Is anyone planning a response to the Finkelhor article?

Three of the easiest responses to make to the article itself, of course, apart from the "general issue", are:

(i) the primary thrust of the article is at attempts (are there any?!) to mount a public health screening program based solely on the use of the original ACEs Questionnaire, in and of itself, by itself. A criticism not so much of the ACEs Screen -- but of a population-focused ACEs Screening Program

(ii) the article is critical of the use of the ACEs Q in practice, especially in isolation from other measures -- in whatever setting it's used as a screening instrument, when other measures might be more reliable.

(iii) some people might react badly to being asked the ACEs Qs and this might negatively influence any relationship between treatment provider and patient/client. 

Given the emphasis I have used you can guess (some of) my counter-arguments, but is anyone planning a response to the article?  Preferably in an academic journal -- hopefully in the same journal or, ideally, someplace else, where it can be published more quickly.

(my "off-the-cuff" response was to mention just the first of these, but the number of criticisms I could make of the article just increased too rapidly -- "Does he fundamentally mis-understand the nature of screening measures?!  ... a sensitive, yet not specific, record of signs of potential need for more in-depth inquiry / assessment"   being yet another, of no doubt several more).

Incidentally, further to the points above:
(i) Has anyone really suggested this?

(ii)  Especially here on this forum, is anyone encouraged to use the Q by itself? What are these other more reliable measures, or is research yet to show these? What safeguards are people already being encouraged to put in place with the use of this screen? With the use of the Resilience Q, are there not already cost-efficient "therapeutic procedures" that can be built into the use of these brief methods?

(iii) Sure, some might, but many more might have such relationships improved by their being asked such questions, if their responses were heeded, and responded to effectively. A comparison is drawn to measures of cigarette, alcohol, and other drugs, use, without any suggestion that the use of these measures might not / does not, for some people, risk / actually damage actual / potential relationships with treatment providers. Let me assure you, they might, they do, and they have, for some people. Are we not therefore wiser and better prepared to identify and limit any negative consequences possibly accruing from their use?

 

Original Post

fyi, David Finkelhor posted a blog here that linked to his article when it came out. I think most of this community has moved so far beyond questioning whether it's a good idea to educate people about ACEs (while screening or not), that it engendered no reaction or response.

and that is exactly the sort of response that has so strangled the effective treatment of these sorts of problems by the American Psychiatric Association for over 30 years, despite challenges by such as the BPS.

By "this community" you refer to only those who subscribe to this forum.

Yes, it's a good idea to "educate people about ACEs"

but how, when, why, and how best to do it -- all valid challenges by Finkelhor -- will NOT go away, despite the best efforts of ill-informed social activists. Their efforts are worthwhile in their contexts but ...

God help poor Colette, who first raised "this question", she has found little here to help her with HER issue in HER context, in medical education, training of nurses, and health care generally -- the major focus of Finkelhor's critique.

Actually, there's quite a bit in this network about this...most specifically about the nascent efforts being done in all three areas, "nascent" being the operative word.

Of course we're all still figuring out how, when and why....and people are making good progress on that front, and sharing that info here, which is terrific. What I was referring to was Finkelhor's POV that people shouldn't be doing it at all until years of research IDs which approach is best, but change based on knowledge of this sort doesn't work very well with that approach.

I too was concerned with an article a year ago (thereabouts) that alluded to the need for lengthy research before any intervention occurs. While we all know the importance of EB studies, to not move forward with what we now know from the ACEs Study and subsequent studies, and the neuroscience of trauma, it would seem like a crime if omission to not act. While I know Finlehors argument is that we do not have the resources to support those screened and need intervention  ( will we ever?), we have to move forward.

Rhonda Hertwig 

 

 

To which Finkelhor might reply "to 'move forward' for one group is to move backward for the group whose resources have been reduced" and when there is no real evidence, as yet, that the first group, or elements of it (those responding negatively to being given the ACEsQ?),  have in fact benefitted, how can that be "social justice"?

No easy answers, especially for people involved in trying to bring about changes in the health care system, like Colette 

Finkelhor's article gets at the lack of empirical evidence that shows the benefits of the screening, something I know very little about.**  But I too am finding a lack of empirical research that measures outcomes.  For my own work, I was hoping to find something more than stories (lots of them, yes) that showed the benefits.  I do qualitative research so I know the power of a story.  But academic research requires certain standards that mean doing the work of setting up a study to track and figure out what measures to look for, find a sample...  Seems all the people doing this good work, there'd be somebody out there studying it.

**[I was a little bothered by how little regard (or credit) he was giving people who could take this new self-knowledge and act on their own behalf -- maybe with or without professional mental health help but there are other resources people can and do rely upon.]

I think before making such criticisms, or investing too heavily in others' statements of them, they first need to do some homework about Finkelhor's academic history, and his overall contribution to the child protection field. Google Scholar is freely accessible to all after all. Perhaps then they can stay "on point" (perhaps what he sees as being proposed -- but has this been proposed?) -- the pros and cons of use the ACEsQ as the center piece of a public health screening program.  IF this has been proposed, I haven't seen it, but if it has, then his article is a lot more "valid".

Paul Metz posted:

I think before making such criticisms, or investing too heavily in others' statements of them, they first need to do some homework about Finkelhor's academic history, and his overall contribution to the child protection field. Google Scholar is freely accessible to all after all. Perhaps then they can stay "on point" (perhaps what he sees as being proposed -- but has this been proposed?) -- the pros and cons of use the ACEsQ as the center piece of a public health screening program.  IF this has been proposed, I haven't seen it, but if it has, then his article is a lot more "valid".

Yes, he has published many impressive books. That no one can take away from him. Without knowing the author, I can see he has contributed a lot in exposing childhood trauma. I do have legitimate concerns on anyone that might throw a wrench into the motion of ACES. My impression was about the article, not the man.

Who has a link to this particular Finkelhor article?  I'm familiar with his work and have followed him for a number of years.  He seems to be the type who thrives on self-restraint and not drawing obvious conclusions.  I frankly do not understand why ANYONE would hesitate to talk about ACEs any more than we talk about Genograms (which outline trauma, violence, addictions, etc.) in family histories.  These are just facts.  We present them as such and we hand power over to our clients by showing them connections between trauma and the future impact on lives.  It's like saying we can't talk about someone's drinking history and show the facts about alcoholism or alcohol addiction.  Perhaps I am missing something?  I'd like to read this article (where was it published?)

My overview of what I find unsettling goes back to what Dr. Felitti stated and the CDC's original publication. I watched a video of Dr. Felitti in Alaska and he tells how healthcare costs could be reduced by as much as one-third. The CDC's ACES report showed a reduction of heath care cost with only one hour of therapy. They saw a reduction in ER visits, Dr office visits, hospital stays and reduced use in pharmaceuticals. No one takes notice of a new trend until it cuts into their market share.  We must keep diligent to the voices of naysayers.

The bizarre thing is that it still doesn't seem to have been "published" yet, so it is still open to being changed - - I get access to a number of papers this way with this understanding. When it is copyright then usually resides with the publisher not the author.

In any event I go back to the question of what is meant by "used as a screening measure" - - something Finkelhor himself isn't clear about. There's a world of difference between my using the ACEsQ as a clinician, with my knowledge and experience, and it being used as something like a chest X-ray for TB but without "medical" review.  In the former case I can build into my practice things which would be much more difficult than in the latter; and it is in the latter cases that his cautions are most valid.

In the end the basic rules apply: people shouldn't rush into using any clinical measure without proper prior knowledge of its limitations. Perhaps before the article is actually printed this could be made plain: Jane Stevens and others on this forum have said much about what cautions need to be in place for it to be used effectively. 

Well, I read David Finkelhor's paper from top to bottom. I even clicked on a few of the resources. I ran into this same precautionary "baby steps" approach with  Trauma Informed Initiative of Western New York a few years ago. (University of Buffalo sponsored) In just three short years UB has produced "Champion Collaborative" which has produced the insight for it's graduates in the use of ACES in the Developmental and Intellectual Disability Services. How ACES effects this population.  There is a quote from the Resilience movie that gives me the breath to continue on. "If you can get the science into the hands of the general population, they will invent very wise actions." 

Peter Chiavetta posted:

 "If you can get the science into the hands of the general population, they will invent very wise actions." 

and that is precisely where you and Finkelhor are in total agreement.

Instead of relying on specious, aspirational claims for "technology" one needs to carefully evaluate the validity of the evidence (data) used to make the claim (that the hypothesis is supported). He merely asks us to evaluate the evidence, in the face of highly emotive arguments being offered by some: "we need to do this or else people will die!" Really?!  One needs to remember (hard in some political climates) that the grander the claims, the more solid the evidence must be to justify their being acted on, to the inevitable "neglect" of other priorities.

But how many of us have done the training, are continuing to build on the training they received, in order to gather, evaluate and present evidence "scientifically" -- sadly, from what I've seen, precious few -- here's one recent article for your convenience (open access). 

Attachments

Paul, I had all the intentions in the world in reading "Degrees in Freedom..." After reading the first two pages at my dyslexic snails pace, I had to stop. I would never get that part of my life back. It reads like a legal document. 

"A preregistration should also be exhaustive because the stipulation that one will test Hypothesis A in a certain way does not preclude the possibility that one can also test Hypothesis B in the study. Therefore, for confirmatory aspects of the study, the word “only” is key (e.g., “we will test only Hypothesis A in the following unique manner”).

Connecting the dots for my patients in the field as an Emergency Medical Technician has been the most rewarding part of my 40 year career.  People are frustrated with the medical community that has more pharmaceutical remedies than face time.  http://www.acesconnection.com/...-emotional-first-aid 

I do see the pit falls of "If you build it, they will come" The ER I frequent the most knows the least about ACES. I had to slow myself down. The inequity in knowledge and practice of ACES would have never been exposed unless I first asked the question "Have you ever heard about ACES?" ERs might of heard about Trauma Informed Care, but it ends there.  

NEAR at Home and Crittenton Foundation Tool Kits have been in place and working.

https://thrivewa.org/nearhome-...ience-home-visiting/

http://www.acesconnection.com/...oolkit-for-providers

Community Resilience building is working across the nation with plenty of examples. I will be attending a two-day seminar in March on this subject. 

I have had the silence of shame reveal itself many times. The second rape of a minor was exposed because she was given an opportunity to read the ACE survey. A male in his 30's tells me he was sodomized at 16 when I asked what age did he start smoking. When I told him of the stats from the original ACE study of one out of six males were sexually abused, there was a sense of relief about his presence. He wanted to know more. I can go on with more awareness moments. What I do know is that people need help now.

My kids gave me a T-shirt for Christmas. "ACES IN YOUR FACES"

 

 

I think Finklehor's points are valid when taken into the context of generalization. I believe he is speaking to a larger model. If you wanted to screen everyone in the United States medical system tomorrow for ACE's you would not have the resources, educated staff (that have addressed their own ACE's), and standardized questionnaire to do it. You would also have pandemonium. I think his article is taken harshly here because you are taking for granted that you already have groups of educated practitioners in community doing this work. But those here are maybe forgetting what it took to get where you are. And what Finlehor is bringing some awareness to is that it's going to take a lot of work to get this to EVERYONE. Which is the goal. 

Good point, Martha. Thanks for your comment. We do indeed have a long way to go, and with the progress we've made in the last few years, it doesn't seem as if it's impossible for people across sectors to embrace and use this new knowledge....in every community!!

Not impossible at all!! A little educational infrastructure can go a long way. And your progress is immense!!! This information is now everywhere. And where it isn't it's still well received.   It's validating so many people. I think it is healthy here to embrace criticisms so that this work can continue to grow.  

Martha Chiavetta posted:

I think Finklehor's points are valid when taken into the context of generalization. I believe he is speaking to a larger model. If you wanted to screen everyone in the United States medical system tomorrow for ACE's you would not have the resources, educated staff (that have addressed their own ACE's), and standardized questionnaire to do it. You would also have pandemonium. I think his article is taken harshly here because you are taking for granted that you already have groups of educated practitioners in community doing this work. But those here are maybe forgetting what it took to get where you are. And what Finlehor is bringing some awareness to is that it's going to take a lot of work to get this to EVERYONE. Which is the goal. 

I think you're absolutely correct, Martha.

And despite what some people think, I wasn't being a smart alec with that article. Unfortunately, very little research -- academic, and hardly any practice-based, research -- is done looking at cost-effectiveness. Look for reviews of the Scandinavian experiment into widespread nationalized support for CBT -- the approach with "the best evidence base"  -- not in national outcome studies there.

So for people to take this "ACEs Science" approach seriously we need more practice-based research including cost-effectiveness outcome data to answer "By doing what, with whom, using what resources, can we produce these outcomes for people with histories of childhood adversity?"

and we must be prepared to give up, when the data shows it's necessary, some of our preconceptions.  Who would have dreamt the outcomes of studies such as that of Nathaniel Lewis? Incarceration --- effect of race or class, Lewis 2018   Somewhere in all that data there'll be a link to ACEs (or there should be!) just as, getting back to Colette's original question, poverty and substance abuse are linked to domestic violence, and ACEs,  documentary "Nigel Latta: Killing Our Kids"  but for a lot of  "traditionally trained" (thus less-informed) people in the medical system, we'll need the evidence to show what needs to, and can be, done.

I completely agree Paul, and you may have been misunderstood. Unfortunately, conventional medicine will only accept ACE's under certain conditions, the ones you speak of. I do believe a lot is being achieved by continuing the grassroots efforts. Because a lot of patients/clients are becoming aware of the impact of their trauma and neglect and are seeking out ACE's and trauma informed care. And they don't want to wait for conventional medicine to catch up. In order for them to catch up we have to give them the data they need to alleviate their cognitive dissonance. So Paul, in order for the whole community to move forward we need someone to give us the data collection template and methods that will satisfy the system. That's out of my wheelhouse :-)  

whoever that person will be, whatever their "qualifications", will need to be both "acceptable" and still a "contrarian"; someone sympathetic to, yet not a "sympathetiser within" so-called "ACEs Science" -- a term not accepted by many who have contributed, for decades, to improving the well-being of those who have weathered the storms of "childhood adversity" -- another valid point of Finkelhor's. Plus a whole host of other personal and skills-based qualities. "Not impossible at all!!"   Let's hope not, but still a lot to ask for. Outlining the right "selection criteria" for the person to ask "the right questions" is yet to begin. Finkelhor has made an invaluable start, imho, by asking some essential, however uncomfortable, questions.

Thank you Jane, for providing access to Finkelhor's article and thank you Martha for your very adept reply!  I really understood Finkelhor's points about generalizing the screening of patients in a medical setting for ACEs.  He is looking at it through a clinical lens, wanting it to be connected with outcomes that are going to help patients, and filters that are going to screen out those who would not benefit from the information.  I look at ACEs screening totally differently, because I am a mental health care provider.  When someone comes in who has been traumatized or shows symptoms that may be connected with trauma, I want to figure that out.  I don't want to symptomize (I know...new word) trauma by diagnosing someone who is acting out of a traumatic experience with very normal and natural reactions, with a DSM label!  There's too many kids who have experienced trauma who are now labeled with ADHD or worse.  In using genograms, which are family-based diagrams showing family dysfunction, cutoffs, triangulation, divorce, abuse, neglect, and other trauma, we are actually mapping out ACEs for the children of those who experienced or are currently struggling with trauma.  For those who don't have kids yet, we can build up the adult's understanding of how trauma affects the brain, affects chiildren, and impacts a life's trajectory (without resilience building).  We can educate about how to build resilience, empower someone who is newly traumatized, and we can help someone who comes from a dysfunctional abusive family understand the "normalization" that occurs -- so that doesn't get passed down.  I don't have an issue with Finkelhor's paper.  I know that medical professionals have an entirely different set of guidelines, rules, and ethics to work with.  I'll just be glad when we, as a country, move to unite the medical with the  mental health professionals and treat the whole person (which is what ACEs research and education is all about!).

Martha Chiavetta posted:

Not impossible at all!! A little educational infrastructure can go a long way. And your progress is immense!!! This information is now everywhere. And where it isn't it's still well received.   It's validating so many people. I think it is healthy here to embrace criticisms so that this work can continue to grow.  

Martha:

I totally agree.  I think doubts and debates are healthy. I think we can share access to this  public health info.  In varied ways in and outside of the context of screening and need not wait for evidence-based whatever before doing so.  As parents,  survivors,  families and communities - we can to decide for ourselves if and we can and are deciding how to use / share ACEs-related aha moments or social movements. Debates will continue.  

I would love evidence based research on the impact of not sharing or screening as well... The fear and avoidance many have,  in and outside of medical settings isn't benign.  

But at least more of us know,   discuss and debate this stuff and I find  that encouraging. Cissy 

Christine Cissy White posted:
Martha Chiavetta posted:

Not impossible at all!! A little educational infrastructure can go a long way. And your progress is immense!!! This information is now everywhere. And where it isn't it's still well received.   It's validating so many people. I think it is healthy here to embrace criticisms so that this work can continue to grow.  

Martha:

I totally agree.  I think doubts and debates are healthy. I think we can share access to this  public health info.  In varied ways in and outside of the context of screening and need not wait for evidence-based whatever before doing so.  As parents,  survivors,  families and communities - we can to decide for ourselves if and we can and are deciding how to use / share ACEs-related aha moments or social movements. Debates will continue.  

I would love evidence based research on the impact of not sharing or screening as well... The fear and avoidance many have,  in and outside of medical settings isn't benign.  

But at least more of us know,   discuss and debate this stuff and I find  that encouraging. Cissy 

Indeed, irrespective of Finkelhor's article, thankfully little is now going to "stop" the ACEs-awareness social movement -- it's never been, nor, realistically, can it ever be an "ACEs Science" -- "ACEs" per se are not scientific facts, they are subjective reports of difficulties people are experiencing with a presumed basis -- the same as any self-reported psychological / social difficulties -- the term is though highly useful as a rallying cry for a social movement. And that social movement will continue, at least for a while, irrespective of, and in the longer term despite, whatever may be the outcomes of research. But let's hope people engaged in the activities of that social movement have the integrity, and the courage, not to mention the skills, to objectively evaluate the cost-benefits of any changes they bring about. That will help address at least one of Finkelhor's longer term concerns.

Paul, when we refer to ACEs science, this is what we mean:

  1. The CDC-Kaiser Permanente ACE Study and subsequent surveys that show that most people in the U.S. have at least one ACE, and that people with four ACEs— including living with an alcoholic parent, racism, bullying, witnessing violence outside the home, physical abuse, and losing a parent to divorce — have a huge risk of adult onset of chronic health problems such as heart disease, cancer, diabetes, suicide, and alcoholism.
  2. Brain science (neurobiology of toxic stress) — how toxic stress caused by ACEs damages the function and structure of kids’ developing brains.
  3. Health consequences — how toxic stress caused by ACEs affects short- and long-term health, and can impact every part of the body, leading to autoimmune diseases, such as arthritis, as well as heart disease, breast cancer, lung cancer, etc.
  4. Historical and generational trauma (epigenetic consequences of toxic stress) — how toxic stress caused by ACEs can alter how our DNA functions, and how that can be passed on from generation to generation.
  5. Resilience research and practice — Building on the knowledge that the brain is plastic and the body wants to heal, this part of ACEs science includes evidence-based practice, as well as practice-based evidence by people, organizations and communities that are integrating trauma-informed and resilience-building practices. This ranges from looking at how the brain of a teen with a high ACE score can be healed with cognitive behavior therapy, to how schools can integrate trauma-informed and resilience-building practices that result in an increase in students’ scores, test grades and graduation rates.


So, there is, indeed quite a bit of science here. More info at ACEs Science 101.

Jane, 

I never said there weren't scientific contributions which had contributed to the debate around ACEs issues, but was explaining that this website's proposal that there was such "a thing" as "ACEs Science" is a lot of hooey -- in my view (with postgraduate qualifications in a few different "real sciences"), and implicitly in the view of "serious scientific researchers", like Finkelhor, but also in the views of many others who have been researching the phenomena you mention for decades before "the" ACEs research, there is no such thing.

But, by all means use the term, on this website, no one not accessing this website will mind YOUR use of it here, but its use, or the suggestion of its use, elsewhere does raise concerns. People on this list have been quite dismissive when others have attempted to explain, in layman's terms, more complex scientific results, saying it's only important what people have to say about the implications of those results -- what they suggest should be the practical implications of those results.

If people want an ACEs Science to exist then the least they can do is submit articles debating the scientific principles behind other scientific contributions for peer review -- but clearly no one wants to do that. I would go so far as to suggest there's a lot more they could do but if people don't feel like it ....

Thanks, Jane, you've just proven my point, as you always will, I like it when it's that easy :-D

And fyi Finkelhor offers arguments, not data, so you can't find any  holes in it, but you can disagree with his arguments, and provide your own, but, as usual  ...

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