Improving the Adverse Childhood Experiences Study Scale

But if you are asked, "what is your evidence behind your screening tool?" Ask "what is the evidence behind yours (for example for pediatric bipolar)?" You will find that the DSM is a group of academic doctors getting together to decide these symptoms mean this diagnosis. The evidence is slim at best.  They can give not genetic, epigenetic, demographic or you name it ... answers.... So the evidence behind childhood adversity and severe adverse mental, physical, and societal outcomes is clear (You don't have to have 5 million ACE studies to come to the conclusion that there is a significant link)... and that society will save in term of money spent and human suffering...... however beware.... if ACEs were to become a reality...a business that makes lots of money on drugs and a profession who learned only to give out drugs may fight back and they fight HARD.....

They have the money and the resources to do so... 

I did cancer research before medical school... we studied a cancer drug that is now making big money for a drug company... I am not 100% sure but I do believe most of the grant funding came from the NCI (National Cancer Institute) little from the drug company but that company is currently reaping the profits of my and our lab's work

One thing that MUST be addressed moving forward is gender bias in the ACES themselves. In the first wave, domestic violence was specifically defined as maltreatment of the mother. I'm not sure that this has been addressed in the questionnaire currently, and it's vital that we do so. 

Sticks, Stones, and Hurtful Words: Relative Effects of Various Forms of Childhood Maltreatment

You may be right about moving away from the gender bias.  Especially in Lesbian, Gay and Bi-Families.. I don't know a lot about this form of violence but I have a family in my practice where this is a pernicious form of violence that the kids are seeing (this is anecdotal).  I try to educate all I can but I have experienced witnessing violence against a sibling.  For me this was terrible.... maybe even one of the worse experiences I have had... So I will share an email conversation from a researcher at Harvard who is looking at this currently... You make good points... I thank you...

Here is a series of correspondence I had with Dr. Teicher about his research on affects on brain development in the context of witnessing violence against siblings. I believe this is an important form of trauma. So I believe question 7 needs tweaking to include not only violence against a parent but also against a sibling.

Here is an Abstract from Dr. Teicher’s Article “Witnessing Violence Towards Siblings: an Understutied but Potent form of Early Adversity”

Abstract

Research on the consequences of witnessing domestic violence has focused on inter-adult violence and most specifically on violence toward mothers. The potential consequences of witnessing violence to siblings have been almost entirely overlooked. Based on clinical experience we sought to test the hypothesis that witnessing violence toward siblings would be as consequential as witnessing violence toward mothers. The community sample consisted of unmedicated, right-handed, young adults who had siblings (n = 1,412; 62.7% female; 21.8±2.1 years of age). History of witnessing threats or assaults to mothers, fathers and siblings, exposure to parental and sibling verbal abuse and physical abuse, sexual abuse and sociodemographic factors were assessed by self-report. Symptoms of depression, anxiety, somatization, anger-hostility, dissociation and ‘limbic irritability’ were assessed by rating scales. Data were analyzed by multiple regression, with techniques to gauge relative importance; logistic regression to assess adjusted odds ratios for clinically-significant ratings; and random forest regression using conditional trees. Subjects reported witnessing violence to siblings slightly more often than witnessing violence to mothers (22% vs 21%), which overlapped by 51–54%. Witnessing violence toward siblings was associated with significant effects on all ratings. Witnessing violence toward mother was not associated with significant effects on any scale in these models. Measures of the relative importance of witnessing violence to siblings were many fold greater than measures of importance for witnessing violence towards mothers or fathers. Mediation and structural equation models showed that effects of witnessing violence toward mothers or fathers were predominantly indirect and mediated by changes in maternal behavior. The effects of witnessing violence toward siblings were more direct. These findings suggest that greater attention be given to the effects of witnessing aggression toward siblings in studies of domestic violence, abuse and early adversity.

Email Correspondance:

Dr. Teicher,

Hello. I am a pediatrician and am working on using the ACE screening questions in the pediatric office along with resiliency questions. I strongly suspect that observing sibling violence may be more harmful than experiencing that against adults. I saw your article on witnessing violence towards siblings: an understudied but potent form of early adversity, and wondered if you could comment. I have a hard time understanding “relative importance – variance decomposition”. I am a pediatrician and I believe that the question 7 of the ACE screening may miss some significant negative psychological impact in adults exposed during childhood by not including violence towards siblings (anecdotally — my experience of seeing sibling violence was much worse that anything I saw against a parent). Thank you for your time. Your response is much appreciated.

Dear Tina,

I expect that you are correct. We certainly see the predominant effect of witnessing violence to siblings in our data. The “relative importance – variance decomposition” is just a statistical way of accurately indicating the percent variance in clinical ratings that could be accounted for by exposure to different types of maltreatment. It’s a sophisticated way of determining it, which is important because exposure to one type of maltreatment is often correlated with exposure to another type, and this approach untangles the interrelationships.

We’re just starting to look at whether there are brain differences associated with witnessing violence to siblings, and preparing an abstract for presentation as part of a symposium on witnessing interparental violence. I’m hoping for the opportunity to open more eyes to the importance of this type of domestic violence. It also fits with my clinical experience.

We’ve developed a scale to serve as an alternative to the ACE that does include sibling violence (and also physical and emotional peer victimization). Right now it exists as a lengthy research instrument, but it’s more that 2X better than the ACE in predicting adverse psychiatric outcome. I’m about to produce a shortened

Great topic! The challenge is distinguishing between what one intuitively feels is significant and what can be proven to have a long term negative impact. On a purely personal level, I always felt that pervasive racial discrimination should be a factor, although variations in frequency and intensity make it difficult to measure accurately. I would believe that pervasive gender discrimination (especially as regards lesbian, gay and transgender persons) should also be included. Perhaps the common factor is the cognitive dissonance created by receiving very different, conflicting social messages. I would love to see the research that could make this a proven addition to the ACEs survey.

Also, in terms of measuring resilience, I would mention that spiritual belief is important, but that in some cultures it is not personified in a belief in a "God."  As someone of Asian background, I have had difficulty honestly answering some questions about spirituality, since belief in a God, or regular attendance at a temple are not key markers to me. I do feel a good resilience test is needed to counter the "history is destiny" feeling some have after seeing their ACEs score.

I feel ACEs is very firmly grounded in the western American experience. I wonder how "relevant" the ACES phraseology appears to new immigrants. Thanks again for raising this topic. (By the way, I am also an INFP, although I move between that and INTP.)

I think there is always some kind of discrimination. In my rural area growing up, everyone was white, but some were poor and that poverty was obvious and it lead to being ostracized and discriminated against (maybe it is a function of the human psyche - or western psyche - to have to compete to somehow feel better about oneself). It is sad however that we cannot see that I believe we "inter-are" but if I really believed that would I have felt the sharp pain of being ostracized? I don't know.  

I also think belief in a higher power is important for resilience. Or maybe just being able to see that there are things that happen in the world that were worse than what happened to me… For example when I was growing up, I was firmly convinced that God did not want me to die, that I was sent that suffering in order to develop a passion and compassion for those who have been so deeply wounded.  I also survived by seeing children from Ethiopia on TV who were starving and their bellies were sticking out with flies all about their tiny faces and I would feel such compassion and empathy. I would hear of children traded by their parents for drugs and would feel so heart broken while at the same time grateful that that at least was not happening to me.  

I guess I have to accept that without the suffering how can we understand what is goodness.  I wish I could wave a magic wand and make ACEs disappear.  I would even give my life if I could do this, but alas that is not the case.  Everything worth accomplishing is worth fighting for.  I do get deeply saddened though when I cannot seem to get people to understand to me what is so obvious -- children are beautiful --- children should be loved and protected and valued and not demeaned.  I am sure that most of those who aren't willing to listen to and join ACEs work don't want to see children suffering or in pain but yet still they can look with a "blind eye" and not be impacted by the suffering. I cannot understand this because when I see a child hurt -- when I am working, for example as a doctor, I do what I can to make it better (like resuscitation of a newborn)--- but when I am by myself and have time to contemplate… I cry for their suffering…...