Our study should be considered in conjunction with several limiting factors. As with all cross-sectional studies, causal inferences should not be taken as sacrosanct, as longitudinal data on adversity exposure is necessary. Next, although previous studies have established acceptable validity of self-reported adversity in childhood [40], the BRFSS relies on data that is self-reported, and thus, may be susceptible to memory and response biases [41]. Additionally, adversity is a complex, multi-dimensional set of processes that the ACEs framework attempts to simplify. There is an argument to be made that not all ACE categories are equal [42], and that protective processes may be just as important as adverse conditions across the lifespan [43]. The BRFSS does not account for multiple instances of a single adversity category (e.g., multiple instances of sexual abuse may be cumulatively as detrimental as experiencing adversity in multiple categories). It should also be noted that that the traditional ACE measure used in this study may not accurately reflect adversity experiences (particularly for individuals identifying as a racial/ethnic minority), and as such, calls for a more nuanced expansion of ACEs have been made [44].
