By Edward L. Machtinger, Alicia Lieberman, and Marguerita Lightfoot, JAMA Pediatrics, May 10, 2021
To the Editor We read with great interest the article by Baldwin et al, which contributes to a substantial body of research describing the staggering population-level effects of adverse childhood experiences (ACEs) on many of the most common
causes of adult illness, death, and health disparities.
The principal conclusion the authors derive from their elegantly designed study is that a deterministic use of ACEs scores should not be used to guide individual-level clinical de cision-making. While this recommendation is important for those unfamiliar with ACEs screening, it obscures more important and actionable aspects of their findings.
Adverse childhood experiences are traumatic experiences. It is well known that trauma exposure alone does not predict how an individual will respond. Health sequelae from
trauma exposure develop in the context of one’s ecosystem, including protective and risk factors (eg, the presence or absence of supportive individuals), material resources, and individual strengths and vulnerabilities. To adequately address trauma, individual-level patient assessment requires an understanding of the triad of adversity (ACEs and other traumatic events), protective factors (resources and strengths), and distress (both physical and emotional). This triadic method of trauma inquiry is the framework we are developing in the California ACEs Learning and Quality Improvement Collaborative (CALQIC), a 53-clinic statewide learning collaborative that is a pillar of California’s ACEs Aware initiative. This framework, Trauma Inquiry for Adversity Distress and Strengths (TRIADS), as with most clinical tools in the emerging fields of ACEs and trauma-informed health care, is still formative and undergoing evaluation. But this comprehensive approach is more representative of how ACEs screening is being introduced into clinical settings than the stand-alone method that the authors describe.
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