In alignment with current and emerging research, Whole Health Louisiana intentionally uses the more expansive term “childhood adversity” when referring to adverse childhood experiences.Christine Lobre, Trauma and Resilience Strategy Manager at the Louisiana Department of Health, Office of Public Health, Bureau of Family Health explains, “The use of Adverse Childhood Experiences (ACEs) as a term can become problematic as it leads to the false assumption that the ten-item ACEs questionnaire is a valid assessment tool with predictive value for health outcomes at the individual level. Additionally, the ACE score does not provide a full picture of adversity burden as it does not assess the frequency, intensity or stage(s) of development at the occurrence of adversity, or include the presence of protective or mitigating factors, or community-level, systemic or structural issues in the equation.”
About the ACE Study
In the late 1990s, the U.S. Centers for Disease Control and Prevention partnered with Kaiser Permanente to conduct the ACEs study, one of the largest investigations of childhood abuse and neglect and household challenges and later-life health and well-being. Over 17,000 insured patients from Kaiser Permanente in southern California completed confidential surveys regarding their childhood experiences and current health status and behaviors. The study demonstrated that these experiences are common and interrelated.
The findings were considered groundbreaking and brought the concepts of childhood adversity and its impacts on public health into mainstream conversations giving many of us a shared language to address childhood adversity and its impacts. Many studies have followed expanding on the initial study’s findings including the Philadelphia Expanded ACEs study that included community-level adverse experiences.
Assessing Childhood Adversity Today
The study’s questionnaire is a ten-item list designed to identify population-level risk. The authors of the ACE study did not intend for the ten-item questionnaire to be used as an assessment tool and have warned against its limitations for use. “Unlike recognized public health screening measures, such as blood pressure or lipid levels that use measurement reference standards and cut points or thresholds for clinical decision making,” Anda, et al, explain in their (2020) article Inside the Adverse Childhood Experience Score: Strengths, Limitations, and Misapplications, “the ACE score is not a standardized measure of childhood exposure to the biology of stress.”
The American Academy of Pediatrics and other experts in the field of childhood adversity have provided guidance against the use of the ACE questionnaire citing that ACE scores are not effective clinically as they do not include or measure the severity, chronicity, frequency or all types of these potentially traumatic experiences.
Assessment of adversity should only be done by trained professionals using validated screening tools endorsed by the professional sector they are licensed by with referral services in place. The prevailing research for the advancement of trauma-informed practices is to adopt universal interventions that focus on risk and protective factors rather than individual-level interventions or treatment.
Shifting the Language
Preferred terms instead of ACEs:
● Childhood adversity (and its impacts)
● Developmental adversity
● Positive and Adverse Childhood Experiences (PACEs)
Broadening the language we use to describe childhood adversity beyond ACEs and ACE scores is essential for a more accurate and equitable understanding of these experiences. The inclusion of positive and protective factors in discussions about childhood adversity ensures that interventions and policy recommendations are solution-focused.