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We need to do something to stop ACEs, but universal ACE screening is probably not the best place to start


5 Oct 2020

Dr Kirsten Asmussen looks at the issues and reasons for caution when it comes to using ACE screening.

This article was originally published in CYPN, along with more in-depth reviews of studies on adverse childhood experiences. 

There is no question that adverse childhood experiences (ACEs) are bad. Six ACE categories are forms of child maltreatment that are punishable by law and four involve negative family circumstances that are typically distressing for all family members.

Every child has the right to grow up in a home that is free from abuse, neglect and family dysfunction and this reason alone should be sufficient to introduce comprehensive measures to stop and reduce ACEs.

However, evidence from the landmark 1998 ACE study makes the need for these measures all the more compelling. This study not only observed that four or more ACEs dramatically increase the likelihood of serious adult mental health problems (an association well established in the child maltreatment literature), but also many life-threatening diseases such as cancer, heart disease and respiratory failure. These findings mean that ACEs could potentially result in early death if nothing is done to stop or reduce them.

It is therefore not surprising that many view universal ACE screening as a logical way to identify individuals with a history of ACEs and offer them further help. However, the evidence reviewed here suggests that implementing universal screening might be a bit premature.

First, the review found that most ACE measures have not yet been sufficiently validated to determine risk or harm at the individual level. While scoring practices might provide some insight into the public health burden represented by four or more ACEs, they provide little value when it comes to determining whether a specific individual might benefit from further treatment. This means that at the very least, ACE measures should undergo further testing before all individuals are screened.

Second, we are concerned that universal ACE screening may cause unintentional harm, especially in light of recent evidence showing that vulnerable individuals (those with a history of multiple ACEs) are uncomfortable when asked about their history of ACEs. This means that universal screening could potentially deter children and adults from seeking further help, even when validated measures are used.

Protocols must therefore also be tested to ensure that screening practices do not cause unintentional harm or stigma. Universal screening conducted in the absence of tested protocols otherwise represents bad practice and should be avoided.

Third, universal screening is both wasteful and unethical if it does not directly lead to evidence-based treatments. Although some have argued that the experience of screening might be beneficial in its own right, this theory needs to be explicitly tested before it is accepted as fact.

In EIF’s review – Adverse childhood experiences: What we know, what we don’t know and what should happen next – more than 30 interventions with strong evidence of either preventing or treating ACEs were identified.

We recommend that more time and money be spent in offering these interventions, before investing any further in untested ACE screening practices.

Simultaneously, ACEs screening measures and protocols should undergo further testing and development to make sure they do not cause any unintended harm and efficiently lead vulnerable individuals to receiving effective treatment.

About the author

Dr Kirsten Asmussen

Kirsten is head of what works, child development, at EIF.