Profound Questions for the ACEs Movement from Dr. Anda and Colleagues

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 [] 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.

  1. 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.")
  2. ACE scores are used appropriately as part of an examination of population health  (see Improving Population Health).
  3. 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.
  4. 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.

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David Dooley and  Craig McEwen can't you both be right? Good parents living in extremely stressful situations of poverty, neglect, and other stressors are not able to be their best selves. Attacking poverty, neglect, and other stressors will be extremely helpful for those good parents. Damaged parenting can happen in any level of socio-economic status. I grew up with a father diagnosed with paranoid-schizophrenia and a mother who was told by psychiatrists in the 1950s that schizophrenia was the result of cold mothers and cold wives. My father was a PhD research scientist making plenty of money when he was working. After my mother finally escaped with her four children, we were on welfare until she could get a job as a secretary. Either way she had very little time to be a "good" parent to us whether there was money or we struggled. All four of us are Adult Children with various levels of dysfunction.

Why can't we address stressful environments AND clinically dysfunctional families? Breaking the stigma of mental illness and the causes of poverty can be addressed. It is not pie, doing one does not diminish the other. 


Good parenting is intergenerationally-transmitted, just as trauma is.   There are a lot of us whose intergenerational transmission wasn't optimal, so we struggle to know better practices.

ACEs are survivable if you have had warm empathic parenting (aka secure attachment).  You will have resilience and resources to deal with trauma.   

What inculcates warm empathic parenting is having received it as a baby, or having had a reparative attachment experience in older life where you feel seen, loved, accepted, and understood.    We have all seen examples of wonderful, kind parents and loved children in poor circumstances, as well as frosty brittle parents in affluent circumstances.

Thank you for this. I have been reflecting deeply since reading the article last week and asking myself the same thing - in what ways have I potentially contributed to the misuse by not emphasizing it as a population-level indicator but as something that is potentially indicative of an individual's risk. These are important questions to ask ourselves as we engage in this work. 

David it seems that you are treating the quality of parenting as a foundational trait that is not affected by outside factors. Quality of parenting is strongly affected by stress which is determined by a person's perception of safety and reliability that their basic needs will be met. In the utopia community, an ineffective or harmful parent will have less stress. They will also be in a great position to heal the accumulated stresses that affect their behavior and ability to learn. As a mental health counselor, it's much easier for me to help people heal from the effects of toxic or traumatic stress if they are in a relatively safe and secure place presently in their life. 

If an effective, positive parent is in a community where basic needs and safety are unreliable, they will eventually accumulate stress and become a lower quality parent. succeeding generations will be likely to continue to degrade if basic needs and safety are at risk.

This is a generality, based on my own assumptions, I know. I just thought I'd weigh in on the discussion.

"...income, food, housing, child care, and much more."

Here's a thought.

Consider a utopia where income, food, housing, and much more is available.  Now populate that utopia with parents who engage in parenting behaviors and practices generally recognized as disrupting the healthy development of children.  Wouldn't that utopia eventually descend into chaos?

Now consider our own far from perfect communties.  Populate them with parents who engage in parenting behaviors and practices generally recognized as supporting the healthy development of children.  I suspect the generations to come will make significant changes to improve our communities.  

Last edited by David Dooley

Great question, David. But improving parenting means improving the resources that parents have available to them, including income, food, housing, child care and much more. Parenting does not happen in isolation. So supports from communities and through public policy can do much to affect the quality of parenting. Certainly, parenting education,  home visiting, and tools such as Vroom (see  can help build positive parenting skills. But diminishing the stress of under-resourced families should be a central concern of public policy. The question then is why are we as a nation so reluctant to do that?

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