Overplaying our ACE card?
Dez Holmes, director at Research in Practice (RiP), questions what is being lost in the translation of ACEs from a lens for understanding to a tool for screening and referral.
EIF’s recent report on adverse childhood experiences is timely, and should give all of us working in and around the children’s sector pause for thought. ACEs have garnered a lot of attention and it’s about time we ask ourselves why the ACEs framework has risen so quickly. What purpose does it serve? What narrative on the evidence does it foreground?
These are questions we need to step back and ask before ploughing on with using ACEs – perhaps in a way in which it’s not intended to be used. Especially because the picture is much more complicated than ACEs can ever capture, given that health inequalities and factors such as poverty are also vital considerations.
Understanding the potential impacts at a population level of different forms of adversity can be useful, particularly in terms of strategic needs assessment and service planning. Two recent reports provide contrasting high-level views: the Marmot ‘10 years on’ review of health inequalities, and EIF’s review of the evidence on ACEs. The Marmot review maintains an incisive focus on the social determinants of health, which provides a powerful lens for understanding the need for health and social policy that addresses inequality, poverty and deprivation. The EIF report on ACEs similarly raises concerns about how many factors outside the 10 used in the ACEs framework are ignored, and yet the social context in which parenting takes places needs to be thought of and addressed.
The ACEs agenda links to the concept of ‘trauma-informed’ practice, and trauma-informed practice can be extremely useful in developing professionally curious, respectful responses. So, why the criticism of ACEs?
It is hard to imagine a practice less congruent with trauma-informed principles than that of completing a checklist. Nonetheless, undertaking a questionnaire or checklist is how some parties are applying the ACEs evidence. The use of such tools has been criticised as reductive and unhelpful, and caution has been urged by many contributing to a recent select committee report focused on early intervention. As Prof Rosalind Edwards reiterates in a recent blog post: ‘It can’t be stressed enough that extrapolations cannot be made from population level epidemiological studies of adversities and outcomes to individual level diagnosis for particular children or young people in service provision.’
The preoccupation with the individual health impacts is also an aspect that colleagues in practice have criticised. Public health registrar Andy Turner rightly notes in his blog post that this bio-medical focus – so popular in the US – has unhelpful implications: ‘There is a danger that ACEs become yet another example of what is essentially a social issue with societal solutions being labelled as a medical one. When that happens, the focus shifts to identifying and ‘treating’ individuals, rather than prevention at the population level.’ Such a lens can quickly lead to the pathologising and blaming of individuals; government can meanwhile be absolved of its responsibilities to address systemic adversities.
Beyond content, or lack thereof, there are a number of problems with the structure and format of the ACEs questionnaire. Multiple issues are collapsed into single questions, which is considered poor practice in survey design; some are prefaced with leading preamble, and responses are restricted to ‘dichotomised “yes/no” response options’. Perhaps most jarring of all, the simplistic scoring used in the majority of ACEs tools do not allow differentiation of experience. One does not have to be an expert in survey instrument design to know that your parents’ divorce might have a different impact on you than my parents’ divorce…
Given the critique of these ACEs questionnaires, it is perhaps surprising that there have been calls to introduce routine screening. In considering the criteria identified as essential to meet before implementing any routine health screening programme, McLennan and colleagues argue that the inaccuracy of the screening tools and the absence of guaranteed services to refer onto render routine ACEs screening inappropriate. This latter seems particularly important in the context of austerity. What are the ethical implications of screening children for adverse experiences, alerting parents and carers to the potential outcomes of these experiences, but being unable to offer support to address them? Would we accept this in any other health screening?
We should also ask whether the training and support being offered to professionals is likely to be adequate for them to undertake routine inquiry and screening of ACEs. We know from studies into the use of scored risk tools that inadequate training and support contributes to inconsistent application. Senior managers commissioning ‘ACEs training’ might want to ask themselves a blunt question: how well trained and professionally experienced would someone need to be before you would let them talk to your child or loved one about painful issues? And how does this compare with the level of training your organisation is offering to staff?
Of course, we all want to help children and families overcome adversity and live fulfilling lives. But there is no magic formula, no miracle tool, that will do this for us. Rather than allowing ourselves to be seduced by the simplistic offer of ACEs questionnaires, we might do better to focus on what is already within our gift. We already have many skilled empathic practitioners, ready and willing to have respectful conversations about difficult issues. There are some excellent managers able to offer reflective and containing support: we must invest in them further. And we know there are leaders striving to ensure a wider culture and system that enables curious, ethical, systemic support to practitioners and families alike.
These are our ace cards, and they are infinitely more useful than any checklist available. Let’s have confidence in what we know matters: relationship-based, evidence-informed practice; critical thinking and reflective supervision; empathy and respect for those we serve; resources available for those that need it. No rocket science required.
1: McLennan JD, McTavish J, MacMillan HL. (2019). Routine screening of ACEs: Should we or shouldn’t we? In G. Asmundson, T. Affifi (Eds.), Adverse childhood experiences (ACEs): Using evidence to advance research, practice, policy and prevention, Academic Press, San Diego (2019): 245–159.
2: Dobrow MJ, Hagens V, Chafe R, Sullivan T, Rabeneck L (2018). Consolidated principles for screening based on a systematic review and consensus process. Canadian Medical Association Journal, 190(14): 422–429.
3: Brown S, Brady G, Franklin A, Bradley L, Kerrigan N & Sealey C. (2016). Child Sexual Abuse and Exploitation: Understanding risk and vulnerability. London, UK: Early Intervention Foundation. https://www.eif.org.uk/report/child-sexual-abuse-and-exploitation-understanding-risk-and-vulnerability; Brown S, Brady G, Franklin A, & Crookes R. (2017). The use of tools and checklists to assess risk of child sexual exploitation. An exploratory study. Centre of Expertise on Child Sexual Abuse. https://www.csacentre.org.uk/our-research/responding-to-csa/risk-tools/