Questioning ACEs in Trauma-Informed Practice

Written by Addison Duane, Ph.D.

Like me, you are probably reading this blog because you understand and are interested in the concept of trauma. For many, our first introduction to the concept of trauma was through the Adverse Childhood Experiences (ACEs) questionnaire. But what many of us likely didn’t know was how, since inception, ACEs has faced critiques in the scholarly literature.

In a recent article, I explore these critiques, and want to break them down here for us. But first, a little history:

Twenty-five years ago the first findings from the ACEs study came out. According to Dr. Vincent Felitti (a practicing medical internist who was one of the architects of the original study), the notion of ACEs came from a group of 286 obesity clinical cases where he observed that histories of sexual abuse reports may have been connected to poor health outcomes. After a conference presentation on this idea in 1991, the CDC invited Felitti to meet with a small group of researchers, where he met Dr. Robert Anda, a medical epidemiologist. Together, the two men developed the initial ACE check list and study, with the explicit goal of pulling together what they called “fragmented pieces of information” to understand the effects of adversity on adult biopsychosocial outcomes. This work, they hoped, would “highlight childhood roots of leading causes of morbidity and mortality in the U.S.” So right out the gate we have two white men looking at obesity and hoping that trauma would be connected to what they perceived as poor health.

Data were collected in two waves in 1995 and 1996. In the first wave, they took those fragmented pieces of information, and created, themselves, eight categories of adverse experiences:
1) Physical abuse
2) Sexual abuse
3) Emotional abuse
4) Alcoholism and drug use in the household
5) Mental illness of a household member
6) Incarceration of a household member
7) Witnessing domestic abuse of a mother or stepmother
8) The divorce or separation of parents

In the second wave, the two men added emotional neglect and physical neglect. These ten items create the original 10-item ACE questionnaire– which becomes a sum score of selected categories.

From study population, to measurement, to analysis, interpretation, and use, many have taken issue with ACEs.

So what are the critiques?

First, the data was collected from a majority upper-middle class, middle-aged White sample (80% White; average age 57 years old). This is important because we now see those same ACE categories applied and widely spread to so many other age and racial groups. Researchers have also questioned the reliability and validity of the study findings, noting that the results used “association,” “causality,” and “impact,” interchangeably which are drastically different concepts in the research world. Additionally, in conceptually creating the ACE questionnaire, both lead investigators have said that their selection, and inclusion of those ten ACE categories were based on reported prevalence by participants in obesity program case-control and pilot studies, not existing scientific constructs or a unifying framework. There was no stated rationale for why those 10 categories, or why other experiences were left off the list.

Scholars have also argued that the 10 items provide very limited information related to the circumstances where ACEs occur. This is because a person’s ACEs score is based on types of exposures, not the impact of the exposures themselves. With their checklist, there is no information about multitude, frequency, duration, nor the age of onset or presence of other risk and protective factors – all of which we know are absolutely crucial in understanding trauma, a highly subjective and individualized experience.

That ACEs centers “household dysfunction” as the primary and most significant form of adversity, is also a problem. We know that trauma can– and does– occur in a range of community settings like schools, hospitals, etc. One critique notes how factors such as violent policing, environmental conditions, weakened support networks, and experiences concentrated in low income communities, (i.e., food insecurity, housing instability, higher contact with juvenile (in)justice systems, etc.) are completely absent in the ACE questionnaire. To this day there remains a debate about what can, and cannot, be considered an ACE. One scholar Sue White and her colleagues so beautifully summarize these conceptual arguments. They say: from the beginning, ACEs has been a “chaotic concept” that lacks conceptual justification.

I’ve been writing and thinking and talking a lot about what we in settings like education and psychology can do instead. One of the architects, Dr. Anda, wrote a piece in 2020 asking us to stop using it as a screener. It may be time to move away from ACEs– even with its updates, given its harmful origins. To learn more, check out this piece.

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