Should We Screen for Adverse Childhood Experiences?

One author outlines the foundations of Adverse Childhood Experiences (ACEs) research, addressing its dimensions, limitations, and potential future directions

Sadie Cathcart
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In an article recently published in Child Abuse and Neglect, Dr. David Finkelhor of the Crimes against Children Research Center of the University of New Hampshire sheds light on the status of research pertaining to Adverse Childhood Experiences (ACEs), and their impact on later outcomes (both psychosocial and medical). Finkelhor critiques the recent rapidity of the development and implementation of screening tools applied in health settings to assess the presence of ACEs in children and adults, arguing that answers to the following three questions should precede continued implementation:

“1) What are the effective interventions and responses [providers] need to have in place to offer to those with positive ACE screening,

2) What are the potential negative outcomes and costs to screening that need to be buffered in any effective screening regime, and

3) What exactly should [providers screen] for?”

Photo Credit: Flickr

There has been substantial research linking the experience of emotional and physical abuse in childhood, and other ACEs, to later-life challenges including depression, schizophrenia, psychosis, ADHD, bipolar disorder. Finkelhor identifies that ties have also been found between ACEs and somatic symptoms physical conditions, such as heart disease.

Thickening the cloud that shrouds the adult experiences of survivors of childhood abuse, adversity may persist as life progresses, freshened by instances of re-traumatization (sometimes within the mental healthcare system). Acknowledging that screening methods for ACEs, some outdated, some newly developed, have the potential to trigger disturbing feelings and traumatic memories in children and adults alike, Finkelhor argues for the importance of having systems in place to support patients after being challenged to emotionally revisit such experiences.

Although many healthcare facilities have adopted procedures to accommodate patients reporting characteristics of concerning ACEs, such interventions are not often sensitive to variations in patient experience, nor are they unique to individual patient needs.

Finkelhor adds that “it is not at all clear that we have evidence-based interventions for high ACE scores, and certainly the protocols for packaging such information into a rigorous intervention are still in the early stages of development.”

Finkelhor’s cost-benefit analysis of ACE screening suggests that the ends may not justify the means. He explores the extent to which the time, effort and training required for providers to complete evidence-based ACE screening with integrity are worth the insight they provide, and reports that the answer is mixed.

Although scores may illuminate otherwise unknown features of a patient or child’s life, the administration of ACE evaluations may compromise patient-provider trust and rapport regardless of the scores generated. Additionally, in relation to ACE screening applied to children, the issue of increased referrals for welfare services increases, and these services are often part of larger, overtaxed systems with mixed impact.

“If general ACE screening were to result in a big increase in unnecessary and inherently expensive child welfare referrals and investigations as one of its main outcomes, we might look back on the ACE mobilization as a disastrous distraction to the development of evidence based child welfare policy. Such concerns merit very serious consideration.”

Finally, despite the notable link between adversity in childhood and later health problems, Finkelhor highlights that continued research is needed to establish awareness surrounding the appropriateness of current ACE assessment inventories, and the possibility of alternative tools superior to the ACE inventory for detecting adverse experience and later health outcomes.

Statistical strength in relationships detected between adversity in childhood and health outcomes has inspired a quick, but perhaps unrefined reaction by policymakers and healthcare systems to zero in on identification before thoughtfully addressing response. Premature systems of identification preceding the development of advanced systems for support weaken the significance of ACE scores and the utility of the screening. Finkelhor asserts that a redirection in ACE research is needed to inform critical improvements in the trajectory of its study and influence.

 

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Finkelhor, D. (2017). Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse & Neglect. (Link)

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Sadie Cathcart
Sadie Cathcart is a doctoral student and researcher within the Counseling and School Psychology program at the University of Massachusetts, Boston. Sadie belongs to the school psychology track, and her research interests include the psychosocial implications of chronic illness in childhood, relationships between health and educational opportunities, and creative approaches to boosting student and family engagement in learning.

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29 COMMENTS

  1. Really, this screening business has long been out of hand. I don’t think we need to be screening for ACEs any more than we need to be screening for FCEs (Favorable Childhood Experiences). However, if you want to go there, I think we would have a lot more success eradicating FCEs than we would have eradicating ACEs.

  2. The problem is the system will continue to abuse people as it has always done regardless of “ACE screening.” Any well-informed and sensitive person will ask questions that lead to information about “ACEs” in the course of a normal conversation intended to help. In fact, even calling them “ACEs” diminishes the power both of the experiences themselves and the survivors’ ability to create their own narrative of the meaning of such experiences.

    A more honest approach would be that “crappy things that happen to you often lead to you feeling crappy and getting sick.” And to allow the person to share such experiences if they like, without giving them a “score” and labeling them as a victim of “ACEs” as if these were some disembodied entities that need to be “assessed.” Same with depression or any other “screening tool.” Sure, doctors and others should be aware of these issues and be willing to talk about them as needed, but “scoring” people on their past difficulties will only serve to dehumanize them even further.

    • Yes…and they are used to justify locking people up involuntarily.

      The reason I was deprived of my liberty and had dangerous drugs forced upon me was assessed that I could be “a danger to others” based on the fact that I had several “ACEs”. NEVER in my life had I exhibited any violence or anti-social or unlawful behaviour (not even a parking ticket), I had successfully raised two children, had a high level exec career, been a volunteer telephone counselor, served on club committees etc. AND I was 50 and female.

      And yet, when I sought “help” after a work related stress breakdown, I answered questions that disclosed that I had experienced not-too-good parenting and a violent rape, instead of being shown respect and caring for having survived and contributed to society, the information was used against me to deemed I was “a danger to others”.

      Locked up and drugged. Treated appallingly. Totally traumatised.

      What was done was far worse than anything that happened to me as a kid. It cost me my career, most of my friends, and my relationship with my mother, who couldn’t handle my being locked up in a psych ward and disowned me.

      This is what assessment for “ACE’s” can be used for. Every box ticked on the violence assessment form (I got copies of my hospital records) was ticked because of childhood ACE’s I had disclosed as part of conversations with a shrink.

      In their minds, we are forever defined (negatively) by our “ACEs”. We can never grow or learn from these experiences, they cannot shape us to be more compassionate and caring people, determined NOT to repeat the cruelties we suffered.

      In the eyes of psychiatry, childhood “ACE’s” define us as being as irredeemably bad and broken, dangerous, and nothing positive we do in a lifetime can wipe that slate clean.

      Screening for “ACE’s” is just another form of psychiatric abuse.

      • What was done to you is pretty crazy. ACE’s don’t predict whether people are a danger to others or not. And ACE’s are not carved in stone. People can change their lives by doing trauma work so that they can counteract the physical effects of the trauma experienced. ACE’s are red flags that can alert people to the fact that they need to do some things for themselves to improve their health in later years. What was done to you was a total misuse of the ACE study. The system is always looking for new ways to drag people in so that they can be drugged to the gills.

        In my experience, working in a state “hospital”, very few psychiatrists that I deal with even know about the ACE study. And if they know about it they don’t consider it important because, as the experts on the lives of other people they know exactly what the problem is. The problem is a broken brain and a chemical imbalance and will be corrected by the use of neurotoxins. When every tool in your tool box is a hammer everything looks like a nail. No trauma work is ever done where I work because they don’t believe it to be important to the task at hand.

        • To clarify, Stephen
          What was done to me (in Australia) wasn’t part of the ACE study, as such. However, the things ticked on my “dangerousness” assessment all would have been classed as adverse childhood experiences, with the exception of my having left a psychologically abusive husband.

          I had, during my lifetime, acknowledged and grown/moved on from my not wonderful childhood and my violent rape at age 12, successfully and gently raising my own kids, and building a successful and secure life and career and a respected place in my communities.

          It appalled me that psychiatry should list events from 35-40 years earlier that had ceased to be issues in my life as reasons to deem me potentially “a danger to others” and lock me up and drug me involuntarily.

          I was going through a breakdown at the time, and really struggling and had sought psychiatric support, but had shown no evidence of being a danger to anyone. My breakdown related to work related stress and career burnout, and the situation in that workplace totally burnt out numerous others too.

          What psychiatry actually did was saddle ME with the “dangerousness” that rested firmly with those who had abused me all those years ago…my parents, my rapists, and my former husband. It used these long since past events as reason to lock me up and drug me.

          I had addressed many issues through therapy, meditation, counseling training, helping others, raising my own kids etc, and so thoroughly agree with your assessment that people can develop and change, but the hospital that captured and drugged me used those old experiences as evidence that I might be dangerous.

          My point is that there is potentially massive danger in screening for ACE’s while ever psychiatry holds the power to detain and drug…you absolutely never know when or how anything they know about you will be used, either to justify diagnosing and drugging of kids or further down the track in adulthood.

          Maybe they should just be red flags that are used to help people, but I have no confidence whatsoever that any information provided on such events will be used as anything but a reason to further punish the innocent.

  3. The ACEs are, unfortunately, extremely limiting.
    There are many forms of trauma that can cause serious adverse health effects that screening for ACEs would completely miss.
    We experience both Bipolarity and Multiplicity.
    We have an ACE score of zero.
    We’ve experienced many traumas, none of which would show up in a screening for the current set of adverse childhood experiences.
    Until they expand their understanding of trauma beyond abuse and neglect, screening for trauma will result in many false negatives.
    -Serenity

    Going off what she said.
    Why do we never hear people talking about the trauma of *having* a “mental illness”?
    Your mind turning against you is a pretty damn horrifying experience. And when it happens when you’re a kid, and no one believes you because (back then) kids don’t get “manic-depression”…?
    Yeah, trauma.

    Another thing. Those of us in the plural/multiple community remember all too well the last time there was a big “fad” about mental health issues later in life meaning something bad happened in childhood.

    It’s a short and slippery slope from “what happened to you?”, to “who did this to you?”
    Too many impassioned laypeople and ambitious docs seize on this stuff?
    You’ve got yourself a moral panic.
    I don’t hear anyone having that conversation or raising those concerns.
    Let’s *not* go there, again.
    -Liberty

    • Right, trauma can happen to a baby when she/he is not a good fit personality wise with her/his mother. The mother doesn’t have to have any malicious intent to cause harm, it just results because mother and child are not a good fit. This is all caught up with attachment stuff that babies and mothers must achieve for the child to mature properly. So, it has nothing to do with any kind of abuse directed at the baby. It just happens, unfortunately. And if a mother doesn’t have good guidance about how to mother her child things can go haywire and the baby and mother don’t attach properly. All this trauma stuff is not as simple as it’s sometimes made out to be.

      There’s someone who posts on MIA who uses attachment theory in walking with his wife on her journey of dealing with many persons within one. I think his moniker is Sam Ruck.

  4. We should not screen for ACEs.

    And I will say I have proof in medical records that when a mother is handed over medical evidence of child abuse, and mentions this to a psychiatrist, the first thing that psychiatrist wanted to do was get my child drugged up by a child psychiatrist. Drugs don’t cure symptoms of child abuse.

    The second thing that psychiatrist did was try to convince my husband that I needed to be drugged up. Antipsychotics do not cure a mother’s concerns about the abuse of her child.

    The number one function of today’s psychiatric industry is drugging up child abuse victims, according to your own medical literature. This functions to aid, abet and empower the pedophiles.

    Western civilization is now controlled by satanic pedophiles, thanks in part to the psychiatric industry’s delusions that psychiatric drugs cure symptoms of child abuse. Rape is not a brain disease, nor is it a chemical imbalance in a person’s head, it’s a crime, thus drugs do not cure symptoms of rape or child abuse.

    https://realitieswatch.com/putin-west-controlled-satanic-pedophiles/

    The “mental health professionals” need to get out of the business of profiteering off of covering up child abuse, since this is illegal. Most of today’s “mental health professionals” actually belong in jail, for functioning as pedophile protectors, according to your own medical literature.

    • 100% agree.

      The massively insulting “me too” parade out of Hollywood is satanic. Those people are in the way, glory pigs yet again, when the real victims are trapped in psychiatry and the mental system (torture, souls ripped apart and destroyed). Those people are LOSING THEIR TROPHIES, AT WORST. It is disgusting. Their movement serves themselves.

      And when that dragon, satan, shakes its sexual immorality head in politics and government, we the people are still left in wait for justice while they all keep stroking along the vainglory train.

      Some doctor with over a hundred victims is less than a drop in the bucket.

      WE are waiting.

  5. I see mass screening for ACE’s to be just another excuse for the drug companies and the system to capture more people in their nets, people that can be a lucrative source of money for both groups.

    If you’re going to go around asking people about these kinds of childhood experiences you’ve got to have something good and appropriate in place to deal with the aftermath of such screenings, and it ain’t going to be pretty. We all know that such a system would never be adequate if they even bothered to create anything in the first place. You’d end up being dragged off to some “hospital” and drugged to the gills, for your own good and the good of others, of course.

    Although I think that the ACE Study is a useful tool in looking at the effects of trauma I don’t support any kind of mass screenings, especially not in schools. There would be mass hysteria because it’s the rare person who doesn’t have at least one ACE and a score of 4 or more ACES is considered serious. How would they deal with all fall out that would take place? I think it’s important to give people a chance to deal with their trauma if they so desire, and it’s easier to deal with your trauma issues at the age of four than it is the age of forty, but I can see this ending up in sheer pandemonium.

    • Something about this reminds me of how we ended up in an “opioid epidemic” once the medical field adopted “Pain as the Fifth Vital Sign” and then started prompting every patient to disclose any pain they felt on a totally subjective scale.

      “You’re at Pain-3?! Here’s some Oxy.”
      “You experienced trauma?! Here’s some brain drugs.”

      -Liberty

  6. Well, I needed two things as a kid.
    I needed education to let me know just what trauma was and what it did to a person. It would have been nice to have a full school assembly and talks by trauma survivors.
    I needed a support group of other trauma survivors, certainly by the time I was a junior in high school. I left high school an absolute basket case, and a good life relating to others was impossible to figure out, and the Vietnam War sure didn’t help.
    I bet none of those things are available even to day for kids at Rockville High in Ct.
    Hugh Massengill, Eugene Oregon

  7. “Should We Screen for Adverse Childhood Experiences?”

    Not if you don’t know what you’re doing, NO. You can, and you should, just be normal caring people. That’s a great place to start. Resist any compulsion to POSSESS and take control of a life that isn’t yours. Resist the conditioning to condition. Resist those subtle abuses that are barely recognizable for the abuses that they are. Don’t PRY. Don’t think anyone owes you their mind (thoughts) or their heart (feelings). Practice integrity. Practice moral wisdom. Practice GUIDANCE, not take over and control. Treating people the way they deserve to be treated is one of the most effective ways to heal and restore a person, including children. Don’t stop striving for right, even when things go wrong.

    “There has been substantial research linking the experience of emotional and physical abuse in childhood, and other ACEs, to later-life challenges including depression, schizophrenia, psychosis, ADHD, bipolar disorder.”

    I wish you knew how destructive (not constructive) and wrong (not right) those conceptualizations are. And, ridiculous too. Please don’t take it personal because they are not *your* concepts. They are group think, and the group’s language is all wrong.

    Edit: There has been substantial research showing the experience of emotional and physical abuse in childhood, and other ACEs, to later-life conditions erroneously and injuriously conceptualized as mental illnesses.

    I hope that was useful. Or helpful. Or beneficial. And gee, it would be a world of difference if it could be EFFECTIVE.

    🙂

  8. No! they should NOT screen for Adverse Childhood Experiences unless other more humane alternative solutions are offered other than drugging the patient into psychosis, suicide and death. U.S. Preventive Services Task Force Seeks Comments on Draft Recommendation Statement on Screening for Depression in Children and Adolescents – WASHINGTON, D.C. – September 8, 2015 – The U.S. Preventive Services Task Force (Task Force) today posted a draft recommendation statement on screening for major depressive disorder (MDD) in children and adolescents, stating that adolescents ages 12 to 18 should be screened for MDD when adequate systems are in place for diagnosis, treatment, and monitoring. .. and with MDD, these feelings last more than 2 weeks. Depression can make it difficult for adolescents to function, relate, and develop, which can affect their performance at school or work and their interactions with family and peers. By screening for depression and identifying young people with MDD, support and treatment can be put in place to alleviate symptoms and lessen the risk of suicide. (We can’t go 2 weeks of feeling heartbroken, down or disparaged without being ‘labeled’ and heavily drugged? Just look how many psychiatric drugs come with a Black Box Warning of causing Suicide? There are no adequate systems in place. They only use neurotoxic psychiatric drugs to treat, and monitoring! That’s a joke. There is no monitoring.) And if that isn’t enough they want to go after pregnant women.:

    ‘Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive Services Task Force – The information in this article is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services’ – policy makers? You mean the ones in Washington DC who are bribed by pharmaceutical companies to pass laws in their favor? and others. Are they referring to pharmaceutical companies directly, the only ones to benefit. It certainly isn’t the patient. It’s quite obvious they want to drug every man, women & child in America and will stop at nothing until they succeed. Most tragically, America drugs the most children than any other country on Earth. And if this doesn’t appall you, I don’t know what will.

    • “No! they should NOT screen for Adverse Childhood Experiences unless other more humane alternative solutions are offered other than drugging the patient into psychosis, suicide and death.”

      Applause!! Oh, I loved that! It was great to read. Made me smile and rejoice 😀

      • Poora, God Bless you for that. I become so angry when I write about what I’ve discovered in my research into the deep annals of so called ‘medicine’, psychiatric drugs, mental health field, FDA, pharmaceutical companies, CDC and more. I’m sorry, I used the wrong word ‘angry’, I meant to say OUTRAGED. Plus, after being heavily drugged for 35 years I had a front row seat to the horror show. And the theater was full.