 − 24.9) | 24.2 (16.3 − 34.4) | 44.0 (35.9 − 52.4) | 39.6 (31.2 − 48.7) | 26.9 (19.5 − 35.8) |
| Asian, NH | 1168 | 3.3 (2.6 − 4.4) | 66.8 (59.8 − 73.1) | 36.6 (31.2 − 42.5) | 5.3 (3.3 − 8.4) | 8.1 (6.2 − 10.6) | 16.1 (12.8 − 20.0) | 18.7 (15.7 − 22.1) | 23.1 (19.9 − 26.6) | 4.7 (3.1 − 6.9) |
| Black, NH | 3258 | 15.6 (12.9 − 18.7) | 60.4 (57.0 − 63.8) | 40.2 (36.4 − 44.0) | 8.8 (6.9 − 11.0) | 12.8 (10.4 − 15.6) | 19.5 (16.9 − 22.3) | 22.1 (18.3 − 26.4) | 25.3 (22.1 − 28.8) | 21.0 (16.7 − 26.2) |
| Native Hawaiian or Pacific Islander, NH | 120 | 0.4 (0.2 − 0.6) | 64.4 (42.2 − 81.7) | 27.7 (19.6 − 37.5) | 8.0 (3.4 − 17.8) | 17.3 (9.4 − 29.5) | 28.4 (20.7 − 37.6) | 27.1 (16.8 − 40.7) | 22.1 (9.4 − 43.7) | k |
| White, NH | 19 880 | 46.9 (42.9 − 50.8) | 69.1 (67.4 − 70.8) | 27.9 (26.4 − 39.4) | 6.8 (5.7 − 8.1) | 6.4 (5.6 − 7.4) | 17.3 (16.2 − 18.4) | 32.3 (30.3 − 34.2) | 41.7 (39.3 − 44.1) | 14.1 (12.7 − 15.6) |
| Hispanic or Latino | 5942 | 27.4 (24.4 − 30.5) | 61.9 (58.5 − 65.2) | 34.5 (32.1 − 37.0) | 10.0 (9.0 − 11.2) | 10.5 (9.0 − 12.1) | 20.8 (18.8 − 22.9) | 30.8 (28.3 − 33.5) | 32.0 (28.8 − 35.4) | 17.8 (15.3 − 20.6) |
| Multiracial, NH | 1714 | 5.3 (4.7 − 6.0) | 76.1 (71.5 − 80.2) | 39.4 (35.4 − 43.5) | 7.9 (5.7 − 11.0) | 7.9 (5.9 − 10.4) | 25.0 (21.6 − 28.9) | 38.3 (34.2 − 42.7) | 48.8 (43.8 − 53.9) | 22.7 (18.1 − 28.0) |
| Age group | ||||||||||
| ≤14 y | 7735 | 19.9 (17.2 − 22.9) | 64.5 (62.1 − 66.8) | 31.3 (28.4 − 34.3) | 7.5 (6.4 − 8.7) | 9.7 (8.0 − 11.8) | 18.8 (16.8 − 21.1) | 28.0 (26.0 − 30.1) | 32.6 (30.2 − 35.0) | 15.9 (13.7 − 18.3) |
| 15 y | 9631 | 27.4 (25.8 − 29.0) | 66.5 (64.2 − 68.8) | 31.8 (30.0 − 33.7) | 8.2 (7.0 − 9.7) | 9.4 (8.2 − 10.8) | 18.0 (16.1 − 20.0) | 29.2 (27.1 − 31.3) | 35.0 (32.4 − 37.8) | 16.9 (14.4 − 19.6) |
| 16 y | 8690 | 27.4 (25.1 − 29.9) | 64.4 (61.3 − 67.4) | 33.1 (30.9 − 35.4) | 7.3 (6.0 − 9.0) | 8.3 (7.0 − 9.8) | 19.2 (17.4 − 21.1) | 31.6 (28.8 − 34.6) | 37.7 (35.1 − 40.3) | 17.5 (15.5 − 19.8) |
| 17 y | 7148 | 25.4 (22.8 − 28.1) | 67.4 (64.6 − 70.1) | 33.5 (30.9 − 36.2) | 9.3 (7.6 − 11.4) | 8.5 (7.3 − 9.8) | 20.5 (18.4 − 32.7) | 31.4 (28.6 − 34.4) | 38.0 (34.9 − 41.2) | 15.2 (13.4 − 17.2) |
| Sexual orientation | ||||||||||
| Heterosexual | 21 532 | 76.1 (74.7 − 77.5) | 63.2 (61.0 − 65.3) | 28.0 (26.2 − 29.9) | 5.3 (4.7 − 6.0) | 8.0 (7.3 − 8.8) | 16.0 (15.2 − 16.9) | 27.4 (25.7 − 29.0) | 30.3 (28.5 − 32.1) | 15.7 (14.3 − 17.3) |
| Gay/lesbian | 1088 | 3.4 (3.0 − 3.8) | 78.6 (72.1 − 83.9) | 45.8 (40.5 − 51.2) | 13.5 (10.4 − 17.4) | 9.3 (6.6 − 12.9) | 33.6 (26.8 − 41.2) | 40.5 (35.2 − 46.1) | 54.6 (47.4 − 61.6) | 18.5 (14.3 − 23.6) |
| Bisexual | 3726 | 11.5 (10.7 − 12.3) | 85.0 (83.0 − 86.7) | 49.3 (46.1 − 52.5) | 19.1 (15.7 − 23.0) | 7.0 (5.6 − 8.7) | 30.8 (27.7 − 34.2) | 48.4 (44.3 − 52.4) | 61.9 (58.0 − 65.7) | 23.3 (20.3 − 26.5) |
| Describe sexual identity some other way/questioning | 2885 | 9.0 (8.3 − 9.8) | 81.0 (77.9 − 83.7) | 46.7 (42.4 − 51.1) | 17.5 (13.7 − 22.1) | 7.7 (5.5 − 10.7) | 27.9 (24.9 − 31.2) | 42.0 (36.4 − 47.7) | 56.0 (52.2 − 59.6) | 16.8 (13.8 − 20.4) |
ACEs, Adverse Childhood Experiences; CI, confidence interval; NH, non-Hispanic; YRBS, Youth Risk Behavior Survey.
a States included Alabama, Arizona, Connecticut, Georgia, Iowa, Indiana, Kentucky, Nebraska, New Hampshire, Nevada, Ohio, Oklahoma, Pennsylvania, Texas, Virginia, and South Carolina.
b Total percentages may not equal 100.0% because of rounding.
c Parent or other adult in the home swore at, insulted, or put the respondent down. Responses were dichotomized to yes/no; responses of rarely, sometimes, most of the time, or always were classified as “yes.”
d Parent or other adult in the home hit, beat, kicked, or physically hurt the respondent. Responses were dichotomized to yes/no; responses of rarely, sometimes, most of the time, or always were classified as “yes.”
e An adult or a person at least 5 y older than the respondent forced them to do sexual things they did not want to do, such as kissing, touching, or being physically forced to have sexual intercourse. A response of “yes” was considered an ACE.
f An adult in the household never or rarely tried to make sure the respondent’s basic needs were met, such as looking after their safety and making sure they had clean clothes and enough to eat. Responses were dichotomized to yes/no; responses of never or rarely were reverse coded as “yes, experienced ACE.”
g Parents or other adults in the respondent’s home slapped, hit, kicked, punched, or beat each other up. Responses were dichotomized to yes/no; responses of rarely, sometimes, most of the time, or always were classified as “yes.”
h The respondent lived with someone who was having a problem with alcohol or drug use. A response of “yes” was considered an ACE.
i The respondent lived with someone who was depressed, mentally ill, or suicidal. A response of “yes” was considered an ACE.
j The respondent was separated from a parent or guardian because they went to jail or prison. A response of “yes” was considered an ACE.
k Cells with <30 respondents were suppressed.
More than 80% of students (80.5%) experienced at least 1 ACE; 24.4% reported 1 ACE, 33.7% reported 2 to 3 ACEs, and 22.4% reported ≥4 ACEs (Table 2). Four or more ACEs were most commonly reported among female (27.7%), non-Hispanic multiracial (33.7%), non-Hispanic American Indian or Alaska Native (27.1%), and gay or lesbian (36.5%), bisexual (42.1%), or questioning students or those who describe their sexual identity some other way (36.5%).
Lifetime Prevalence of Cumulative ACEs Among US Adolescents in 16 Statesa by Sociodemographic Characteristic, YRBS 2021
| . | Cumulative Number of ACEsb, Weighted %c (95% CI) . | |||
|---|---|---|---|---|
| Characteristics | 0 (unweighted N = 5319) | 1 (unweighted N = 6849) | 2−3 (unweighted N = 9426) | ≥4 (unweighted N = 6191) |
| Total | 19.5 (18.3−20.8) | 24.4 (23.5−25.4) | 33.7 (32.3−35.1) | 22.4 (20.8−24.0) |
| Sex | ||||
| Male | 23.0 (21.4−24.8) | 28.1 (26.9−29.4) | 32.2 (30.5−33.8) | 16.7 (15.1−18.5) |
| Female | 16.2 (14.9−17.6) | 20.8 (19.4−22.3) | 35.3 (33.2−37.5) | 27.7 (25.4−30.1) |
| Race and ethnicity | ||||
| AI/AN, NH | 15.5 (10.7−21.8) | 25.8 (19.3−33.5) | 31.6 (24.8−39.3) | 27.1 (18.0−38.8) |
| Asian, NH | 20.2 (15.9−25.3) | 28.0 (24.0−32.5) | 38.9 (35.1−42.8) | 12.9 (10.1−16.4) |
| Black, NH | 21.4 (18.0−25.2) | 21.3 (18.9−24.0) | 37.0 (31.5−42.7) | 20.3 (16.7−24.4) |
| Native Hawaiian or Pacific Islander, NH | d | d | d | d |
| White, NH | 18.7 (17.4−20.1) | 25.8 (24.3−27.4) | 33.9 (32.6−35.3) | 21.5 (19.9−23.3) |
| Hispanic or Latino | 20.7 (18.3−23.2) | 24.7 (22.3−27.2) | 30.7 (28.5−33.0) | 23.9 (21.7−26.4) |
| Multiracial, NH | 13.5 (10.2−17.8) | 17.3 (14.0−21.3) | 35.4 (31.8−39.3) | 33.7 (29.0−38.7) |
| Age group | ||||
| ≤14 y | 20.1 (18.1−22.2) | 25.4 (23.5−27.4) | 35.0 (32.6−37.5) | 19.5 (17.4−21.8) |
| 15 y | 19.4 (17.9−20.9) | 24.1 (22.3−25.9) | 34.6 (32.4−36.9) | 21.9 (19.8−24.2) |
| 16 y | 19.9 (17.6−22.3) | 23.8 (22.1−25.6) | 33.0 (30.1−36.1) | 23.3 (20.4−26.5) |
| 17 y | 19.0 (16.5−21.6) | 24.8 (22.4−27.3) | 32.5 (30.6−34.4) | 23.8 (21.4−26.4) |
| Sexual Orientation | ||||
| Heterosexual | 22.0 (20.5−23.6) | 27.1 (25.8−28.3) | 32.5 (31.2−33.8) | 18.4 (17.2−19.7) |
| Gay/lesbian | 9.2 (5.4−15.5) | 18.6 (13.8−24.7) | 35.6 (29.8−41.9) | 36.5 (30.3−43.3) |
| Bisexual | 5.8 (4.2−8.0) | 13.9 (11.6−16.7) | 38.2 (33.7−42.9) | 42.1 (37.8−46.6) |
| Not sure of sexual identity (questioning) or describe sexual identity some other way | 8.2 (6.4−10.5) | 17.1 (14.1−20.5) | 38.3 (32.9−43.9) | 36.5 (31.6−41.6) |
| . | Cumulative Number of ACEsb, Weighted %c (95% CI) . | |||
|---|---|---|---|---|
| Characteristics | 0 (unweighted N = 5319) | 1 (unweighted N = 6849) | 2−3 (unweighted N = 9426) | ≥4 (unweighted N = 6191) |
| Total | 19.5 (18.3−20.8) | 24.4 (23.5−25.4) | 33.7 (32.3−35.1) | 22.4 (20.8−24.0) |
| Sex | ||||
| Male | 23.0 (21.4−24.8) | 28.1 (26.9−29.4) | 32.2 (30.5−33.8) | 16.7 (15.1−18.5) |
| Female | 16.2 (14.9−17.6) | 20.8 (19.4−22.3) | 35.3 (33.2−37.5) | 27.7 (25.4−30.1) |
| Race and ethnicity | ||||
| AI/AN, NH | 15.5 (10.7−21.8) | 25.8 (19.3−33.5) | 31.6 (24.8−39.3) | 27.1 (18.0−38.8) |
| Asian, NH | 20.2 (15.9−25.3) | 28.0 (24.0−32.5) | 38.9 (35.1−42.8) | 12.9 (10.1−16.4) |
| Black, NH | 21.4 (18.0−25.2) | 21.3 (18.9−24.0) | 37.0 (31.5−42.7) | 20.3 (16.7−24.4) |
| Native Hawaiian or Pacific Islander, NH | d | d | d | d |
| White, NH | 18.7 (17.4−20.1) | 25.8 (24.3−27.4) | 33.9 (32.6−35.3) | 21.5 (19.9−23.3) |
| Hispanic or Latino | 20.7 (18.3−23.2) | 24.7 (22.3−27.2) | 30.7 (28.5−33.0) | 23.9 (21.7−26.4) |
| Multiracial, NH | 13.5 (10.2−17.8) | 17.3 (14.0−21.3) | 35.4 (31.8−39.3) | 33.7 (29.0−38.7) |
| Age group | ||||
| ≤14 y | 20.1 (18.1−22.2) | 25.4 (23.5−27.4) | 35.0 (32.6−37.5) | 19.5 (17.4−21.8) |
| 15 y | 19.4 (17.9−20.9) | 24.1 (22.3−25.9) | 34.6 (32.4−36.9) | 21.9 (19.8−24.2) |
| 16 y | 19.9 (17.6−22.3) | 23.8 (22.1−25.6) | 33.0 (30.1−36.1) | 23.3 (20.4−26.5) |
| 17 y | 19.0 (16.5−21.6) | 24.8 (22.4−27.3) | 32.5 (30.6−34.4) | 23.8 (21.4−26.4) |
| Sexual Orientation | ||||
| Heterosexual | 22.0 (20.5−23.6) | 27.1 (25.8−28.3) | 32.5 (31.2−33.8) | 18.4 (17.2−19.7) |
| Gay/lesbian | 9.2 (5.4−15.5) | 18.6 (13.8−24.7) | 35.6 (29.8−41.9) | 36.5 (30.3−43.3) |
| Bisexual | 5.8 (4.2−8.0) | 13.9 (11.6−16.7) | 38.2 (33.7−42.9) | 42.1 (37.8−46.6) |
| Not sure of sexual identity (questioning) or describe sexual identity some other way | 8.2 (6.4−10.5) | 17.1 (14.1−20.5) | 38.3 (32.9−43.9) | 36.5 (31.6−41.6) |
ACEs, adverse childhood experiences; CI, confidence interval; NH, non-Hispanic; YRBS, Youth Risk Behavior Survey
a States included Alabama, Arizona, Connecticut, Georgia, Iowa, Indiana, Kentucky, Nebraska, New Hampshire, Nevada, Ohio, Oklahoma, Pennsylvania, Texas, Virginia, and South Carolina.
b Cumulative number of ACEs were calculated by summing “yes” responses to 8 individual ACEs. Cumulative ACEs were calculated for respondents with ≥5 non-missing responses to the 8 ACE questions.
c Total percentages may not equal 100.0% because of rounding.
d Cells with <30 respondents were suppressed.
Discussion
ACEs were common in this large, population-based study of US high school students; 4 in 5 students experienced at least 1 ACE, and 1 in 5 experienced ≥4 ACEs. Students who were female, non-Hispanic American Indian or Alaska Native, non-Hispanic multiracial, or a sexual minority experienced the highest ACEs burden. Patterns varied by race and ethnicity for individual ACE types, emphasizing the wide range of experiences across and within racial and ethnic groups.13 For example, although non-Hispanic American Indian or Alaska Native adolescents experienced the highest prevalence of household substance use, they also experienced the lowest prevalence of physical abuse, and non-Hispanic Asian adolescents reported a low prevalence of incarcerated parents or guardians but one of the highest prevalence estimates for physical abuse. For all individual ACE types, sexual minority students, particularly bisexual students, had a higher prevalence of individual ACEs, compared with heterosexual students. Differences in the experiences of ACEs by students belonging to racial, ethnic, or sexual minority groups highlight the need to tailor prevention and mitigation efforts to different social and cultural contexts, rather than employing a universal approach to prevention and intervention, to better support groups disproportionately impacted by ACEs. Further research examining the experiences and effectiveness of the prevention and mitigation of ACEs by intersectional identity is needed, as is research including measures of economic status in intersectional analyses.13
The prevalence of lifetime individual and cumulative ACEs reported by adolescents in this study is considerably higher than those reported retrospectively by adults or by parental report. Among US adults surveyed from 2011 to 2020, ∼2 in 3 reported at least 1 ACE, and 1 in 6 reported ≥4 ACEs.2 By parental report in 2022, 2 in 5 youth aged 12 to 17 years experienced at least 1 ACE, and 1 in 5 experienced ≥2 ACEs. In our study, 4 in 5 experienced at least 1 ACE, and 1 in 5 experienced ≥4 ACEs. Whether the differences in findings are due to differing generational trends in ACEs, differences in question-wording, the diminished recall bias of adults in retrospective surveys due to remoteness from the events in question, social desirability bias or lack of awareness among parents, or other factors, our results underscore the importance of collecting ACE data directly from adolescents to understand more recent patterns and monitor the efficacy of prevention and mitigation efforts.
A high percentage of students reported lifetime experiences of abuse; nearly 2 in 3 (65.8%) reported emotional abuse, 1 in 3 (32.5%) reported physical abuse, and 1 in 12 (8.1%) reported sexual abuse. These prevalence figures are considerably higher than those reported during the 2013 to 2014 NatSCEV (ref: 23.9% emotional abuse, 18.1% physical abuse, 0.2% sexual abuse).3 Some of the differences between these estimates may be attributable to small variations in age range (YRBS: 9th to 12th graders (<18-year-olds); NatSCEV: 14-17-year-olds) or question-wording (YRBS: a parent or guardian swore at, insulted, or put down the child; NatSCEV: an adult made child scared or feel really bad by name-calling, saying mean things, or saying he or she did not want the child).3 It is also possible that the prevalence of abuse has increased since 2013 and 2014; however, given broader trends revealing declines in substantiated cases of child maltreatment over the past decade,14 these differences in prevalence between YRBS and NatSCEV likely speak to the importance of survey modality for disclosure of ACEs. The anonymity (and distance from potential perpetrators of abuse) offered by the school-based administration of YRBS may offer a safer venue for youth to disclose experiences of abuse.
Youth-based surveillance of ACEs is critical; adolescents are able to consent and assent to, understand, and participate in surveys and accurately recall and report sensitive experiences that have occurred in their childhood to date.15 These data are invaluable for understanding the current prevalence and incidence of ACEs, trends over time, and the impact of prevention and mitigation efforts.5 Self-reported data from youth benefit from temporal proximity to the events in question, thereby providing more current estimates and potentially minimizing (but not eliminating) recall bias.16 However, self-reported data from adolescents are not without challenges. Of primary concern is the health and safety of participants; disclosures of contemporary experiences of child abuse and neglect may be reportable to local authorities and have health and safety implications. Safety, confidentiality, legal, and ethical considerations should be integrated into any system that measures the experiences of youth.17 One study among Malawian adolescents revealed that external events, such as demographic and economic circumstances, and internal states of psychological and cognitive well-being can impact the longitudinal consistency of adolescents’ self-reports of ACEs and are theorized to take place through the consolidation of one’s life story.18 Additional research is needed to understand the impact of recall bias in adolescent reports and to improve the measurement of childhood adversity.
Limitations of YRBS have been outlined previously;7 one notable limitation is that the sampling frame for state and local YRBS is limited to public schools. As such, our study only reflects estimates among public high school students in the 16 surveyed states; estimates may differ in other states and among private school students or adolescents not attending school. Additionally, it is important to recognize that these ACE questions do not reflect the full range, severity, or frequency of childhood adversity; important ACEs, such as experiences of racial discrimination,19 basic needs instability, and witnessing community violence, were not included and are critical avenues for future research. Lastly, YRBS does not collect socioeconomic indicators from students. Given the accumulating body of evidence that racial and ethnic differences in ACEs are confounded by economic status,13 this is a limitation of YRBS.
Disparities in ACEs are closely linked to the social and economic conditions in which some families live.12 Understanding the burden of ACEs among different sociodemographic groups through the collection of self-reported data from adolescents allows the field to more effectively guide policy and programmatic interventions to reduce inequities and prevent ACEs. CDC’s Adverse Childhood Experiences Prevention Resource for Action can help states and communities leverage the best available evidence to prevent ACEs and mitigate their harms.1
Acknowledgments
We would like to thank the students who participated and the YRBS coordinators in the Alabama State Department of Education, Arizona Department of Health Services, Connecticut Department of Public Health, Georgia Department of Public Health, Iowa Department of Public Health, Indiana State Department of Health, Kentucky Department of Education, Nebraska Department of Education, New Hampshire Department of Education, Nevada System of Higher Education Board of Regents, Ohio Department of Health, Oklahoma State Department of Health, Pennsylvania Department of Education, South Carolina Department of Education, Texas Department of State Health Services, and Virginia Department of Health for their contributions to collecting these data.
Drs Swedo, Anderson, and Niolon conceptualized and designed the study and drafted the initial manuscript; Drs Li and Aslam analyzed and verified the data and created tables; Drs Brener, Mpofu, and Underwood coordinated and supervised data collection and provided subject matter expertise on the methodology and data source; and all authors critically reviewed and revised the final manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: The Centers for Disease Control and Prevention (CDC) funded the design and conduct of the study, the collection, management, analysis, and interpretation of secondary data, the preparation, review, or approval of the manuscript, and the decision to submit the manuscript for publication. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
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