Max Littman, LCSW

September 9, 2025

The original Adverse Childhood Experiences (ACEs) study revolutionized preventative health care by showing a graded, dose–response link between ten childhood household adversities and health problems later in life. Its inquiries focused on abuse, neglect, and household dysfunction. However, broader social harms were excluded. That narrow scope leaves out three realities that shape many lives: ongoing prejudice and oppression in the world outside the home, prenatal adversity, and trauma transmitted across generations. A modern revision of ACEs categories should widen the lens to include these categories.

Intergenerational and Historical Trauma

Intergenerational trauma is not new to the science of health. Yehuda and colleagues have documented epigenetic differences in stress-related genes among Holocaust survivors and their adult children, consistent with biological embedding across generations. Reviews summarize pathways that include in-utero stress exposure, parenting under trauma, and social transmission. 

Indigenous scholars have long described historical trauma: cumulative, group-level wounding across generations due to colonization, genocide, and forced removal. This framework predates and complements ACEs and can guide any revision interested in accuracy for Native communities and other groups subjected to mass oppression. 

Contemporary cohorts are now designed to test intergenerational pathways prospectively. For example, new studies are following mothers with ACE histories and their infants to map links among parental adversity, inflammation, child epigenetics, and development.

Oppression-Based Trauma

While intergenerational and historical trauma point to wounds carried through family lines and collective histories, many individuals also face the direct, lived experience of prejudice and oppression in their own lifetimes. These encounters—being harassed for one’s race, denied opportunities because of gender, shamed for sexuality, targeted for immigration status, dismissed due to disability, or subjected to persistent microaggressions—are not peripheral stressors. They are traumas in their own right.

Research already shows that experiences of racism and discrimination are linked to heightened risk for depression, anxiety, substance use, and chronic illness, with outcomes comparable in scale to those associated with the original ACEs. The Philadelphia Urban ACE Survey was one of the first large-scale studies to include racism and community-level violence as adverse experiences, and subsequent studies have confirmed that discrimination predicts poorer mental and physical health even after accounting for socioeconomic hardship. Scholars have also called for the explicit inclusion of racism and oppression in ACEs frameworks, though consensus and standardized measures remain in development.

Oppression-based trauma often strikes at identity itself, teaching people that who they are is unsafe or unworthy. Unlike private forms of household adversity, these experiences are continually reinforced by cultural structures, making them harder to recognize as abnormal or unjust.

Naming oppression-based trauma as its own category allows us to distinguish it from family history and from community adversity. It gives practitioners a framework to acknowledge the psychic toll of everyday prejudice, and it validates people’s pain as real rather than incidental. In doing so, it reframes direct oppression not just as a background stressor but as a central source of wounds—ones that deserve as much attention, care, and healing as the ACEs that occur within the home.

Prenatal Adversity

One of the most striking gaps in the original ACEs framework is the absence of prenatal trauma and adversity. The womb is the first environment every human inhabits, and the conditions of that environment matter. Decades of research in developmental neuroscience and the “developmental origins of health and disease” (DOHaD) field demonstrate that stress, violence, malnutrition, discrimination, and substance use during pregnancy can shape fetal development in ways that echo across the lifespan. Yet the ACEs study began its inquiry only after birth, leaving this crucial stage unaccounted for.

Prenatal adversity can take many forms: maternal depression and anxiety, intimate partner violence during pregnancy, toxic stress from poverty or racism, inadequate nutrition or exposure to pollutants, and intergenerational trauma that plays out in the body of the pregnant parent. Each of these can influence epigenetic expression, stress regulation, immune functioning, and later susceptibility to mental and physical illness.

What is Already Underway

Before turning to how oppression-based, intergenerational, and prenatal trauma might be included in a new ACEs survey, it is worth reviewing the work already underway. For more than a decade, researchers and public health leaders have been widening the lens, and their efforts provide a foundation for the kind of expansion I am advocating here.

  • Urban and community-level ACEs. The Philadelphia Urban ACE Survey added items beyond the household, including exposure to community violence, feeling unsafe, foster care, bullying, and experiencing racism or discrimination. These community adversities were common and tracked with poor outcomes.
  • The “Pair of ACEs.” Ellis and Dietz proposed that child adversity is entwined with adverse community environments such as poverty, segregation, housing instability, and discrimination. Their “tree” model frames community conditions as roots feeding individual adversity.
  • Clinical guidance acknowledging racism as toxic stress. The American Academy of Pediatrics named racism a key driver of toxic stress and health inequities in children. California’s ACEs Aware initiative trains clinicians on racism and discrimination as risk factors and uses PEARLS, a pediatric screener that explicitly asks about discrimination, neighborhood violence, housing, and food insecurity.
  • National surveillance begins to include discrimination. CDC analyses and the National Survey of Children’s Health have incorporated measures of perceived racial or ethnic discrimination and examined their association with health conditions.
  • Racism as an ACE: empirical signals. Multiple studies show that racial discrimination is associated with internalizing problems and other health risks at magnitudes comparable to conventional ACEs. Recent work also evaluates whether adding discrimination improves prediction beyond socioeconomic hardship, with mixed results that argue for careful measurement rather than simple score inflation.
  • Clinical leadership expanding ACEs. Pediatrician Nadine Burke Harris has been one of the major contributors and the most visible public face of the ACEs movement since the original study. In her clinical work and in her book The Deepest Well, she highlighted how poverty, racism, and community violence function as toxic stressors with health effects as real as abuse or neglect. As California’s first Surgeon General, she launched the ACEs Aware initiative, which trains clinicians to screen for ACEs and explicitly recognizes discrimination, neighborhood violence, housing instability, and food insecurity as key drivers of toxic stress. Her advocacy has helped move these expanded categories from research into clinical practice and public policy.

Proposed Categories to Add to ACEs

Below are pragmatic category sets that are compatible with existing tools and capture oppression-based, intergenerational, and prenatal harm. For statistical integrity, each item set should be validated, broken out by identity, and scored within its own domain rather than collapsed into a single total.

A. Prejudicial and oppression-based adversity

These experiences can be frequent, chronic, and identity-specific. They belong in their own domain rather than buried under “household dysfunction.”

  1. Interpersonal discrimination and hate: repeated experiences of being demeaned, excluded, or targeted due to race, ethnicity, religion, immigration status, language, gender identity, sexual orientation, disability, or intersecting identities; explicit hate incidents and bias-motivated bullying. PEARLS already screens for discrimination broadly, offering a tested template.
  2. Institutional or structural discrimination: school discipline disparities, tracking or denial of services, discriminatory policing, housing discrimination or forced moves, and barriers to healthcare due to identity. These fit the Pair of ACEs roots and map to known toxic-stress pathways recognized by pediatric and public-health bodies.
  3. Community threat climate: neighborhood violence, threats or harassment by neighbors or authorities, and chronic feelings of unsafety. This is already standard in expanded ACE tools and should remain.

Measurement notes: Capture frequency, chronicity, age of first occurrence, and perpetrator context. Include identity-specific checkboxes so intersectional patterns are not lost. Consider brief, validated discrimination scales for children and adolescents within the ACE workflow. 

B. Adverse Community Conditions

Add a short set that reflects community-level exposures known to seed toxic stress: 

  • Housing instability 
  • Food insecurity 
  • Exposure to environmental hazards 
  • Lack of safe spaces
  •  Neighborhood poverty or segregation. 

PEARLS again provides a practical starting point. 

C. Intergenerational and Historical Trauma

Create a distinct domain for inherited and family-level trauma that predates the child’s birth.

  1. Parent or caregiver trauma history: a brief parent ACE screen already exists; incorporate it into pediatric encounters to model intergenerational risk in real time. Use separate scoring to avoid blaming.
  2. Exposure to historical or mass trauma in the family line: items for family histories of genocide, enslavement, forced displacement, boarding schools, internment, or war, paired with the caregiver’s perceived impact on the family today. This aligns with historical-trauma frameworks.
  3. Biological embedding indicators in research settings: optional research modules could include biospecimens for epigenetic or inflammatory markers to test mechanistic pathways, given the growing literature linking parental adversity to child DNA methylation patterns. These should remain research-only until there is clear clinical utility.

D. Prenatal Trauma

One domain could capture Adverse Prenatal Experiences (APEs) as a complement to postnatal categories. This domain might include:

  1. Maternal stress and mental health during pregnancy (e.g., persistent anxiety, depression, trauma symptoms).
  2. Exposure to violence or abuse during pregnancy (particularly intimate partner violence).
  3. Substance use during pregnancy (alcohol, tobacco, illicit drugs, or misuse of prescribed substances).
  4. Nutritional deprivation or environmental toxins (e.g., lead, pesticides, unsafe water).
  5. Chronic systemic stressors such as racism, housing instability, or lack of access to prenatal care.

Like the other proposed expansions, these items should not be collapsed into a single summed score but considered as a distinct prenatal domain. That allows researchers and clinicians to trace how prenatal stress interacts with postnatal ACEs, community-level adversity, and intergenerational transmission.

Scoring and implementation

Instead of adding everything into one big number, it’s better to keep separate scores—for household, community, oppression-based, intergenerational, and prenatal adversity. This way the meaning isn’t lost, and we avoid double-counting things like poverty and discrimination that often overlap.

It also helps to look at protective factors alongside risks. Asking about Positive Childhood Experiences gives a fuller picture and reminds us that strengths and supports matter just as much as hardships.

Finally, any screening should be done with care, humility, and attunement. Ask only when there are real supports and referrals available, and when privacy can be protected. Safety and equity are paramount. The goal of awareness is useless without this foundation.

Clinical and Cultural Implications

Including prenatal adversity is not about pathologizing mothers or assigning blame. It is about naming a reality so that care can be offered earlier and more comprehensively. Proactively, clinicians already integrate questions about pregnancy stressors into pediatric and obstetric care, normalizing the idea that health begins before birth. As healing professionals, we can hold prenatal factors in mind as possible trailheads when working with clients whose struggles resist explanation within postnatal ACE categories.

The same logic applies to oppression-based trauma. To name racism, sexism, homophobia, ableism, or xenophobia as forms of adversity is not to reduce a person to victimhood—it is to acknowledge how discrimination and microaggressions leave real imprints on health. Clinicians who proactively invite stories of prejudice can validate experiences often minimized or silenced, while those who hold awareness patiently can notice when unexplained anxiety, mistrust, or hypervigilance may signal a history of oppression. Naming oppression-based trauma in care settings helps shift cultural understanding: prejudice is not an incidental inconvenience but a recognized source of harm that deserves the same attention as other adversities.

Intergenerational trauma also calls for this balance. Proactively, providers can incorporate questions about family history of displacement, war, enslavement, or forced assimilation to make space for legacies that may otherwise remain unspoken. Patiently, they can recognize when present-day symptoms—chronic fear, silence, despair—may echo wounds inherited across generations. Naming these legacies changes how our culture understands health: not as an individual’s isolated struggle, but as part of a longer story carried through bodies, families, and communities.

Over time, naming these adversities could help us shift our perspective on health as not just a private, personal matter, but as a shared responsibility where cultural and environmental well-being is a public health priority. Much like the evolution of PTSD recognition, the hope is that what was once invisible becomes “normal” to consider—and vital to address—in supporting the health of body, mind, spirit, and soul across generations.

Implications for Whole-Person Clinical Care

Expanding ACEs to include oppression-based, intergenerational, and prenatal trauma is not only a matter of measurement—it has direct implications for how healing practitioners approach the body, the mind, the spirit, and the soul. Physicians, psychotherapists, nurses, social workers, and spiritual care providers alike encounter the compounding effect of toxic stress in their work. When prejudice, discrimination, and inherited wounds are left unnamed, they risk being misread as isolated symptoms or character flaws. Naming them creates a shared language for understanding how stress embeds in the body through inflammation and illness, how psychological and spiritual burdens constrict the mind through shame and anxiety, how despair can eclipse the spirit, and how the soul longs for recognition of pain carried across generations.

By placing these adversities alongside more familiar, broadly accepted categories of abuse and neglect, practitioners can gain permission from patients to attend to them with less concern or skepticism. It becomes possible to view hypertension, autoimmune flare-ups, depressive episodes, or dissociation not only through a biomedical lens but as embodied echoes of prejudice and historical loss. This shift invites clinicians into a stance of curiosity and reverence rather than reductionism, aligning care with the full spectrum of human experience.

Naming as Cultural Transformation

It cannot be overstated: the act of naming matters. PTSD was once dismissed as weakness, malingering, or “shell shock” before persistent research and testimony made it visible and valid. Today, few would deny its importance. A similar cultural shift is needed around oppression-based, intergenerational, and prenatal trauma. 

If we consistently name them, in clinics, classrooms, and communities, they will over time be understood as “normal” and essential to consider in health and healing.

Importantly, this naming should not be another invitation to mine and fix, as though these adversities were just one more diagnostic box. Rather, they can be honored as trailheads—markers pointing to places where healing is needed. For practitioners, this means approaching disclosures of discrimination or family history of oppression not with a rush to treat but with deep listening, curiosity, and connection. For communities, it means cultivating the collective courage to bear witness and offer repair. And for the broader culture, it means slowly weaving into our shared fabric the truth that bodies, nervous systems, minds, spirits, and souls are shaped not only by individual households but by the societies and histories in which they live.

The Practice of Naming: Proactive and Patient Approaches

If healing professionals and systems of care decide to implement this expanded way of thinking, the way we name oppression-based, intergenerational, and prenatal trauma will shape the quality of care. Two approaches can be especially helpful:

Proactive Naming

In a proactive stance, practitioners can integrate questions about discrimination, prejudice, and family legacies of trauma into their standard intake or assessment processes. Much like screening for substance use or intimate partner violence, these questions normalize the conversation and give clients permission to speak about experiences that otherwise remain invisible. 

Proactive naming can signal to patients: this matters, and you do not have to be alone in it. It can be woven into electronic health records, routine health visits, and even community health outreach, ensuring that the recognition of social and historical wounds is not left to chance.

Proactive naming can also appear in how clinicians frame the body’s stress responses. Instead of only noting “hypertension” or “panic attacks,” a provider might contextualize them as possible reverberations of lived or inherited adversity. This does not replace medical treatment but complements it by broadening the story around the symptom. The relationship between a provider and patient is known to be a significant factor in success rates of treatment, priming the body and nervous system to let healing do its work. When done with sensitivity, proactive naming can be liberating: it transforms what might feel like private shame into something recognizable, common, and worthy of care. 

Patient, Attuned Naming

At the same time, a rush to naming may inflict harm. A patient and attuned approach emphasizes awareness, waiting for cues, and following the trailheads that emerge naturally in conversation. Here, clinicians hold in mind that discrimination or intergenerational trauma may lie beneath physical or emotional symptoms, but they do not press for disclosure. Instead, they listen for openings—a client’s allusion to having felt unsafe in their neighborhood, a patient’s hesitation when describing family history, or a story of chronic vigilance around authority figures.

In these moments, the practitioner does not diagnose or pathologize but gently mirrors what they hear: “It sounds like you’ve been in environments that haven’t always been safe or fair.” This kind of naming is invitational, not prescriptive. It helps people recognize their own stories at a pace that honors safety and trust.

Holding Both Approaches

Proactive and patient naming are complementary postures. Together, they can ensure that oppression-based, intergenerational, and prenatal trauma are neither overlooked nor forced into the open prematurely. The goal is not to mine trauma for another checkbox but to open pathways of understanding that can lead to healing—sometimes through formal intervention, sometimes simply through the relief of being seen and named. Over time, this dual approach can help shift clinical culture toward a fuller acknowledgment of the forces that shape health across body, mind, spirit, and soul.

Mapping Expanded ACEs Through an IFS Lens

Much of my readership are IFS clinicians or IFS-knowledgeable practitioners, and it is worth briefly naming how these broader categories of adversity connect to parts language and internal dynamics. The original ACEs categories already point to exile experiences—children left alone in terror, shame, and neglect—and to the protector strategies that emerge in response. When we extend ACEs to include oppression, intergenerational trauma, and prenatal adversity, we are naming additional pathways through which burdens are accrued and carried forward.

  • Exiles: Experiences of discrimination or historical oppression often exile parts that carry deep shame, invisibility, or unworthiness. For example, a Black adolescent repeatedly harassed by peers and teachers may exile the part of him that longs to be carefree and expressive. A child who grows in the womb of a mother enduring domestic violence may exile parts that hold early imprints of fear and unsafety, even before memory forms.
  • Firefighters: In adulthood, firefighters may step in with intensity when these exiles are touched. Alcohol or substance use may soothe the body’s echoes of intergenerational trauma. Rage, withdrawal, or compulsive achievement can also emerge as strategies to keep the pain of marginalization at bay. A client may not consciously link their sudden shutdown at work to the legacy of their family’s displacement, but their firefighters know the association all too well.
  • Managers: To preserve stability, managers may work tirelessly to avoid exposure to the systemic wounds. A queer client may cultivate perfectionism to stay “beyond reproach,” a manager’s strategy formed against the backdrop of cultural burdens that labeled their identity as unsafe or deviant. Another may adopt hypervigilance and people-pleasing to pre-empt any hint of rejection.
  • Personal burdens: These are the stories and beliefs that land in a single system: “I am unworthy,” “My body is broken,” “It’s my fault.” Naming prenatal and oppression-based ACEs helps us see that these beliefs are not just private failings, but the imprint of conditions no child freely chose.
  • Legacy burdens: When family histories carry genocide, enslavement, forced migration, or unhealed trauma, descendants often absorb burdens of silence, mistrust, or despair. A client may discover that their dread of authority is not just their own, but echoes a grandparent’s survival of state violence.
  • Cultural burdens: Beyond the family, whole societies transmit burdens: white supremacy, patriarchy, homophobia, ableism. These become embedded in children not just through explicit acts of discrimination but through the daily air they breathe. For many clients, simply naming cultural burdens as part of the “adversity load” can be profoundly relieving.

By tracking ACEs in this way, we recognize that the adversities named here do not only leave statistical traces on population health—they weave themselves into the fabric of parts and burdens. And just as with any trailhead, the task is not to pathologize but to approach with curiosity and care, helping clients witness and tend to these parts in relationship with Self.

Holding the Expansion Lightly

As compelling as these expanded ACEs categories are, it is important to hold them lightly. Many of the experiences described—prenatal adversity, intergenerational trauma, cultural burdens—are not things a patient will walk into a clinic and readily name. In some cases, they may never be consciously accessible. The imprint may show up as chronic pain, panic, shame, or relational struggle, but the narrative roots are obscured by time, silence, or layers of protection.

For clinicians, this means resisting the temptation to demand detail or to treat the expanded ACEs framework as a new diagnostic checklist. Instead, it can serve as a map of possibility, reminding us that what is visible in the room is often only part of the story. We can be curious about potential trailheads—an unexplained illness, a sense of never belonging, a recurring dream—without insisting on definitive answers.

From an IFS perspective, this is another invitation to trust the system’s wisdom. Parts reveal what they are ready to reveal. Some burdens will remain implicit, known only in the body or the nervous system. Healing does not depend on perfect recall but on a loving and attuned presence, the safety of relationship, and the willingness to honor what surfaces. In this way, expanded ACEs categories can guide our awareness while keeping us grounded in humility: we name what we can, and we hold space for what we may never know.

Additional ACEs Worth Naming

Beyond oppression, prenatal, and intergenerational trauma, there are other forms of childhood adversity that researchers and clinicians have begun to identify as potentially significant. While I won’t explore them in depth here, naming them helps widen the lens of what we might someday consider when talking about ACEs.

  • Bullying and peer victimization. While the Philadelphia Urban ACEs survey includes bullying, it has not been integrated into the core ACEs checklist. Repeated peer victimization can have long-term impacts similar in magnitude to abuse, particularly on depression, suicidality, and social anxiety.
  • Medical trauma and chronic illness. Children who undergo painful procedures, prolonged hospitalizations, or experience invalidation of their pain often carry trauma that shapes both body and psyche.
  • Separation due to migration, detention, or foster care. Forced family separation—whether by child welfare, immigration policy, or carceral systems—creates attachment ruptures not captured by the original ACEs. These can reverberate both individually and across generations.
  • Digital and media-related harms. A newer area of concern: cyberbullying, online exploitation, and the overwhelming stimulation of unfiltered media exposure. While research is still emerging, many clinicians see the burdens of shame and comparison tied to online experiences.
  • Environmental disasters and climate-related trauma. Increasingly, children are exposed to wildfires, hurricanes, floods, and chronic air or water contamination. These experiences create a backdrop of insecurity and loss that can function like community-level ACEs.
  • Spiritual betrayal or religious trauma. For some, experiences of shaming, exclusion, or abuse in religious contexts leave deep soul wounds. These are rarely named in ACEs research but often emerge in clinical practice.

Summing It All Up

If we rebuilt ACEs today, we would retain the core questions about childhood adversity in the household and add four evidence-based domains: oppression-based adversity, adverse community conditions, intergenerational or historical trauma, and prenatal exposure to trauma. The science, policy statements, and real-world tools already point the way. What remains is consensus on brief, validated items, domain-specific scoring, and ethical and flexible implementation that connects individuals, families, and communities to care while pushing systems to tend to the “soil” in which children grow.

For feedback and comments, I can be reached at max@maxlittman.com.

I provide consultation and therapy for therapists.

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References

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