Hi, has anybody got any links to peer-reviewed journal articles where an individual's ACE score/questionnaire is used to inform practice?  I know it's fairly common practice now in some areas to enquire about ACEs, but I struggle to find any papers describing how that information is then used.  Would be good to find some examples where, say, a score of four leads to a more targeted intervention or response, for instance.

Thanks.

Original Post

Hi Andrew,

Good question. Since an ACE "score" is a number it would seem hard to assign a targeted intervention given that  the number does not indicate which specific adversity is present (e.g., a 4 could include sexual abuse or not; how can one target an intervention when the score itself is non-specific?).  This lies at the heart of the controversy about whether screening with an ACE score (as opposed to a more detailed inquiry about specific ACEs and toxic stressors) has clinical utility.  It also depends on whether you're using this with adults (in describing their history of childhood adversity) or with children/youth (addressing present ACEs). A score is also problematic in that it assumes that all individual ACEs have the same "weight", since each is given a value of "1". Many have questioned that assumption.

In my opinion, ACE scores are helpful from an epidemiologic perspective (population prevalence and assessing relative risk) , but have little value in and of themselves in a clinical setting where identifying specific interventions are needed. 

Lee  

Hello Andrew. 

You pose a great question which has direct implications across settings.  I appreciate the question and also the controversy cited by Dr. Pachter.   I do not have formal medical training myself, and I know of no peer-reviewed papers linking a simple numeric score to a specific intervention. 

Nevertheless, without specific interventions, if you will humor me, I do have some add-on queries:

Could one value of the "simple score" in a clinical setting (and other one-on-one settings) be as simply a "discussion-starter"? 

I am thinking particularly of those patients who are hesitant to speak directly in a "history" or in a routine office visit.  They also may not otherwise think to make connections with somatic issues.  The process could be adaptable for children, or parents of children also.  It would seem that sharing a simple number (from a pencil "survey" in waiting room) may be a more private, tenable start than a bold statement face-to-face about specific interpersonal adversity or even community violence. 

Likewise, could the simple score have potential value as an avenue for those patients who are  internalizing (so they aren't presenting any obvious external clues), camouflaging or even actively covering up (behaviorally) ? 

Beyond "discussion-starter",  then it seems that sometimes there may come an opportunity for "painlessly" beginning patient awareness and "education" regarding the mind-body connection and the power of adversities, as general information, now that the patient has interacted personally with the concept?   (I'm thinking like a teacher).

Of course, ultimately the discussion momentum could lead to a cascade of more specific aspects of a particular patient history and presentation.  If the process is only helpful with specifics on five times out of ten, would that be a nuisance or would it be useful in your particular setting?

 

Lastly,  could the "simple number" (with no specificity) add some perspective on cumulative stress(ors) or allostatic load?  It seems like a simple score could have value as a warning "flag".   It would only be one diagnostic input, but the proxy (score) for cumulative experience may shed light on seemingly eclectic somatic presentations.  The research has much to say about the systemic effects of accumulated adversity.  Might it be useful to understand the patients cumulative burden irrespective of specifics, at least as a starting point ?  

 

Maybe more later.  Thank you for humoring me.

A quick search at PubMed found this on the first page, so there must be other examples out there. "Early prevention strategies could use high ACE scores as a marker for adolescents at risk for early opioid initiation. Including the ACE measure in assessment batteries for patients seeking treatment of opioid use disorders may provide a standardized way to identify patients at heightened risk for injection and overdose." 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599365/ 

Search for: ACEs screening individuals

 

There are several on Google Scholar. I especially like that some of the them are directed towards physicians who are increasingly screening for mental health issues, especially in annual wellness check-ups. Family physicians and other primary care doctors are often the first to see those with trauma histories. Here are some examples:

 

 

https://www.academicpedsjnl.net/article/S1876-2859(17)30324-8/fulltext

https://dk-media.s3.amazonaws....ournal-s.pdf#page=12

https://journals.sagepub.com/d....1606/1044-3894.4257

 

I would suggest checking various categories in ACEs Connection's Resources Center. The ACEs Surveys category has lists of links to surveys and their background information, research, and practice. The ACEs Science Research category may also be of interest since it has links to PubMed category searches that update continuously and links to a wealth of research articles pertaining to ACEs and potentially ACEs surveys informing practice. There are also several categories regarding ACEs and professionals who use ACEs surveys in practice. Hope this helps!

Andrew Turner posted:

Hi, has anybody got any links to peer-reviewed journal articles where an individual's ACE score/questionnaire is used to inform practice?  I know it's fairly common practice now in some areas to enquire about ACEs, but I struggle to find any papers describing how that information is then used.  Would be good to find some examples where, say, a score of four leads to a more targeted intervention or response, for instance.

Thanks.

Hi Andrew,

In addition to the helpful information others have provided here, I'd also suggest that you join the ACEs in Pediatrics community on ACEs Connection and post the same query there. (Click on communities at the top of the home page, and scroll down to find ACEs in Pediatrics.)  It might generate additional helpful replies. Thanks for  your query!  

Hi Andrew,

While I'm not aware of any validated studies on best practice use of ACE scores, some members of my clinical teams have been using the ACE screening with clients. What we've found, in particular with our adult population, is that when a person learns about ACE's and their ACE score they express a huge sense of relief, realizing their desire or need for treatment is not the result of some personal fault but the result of what they've lived through. They also often express a sense of pride, strength and recognition of their own resilience in having a high ACE score and still managing to work, raise a family, become sober or any other accomplishment they choose to recognize through guidance from their clinician.

One clinician in particular often cited ACE health outcome data to highlight her client's strengths in comparison to particular health disparities linked to specific ACE scores.

I see it as a tool to empower ourselves and others; what's predictable is preventable. If I know my ACE score and it's associated risks I can be more targeted in my healing and prevention. I can also be a voice of hope for others with high ACE scores, proof that resilience is possible!

Great question!

Andrew:

I think this topic would make for an excellent webinar or podcast or panel discussion. It's an important and complex issue and evokes lots of strong sentiments among many of us and for lots of different reasons.

While I don't favor screening for ACEs, because I don't trust most systems have dealt with bias towards those most likely to score high (people of color, women, poor people, those in the LGBTQ community), I do believe sharing information widely about ACEs is important. I believe the silence and avoidance, common to date, has been detrimental to many. I believe efforts that increase medical providers comfort having conversations about the way early life impacts adults health (for all of us, whether that means higher or lower health risks with higher or lower scores) is important - and hopefully will reduce judgments and increase listening, respect, and compassion when people understand that what many think of as self-created good health is often correlated with early adversity. 

It seems beneficial, for example, for a doctor or nurse to know someone might be more likely to hit early menopause, or have a more complicated path through menopause, have accelerated aging, more complicated times during pregnancy, and early parenting, etc. etc. and may respond to kids, as parents, in ways related to childhood. These may be things that would improve a health provider's treatment, advice, or care. We, with high scores, might be more likely to have specific diseases but of course that doesn't mean we will have. We know those with lower scores are less likely to get many outcomes, but also, it doesn't mean that they won't have any. We simply know more about higher and lower risks of groups of people with specific ACE scores.

But, as Laura Porter says, ACE scores don't tell us anything on the individual level. I've heard her speak once and she also talked about "right fit" responses, an example of a criminal justice system where one probation officer had exceptionally good results with those with high ACE scores and then was able to train other probation officers who were less effective. Again, it wasn't to diagnose or asses a specific kid, but general info. used to improve the training of the probation officers less effective with some kids than other probation officers were. In essence, used to improve the skills of the probation officers. I find that fascinating.

My fear though is that the screening process will speed up referral to behavioral health or to the child welfare systems, etc. which can and sometimes have done more harm than good - especially to the same groups most likely to be impacted by high ACE scores. For me, until systems address bias and structural inequity, seems the priority since it's so relevant to those with high ACE scores.

For me, that's the blaring caution that I have. I worry that ACE scores will be another way to label people, or for insurers to somehow calculate risk of super utilizers without looking at wider context and co-existing issues and conditions. For me, that's my concern.

That said, I do believe the general public, providers, parents, and everyone should know more about ACEs and the information itself is powerful.

I have had great experiences at a doctor's office (which hasn't been my norm) when I could share openly with a provider. I write about that here. I wish I had learned more, earlier, not only about my own ACEs but about the presence and lack of ACEs in others. For me, the most shocking part about the ACEs study is how many people have no ACEs or one or two ACEs. It was not what I would have guessed or predicted, and it's not what I saw growing up in a family and community with lots of ACEs (meaning adverse childhood experiences and community environments).

Again, I think so many of us are thinking lots about all of this and how the research and information about ACEs is used, is important. I'm grateful for discussions and hearing the views of others.

Cissy

Thanks all, really useful.  I have my doubts about the use of the ACE questionnaire for individuals, but I do see it being rolled out in various ways with no evaluation of whether it actually has any tangible benefit. I thought rather than just getting into debates about it on Twitter (which happened when I posted this: https://twitter.com/andykturne.../1090298657000378369), which are fascinating but not of real practical use, I thought I'd try and do a proper, objective systematic review of the available evidence.  But, despite ACE screening being rolled out quite commonly, I've really struggled to find any studies to even include in my review so far.  Quite a few in the grey literature, but very few peer-reviewed ones.  Maybe that's an important finding in itself.

Cissy White (ACEs Connection Staff) posted:

Andrew:

I think this topic would make for an excellent webinar or podcast or panel discussion. It's an important and complex issue and evokes lots of strong sentiments among many of us and for lots of different reasons.

While I don't favor screening for ACEs, because I don't trust most systems have dealt with bias towards those most likely to score high (people of color, women, poor people, those in the LGBTQ community), I do believe sharing information widely about ACEs is important. I believe the silence and avoidance, common to date, has been detrimental to many. I believe efforts that increase medical providers comfort having conversations about the way early life impacts adults health (for all of us, whether that means higher or lower health risks with higher or lower scores) is important - and hopefully will reduce judgments and increase listening, respect, and compassion when people understand that what many think of as self-created good health is often correlated with early adversity. 

It seems beneficial, for example, for a doctor or nurse to know someone might be more likely to hit early menopause, or have a more complicated path through menopause, have accelerated aging, more complicated times during pregnancy, and early parenting, etc. etc. and may respond to kids, as parents, in ways related to childhood. These may be things that would improve a health provider's treatment, advice, or care. We, with high scores, might be more likely to have specific diseases but of course that doesn't mean we will have. We know those with lower scores are less likely to get many outcomes, but also, it doesn't mean that they won't have any. We simply know more about higher and lower risks of groups of people with specific ACE scores.

But, as Laura Porter says, ACE scores don't tell us anything on the individual level. I've heard her speak once and she also talked about "right fit" responses, an example of a criminal justice system where one probation officer had exceptionally good results with those with high ACE scores and then was able to train other probation officers who were less effective. Again, it wasn't to diagnose or asses a specific kid, but general info. used to improve the training of the probation officers less effective with some kids than other probation officers were. In essence, used to improve the skills of the probation officers. I find that fascinating.

My fear though is that the screening process will speed up referral to behavioral health or to the child welfare systems, etc. which can and sometimes have done more harm than good - especially to the same groups most likely to be impacted by high ACE scores. For me, until systems address bias and structural inequity, seems the priority since it's so relevant to those with high ACE scores.

For me, that's the blaring caution that I have. I worry that ACE scores will be another way to label people, or for insurers to somehow calculate risk of super utilizers without looking at wider context and co-existing issues and conditions. For me, that's my concern.

That said, I do believe the general public, providers, parents, and everyone should know more about ACEs and the information itself is powerful.

I have had great experiences at a doctor's office (which hasn't been my norm) when I could share openly with a provider. I write about that here. I wish I had learned more, earlier, not only about my own ACEs but about the presence and lack of ACEs in others. For me, the most shocking part about the ACEs study is how many people have no ACEs or one or two ACEs. It was not what I would have guessed or predicted, and it's not what I saw growing up in a family and community with lots of ACEs (meaning adverse childhood experiences and community environments).

Again, I think so many of us are thinking lots about all of this and how the research and information about ACEs is used, is important. I'm grateful for discussions and hearing the views of others.

Cissy

Hi Cissy,

With all due respect, I'm puzzled by your comment: "My fear is that the screening process will speed up referral to behavioral health or to the child welfare systems, etc. which can and sometimes have done more harm than good - especially to the same groups most likely to be impacted by high ACE scores. For me, until systems address bias and structural inequity, seems the priority since it's so relevant to those with high ACE scores."

Yes, it's true and I completely agree that systems in society—all systems—need to address implicit bias. And I have another viewpoint on the child welfare system.

As a mental health practitioner who used to conduct court-ordered family evaluations for abused children, I saw first-hand how these systems helped, rather than harmed, children. Of course there are many situations where children may be retraumatized and placed in other unsafe situations. Tragically, yes, that happens. But there are many more situations where children and teens are saved from horrible circumstances.

The system we have can be improved upon for sure. But that's no reason to avoid screening for ACEs and intervening in a family—and sometimes taking a child away from their caretakers—when abuse and neglect is discovered. The behavioral health and child welfare systems are filled with compassionate and dedicated professionals who only want what's best for children and families. It saddens me to think they're perceived otherwise.


A very thought provoking discussion! Because our agency works only with trauma impacted individuals, I see benefits in an ACE score. The "check engine" light in my vehicle doesn't give me any specific information or inform my choices beyond telling me, "Something is amiss here, Harry, look into this soon!" 

In particular, I found myself nodding enthusiastically to comments like:

From Daun,"Could one value of the "simple score" in a clinical setting (and other one-on-one settings) be as simply a "discussion-starter"?' 

And from Elizabeth "What we've found, in particular with our adult population, is that when a person learns about ACE's and their ACE score they express a huge sense of relief, realizing their desire or need for treatment is not the result of some personal fault but the result of what they've lived through."

A few days ago I was working on grief/loss issues with a young adult. 

I knew they reported a score of "five" on the ACEs Quiz. I don't have any idea WHICH experiences are included. But it is (I believe) a warning light saying "attention please!" In planning for future work, I just asked, "Is my memory correct, you scored 5..." The person knew the experiences and pain those five questions brought to mind. They had obviously been thinking about them. It was a short path to, "Yes, I really need to talk about those soon!" 

Harry

 

 

Elizabeth Fitzgerald posted:

Hi Andrew,

While I'm not aware of any validated studies on best practice use of ACE scores, some members of my clinical teams have been using the ACE screening with clients. What we've found, in particular with our adult population, is that when a person learns about ACE's and their ACE score they express a huge sense of relief, realizing their desire or need for treatment is not the result of some personal fault but the result of what they've lived through. They also often express a sense of pride, strength and recognition of their own resilience in having a high ACE score and still managing to work, raise a family, become sober or any other accomplishment they choose to recognize through guidance from their clinician.

One clinician in particular often cited ACE health outcome data to highlight her client's strengths in comparison to particular health disparities linked to specific ACE scores.

I see it as a tool to empower ourselves and others; what's predictable is preventable. If I know my ACE score and it's associated risks I can be more targeted in my healing and prevention. I can also be a voice of hope for others with high ACE scores, proof that resilience is possible!

Great question!

Thank you for sharing your experience. I have just started working in a clinic as a Trauma Informed Care Coordinator. Coming from a psychology background, we talk about ACEs and their utility in a similar way. I'm refreshed to hear that the response from your patients has been that they are proud of their resilience. I'm wondering what type of training they received or how the survey was introduced to them. Also, if the clinic is private practice or community based (though I'm not sure exactly of the difference, I believe there might be an excess of paperwork that seems to be a barrier for our providers to take the time that they would like with patients.) Happy to connect!

Andi

Andrew Turner posted:

Hi, has anybody got any links to peer-reviewed journal articles where an individual's ACE score/questionnaire is used to inform practice?  I know it's fairly common practice now in some areas to enquire about ACEs, but I struggle to find any papers describing how that information is then used.  Would be good to find some examples where, say, a score of four leads to a more targeted intervention or response, for instance.

Thanks.

Hi Andrew, 

I'm 64 years old and was trafficked for 18 years before landing a government job that I retired from 4 years ago. Right now I'm working with a professor here in Michigan who is co-authoring an article with me for the American Journal of Nursing. I can keep you posted of when it's published if you like. 

I wrote an article about how the ACE study helped me "reach the other side" and I posted it here  https://www.acesconnection.com...to-human-trafficking and other social media in case your interested.  

I'm hoping to find studies that connect ACEs to HT. 

Thank you

Ruth Rondon

 

Thesis; ACE's Knowledge and Awareness is a POWERFUL Therapy that delivers proven effective Therapeutic Healing in and of Itself.

Simply knowing of ACE's and of one's own score is healing above any therapeutic intervention currently in use, to the best of my knowledge - odd as this might sound to those whose livings are made providing such therapies - not that these are not also beneficial - but the numbers speak for themselves I think. 

Dr. Nadine Burke-Harris has published some crude data on those she has evaluated in her practice over the years and the beneficial outcomes she reports are unexpectedly large - even with minimal to no interventions in many cases in which there was just the taking of the ACE evaluation and exchange of minimal information.

What was conveyed in many cases was only a basic conceptual framework of what ACE's is, and where oneself or one's child is on the scale. That's it - and from this alone benefits were reported that make other interventions pale in comparison.

Ergo; It may be that self-empowerment and eliminating or reducing shame by speaking to someone of such matters, sometimes for the first time is the most powerful therapeutic agent.

The data provided by Dr. Burke-Harris seems to indicate none of the five competencies have nearly the same measurable outcome on high ACE scoring persons and families as does simply;

(1) knowing of ACE's,

(2) taking an ACE's evaluation, and

(3) knowing of one's own ACE score and/or that of one's child, and/or significant other, and

(4) having gone through the social process involved in having either shared this information or even more minimally, having at least been asked by someone that showed an interest in one's taking the questionnaire and one subsequently having complied - as occurred in the clinical practice of Dr. Burke-Harris.

All four are important I suspect and together comprise what I believe to be the most important Core Healing Competency of SEL, (social-emotional learning), that being to have ACE's Awareness and knowledge. 

XXXXXXXXXXXXXXX

The Collaborative for Academic, Social, and Emotional Learning (CASEL) defines five core SEL competencies, including (1)self-awareness, (2)social awareness, (3)self-management, (4)relationship skills, and (5)responsible decision making. 

The CASEL Five SEL competencies ARE NOT (I don't believe) sufficient to achieve that which they were created to accomplish and which CASEL itself was created to accomplish.

Knowledge & Awareness of ACE's itself AS the Most Powerful Therapeutic Healing Agent; There should be 6 core competencies, not five, (in my opinion) and the (proposed) 6th would be the one that is by far the most important.

Culture is Biology.

We must always look to ourselves when addressing important issues to ensure that we are not speaking from a place of trauma and illness that affects one's very mind in how one thinks and processes information. Only by having ACE Awareness and knowing to look, to check one's own thinking, can one overcome this potential limitation. This is what a proposed 6th core competency enables and a powerful argument for why it should, I believe, be officially added to CASEL's five core competencies. What do you think?

It is from atop the shoulders of those that created the CASEL organization, that a proposed key 6th competency can now be conveyed. WE ARE READY, if we dare, thanks to their good works and efforts. This means educating children, especially. If this sounds impossible or unrealistic to you, it is not, it is already happening - I encourage the reader to investigate the wonderful work of Mrs. Goldie Hawn's, the Hawn Foundation, in making it her and their mission to educate children about their own brains and emotions from a very early age by creating the education enterprise, MIND UP. If hearing a second-grader say to be patient because her friend is upset and their amygdala is over-reacting doesn't inspire one to have hope for the future, I don't know what will. https://mindup.org/ 

The MindUp program provides separate sets of lessons for three levels: prekindergarten through second grade; third through fifth grade; and sixth through eighth - https://casel.org/guideprogramsmindup/
 

It is hard (oftentimes) to see the "ELEPHANT IN THE ROOM" because we are standing on it - arguably, the number one core piece of knowledge that is central to coalescing one's knowledge is to understand ACE's, to be ACE's-Aware. For this reason, it is proposed that a SIXTH core SEL competency should be ACES-AWARENESS.

This (proposed 6th) ACE's-Awareness SEL core competency is key to being able to heal one's self, meaning to have resilience and this knowledge is also key to enabling the healing to spread - to be able to pass on the benefits of said self-change and self-knowledge.

In other words, to counter the behaviorally transmitted *negative* effects of trauma and ACE's with the behaviorally transmitted positive effect of knowledge. ACE's as a 6th CORE SEL COMPETENCY is (I believe) needed to tap into and be able to behaviorally transmit the seldom discussed or contemplated, but clearly extant, *positive* counter-effect to the negative behaviorally transmitted neurotoxic effects of ACE's.

As with the introduction of Sanitary Hygiene to an incredulous populace in the 1900s, little believing that millions of "invisible creatures" are living on ones' hands and all around us requiring doctors to wash their hands and disinfect surgical instruments, so too there is significant public resistance in our own day to modern concepts of Mental and Behavioral Hygiene that accompany trauma-informed ACE Awareness, Similarly, one must be educated in ACE's to be able to see and know what it is that oneself and one's society is affected by to be able to hope to overcome it. Knowledge of ACES must (I therefore believe) become a 6th CASEL Core Competency. 

Biology is Culture; At one time we though witches and evil spirits caused the deaths that we now know come from micro-organisms through a process we now categorize as a disease. To defeat this "evil" we needed to understand the science behind it. The same is true if we wish to see an END to the statistic of 1 in 3 children sexually assaulted and 1 in 7 abused or neglected. This MUST (it seems reasonable to presume) happen to END the trauma and abuse, as compared to merely seek to reduce and manage it as if it was an inherent part of the "human condition" and thus impossible to ever see go away. Trauma and abuse, like a disease, are NOT an inherent part of the human condition and what humanity is, it is a blight upon it that we can and must exercise our combined wills to see extinguished. 

Rising Above Our Biology; We must all strive to see the elephant we all stand upon; ACE's Awareness by everyone, young and old, in order to "rise above" our biology and that of society and culture - to no longer be confined by the black/white thinking that limits one to seeing things, one's self, and others in competitive terms of good and bad which way of seeing is itself the key feature of a traumatized reactive mind.

One is NOT damaged by ACE's, ACE's changes one's brain and perceptions to be better adapted to a damaged World. The 6th core SEL competency enables us to Rise Above this limitation of our Biology - to consciously change the World.

A high ACE score means one is highly prone to having a 'fixed' mindset - and it is hoped that through knowledge of ACE's we can be empowered to see things differently - to have what is called a 'growth' mindset or at least to perceive things more in terms of having a growth mindset. We are at a cultural tipping point. It is time to step into self-awareness and rise above our biology. It is time (I believe) for us all to embrace not just our own individual biologies but to also see that Culture (too) is Biology. 

ONWARD!



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