This report presents the first lifetime national prevalence of self-reported individual and cumulative ACEs among U.S. high school students aged <18 years, associations between cumulative ACE exposure and negative health conditions and risk behaviors in adolescence, and population-attributable fractions related to ACEs for each condition and behavior. Policymakers and public health professionals can use this information to understand current prevalence of ACEs among U.S. high school students, and the proportion of negative health conditions and risk behaviors that could potentially be reduced or eliminated by implementing evidence-based strategies and approaches to prevent ACEs and mitigate their consequences.
This report includes data from the 2023 Youth Risk Behavior Survey (YRBS) (N = 20,103), a cross-sectional, school-based survey conducted biennially since 1991. Each survey year, CDC collects data from a nationally representative sample of public and private school students in grades 9-12 in the 50 U.S. states and the District of Columbia. Additional information about YRBS sampling, data collection, response rates, and processing is available in the overview report of this supplement (8). Prevalence estimates for ACEs for the overall study population and by sex, race and ethnicity, grade, and sexual identity are available at https://nccd.cdc.gov/youthonline/App/Default.aspx. The full YRBS questionnaire, datasets, and documentation are available at https://www.cdc.gov/yrbs/index.html. Institutional review boards at CDC and ICF, the survey contractor, approved the protocol for YRBS. Data collection was conducted consistent with applicable Federal law and CDC policy.*
Information about question content and coding for all demographics, ACEs, and included health conditions and risk behaviors is presented (Table 1). Students self-reported lifetime experiences of eight ACEs (emotional, physical, and sexual abuse; physical neglect; witnessing intimate partner violence; household substance use; household poor mental health; and parent or guardian incarcerated or detained). Questions align with and were adapted from the original ACEs included in the seminal CDC-Kaiser Permanente ACEs Study (3) and subsequently used for adult retrospective data collection from the BRFSS (4). Slight adaptations were made to ACEs questions to align with age of respondent (i.e., changes to the question stem from "before you were 18 years of age" to "during your life"), and to reduce the number of questions used to capture sexual abuse and household substance use. ACEs questions were cognitively tested with high school students to ensure fidelity to question intention and suitability for adolescent populations; cognitive testing results are available (https://stacks.cdc.gov/view/cdc/150784). In addition to examination of the presence of individual ACEs, a cumulative ACEs count (cumulative ACEs) was calculated (zero, one, two or three, or four or more) following CDC guidelines for coding ACEs responses using YRBS data (10).
Students also self-reported on 16 measures across a spectrum of risk behaviors and health conditions. These included carrying a weapon at school, being in a physical fight, multiple forms of substance use (i.e., current electronic vapor product use, current alcohol use, current binge drinking, and current prescription opioid misuse), sexual behaviors (i.e., alcohol or drug use before last sexual intercourse, currently sexually active with multiple partners, and did not use a condom during last sexual intercourse), weight and perceived weight status, persistent feelings of sadness or hopelessness, and suicide risk (i.e., seriously considered attempting suicide or attempted suicide). Most questions referenced conditions or behaviors that took place during the past 12 months or past 30 days, increasing the chances that the condition or behavior took place after initial ACE exposure.
Demographic variables included sex (female or male) and race and ethnicity (American Indian or Alaska Native [AI/AN], Asian, Black or African American [Black], White, Hispanic or Latino [Hispanic], and multiracial [selected >1 racial category]). (Persons of Hispanic or Latino origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic.) Prevalence estimates for Native Hawaiian or other Pacific Islander students had denominators <30 and were therefore considered statistically unreliable and were suppressed (8). Other demographic variables included age (≤14, 15, 16, and 17 years), and sexual identity (heterosexual, gay or lesbian, bisexual, questioning [I am not sure about my sexual identity/questioning], or describe identity in some other way [I describe my identity some other way]).
The analytic sample was restricted to those aged <18 years (n = 17,838) to ensure the adversity occurred during childhood. Weighted prevalence and 95% CIs for individual and cumulative ACEs count, overall and by each demographic, are presented. Demographic differences in the prevalence of individual ACEs and cumulative ACEs count were examined using pairwise t-test analyses. All prevalence estimates and measures of association used Taylor series linearization. Cumulative ACEs counts were only calculated for participants with complete data on at least five individual ACEs.
The weighted prevalence and 95% CI of each health condition and risk behavior by cumulative ACEs count are presented. Adjusted prevalence ratios (aPRs) were calculated using logistic regression with predicted marginals; models fit cumulative ACEs count as the independent variable and each risk behavior or health condition as the dependent variable, adjusting for sex, race and ethnicity, age, and sexual identity. Population-attributable fractions, adjusted for aforementioned model covariates, were calculated using Miettinen's formula, aPRs, and weighted prevalence estimates of each health condition and risk behavior by each cumulative ACEs count level (Supplementary Table, https://stacks.cdc.gov/view/cdc/160323). These population-attributable fractions were used to ascertain the percentage reduction in the number of observed cases of each outcome that would be expected if ACEs exposure were incrementally reduced or eliminated in the study population (7,11). Findings were considered statistically significant if p<0.05. Prevalence ratios were considered statistically significant if 95% CI did not cross the value of 1.0. All analyses except estimates of population-attributable fractions were conducted in SAS-callable SUDAAN (version 11.0.3; RTI International) using sample weights to account for complex survey design.