To the Editor The commendable efforts of Merrick et al1 to examine adverse childhood events (ACEs) on a large scale is invaluable to understanding the pervasive nature of ACEs in the United States.1 This larger, more diverse sample adds to our understanding of who is affected by ACEs. However, we express a few concerns regarding how these results were presented, in particular, the additive ACE index. In the original ACE study, Felitti et al2 created an assessment tool to better examine the effect that cumulative exposure to childhood trauma might have on health outcomes in adulthood.2 Although existing literature has consistently reported ACEs are associated with health consequences, the common practice of treating ACEs equally in an additive index is based on the risky assumption that each ACE is equally traumatic. However, children are likely to experience diverse combinations of ACEs at various levels of distress.2 Certainly the effect of childhood sexual abuse is greater than exposure to a family member with mental illness.
Gebauer S, Moore R, Salas J. All Traumas Are Not Created Equal. JAMA Pediatr. Published online February 18, 2019173(4):398–399. doi:10.1001/jamapediatrics.2018.5556
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