Childhood adversity screenings are just one part of an effective policy response to childhood trauma [childtrends.org]

 

By David Murphey and Jessica Dym Bartlett, Child Trends, July 9, 2019.

Exposure to adversity in childhood is widespread and can pose a serious threat to individual health and well-being over the life course. By age 18, nearly half (45 percent) of children in the United States have had at least one adverse experience; among young children and other vulnerable subgroups, the prevalence is much higher. Childhood adversity is defined as one or more stressful events or conditions that can threaten a child’s sense of safety and negatively affect the child’s developing brain, physical and mental health, and behavior. Examples of common childhood adversities include abuse and neglect, living with a parent with mental illness or a substance abuse disorder, or witnessing violence.

Amid increasing public awareness and concern about the harmful consequences of early adversity, policymakers in a number of states are calling for routine screening of individual children—in pediatric care, home visiting programs, early care and education, schools, and other child and family service settings—using the short list of adversities included in the original Adverse Childhood Experiences (ACEs) study. As this movement gains traction, it is essential for policymakers to understand the limitations of this approach, as well as its potential for unintended consequences. These include:

  • The potential for re-traumatizing children and families
  • Contributing to stigma and a deficits focus
  • The lack of age- and culture-sensitive screening tools
  • A misleadingly narrow conception of adversity


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Jessica Bartlett posted:

Many thanks for posting our brief!  I'm very interested in ensuring that we're all working together, and yet it seems critical to point out that the original ACEs index is not appropriate for assessing childhood adversity--what about bullying, community violence, separation at the border, extreme poverty, war, etc.?  So, here's my question: How can we build on what works for people about ACEs while still acknowledging the complexity of children's experience and also assessing their individual reactions, needs, and strengths more holistically?  I would love to hear everyone's thoughts!

Jessica/Jess:

As you know, I LOVE the ACEs as a way of introducing people who don't have a PhD or know anything about public health (hand up) more about context, social context, and how ACEs aren't just our own individual and personal problems and that there's something wrong with us that we're struggling or impacted.

I love the neutrality of ACEs, in the language, and it being a way to note what someone has lived through (as opposed to symptoms or results). It places the cause of symptoms front and center which is a radical relief when compared with being diagnosed and labeled (as an individual, family) without looking at all that which has happened for eons.

I LOVE the sharing, person to person, of ACEs scores, quizzes, tests, and sharing the original 8, the classic 10, the expanded versions, and the pair of ACEs and broad WHO and CYW versions. For those of us who had early trauma, who felt that as just part of who we were, before the "not what's wrong but what happened to you" idea was formed, that's epic and important. It helps us learn about others, about trauma survivors in general, and connect with peers, and get way broader perspectives. ALL THAT is powerful and healing, and for lots, more healing than any traditional trauma treatment. 

What I fear, especially lately, is the way that ACEs screenings are often (not always) done in medical settings which returns it to a diagnose/label/funnel/refer out model that has  lots of issues.

There's a reason so many of us with a ton of ACEs who have had the best of evidence-based treatments for ourselves, families, loved ones and in communities joined this movement despite our lack of academic or clinical background - and it's because even the best of the best often isn't: affordable, available, and effective and can re-traumatize, etc. It's not been survivor-informed, survivor-led, co-led, etc. (in meaningful non-token & non-patronizing) ways. It's often viewed trauma as what happened to veterans and soldiers, or acute types of trauma, not developmental, chronic, daily. 

ACEs conversation CAN pull us ALL TOGETHER, and into the conversation, at least when it's a conversation with and for all. That can include and prioritize families and communities and survivors who should be centered and are often after thoughts.

I worry that making it primarily a screening tool, used in systems, one on one, person to person, before systems themselves are changed, will not keep the public as engaged in this public health tool, will not help families, survivors, communities to mobilize, and will return the "trauma conversation" entirely to the clinical/medical model space it's long been located, which hasn't been all that useful for those with complex trauma, developmental trauma, trauma cause din the interpersonal and community and systems sphere). The model is based on treating post-traumatic stress but was said in the powerful congressional testimony yesterday, it's often not Post-Traumatic Stress people have and suffer with, it's Present Traumatic Stress, Persistent Traumatic Stress and that isn't well-addressed or remedied in current medical models covered by insurance.

We need to keep parents, survivors, communities central and that's not the norm in most medical settings (I know that the Center for Youth Wellness is an exception and it's not the only one). But until the exception is more the norm, I don't know how we implement without causing more harm than good.

Once again, went rather long with my comments. Thanks for opening up and continuing this conversation being had all over the place by so many of us. It was great to hear survivors, other experts, elected officials during yesterday's briefing talking about ACEs, their own families, communities, about ACEs Connection, Self-Healing communities, about hope, shame, despair, and flourishing.

I'm grateful for these continued conversations and folks sharing what's working, what's not working, fears that were had, and not realized, as well as plans that were hopeful or with good intentions that had unintended consequences. It's all so new and we need to keep sharing, in my view.  

Cissy

Many thanks for posting our brief!  I'm very interested in ensuring that we're all working together, and yet it seems critical to point out that the original ACEs index is not appropriate for assessing childhood adversity--what about bullying, community violence, separation at the border, extreme poverty, war, etc.?  So, here's my question: How can we build on what works for people about ACEs while still acknowledging the complexity of children's experience and also assessing their individual reactions, needs, and strengths more holistically?  I would love to hear everyone's thoughts!

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