In the 1990s epidemiologists Drs. Robert Anda and Vincent Felitti conducted a ground-breaking study that definitively linked adverse experiences in childhood to poor outcomes in adulthood. Adverse Childhood Experiences (ACEs) are potentially traumatic events or circumstances that occur prior to age 18. The original ten ACEs consist of five forms of child maltreatment, physical, emotional and sexual abuse, physical and emotional neglect, and five of household dysfunction, mother treated violently, substance abuse in the household, mental illness in the household, parental separation or divorce and an incarcerated household member. These have been shown to increase the risk of poor mental, behavioral and physical health and negatively influence life outcomes in adulthood. The higher the count of ACEs, the higher the likelihood of problems in adulthood.
Ten years ago, the Child Abuse and Neglect Prevention Board, along with numerous partners, began the process of collecting ACE data in Wisconsin. When the study was replicated in Wisconsin, the findings mirrored the original study indicating that ACEs are common in Wisconsin and they tend to cluster or occur together. Approximately 3 out of every 5 Wisconsin adults have reported experiencing one or more ACES and, of the Wisconsin adults who experienced one or more ACEs, almost 25% of that same group reported experiencing a total of four or more ACEs.
In the intervening years, much national attention has been directed toward identifying and preventing ACEs. One method that has gained traction is the use of the questionnaire from the ACE study as a screening or assessment tool, either as is or with minor adaptations. The tool is used for adults to attempt to diagnose underlying causes of existing or potential problematic behavior and with children to assess for risk of future poor outcomes. Dr. Anda, as well as a number of other researchers, have declared this increasing practice to be troublesome for the following reasons:
- The ACE questionnaire was designed to assess population-based risk and not individual-level risk and is a relatively crude measure of childhood stress exposure which can vary greatly from person to person.
- The questionnaire is not a standardized nor well tested measure of childhood stress. It was not designed to be a diagnostic tool and is not sensitive to the frequency, intensity or chronicity of ACEs nor does it account for the variability of response toward stress and trauma based on sex differences or the timing of exposure with respect to sensitive periods. A person with intense, chronic and unrelenting exposure to a single type of adversity will, nonetheless, have a much lower ACE score than a person with low exposure to multiple types of adversity.
- Use of this tool can result in significant underestimation or overestimation of risk. Hazards can include stigmatizing of individuals or making future predictions based on high ACEs scores or miscalculating someone’s level of need and failing to provide appropriate resources based on a low ACEs score.
- In contrast, practitioners argue that the ACE assessment has great value for families when it is used, not as an evaluative or predictive tool, but as a conversation starter and resource for relationship and empathy building. In this context the assessment is as much for the practitioner as it is for the patient and users argue that it is valuable for informing the plan of care.
Before incorporating wide usage of this tool, a determination needs to be made as to whether ACE screening practices are the most appropriate way of understanding adversity or if there may be more effective tools or methods. This requires testing of defined administrative procedures and interpretation of results utilizing a strengths-based approach. Assessment also needs to take into consideration the accompanying context and presence of protective factors which can offset risk and support resilience. If adopted, ACE screening must be embedded into a system of coordinated assessments leading to a care pathway that provides further offerings, including evidence-based or evidence-informed approaches. Ultimately the prevention and reduction of ACEs requires grounding within a larger public health framework that not only offers tertiary care targeted to those parents and children who exhibit signs of trauma or secondary care to a selective population with identified risk factors but consists of a comprehensive, coordinated system offering primary care universally with referral to more intense levels of care only as needed.