Although Covid-19 is on the top of everyone’s list for attention, the posting earlier this week of a link to Dr. Robert Anda, et al.’s paper, Inside the Adverse Childhood Experience Score: Strengths, Limitations, and Misapplications [ajpmonline.org] should also be front and center because it raises profound questions for everyone involved in the ACEs movement.
On the surface, the article is a pointed critique of ACEs screening. But it is much more than that. It raises fundamental questions about how ACEs research and ACEs science should be presented and promoted in the education, training and advocacy that we do.
The major challenge that article presents is, I fear, hidden in its academic language. I thus, provide my brief translation and summary below with a very useful link to the concept of population health. Dr. Anda and colleagues. don’t use this term but it is what they are talking about when they say " [ACE] is useful for research and public health surveillance."
My translation of Dr. Anda, et al.
- ACE scores are misused when they are applied to individuals. ("...the authors caution against the misapplications of ACE scores that assume an ACE score associated with risks derived from epidemiologic studies can sensibly be used to infer risk or make decisions about services, treatment, or care of individuals.")
- ACE scores are used appropriately as part of an examination of population health (see Improving Population Health).
- Population health, as the linked blog states, examines health and quality of life outcomes in a population (e.g. South Carolina or United States) and disparities in rates of those outcomes across socio-economic status, gender, geographic location, and race/ethnicity.
- When looking at population health, researchers seek to identify the determinants of those patterns of health outcomes, including particularly,
- social environments – ACEs are an important dimension of social environments
- physical environments,
- behavior patterns,
- access to health care
- genetic patterns.
5. ACE research is used appropriately when it prompts examination of policies and practices that can reshape health determinants (e.g. childhood adversity) and thus improve health outcomes and reduce disparities. Dr. Anda, et al. say approvingly, for example, that ACE research has “raised awareness of the childhood origins of public health problems for policymakers and legislators.”
The questions for the ACEs Movement then, if we take Dr. Anda seriously as we should, are how do ACEs Communities, ACEsConnection and ACEsTooHigh represent the most appropriate uses of ACE scores and ACEs Science on the web and in trainings? Do we contribute at all to misuses and, if so, how? How well do our Communities understand and recognize these important distinctions?
These are profound questions for self-examination but vitally important ones for the ACEs movement.