ACES screening debate article

A new article about possible dangers to ACES screening that references a 2017 study on the subject.

https://www.centerforhealthjou...-do-more-damage-good

An excerpt from the referenced study (and generally the tone of the article):

Any screening around childhood adversities should make sure that sufficient evidence based treatment resources are available to

handle likely referrals. Since many communities have a limited supply of these resources, screening is not justified unless funding to

assure the needed additional resource is in place. It is not ethical to have a Field of Dreams attitude that if we manifest the need, the

resources will magically appear.

I understand general concerns - and the need to have somewhat settled on which ACE screenings are most appropriate for whom - and the kind of support needed for those interpreting the results. What I struggle with, and I can't really pinpoint why it bothers me as much as it does, is the notion that people knowing information without knowing exactly how to deal with it is worse than not knowing. An ignorance is bliss sort of approach.

It is not just ACES where this occurs. I'm in the juvenile justice field and while we know we need to focus efforts on juveniles with the greatest risk (to themselves and others) we often say - why should I know this young person is a high risk - when we aren't sure what local services yet (or maybe we do not have the funds or capacity to bring in a recognized best practice service) to best meet their needs. So that we can measure, refine, and figure out what is best? I'm sure there are other examples. It doesn't make sense to me for instance that a Dr. would find a disease but not have a cure and say - I better not let this patient know.

I sort of lean on Dr. Felliti's own words - paraphrased - listening to someone talk about their ACEs history, without judgement, is in itself a powerful intervention. When we normalize that most of us have an ACEs history and that not dealing with it could have adverse impacts - and maybe says something about the source of our current struggles - it makes us human. And realizing that we need others to get through a tough world is a great thing. I'm sure that there are good reasons for concern - but sticking our head in the sand brings even more for me.

Greg

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I recently had this conversation with a group of folks. One point that was brought up is that without screening, you don't necessarily know what types of resources are needed. I live and work in a very rural, under-resourced community. If and when our medical community (or someone else) starts doing routine screening of ACEs, there definitely will be many cases in which there aren't options for referral. But if we don't start screening because we know there will be barriers for follow-up, we won't know what kind of follow-up we need to develop.

We are also so small that we don't have good data from the state about % of children or adults with high exposure to ACEs in our county. Our data is lumped in with 7 other counties, some of which are hundreds of miles away. We believe we are probably higher than most of the rest of the state based on related data, but we don't have the ACEs-specific data to back that up. It makes it harder to go after funding if we're up against counties that can say, "XX% of adults have ACEs score of 3 or more."

When we start screening, we will have better data for planning and seeking funding for the services that will most support people in our community. 

Ms. Godbold makes an excellent point about "survivor empowerment." The ACE score is a tool best used by the individual for the ways in which it can lead them to their own power/choice to enter a healing process. Knowing "the score" gives a starting point; information about how to engage healing should come next...and then it is up to the individual to select from a number of modalities that they feel comfortable with and will use for relief. The resiliency score helps build in empowerment for acceptance of healing. And, I'm no expert, but I believe healing also includes how to feel free from the cloak of hurt--how to enter the "what you don't know" as opposed to going back to "the hurt that is still hurt-y but comfortable in its familiarity."

In the end, it's about survivor empowerment. That is the goal of trauma-informed care. Cooperation, collaboration, choice - power-with rather than power-over so that the survivor is not retraumatized by once again having power and control taken away.

We had a debate about parents taking the ACES test in our parenting classes. In the end, we decided to ask the parents themselves. They unanimously wanted to do it. (And were anyway going home and looking it up online to take the test.) If we offer the ACES test in class, we are able to provide a resiliency questionnaire first, so parents do not just see themselves as having 'deficits'. People are given the choice to opt-out of taking the test or to take it at home. (No one ever does.) In the subsequent classes, we provide knowledge, skills and tools for overcoming the impact of trauma - especially as it relates to parenting. 

The score remains with the parents. It is their information and we have no business knowing unless they choose to share (which many do - with the group). We collect the tests (anonymously) from those who wish to submit them, tally the scores, and then reflect back the percentage of people in the room scoring for each item. This normalizes the often high scores our parents have. 

What bothers me about screening is the presumption that any service provider has the right to know people's ACES scores. (If someone wants to share, great. But it is their life and their information.) But what bothers me more, is that we 'professionals' should have the information about ACES and not share it. When we asked parents if they wanted to take the test they said, "Hell yes! We need to know this information. Why would you keep it to yourselves?"

 

Greg, perhaps one of the reasons "the notion that people knowing information without knowing exactly how to deal with it is worse than not knowing" bothers you is its paternalistic application to healthcare or in the provision of other human services. By paternalistic I mean a provider who presumes to know what's best for end-users of services who are capable of making that decision for themselves. I understand the quandary discussed by William Heisel in the article you refer to. However, I believe the ethical approach is to obtain an informed consent from individuals prior to responding to ACEs inventories. The process of informed consent would ensure that "the right not to know" is respected. 

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