Client and provider discomfort with an adverse childhood experiences survey
The Early Intervention Foundation
Tuesday, September 29, 2020
The presumed causal relationship between ACEs and poor life outcomes has resulted in some policy and health organisations to advocate for ACE screening to be implemented universally so that vulnerable individuals can be offered treatment.
Authors: JP Mersky, CTP Lee and RM Gilbert
Published by: American Journal of Preventive Medicine, 2019
Typically, ACE screening involves asking individuals to answer yes/no questions taken from the original ACE-study questionnaire that counts ACEs and generates an ACE score. This score is then used by frontline practitioners to initiate a conversation about the individual’s history of ACEs to explore whether further treatment might be helpful. In some cases, individuals are then made aware of their treatment options, although some believe that conversations about ACEs may be beneficial in their own right.
Universal ACE screening is increasingly being implemented in local areas in North America and the UK, although ACE screening practices have recently been criticised on the grounds that most screening tools have not been sufficiently validated and that reliable treatment protocols have yet to be established.
There is also growing evidence that some screening practices may inadvertently cause stigma and re-traumatisation. More research is therefore necessary to understand if ACE screening is acceptable for vulnerable families, and if it is sensitive and specific enough for making treatment decisions.
Study aims
While there is preliminary evidence suggesting that the majority of individuals do not mind being asked about their history of ACEs, the most vulnerable people – those who are the most likely to have been exposed to a high number of ACEs – typically do not participate in these studies. This study therefore sets out to investigate the acceptability of universal screening from the perspectives of highly vulnerable individuals. In total, 1,678 vulnerable parents and 161 practitioners delivering a home visiting intervention in the US state of Wisconsin completed the ACEs survey and then answered a series of questions that measured their level of discomfort.
Key Findings
This study observed that 80 per cent of those participating in universal ACE screening did not experience discomfort when answering the ACE questions. However, 20 per cent expressed discomfort and this was directly associated with their history of ACEs and their current symptoms of depression. The study also observed a positive association between practitioner discomfort and client discomfort — meaning that practitioners felt less comfortable about discussing ACEs as client discomfort rose.
Conclusions
While it is clear that most individuals are not uncomfortable with the ACE questions, those with a history of ACEs are likely to be less comfortable and may not answer ACE questions truthfully. This suggests that many ACE screening practices could discourage vulnerable families from seeking effective treatment, and inadvertently increase their feelings of trauma.
More broadly, the validity of ACE screening tools needs to be established before they can be used for making treatment decisions. Clear protocols are also necessary to ensure that ACE screening leads to effective treatment.
Implications for practice
Adverse childhood experiences include forms of abuse and neglect that frequently increase children’s exposure to trauma and are also punishable by law. This reason alone should be sufficient for making interventions that stop or prevent ACEs, or reduce symptoms of ACE-related trauma, more widely available.
ACE research has helpfully shed light on the relationship between childhood adversity, high levels of trauma and life-threatening conditions. However, the retrospective survey design employed in most ACE studies is subject to biases that make their findings inappropriate for estimating the public health burden associated with ACEs, or confirming any specific causal assumptions.
There is strong and consistent prospective evidence linking ACEs to poor mental health outcomes. However, the prospective relationship between ACEs and physical health outcomes is less clear. This means that evidence-base efforts targeting ACEs are more likely to provide mental health benefits over physical health benefits.
There is growing evidence that vulnerable individuals experience discomfort when answering questions about ACEs. The validity of most ACE screening measures has also not been established. ACE screening should therefore not be implemented until valid measures are available and it is clear that they are not distressing for the most vulnerable individuals.
- The Early Intervention Foundation is a What Works Centre that champions and supports the use of effective early intervention to improve the lives of children and young people at risk of experiencing poor outcomes
- Read more in the Adverse Childhood Experiences Special Report