The use of ACE scores for individuals

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.


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