Growing Awareness and Building Community
The Centers for Disease Control Adverse Childhood Experiences (ACE) Study was one of the largest studies ever conducted on the long-term health impacts of child abuse and other forms of adversity. This groundbreaking study holds many lessons for public health policy and has contributed greatly to our understanding of how stressful life experiences during childhood contribute to morbidity and mortality over the lifespan and across generations. As with any study, the ACE Study has both strengths and limitations that should be carefully considered when attempting to translate findings into practice.
The Child Trauma & Resilience Committee of the Indiana Commission on Improving the Status of Children (Children’s Commission), Dr. Robert Anda, Principal Investigator of the ACE Study, and the ACE Interface Trainers in Indiana endorse the use of ACE scores for population surveillance and the design and evaluation of public health promotion and prevention strategies. ACE scores should not be used, however, for screening or diagnosing individuals or assigning individual risk for decision making about need for services or treatment. Importantly, systemic inequities may undergird the presence of ACEs in many populations and are critical to consider when assessing, interpreting, and responding to ACEs.
A robust dose-response relationship has reliably been observed between ACE scores and mental and physical health outcomes in epidemiological studies where responses are analyzed in aggregate. Understanding ACEs within a population can therefore be valuable in determining what resources and programming may be needed to reduce exposure to toxic stress and prevent associated harms within that population.
There is interest among some policy leaders to use ACE scores as an individual-level screening or diagnostic tool to guide decisions about need or eligibility for services. The use of ACE scores, thresholds, cut points, or ranges in this way is not recommended for the following reasons:
The use of ACE scores for individual screening has not been evaluated by the U.S. Preventive Services Task Force (USPSTF) – an independent panel of experts that evaluates the safety and efficacy of public health screening and clinical preventive services –a national standard for instruments used in this manner.
ACE scores can provide useful information about grouped (average) risk for many public health outcomes, but projecting those values onto any individual’s ACE score to make inferences about health, educational, or social consequences may lead to significant underestimation or overestimation of actual risk.
The questions used in the ACE Study to define the 10 forms of adversity are incomplete measures of a person’s actual exposure to trauma and stressful life events. ACE scores do not include consideration of frequency, severity, timing or other important risk and protective factors that may influence how ACEs impact a specific person’s development and functioning. As a result, two people with the same ACE scores may have dramatically different experiences and needs.
Individual ACE scores convey little actionable information to guide intervention planning, which is often a goal of screening. For example, a person who experienced intense, chronic, and unrelenting exposure to a single type of abuse would have an ACE score of 1 and yet may require more healthcare and other support services than someone with a higher ACE score who is generally healthy and functioning well. This is why determining a cut-off point, such as an ACE score of 4, is not accurate or appropriate.
Research on ACEs has stimulated further research into the biology of stress and inspired meaningful changes in public policy and human services. ACE scores can offer a basis for conversations about a person’s history and to learn more about why some groups may have more challenges in their lives. Ultimately, a greater understanding and awareness of ACEs and appropriate application of ACE science can help create communities and systems that foster healing and resilience. However, the ACE score is neither a diagnostic tool nor is it predictive at the individual level. Thus, great care should be used when obtaining ACE scores for children and adults as a part of community-wide screening, service, or treatment.
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