The first appointment usually catches people off guard. They have arrived with a folder of lab results, some of them years old, most of them flagged “normal,” expecting me to open it right away and start reading. Instead, I set it aside and ask about their life. When did the fatigue start, and what else was happening that year? What were the hard seasons? What was childhood like?
I understand why that can feel like a detour. You came for a biological answer, and here I am asking about your history. But I promise I am not doing therapy, and I am not looking for something to blame. I am gathering clinical data. In functional medicine, your life history is a load-bearing part of the diagnosis, not soft background to the “real” information in the bloodwork. It shapes what I decide to test, what I address first, and what a given lab value actually means in you rather than in a population. This is one of the clearest places where a functional medicine assessment differs from a standard fifteen-minute medication check, and it is worth explaining why.
Your history is data, gathered in the same breath as your labs
The framework I work from comes out of the Institute for Functional Medicine, and it is more structured than most people expect. One of its core tools is the Timeline: a chronological map of a person’s life placed directly alongside their biomarkers. In the clinical decision-making tools I use, whether the presenting concern is thyroid, adrenal and HPA-axis function, cardiometabolic health, or something else, “Timeline” sits under Medical History on the very same page as the lab panels. In the adrenal and stress-hormone workup, for example, trauma history is listed as a medical-history item right next to salivary cortisol and DHEA.
That placement is the whole point. Rather than treating life history as a preamble you get through before the science starts, the model treats history and biochemistry as two readings of the same person, gathered together, because neither one is interpretable without the other. A cortisol curve is a number until I know what nervous system produced it. A story is just a story until I can see what it did to the body. Put them side by side and they start to explain each other.
Antecedents, triggers, and mediators: three kinds of “why”
To organize a life’s worth of history into something clinically useful, functional medicine uses a simple structure with three categories. Once you see it, you cannot un-see it, and it changes how you understand your own timeline.
Antecedents are the factors, some genetic and some acquired, that predispose a person to a pattern in the first place. These include experiences, earlier illnesses, occupational and environmental exposures, nutrition, and lifestyle across the years. Antecedents set the stage. They are the soil conditions that make one particular problem more likely to grow than another. Adverse childhood experiences live here, in the category of formative experience.
Triggers are the factors that actually provoke symptoms into appearing: an infection, a physical or emotional trauma, a toxic exposure, an allergen. Triggers are usually easier to name because they often come with a “before and after.” Many people can point to the year things changed.
Mediators are the factors that keep the pattern going once it has started, and this is the category most people have never been offered. Mediators can be biochemical: inflammatory cytokines, hormones, neurotransmitters, reactive oxygen species. But mediators can also be psychosocial: ongoing stress, isolation, a sleep pattern that never recovered, a relationship that keeps the alarm system switched on. That dual nature, part biochemistry and part life, is essential, and I never want you to leave thinking mediators are only molecules. They are the ongoing conditions, inside and outside the body, that perpetuate the problem.
The loop is the point, and it is where the leverage is
Here is the part that matters most, and the reason I am careful about how I tell this story.
These three categories are not a straight line from past to present. Functional medicine draws them as a feed-forward cycle. Mediators do not just sit downstream of the original antecedent and trigger; they loop back and re-provoke the system, which generates more mediators, which sustains the pattern. It is a circuit that can keep running on its own.
That circuit explains something that otherwise makes no sense to people: why a pattern can persist for decades after the original antecedent, and long after the trigger that set it off is gone. The stress physiology literature has a name for this accumulating wear, allostatic load, and for the mediators that both protect us in the short term and damage us when they never switch off [1]. Early adversity, specifically, has been mapped onto this same allostatic-load model as a driver of later, age-related disease [2]. In one well-known life-course study, childhood maltreatment predicted elevated inflammation in adulthood, a measurable mediator still circulating years later [3]. Developmental researchers call this the biological embedding of early adversity: the way sustained early stress can get written into the body’s regulatory systems and shape their set points long afterward [4].
Now hold those two facts together, because their combination is the entire reason I am optimistic in a room where the history is heavy. Your antecedents are not modifiable: I cannot change what happened to you, and I am not going to pretend the goal is to fix your past. But what your antecedents set in motion is modifiable, because the mediator loop is the interruptible part of the circuit. The framework itself insists on this distinction: in the functional medicine model, “antecedents, triggers, mediators” and “modifiable lifestyle factors” are drawn as separate inputs feeding the assessment. History is one axis; the modifiable factors are another. Your history is the context I read the labs against. It is not the target of treatment. The mediators — the inflammation, the disrupted rhythms, the nutrient gaps, the stress signaling that keeps looping — are the target. That is where clinical leverage lives, and that is what we go to work on. I have watched a modifiable factor blunt one of these pathways in my own research: in the same Los Angeles cohort, perceived social support moderated the association between household-dysfunction adversity and drug use. The association was substantially stronger among the men reporting lower support and weak among those reporting higher support [5]. A chain that began in a non-modifiable antecedent was softened by a present-day, changeable factor. And the factor was psychosocial rather than biochemical, which is exactly what the framework means when it insists that mediators are both. You should finish reading this with more room to move than you started with, not less. If any part of your history has ever been handed to you as a verdict, I want to be clear that biology does not read it that way. A predisposition is not a sentence; it is a starting position.
Where ACEs fit, and one thing they are not
Adverse childhood experiences entered mainstream medicine through a large study published in 1998 by Felitti, Anda, and colleagues, which found a strong graded relationship between the number of adverse experiences in childhood and a wide range of adult health risks [6]. A later systematic review and meta-analysis of more than a quarter-million people confirmed the same dose-response pattern and its reach into mental health outcomes [7]. This is real, and it is why any thorough mental health assessment should make room for early history at all.
But there is a widespread misunderstanding about what that “ACE score” can do, and getting it wrong does harm.
Why I do not treat your ACE score as a lab value
The ACE questionnaire was built as a population-level, epidemiological instrument. It was designed to describe patterns across large groups of people, to show public health researchers that childhood adversity, in aggregate, tracks with adult disease. It was never designed to forecast the future of the individual person sitting in front of me.
This is not my reinterpretation of the tool. One of the original ACE Study authors has said it plainly. In a 2020 commentary, Anda and colleagues cautioned that the ACE score “is neither a diagnostic tool nor is it predictive at the individual level,” and warned specifically against its being “misappropriated as a screening or diagnostic tool” to infer a given client’s risk [8]. The reasoning is straightforward once you see it. A dose-response curve at the population level is a statement about averages across thousands of people; it is not a prognosis for one. Two people can report the identical number of adverse experiences and have lived completely different realities: different severity, different duration, different timing, different protective relationships, different everything that actually shapes an outcome. The number flattens all of that into a single digit. Researchers who study this have raised similar cautions about turning ACE scores into a clinical screening checklist [9]. A score is not a lab value. It has no reference range for a single life.
I have run into this limitation directly in my own work. In two separate analyses of the same longitudinal cohort (a group of low-income, predominantly Black and Latino men who have sex with men in Los Angeles, n=321), the number of ACEs never behaved like a smooth dose-response dial, and it behaved inconsistently from one outcome to the next. For depressive and anxiety symptoms, the count mattered only past a threshold rather than climbing steadily step by step, and among the individual dimensions it was childhood maltreatment, not household dysfunction, that tracked most closely with depressive symptoms [10]. For self-reported drug use, the cumulative count showed no clear overall association at all, yet the household-dysfunction dimension did, while maltreatment did not [5]. Same total, opposite composition, different story. I want to be careful not to over-read one specific sample (these associations belong to that cohort, not to every person who walks in), but the methodological lesson travels: a single total conceals which adversities a person is actually carrying, and that is precisely the information a clinician needs.
So what do I use instead? The narrative Timeline, not a tally. Rather than asking you to add up a list and hand me a number, I want to understand when things happened relative to when your symptoms appeared and when other exposures landed. That is a different kind of question, and it produces a different kind of information. It tells me sequence, context, and plausibility (the things that actually help me interpret a lab result), where a score tells me almost nothing about you specifically. (You will notice I have not reproduced the ACE questionnaire’s items here, and I do not walk through them like a checklist in session either. The point is never to make you account for a list. The point is to understand your story well enough to read your biology correctly.)
What the history actually changes in practice
This is not a philosophical exercise. Your history changes three concrete things about your care.
It changes what I test. A timeline marked by prolonged early stress raises my suspicion for a dysregulated stress-hormone rhythm, so I am more likely to prioritize a detailed look at the HPA axis, the same cortisol-and-DHEA territory I have written about in the context of feeling wired, tired, and told you are “fine”. A history that points toward chronic inflammatory load steers me toward different markers. Comprehensive does not mean ordering everything; it means reviewing what already exists, finding the specific gaps, and testing what will actually change the plan.
It changes what I address first. When findings pile up across several systems, the history helps me decide the order of operations: establishing a stable foundation before layering in more targeted work, because sequence determines whether an intervention lands or backfires. Two people with similar labs can need very different starting points, and the history is often what tells them apart.
And it changes what a finding means. The same result reads differently against different histories. A flat cortisol curve in someone with a long history of early adversity is telling me something about a system that has been adapting for a very long time — not a random anomaly, but a coherent response with a traceable origin. This is where the disparate results in that old folder often stop looking like a pile of unrelated flags and start making sense as one story. In the functional medicine process, that step even has a name: telling the patient’s story is a formal stage of the work, not a bedside-manner nicety. The model frames a complete assessment as three legs of one stool: retelling your story with its antecedents, triggers, and mediators; organizing the biological imbalances; and personalizing the modifiable factors. The story alone is not a plan. The labs alone are not a story. You need both, which is exactly why I will not choose between them.
It is worth naming that the mental, emotional, and spiritual dimension sits at the center of this framework, not off to the side. Sometimes a behavioral pattern (how someone eats, for instance) functions as a mediating step in the loop rather than a moral failing or a simple choice, and this is another place my own research shapes how I read a timeline. In a sample of adults seeking nutrition counseling, adverse childhood experiences were associated with greater ultra-processed food intake and with symptoms of ultra-processed food addiction, which were in turn associated with broader eating pathology: a chain of mediating associations linking a childhood antecedent to an adult presentation [11]. In a related sample, the association between cumulative adversity and ultra-processed food addiction was itself moderated by a person’s substance-use history [12], context changing the strength of the link again. These are cross-sectional and modeling associations, not evidence that one thing causes another, and I raise them only as an example of the framework in action, a pattern read at the level of mechanism, developed further in my webinar on a unified theory of eating. None of this is dietary advice. And because biology and inner life are genuinely entangled, the relationship between functional medicine and depth psychological work is something I take seriously rather than treating the body and the story as separate departments.
This is sense-making, not blame
I want to close where I started, because the tone of this matters as much as the content.
When I ask about your childhood before I read your labs, I am not searching for a culprit, and I am not implying that an unexamined history is a personal failing. I am trying to give you the coherence that a decade of disconnected test results never did: the moment where the picture finally clicks into place and the pattern stops feeling mysterious. That coherence is the deliverable. It tends to come with relief, not shame, because understanding why a system has been behaving this way is the first thing that makes the system feel changeable.
This is also the honest core of a phrase I use a lot: you are probably not treatment-resistant; you may simply have been undertested, and under-understood. The standard evaluation had no room for your history and no framework to connect it to your biology, so of course the picture stayed incomplete. At FxMed Mental Health, the assessment is built to hold both. Our two-month Testing and Consultation process pairs a comprehensive seven-test workup with a structured read of your history, and the whole thing exists to produce one coherent, personalized roadmap rather than another pile of supplements. You leave understanding your own biology well enough to act on it, with me and your other providers, or on your own.
Your past is not the thing I am trying to fix. It is the thing that finally lets the rest make sense. That is why it comes first.
If you are carrying a folder of “normal” labs and a history no one has ever connected to them, that gap is exactly what a comprehensive functional medicine assessment is built to close. You can learn how the two-month Testing and Consultation process works and book a free 15-minute discovery call whenever you are ready.
Frequently asked questions
Why does a functional medicine provider ask about my childhood before ordering or reading labs?
Because in this model your life history is clinical data, not background. The Institute for Functional Medicine framework places a life Timeline directly alongside your lab panels and gathers them together, because a biomarker is hard to interpret without knowing the person and the history that produced it. Your history helps determine what gets tested, what gets addressed first, and what a given result actually means in you.
Does a high ACE score mean I am destined to be sick?
No. Adverse childhood experiences act as antecedents, factors that can predispose a pattern, but they are not modifiable and they are not the target of treatment. What they set in motion, the self-perpetuating “mediator” loop of inflammation, hormone and nervous-system signaling, is modifiable, and that is where treatment works. A predisposition is a starting position, not a verdict.
Do you use the ACE questionnaire to screen or diagnose patients?
No. The ACE score was built as a population-level research instrument, and one of the original study’s authors has cautioned that it is neither diagnostic nor predictive at the individual level and should not be used as a screening tool for a specific person. Instead of a tally, I use a narrative timeline (understanding when events happened relative to symptoms and exposures), which is far more useful for interpreting your biology.
If the antecedents cannot be changed, what is there to actually treat?
The mediators. Functional medicine draws antecedents, triggers, and mediators as a feed-forward loop, and the mediators — biochemical ones like inflammation and hormone signaling, and psychosocial ones like chronic stress and disrupted sleep — are the part of that loop that can be interrupted. Alongside modifiable lifestyle factors, they are the practical targets of care.
Is this the same as therapy?
No. Mapping your history is a clinical assessment step, not psychotherapy. The goal is sense-making that guides testing and treatment: understanding your story well enough to read your labs correctly. At FxMed Mental Health, psychological consultation is provided by Gretchen Kubacky, PsyD, and any psychiatric medication is coordinated with a collaborating prescriber by referral.
The bottom line
Your history is neither a verdict nor a number. In the framework this piece describes, the events of a life enter care as antecedents, triggers, and mediators, and it is the mediators, the self-perpetuating loop of biology and circumstance, that treatment can actually reach. A cumulative adversity score cannot tell me which of those a given person is carrying, but a narrative timeline can, and it changes what I test, what I address first, and what a lab result means once I see it. If you have done the work (therapy, medication, real effort) and still feel stuck, it is worth asking whether anyone has ever placed your history and your biology on the same page. You are not a single data point, and you deserve an assessment that reflects that. If that question resonates, a free discovery call is a low-stakes place to begin.
About the author
David Wiss, PhD, RDN, FMCP is the founder of FxMed Mental Health, a virtual functional medicine practice focused on complex, treatment-resistant mental health. With a doctorate in public health and a background as a registered dietitian nutritionist, David has published peer-reviewed research on adverse childhood experiences and their links to mental and physical health, and his clinical work centers on cross-system pattern recognition: connecting findings across the gut, hormones, nutrients, genetics, and inflammation to understand the biology beneath mental health symptoms. You can read more about his background or browse his published research. FxMed Mental Health coordinates with patients’ prescribing providers and does not replace psychiatric care.
Disclaimer
This article is for educational purposes only and does not constitute medical advice. It is not intended to diagnose, treat, cure, or prevent any condition. The research and frameworks discussed here describe general patterns and do not predict any individual’s results or outcomes. Adverse childhood experiences and functional medicine assessment are context for understanding health, not treatments in themselves, and an ACE score is not a diagnosis. Do not start, stop, or change any medication or supplement based on this article. Always consult your physician or qualified mental health provider about your individual situation, and never disregard or delay seeking professional advice because of something you have read here. If you are in crisis, contact your local emergency services or a crisis line immediately.
References
All references below were independently verified through PubMed prior to inclusion. According to PubMed:
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