Administering ACE questionnaire in a clinical setting

Hello Jane Stevens & Keith Haas, It appears some folks may be drifting a bit off topic here. While discussing the ACE Study (1998) in the Chadwick Manual, Dr. Felitti and Dr. Anda stated that "Surprisingly, the ten categories turned out to be essentially co-equal in terms of long-term effects".

If this is true, our efforts to respond to ACEs should be pursued co-equally.

We should start the helping process by;

1. Clearly identifying any specific court ordered legal rights (PPOs, Custody/Parenting Time) associated with any identified ACE.
2. Assess that person's needs to establish, change, or enforce any of these types of legal rights.
3. Link them directly to "Court Services" to establish, change, or enforce their legal rights.
4. And then, we can move on to 'coping skills' for the rest of the ACEs.

Think about when a child starts any treatment program and then their parents get divorced. How should we address this new "ACE" to prevent additional ACEs and the possible sources of ongoing toxic stress?

I think we should address the Divorce ACE co-equally, as if it were Domestic Violence or Sexual Abuse. Right?   

In my opinion, any other interpretation of the ACE Study (1998) should be discouraged and not allowed in this conversation. Its counterproductive and may very well be an attempt by some to justify why they don't want to following-up on [all] of the ACEs identified, especially Divorce.

Divorce = Divorce Court = Legal Rights = System of Care running to Hide. 

Some helping professionals seem to be willing to move on so fast, they sometimes overlook the most important thing in the life of the person being served;

• "To participate in the regular, consistent, and nurturing family  relationships they already have according to a current court ordered standard of care".

I believe the single most beneficial use for an ACE Questionnaire/Survey is prevention, both for the children and for the parents who may be repeating the 'relational abuse' that their own parents perpetrated against them.  

Children cannot defend themselves alone. Some of them will spend their entire lives practicing the negative coping strategies because they now see their own parents thru a lens of 'Parental Betrayal' and 'Social Injustice'.

Rose-colored glasses will not help. We must at some point begin to eliminate/prevent the legal and human rights violations perpetrated against our children in real-time. 

Please forward the details and include me in the conference call that you are trying to schedule about  "Administering ACE questionnaire in a clinical setting". Thanks!

James Gallant, Marquette County Suicide Prevention Coalition (906) 360-3045 mqtsuicidepreventioncoalition@gmail.com

James, if you're referring to people being off topic asking about the Resilience/Child Protective Factors history 'score' I beg to differ and believe it has everything to do with the discussion.  Keith initially asked about the resilience score, so it is on topic.

Because it gives you the biggest picture of the client's childhood.  The question is how to administer sensitively as it can potentially traumatise people for a while when it sinks in if one has a really low score, yet is so pertinent I believe to understand that whole picture.  If you understand exactly what you went through, and you're young, you have your lifetime to try to heal, with a realistic grounding in what actually occurred and what you need to do, with help. So after such a score/history it needs to be followed up with something positive - empowering as well as the 'truth', to give hope.

At least that's my take on it!

Mem Lang posted:

So Jane, and all those experienced in ACE understanding and possibly administration of to clientele, would you use or advocate the use of the Resilience history score?

I don't think I'll get the definitive answer I am looking for...!

All the best with the call.

I haven't been around in awhile but I hate that scale. 

that scale has no validation.  a very good pediatrician looked at literature and came up with the questions. 

I think they are horrible for very high acers who have a High ACE and LOW, LOW, LOW on that.   The peds at the children's clinic are using CD risk.  You can get it for 50 dollars if you email the fellow.  I emailed and he was fine with using it in the clinic.

Mem Lang posted:

So Jane, and all those experienced in ACE understanding and possibly administration of to clientele, would you use or advocate the use of the Resilience history score?

I don't think I'll get the definitive answer I am looking for...!

All the best with the call.

Mem, I don't like the resiliency questionnaires that have been developed so far, because I don't think they are useful in understanding specific vulnerabilities. They don't educate what you need to focus upon. Resiliency is about community and relationships, but it is also about general cortical capability, sensory reactivity and physiological regulation. Resiliency is about the way the reward system has developed due to the quality of relational reward early on.

That said, I created my own resiliency questionnaire, based upon my understanding of the sequential development of the brain (leaning upon the work of the ChildTrauma Academy). So I asked questions that directly address relationship/community (relational reward), reliance on sensory soothing (somatosensory reward), level of physiological arousal (self regulation), and the capability of the higher mind to mitigate stress (cortical modulation).

Children have specific vulnerabilities in these areas, and so do parents. Parents need to know where their areas of strength and vulnerability are so that they can recognize where they may need support in order to better meet their children's needs and also their own.

Robbyn Peters Bennett posted:

Mem Lang posted:

So Jane, and all those experienced in ACE understanding and possibly administration of to clientele, would you use or advocate the use of the Resilience history score?

I don't think I'll get the definitive answer I am looking for...!

All the best with the call.

Mem, I don't like the resiliency questionnaires that have been developed so far, because I don't think they are useful in understanding specific vulnerabilities. They don't educate what you need to focus upon. Resiliency is about community and relationships, but it is also about general cortical capability, sensory reactivity and physiological regulation. Resiliency is about the way the reward system has developed due to the quality of relational reward early on.

That said, I created my own resiliency questionnaire, based upon my understanding of the sequential development of the brain (leaning upon the work of the ChildTrauma Academy). So I asked questions that directly address relationship/community (relational reward), reliance on sensory soothing (somatosensory reward), level of physiological arousal (self regulation), and the capability of the higher mind to mitigate stress (cortical modulation).

Children have specific vulnerabilities in these areas, and so do parents. Parents need to know where their areas of strength and vulnerability are so that they can recognize where they may need support in order to better meet their children's needs and also their own.

Hi Robyn, 

What questions do you ask? Curious.

Tina Marie Hahn, MD posted:

that scale has no validation.  a very good pediatrician looked at literature and came up with the questions. 

 

I think they are horrible for very high acers who have a High ACE and LOW, LOW, LOW on that.   The peds at the children's clinic are using CD risk.  You can get it for 50 dollars if you email the fellow.  I emailed and he was fine with using it in the clinic.

 

 

 

Hi Tina, Can you send me a link to the CD risk assessment? I'm not familiar with it, but am very interested. Thank you!

Tina Marie Hahn, MD posted:

Robbyn Peters Bennett posted:

Mem Lang posted:

So Jane, and all those experienced in ACE understanding and possibly administration of to clientele, would you use or advocate the use of the Resilience history score?

I don't think I'll get the definitive answer I am looking for...!

All the best with the call.

Mem, I don't like the resiliency questionnaires that have been developed so far, because I don't think they are useful in understanding specific vulnerabilities. They don't educate what you need to focus upon. Resiliency is about community and relationships, but it is also about general cortical capability, sensory reactivity and physiological regulation. Resiliency is about the way the reward system has developed due to the quality of relational reward early on.

That said, I created my own resiliency questionnaire, based upon my understanding of the sequential development of the brain (leaning upon the work of the ChildTrauma Academy). So I asked questions that directly address relationship/community (relational reward), reliance on sensory soothing (somatosensory reward), level of physiological arousal (self regulation), and the capability of the higher mind to mitigate stress (cortical modulation).

Children have specific vulnerabilities in these areas, and so do parents. Parents need to know where their areas of strength and vulnerability are so that they can recognize where they may need support in order to better meet their children's needs and also their own.

Hi Robyn, 

 

What questions do you ask? Curious.

 

Sorry for replying with a quote.. I don't know how to do a simple reply. Ack.

Attached is my flyer and assessment.

Robbyn Peters Bennett posted:

Tina Marie Hahn, MD posted:

Robbyn Peters Bennett posted:

Mem Lang posted:

So Jane, and all those experienced in ACE understanding and possibly administration of to clientele, would you use or advocate the use of the Resilience history score?

I don't think I'll get the definitive answer I am looking for...!

All the best with the call.

Mem, I don't like the resiliency questionnaires that have been developed so far, because I don't think they are useful in understanding specific vulnerabilities. They don't educate what you need to focus upon. Resiliency is about community and relationships, but it is also about general cortical capability, sensory reactivity and physiological regulation. Resiliency is about the way the reward system has developed due to the quality of relational reward early on.

That said, I created my own resiliency questionnaire, based upon my understanding of the sequential development of the brain (leaning upon the work of the ChildTrauma Academy). So I asked questions that directly address relationship/community (relational reward), reliance on sensory soothing (somatosensory reward), level of physiological arousal (self regulation), and the capability of the higher mind to mitigate stress (cortical modulation).

Children have specific vulnerabilities in these areas, and so do parents. Parents need to know where their areas of strength and vulnerability are so that they can recognize where they may need support in order to better meet their children's needs and also their own.

Hi Robyn, 

 

What questions do you ask? Curious.

 

Sorry for replying with a quote.. I don't know how to do a simple reply. Ack.

Attached is my flyer and assessment.

I would love to hear more about how you use your own resilience measure. Is this something others could use?

My hope is to distribute this to Pediatrician offices that are screening for ACEs, because pediatricians have told me that they need a way to offer something useful to the parent who is higher risk and who needs a "quick fix" to parenting problems. Sometimes, if we ask the parent about themselves and their needs, it can help with their sense of overwhelm. 

The resiliency section is intended to help the parent think about what they need for themselves and to also show where they are doing well. 

The flyer has a link to resources that can help. A common complaint from pediatricians is that they ask if parents need parenting support, and parents almost unanimously say "yes!," but hardly anybody shows up for onsite parenting classes.

So, we are trying something different. We are offering an online free positive parenting webinar and directing them to truama-informed, resiliency-based parenting closed Facebook groups for support. We are also offering a LIVE online class (for a fee) that they can sign up for. They don't have to drive anywhere or get a sitter.

Ideally, I wish I could get funding to support offering this class at a discount or free to high risk families.

You are welcome to use the resiliency assessment. I should probably do a webinar about it, so it makes more sense. So little time, so much to do!

Hello Mem, I agree we should do comprehensive ACE/Resiliency assessments and surveys looking at [all] of these issues from multiple lenses and angles.

My point about "drifting a bit off topic here" stems from my observation, nationally, that some prominent programs implementing trauma-informed care in America appear to be content with excluding and/or paraphrasing some of the most fundamental components of the ACE Study (1998) and its conclusions.

1. The ACE Study identified 10 fundamental categories of trauma.
2. It concluded that all 10 fundamental categories of trauma are "essentially co-equal in terms of long-term effects".
3. An ACE score of (4) holds a 1220% increase in the relative risk for attempting suicide, no matter which (4) of the 10 ACEs are identified.

Therefore, in my opinion, all 10 of original ACEs (1998) including "Divorce", should be included in all ACEs Histories/Surveys/Questionnaires to protect the family relationships in real-time according to a "specific court ordered standard of care" as determined in a court of law (Divorce Court).

That's why I advocate for all systems of care to identify all court ordered legal rights and standards of care where the person being served is the subject.

Additional categories of (alleged trauma) can surely be add to the assessed ACEs, but 'none' of the original 10 ACE Study (1998) categories should ever be excluded from an assessment that's portrayed as comprehensive.

Please consider the ACEsConnections blog post from Ed Finkel on 1/22/16 concerning 'One Hope United' and their 'Healing Paths Program' in Illinois, USA.

The blog post states that;

1. One Hope United attempts to lead those affected by childhood trauma down a Healing Path.
2. “It’s specifically trauma-based treatment, rooted in evidence-based practices,” says Jill Novacek, director of programs...
3. The organization works to ensure safe, loving environments for children by educating and empowering them and their parents...
4. The program serves children from three through 18 years old. Most have a complex set of ACEs.
5. ACEs refers to the CDC-Kaiser Permanente Adverse Childhood Experiences Survey...
6. The approach of integrating ACEs, prompted by requirements under contracts with the Illinois Department of Children and Family Services...
7. It gives us more common language and understanding about the impact of trauma over the lifespan...
8. The ACE Study measured 10 types of childhood adversity...They are...losing a parent to divorce, separation or death.
9. When they have their first meeting with a child, Healing Path counselors use a modified version of the traditional 10-question ACE survey.
10. Their list includes: abuse, neglect, accidents or injuries, loss of a loved one, abandonment, homelessness, domestic violence, peer and community violence, natural or man-made disasters, substance abuse, serious illness, terrorism or war zone trauma.
11. The traumas from the original ACE Study that are not included are losing a parent to separation or divorce, living with a household member who is depressed or has other mental illness, and having a household member who is incarcerated.

It appears this "Healing Paths" program has "drifted a bit off topic here". They've specifically avoided (3) known forms of "trauma" (ACEs) in the lives of the children they serve, yet they added several other forms of alleged trauma.

How do the rest of you ACEs Connections folks feel about participating in the institutionalization and the normalizing of "willfully incomplete" ACEs Histories, Surveys, and Questionnaires in the helping professions? 

James Gallant, Marquette County Suicide prevention Coalition (906) 360 -3045 mqtsuicidepreventioncoalition@gmail.com

Robbyn Peters Bennett posted:

My hope is to distribute this to Pediatrician offices that are screening for ACEs, because pediatricians have told me that they need a way to offer something useful to the parent who is higher risk and who needs a "quick fix" to parenting problems. Sometimes, if we ask the parent about themselves and their needs, it can help with their sense of overwhelm. 

The resiliency section is intended to help the parent think about what they need for themselves and to also show where they are doing well. 

The flyer has a link to resources that can help. A common complaint from pediatricians is that they ask if parents need parenting support, and parents almost unanimously say "yes!," but hardly anybody shows up for onsite parenting classes.

So, we are trying something different. We are offering an online free positive parenting webinar and directing them to truama-informed, resiliency-based parenting closed Facebook groups for support. We are also offering a LIVE online class (for a fee) that they can sign up for. They don't have to drive anywhere or get a sitter.

Ideally, I wish I could get funding to support offering this class at a discount or free to high risk families.

You are welcome to use the resiliency assessment. I should probably do a webinar about it, so it makes more sense. So little time, so much to do!

Sorry, I don't know how to reply without a quote either!? I work with adults living with HIV/AIDS. I love your resilience assessment, because it outlines essential skills for effective living, and also seems to be a great working list for potential treatment plan goals. I plan on using this in our clinic, if you are ok with it. I also love Bruce Perry's work, and the Neurosequential model. It looks like you are doing incredible work!  Thanks for passing this along.

Hi guys,

Just wanted to let you know that I got an early prototype of the ACE Toolkit online.

You can head over to https://www.pacesconnection.com/...e-ace-toolkit-online and learn more.

Best,
Thomas

Hi Robyn,

I am going to copy your handout - mainly the "How do I develop Resiliency page" and put it in my peds room.  I have the educational one from Spokane and it flies out of the room so fast but I want people to know how to develop that resiliency in the here and now as we cannot do anything about how our parents were to us in the past. 

I look at that resiliency PDF from Maine as really only being an extension in a way of the ACE scale.  If your parents didn't love you and your teacher or no one else thought you were special well the impact of your toxic stress is going to be a lot higher.  If you had those things, your toxic stress impact from ACEs will be a lot lower.  So thanks for uploading it.  I will let you know what pediatric parents and adolescents think about it in the medical clinic.   

Since the World Health Organization's (WHO) ACE International Questionaire is modeled after the U.S. CDC/Kaiser- ACE study questionaire, but includes more than the ten questions/types of toxic stress (Poverty is another category used in the WHO ACE International Questionaire), might we also consider using such factors, as well as the Resilience Inventories mentioned by ACEsConnection members? I thought the ACEsConnection members from the Netherlands (which scored 1st in the WHO 2013 assessment of the world's healthiest children, using the ACE screening questions), might benefit from being included in this group discussion as well.

I think ideally the scores are all combined.

That is there are three components:

• your ACEs
• your initial resilience/child protective factors
• your current resilience 

That way everything is covered, and understood.  After all we know about the initial resilience/child protective factors score, why shouldn't others?! IF it's followed up by the current resilience score - what you can proactively do today, with help. 

Robbyn, the current resilience scoring looks good.  

Tina, as Robbyn asked, what is the CD risk assessment? 

I know of a few therapists who think trying to squeeze some initial resilience factors out of virtually none and apply them to the current situation, does NOT work.  Yes, I had a few kindnesses along the way in my childhood, but nothing that could be described as anything consistent, kinda thing. And it's hell annoying to watch therapists try to wring something - anything out of such a score!!  But at least the client gets to know what score they have and to go back there with therapy is pointless and to now focus on today, still keeping in mind that those initial resiliency scores don't make it easy, there's always that relevant background knowledge, but it IS doable to work on current resilience factors today.  To acknowledge, I got a crappy score and keeping that in mind, I'm moving on...

I'd love to think it was possible for all or majority to agree on exactly what and how to administer this.  An impossibility at this stage, I know, as it's evolutionary; and for all to even look at it, must be scientifically validated and grounded in evidence based research.  

Can't help but feel a little impatient at times for all to be potentially on exact same page!

 

Tina Marie Hahn, MD posted:

Hi Robyn,

I am going to copy your handout - mainly the "How do I develop Resiliency page" and put it in my peds room.  I have the educational one from Spokane and it flies out of the room so fast but I want people to know how to develop that resiliency in the here and now as we cannot do anything about how our parents were to us in the past. 

I look at that resiliency PDF from Maine as really only being an extension in a way of the ACE scale.  If your parents didn't love you and your teacher or no one else thought you were special well the impact of your toxic stress is going to be a lot higher.  If you had those things, your toxic stress impact from ACEs will be a lot lower.  So thanks for uploading it.  I will let you know what pediatric parents and adolescents think about it in the medical clinic.   

 

Tina, I hope you will consider using the entire pamphlet, because there are resources on the P4R part that help parents understand neurobiologically informed parenting, and I believe that is really important information for parents to learn if we want to prevent ACEs with their children.

The first link on that handout is to a free webinar on positive discipline (parenting beyond punishment which is really helpful for parents who have high arousal themselves) along with a presentation my colleague Dr. George Davis and I gave at the IVAT conference on co-regulation. 
http://robbynpetersbennett.org...parenting-resources/

The second link is to closed Facebook pages with skilled moderators who answer parenting questions. It helps build community for parents and gives them a lot of free support. One is sponsored by Parenting Beyond Punishment, and the other by Dr. Ross Greene's group "LivesInTheBalance"

Here is the youtube we reference on the P4R handout that talks about neuro-developmentally informed parenting: https://www.youtube.com/watch?v=KW_varQxQRE

 

Hi, Everyone -- Here's an update about the upcoming chat. We decided to schedule it Tuesday, March 1, a few days after the launch of the ACEs in Primary Care group on Feb. 26. We'll also be restructuring and upgrading of the ACEs in Pediatrics group (to see the new interest-based group structure, check out the ACEs in Education group).

For the chat, I'm hoping to have someone from a primary care clinic that has  integrated the ACEs survey be the featured guest, so that we can get some information about how it's being implemented, and how it's working.

Thanks for your enthusiasm -- and your patience!

As soon as we have ID'd our featured guest, we'll announce time/date.
With the interest we see in this topic, we anticipate doing a chat every two or three weeks.

Cheers, Jane

Keith -- To reply without a quote, just scroll to the bottom where the open box is, and put your comment there. That doesn't keep your comment within the sub-thread where you're commenting, though.

Getting back to the original question, and context, here's some work folks might be interested in http://dx.doi.org/10.1007/s40596-014-0186-8 also discusses some extensive online training resources -- my contact person in the past has been Mary Ann Cohen macohen@nyc.rr.com

Readers may be interested in the results we unexpectedly attained when the ACE questions were routinely integrated into the general medical questionnaire we used as Step 1 in comprehensive medical evaluation of >400,000 adults over a multi-year period in one setting.  They are described starting on p211 of the attached overview of ACE Study findings.  Anyone may feel free to use the ACE Study questionnaire in their own work.  I'd certainly be interested in hearing what was learned.

Dr. Felitti, 

looking forward to meeting you here in Hagerstown in March. I work with Joan Gillece and Tonier Cain. 

We are excited to hear you.

David

Jane Stevens posted:

Hi, Everyone -- Here's an update about the upcoming chat. We decided to schedule it Tuesday, March 1, a few days after the launch of the ACEs in Primary Care group on Feb. 26. We'll also be restructuring and upgrading of the ACEs in Pediatrics group (to see the new interest-based group structure, check out the ACEs in Education group).

For the chat, I'm hoping to have someone from a primary care clinic that has  integrated the ACEs survey be the featured guest, so that we can get some information about how it's being implemented, and how it's working.

Thanks for your enthusiasm -- and your patience!

As soon as we have ID'd our featured guest, we'll announce time/date.
With the interest we see in this topic, we anticipate doing a chat every two or three weeks.

Cheers, Jane

When on Tuesday, Jane, and by what medium?  Having done this with 440,000 adult patients in one setting, I have some possibly useful ideas, but Tuesday is a busy day. 

Although I've been in touch with a person at the primary care clinic that I'd like to be our featured guest, I haven't received confirmation. To make sure we give everyone enough lead time, we'll try to schedule this the week of March 7. As soon as I know, you'll know!!
And once we get the first one organized, then we'll have a regular schedule for chats.
Thank you for your patience!!

Hello,

Did you all end up having a group phone call?  If not and you are still planning to talk, I would love to join!

thank you

rachel

Rachel Gilgoff posted:

Hello,

Did you all end up having a group phone call?  If not and you are still planning to talk, I would love to join!

thank you

rachel

I'm hoping Jane will follow up her previous comment  in this thread, otherwise it may be hard to find.

The person I was hoping would be our first guest wanted to wait three more months. I have another clinic in mind, and will keep everyone posted. We'll announce it well in advance, to make sure that people have enough lead time to get it on their calendars.
Thank you for your patience!Cheers, Jane

Many thanks, Jane. 

Responsive and prompt as usual :-) 

I'm either prompt, or take weeks to respond!  Doesn't seem as if there's much inbetween!  ;-))

Dr. Felitti, 

I appreciate the Chadwick Chapter 10 you posted. I am disappointed that I can not find the book Lost Lives by Dr. Helander. 

As noted earlier I work in an ER in Baltimore. My position was created to address 30 day readmissions.  The system has really improved services for common I illnesses such as COPD and CHF. Digging deeper leads one to the ACE's. Unfortunately my boss specifically forbid me to ask the ACE's in the ER citing that the context of the ER is inappropriate and we don't have the services they need. (I was mostly asking those with substance issues). 

I have backed it up a couple steps and am currently working on expanding the treatment resources in my state. I am fond of the work of Bessel Van der Kolk in forwarding our understanding of why we need to expand solutions beyond Cognitive Based Therapies such as the Creative Arts, Trauma Informed Yoga Therapy etc.

As a Case Manager I can only refer to practitioners who are recognized by the state which at this point is CBT and Art Therapist. I am trying to work to get more of the Creative Therapies recognized (http://www.nccata.org) in my state. The first goal is that Case Managers such as myself would be educated. My second goal is that patients would be educated so they could participate in picking a provider that most matches how they learn. Ideally Case Managers or a special 'Therapy gatekeeper' role would be created in Patient Navigation models whose role is to have an deep knowledge of the pros/cons of each therapy and do an initial screening of patients to point them to the provider most likely to facilitate permanent change. 

Once some sort of community referral system is in place I hope to revisit question of Acute Care Hospitals asking the ACE questions. 

You might write write to Dr. Helander to purchase a copy directly.  He is at <meghelander@netcabo.pt> and his web site is <www.EinarHelander.com>.  Alternatively a hospital library could probably find you a copy somewhere in the US for inter-library loan.  

The attached chapter, starting on p211 might be of interest re OPD and ER visits.  If you used the one-page version of the ACE Questionnaire, and if it caused a measurable reduction in subsequent visits, you'd have a publishable article, regardless of whether you could enter the information in your ER notes.