The Revised ACE Pyramid: A Contemporary Framework for Understanding Childhood Adversity and Advancing Toxic Stress Prevention and Healing

Background: The Adverse Childhood Experiences (ACE) Pyramid has been widely used for more than two decades to illustrate pathways linking childhood adversity to health outcomes across the lifespan. Since its development, substantial advances in the science of toxic stress have expanded understanding of the biological mechanisms through which adversity influences lifelong health. Objective: To describe the development and scien-tific rationale for a revised ACE Pyramid that reflects contemporary evidence on toxic stress, the biological pathways linking childhood adversity to health, and opportunities for prevention and healing. Methods: An interdisciplinary revision process was con-ducted in collaboration with subject matter experts from government, academia, healthcare, professional associations, and community-based organizations. Iterative re-view and refinement were used to align the framework with current scientific evidence and practice. Results: The revision process resulted in a revised ACE Pyramid that preserves the familiar structure of the existing framework while incorporating contem-porary scientific understanding of toxic stress, the biological pathways linking childhood adversity to lifelong health, and opportunities for prevention and healing. Compared with the ACE Pyramid featured on the CDC website during development of the revised framework, the revised framework more explicitly emphasizes prolonged or excessive activation of the stress response as a central mechanistic pathway linking childhood adversity to lifelong health, expands the biological layer to encompass multiple inter-acting biological systems beyond neurodevelopment alone, and integrates prevention and healing opportunities throughout the framework. Discussion: The revised ACE Pyramid provides a contemporary conceptual framework for understanding how childhood adversity influences lifelong health while highlighting opportunities for prevention and healing. By integrating advances in the science of toxic stress with current understanding of the biological pathways through which adversity affects health, the framework offers an updated foundation for understanding, preventing, and treating toxic stress across the life course. Conclusions: The revised ACE Pyramid translates decades of advancing science into an accessible framework that can support trau-ma-informed clinical care, public health action, and multidisciplinary efforts to prevent and treat toxic stress. By providing a shared scientific foundation for prevention and healing, it can help advance health equity and improve outcomes for children and families.