Not Just a Buzzword: Adverse Childhood Experiences (ACEs) and Aggression and Criminality

Not Just a Buzzword: Adverse Childhood Experiences (ACEs) and Aggression and Criminality

A sample of male and female forensic psychiatric inpatients reported significant exposure to Adverse Childhood Experiences (ACEs) overall, with significant differences to exposure depending on race and gender. In addition, ACE score, race, and foster care or investigations of child abuse were significant predictors of outcomes such as aggression and criminality. This is the bottom line of a recently published article in the International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.


Featured Article | International Journal of Forensic Mental Health | 2021, Vol. 20, No. 4, 374-385

Adverse Childhood Experiences and the Onset of Aggression and Criminality in a Forensic Inpatient Sample


Jill D. Stinson, East Tennessee State University
Megan A. Quinn, East Tennessee State University
Anthony A. Menditto, Fulton State Hospital
Carrie C. LeMary, East Tennessee State University


Offenders and persons with serious mental illness experience disproportionate exposure to Adverse Childhood Experiences (ACEs). This study examines prevalence, distribution, and correlates of ACEs in 182 male and female forensic psychiatric inpatients in secure care. Descriptive statistics, chi-squares analysis, ANOVA, and logistic regression were used to describe ACEs by race and gender and to identify associations between ACEs and onset of aggression, arrest, and psychiatric hospitalization. Participants evidenced significant exposure to ACEs, with significant differences by race and gender. ACE score, race, and foster care or investigations of child abuse were significant predictors of outcomes related to aggression and criminality.


Adverse childhood experiences, child maltreatment, forensic inpatients, aggression

Summary of the Research

“Studies of adult inmates in correctional institutions describe reported prevalence rates of abuse and neglect ranging widely from 18-98%…and prominent histories of out-of-home placement, familial violence, and parental substance abuse, mental health needs, and incarceration…Findings are similar among justice-involved youth…Among forensic mental health populations…similar findings emerge…Though there is evidence of increased frequency of trauma, maltreatment, and other forms of adversity in correctional and forensic mental health samples, little…research has utilized ACE survey methodology to categorize developmental experiences of abuse, neglect, and household dysfunction…Thus, the current study aimed to explore ACEs and their associated outcomes in a unique sample, evaluating the following broad hypotheses: 1)…we anticipate that the experience of early adversity, as measured by the ACE survey items, among a sample of men and women residing in a secure forensic psychiatric hospital will exceed population norms; 2)…we expect that female and racial minority participants in our sample will similarly evidence a greater frequency of exposure to individual ACEs and will exhibit higher ACE scores overall; 3)…ACE score itself…will be significantly associated with age of onset of aggression, arrest, and psychiatric hospitalization; and 4)…factors like ACEs and associated variables…and history of aggression and known psychiatric problems will predict whether the participant’s first criminal justice contact led to arrest vs. psychiatric hospitalization (p.375-376).

“Participants were selected from a secure forensic psychiatric facility in the Midwestern United States…As expected, participants in the current sample displayed ACEs at rates far exceeding those reported in community samples, with mean ACE scores of nearly 4 for women and 2 for men. Further, one-third of participants evidenced a score of 4+ on the ACE survey, with far more women endorsing higher-end ACE scores and individual ACE items describing abuse and neglect…This suggests that women in secure forensic care present with greater vulnerabilities that may necessitate targeted intervention and increased considerations of safety within their environment…” (p.376-380).

“In addition, racial differences emerged – despite nearly equal numbers of White and nonwhite participants, experiences of physical and familial sexual abuse were significantly more often reported by White participants, as is consistent with some previous literature…but generally conflicts with what has been identified in other forensic samples…while the ACE score remained significant as a differential predictor for onset of aggression, violent arrest, and psychiatric hospitalization, other factors emerged that may provide additional context related to ACEs in the participants’ homes of origin, including placement in foster care or a group home prior to the age of 18 and any investigation by child protective services…Interestingly, the ACE score was not predictive of the age at first arrest, though any investigation by child protective services and nonwhite race, in combination, were significant…” (p.381-382).

Translating Research into Practice

“Our findings indicate the need for continued prevention and intervention efforts with not only those who have experienced early childhood adversity, but perhaps more so for those who are disproportionally exposed to multiplicative ACEs and associated events like foster care or group home placement, repeated out-of-home placements, and frequent contacts with child investigative agencies…Additional research is needed to determine and define factors that may further identify persons at such high risk for negative behavioral outcomes in adulthood, and we need additional research to assist with promoting resilience in this population. Such efforts may lead to early identification of those most at risk, while also affording preventative opportunities for mental health screening and care, as well as targeted efforts to promote effective behavioral and emotional regulation strategies to potentially reduce aggressive behavioral outcomes. Additionally, our findings call for attention to gender- and race-informed practices, as persons of varied gender and racial identities with histories of trauma, serious mental illness, and justice-system involvement may present with unique needs, experiences, and vulnerabilities that should be integrated into their care…” (p.382).

“Further, the increased exposure to ACEs across contexts for those residing in forensic care has implications for effective care and treatment of this population. The frequency with which such individuals have been exposed to adversity has far-reaching implications for the ability to form attachments and elicit positive social support, to self-regulate emotions and behaviors, and to thrive in forensic environments, which are often characterized by a high degree of stress and violence exposure…Efforts to train clinical and front-line staff in trauma-informed care and other similar approaches designed to facilitate client improvement in the face of traumatic experiences and toxic high stress may be beneficial given the high degree of ACEs exposure in offender groups…Further, assessing risk of future violence and psychiatric decompensation in light of the client’s experiences of adversity in their home of origin may inform safety plans and necessary risk management strategies” (p.382).

Other Interesting Tidbits for Researchers and Clinicians

“…The impact of race and known investigation of the family may be social contextual factors that uniquely contribute to the likelihood of early behavioral problems resulting in justice involvement and youthful arrest…Similar findings emerged suggestive of a potential social-contextual influence on the likelihood of arrest preceding psychiatric hospitalization, in that a model including non-white race, history of foster care or group home placement, more youthful suicidality, and lower ACE score predicted arrest preceding first psychiatric hospitalization. Here, the impacts of systemic racism and discrimination, overuse of arrest in minority communities, and more global racial disproportionalities in the [United States] criminal justice system may be apparent…” (p.381).

“…there is also a limitation in using the ACE survey itself, particularly in a population with a high degree of ACEs and other related experiences. The ACE survey, with its ‘present vs. absent’ coding, does assume equivalence across a range of experiences of trauma, maltreatment, and household dysfunction without accounting for important variability in perceived severity, duration, or contextual occurrence of these experiences. Similarly, this initial ACE survey that includes 10 items does not account for many other experiences that may similarly contribute to detrimental outcomes, such as neighborhood violence, extreme poverty, experiences of bullying or discrimination, and the like…” (p.382-383).

Join the Discussion

As always, please join the discussion below if you have thoughts or comments to add!