Finkelhor, D. (2017). Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse & Neglect. (Link)
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Hi Colette,
While I’m not going to purchase the article to read it, I think cautions or arguments against ACE screening are fear based. I’ve had many clients feel a profound sense of relief to be able to identify the underlying causes of their dysfunction and dis-ease. As I see it, the screening provides the universal language that shapes our conversations towards health. If I don’t understand why I am prone to depression, how can I possibly understand how to address it?
Rebecca
Fwiw iw USD36!!
Laudable aims on the part of one of the "older statesmen" in the child protection field, but this is one of those situations where very considerable practice has preceded the research by decades.
By all means conduct more research on how the practice can "best" be done (such research will take another 10 years) but let's not forget the very real costs of screening NOT being more widely, and carefully, introduced.
I think routine screening for trauma is generally a bad idea and is not trauma-informed. These are sensitive and potentially distressing questions that should only be asked in the context of an on-going relationship with a provider. To be asked these questions at intake by a stranger can not only be distressing, it can make people hesitant to answer honestly. I spent time a trauma-informed women's prison where, rather than screen for trauma, they gave everyone factual information about trauma and its impact as part of orientation. So women were provided with meaningful information and, if they felt it applied to them, they could chose to disclose when and if it felt safe. I think that's a trauma-informed way of handling it.
I think it is always good to know both the benefits and drawbacks to any intervention and screening. One of the things clinicians and others need to keep in mind is that ACEs are risks of adverse outcomes, not a guarantee. I've seen premature judgments made in the field based on risks rather than the reality of a person's situation or difficulties. There is a lot that offsets ACEs that also need to be assessed.
One needs to be remember that these same fears were around in the early days of researching adult recollections of childhood sexual abuse -- in part forming a special issue of American Psychologist -- back in the wicked old days of "recovered memories" with the consensus being that such research, if done carefully, not only could be done, but it was important that it should be done. No one is saying people are obliged to answer the questions, but all the research sfaik has shown that people don't mind answering the questions -- the original ACEs research was not done as part of ongoing therapeutic relationships after all.
Thanks everyone, appreciate you all taking the time to reply.
David Finkelhor has a couple of publications about this in Child Abuse & Neglect: One is "A revised inventory of Adverse Childhood Experiences"; the other is "Screening for adverse childhood experiences (ACEs): Cautions and suggestions".
In the first (A revised inventory), Finkelhor suggests that other types of adverse childhood experiences (ACEs) be added to ACE surveys. In fact, over the last several years, many people and organizations have added other types of ACEs. Pediatricians at The Children’s Clinic in Portland, OR, at Bayview Child Health Center in San Francisco, and at Roseland Pediatrics in Santa Rosa, have added additional ACEs, including racism, bullying, involvement in the foster care system, witnessing violence outside the home, living in an unsafe neighborhood and losing a family member to deportation. The Philadelphia Urban ACE Study added five other ACEs to its survey. Dr. Martin Teicher at Harvard University uses emotional neglect, non-verbal emotional abuse, parental physical maltreatment, parental verbal abuse, peer emotional abuse, peer physical bullying, physical neglect, sexual abuse, witnessing interparental violence and witnessing violence to siblings to study effects during each year of childhood.
Wendy Ellis, who leads the Building Community Resilience initiative, developed the “pair of ACEs” concept to include adverse community environments — poverty, discrimination, lack of opportunity, poor housing quality and affordability, and violence — as well as maternal depression and homelessness. Prevention Institute in Oakland, CA, also adds adverse community experiences.
And we at ACEs Connection add ASEs — adverse system experiences — to include attending a zero-tolerance policy school, and involvement with the juvenile justice system, the healthcare system and social service systems if they have not integrated trauma-informed and resilient-building practices based on ACEs science (which, at the moment, includes most of the organizations in the U.S.).
btw, ACEs science includes the epidemiology of ACEs (original ACE Study plus subsequent ACE surveys); neurobiology of toxic stress from ACEs, especially the effect on a child’s developing brain; health consequences of toxic stress from ACEs; epigenetic effects of toxic stress from ACEs; and resilience research, which includes trauma-informed and resilience-building practices.
Regarding Finkelhors’ cautions and suggestions: Thousands of organizations across sectors — including healthcare, social services, behavioral health, home visitors, juvenile justice, education, business, faith-based community and even state agencies — are using ACE — and resilience —questionnaires to survey, screen, educate and empower staff and clients/patients/students/prisoners.
ACEs science is too powerful to wait years to begin developing evidence-based practices, and some of the early adopters already have substantive results to spur on adoption, and thus, refinement of practice.
There’s the 50% plus drop in births to teen mothers. The 98% drop in youth suicide and suicide attempts. A 90% drop in school suspensions, and the elimination of school expulsions. Over one year, zero violent incidents in a juvenile detention facility. After a year involvement in Safe Babies Courts, 99% of kids no longer suffer abuse. A 30% drop in emergency department visits. At an organization that implemented trauma-informed practices throughout its workforce, a 5% drop in health insurance rates. Radical cost savings for state and local governments.
If nothing else, encouraging people in healthcare and other sectors to educate their patients/clients/customers about ACEs science is imperative. The NEAR@Home toolkit was developed in Washington State for home visitors – people who work with new parents eligible for the program because they’re poor. They say that learning about ACEs is a social justice issue: ”Parents have the right to know the most powerful determinant of their children’s future health, safety and productivity.”
As people are developing practice-based evidence, early research shows that taking this approach is definitely on the right track. Robust research that continues to support this work will continue to refine and advance our understanding of the import of applying practices based on ACEs science now.
Hi Jane, Many thanks for your response - very enlightening and articulate and appreciated. I'm doing some research on Trauma Informed Care and Trauma Informed Approaches and I am immersed in thinking how I can put forward the most robust approach in why this work is so important. As you can imagine there are quite a few 'critics', and I guess I want to be able to construct the best thesis that I can - this work is too important not to.
I am including a link to a paper from the British Psychological Society (Jan 2018) 'The Power Threat Meaning Framework Overview'. Some quotes from this framework include: "It does not assume 'pathology'; rather, it describes coping and survival mechanisms which may be more or less functional as an adaptation to particular conflicts and adversities in both the past and present.": "It offers alternative ways of fulfilling the service-related, administrative and research functions of diagnosis.": "It includes meanings and implications for action in a wider community/social policy/political context."
"In summary, this PMT Framework for the origins and maintenance of distress replaces the question at the heart of medicalization, "What is wrong with you?" with four others:
What has happened to you? (How has Power operated in your life?)
How did it affect you? (What kind of Threats does this pose?)
What sense did you make of it? (What is the Meaning of these situations and experiences to you?)
What did you have to do to survive? (What kind of Threat Response are you using?)
Translated into practice with individual, family or group, two additional questions need to be asked: What are your strengths? (What access to Power Resources do you have? ...and to integrate all the above: What is your story?" https://www1.bps.org.uk/system...PTM%20Main%20web.pdf
I think this is a very well researched, powerful framework with huge implications for changing how we do things and how people experience health (mental health & addiction) services and beyond...education, corrections, etc., and all the things you mentioned Jane. First and foremost I believe people need to be acknowledged, and validation given to their experiences, with compassion. And I do believe the contribution of ACE's science is the fuel for this paradigm shift so thank-you to everyone involved in this work.
Hi again, thee link in the earlier email is the full report (400 pages, and well worth the read), but the over-view link is here:
Thanks, Colette. That's very interesting. In my presentations, I include this slide to explain the change in beliefs people have about themselves when they learn about ACEs science:
1.They weren’t born bad.
2.They weren’t responsible for the things that happened to them when they were children.
3.They coped appropriately, given that they were offered no other ways to cope; it kept them alive and sane.
4.They can change.
Jane, did you mean to include a slide with your last response.
I won't comment further except to remind people to consider the historical context from which people such as Finkelhor and the BPS are speaking and to consider the messages they offer - - a context, I might add, strongly influencing the way in which "messages" from this forum originate, which strongly influences the challenges confronting Colette, and the frequent difficulties reconciling those perspectives.
Paul, I don't understand your comment at all. Can you please clarify? Thanks.
Hi, Paul -- That's the slide content.
Colette Ryan posted:Hi Jane, Many thanks for your response - very enlightening and articulate and appreciated. I'm doing some research on Trauma Informed Care and Trauma Informed Approaches and I am immersed in thinking how I can put forward the most robust approach in why this work is so important. As you can imagine there are quite a few 'critics', and I guess I want to be able to construct the best thesis that I can - this work is too important not to.
I am including a link to a paper from the British Psychological Society (Jan 2018) 'The Power Threat Meaning Framework Overview'. Some quotes from this framework include: "It does not assume 'pathology'; rather, it describes coping and survival mechanisms which may be more or less functional as an adaptation to particular conflicts and adversities in both the past and present.": "It offers alternative ways of fulfilling the service-related, administrative and research functions of diagnosis.": "It includes meanings and implications for action in a wider community/social policy/political context."
"In summary, this PMT Framework for the origins and maintenance of distress replaces the question at the heart of medicalization, "What is wrong with you?" with four others:
What has happened to you? (How has Power operated in your life?)
How did it affect you? (What kind of Threats does this pose?)
What sense did you make of it? (What is the Meaning of these situations and experiences to you?)
What did you have to do to survive? (What kind of Threat Response are you using?)
Translated into practice with individual, family or group, two additional questions need to be asked: What are your strengths? (What access to Power Resources do you have? ...and to integrate all the above: What is your story?" https://www1.bps.org.uk/system...PTM%20Main%20web.pdf
I think this is a very well researched, powerful framework with huge implications for changing how we do things and how people experience health (mental health & addiction) services and beyond...education, corrections, etc., and all the things you mentioned Jane. First and foremost I believe people need to be acknowledged, and validation given to their experiences, with compassion. And I do believe the contribution of ACE's science is the fuel for this paradigm shift so thank-you to everyone involved in this work.
Thank you for this excellent resource! I am so impressed by the level of research and insight. It really seems that the various disciplines doing this work aren't really talking to each other. I do social science research and I don't think I would have come across this as it seems more provider oriented. There are sociologists doing this work, epidemiologists, physicians, anthropologists, psychologists, social psychologists... I wonder how many of us read outside our discipline. Thanks again.
Paul Metz posted:How did you get the right to publish the article in this forum?
If you go to google scholar and type in the name of the article, there is a pdf from University of New Hampshire available, free access. Looks as if perhaps Finkelhor himself posted it.
here is a link to the google search: http://www.unh.edu/ccrc/pdf/CV350-InPress.pdf
Thank you for this excellent resource! I am so impressed by the level of research and insight. It really seems that the various disciplines doing this work aren't really talking to each other. I do social science research and I don't think I would have come across this as it seems more provider oriented. There are sociologists doing this work, epidemiologists, physicians, anthropologists, psychologists, social psychologists... I wonder how many of us read outside our discipline. Thanks again.
Indeed, it's not often these days that psychological material is included for review on this forum, but one recent study, of mediators between a particular type of adversity, bullying during childhood, and later psychosocial adjustment, illustrates just how important the role of such factors can be -- this article IS available "Open Access" and is very much in tune wiith the approach of the BPS -- see here https://doi.org/10.1080/20008198.2017.1418570
"shame mediated 70% of the association between bullying victimization and psychological distress, 55% of the association between bullying victimization and impaired functioning, and 40% of the association between bullying victimization and social support barrier"
it's rare that a single variable of any type has this strength of effect, but, depending on the type of stressor, other mediators include such trait variables as neuroticism, extraversion, and such cognitive variables as attribution biases, experiential avoidance (avoidance of any type in cases of trauma), psychological inflexibility, early maladaptive schemas, as well as many others -- as Finkelhor notes, your average clinician might not be au fait with all these, and aware of clinical interventions to address these factors, but the ACEs, as a screening tool, backed up by an uptodate (the article cited is 2018) knowledge of the research in such areas can provide a very valuable lead-in to assisting those affected by these adversities.
A March 4th 2018 blog in New Zealand warning about relying on ACEs checklists.
The problem with checklists in child protection work
As she finally concludes - after a considerable focus on ACEs limitations - ACEs are a tool.
We know! A very valuable tool.
What disappoints me most about the blog article is that it appears to have a number of very low expectations and assumptions about social workers who may be utilizing ACEs in their work. We do not think it is a quick fix to holistic needs assessment, we do not think it is a stand alone tool AND we do not just blindly take the results without analysis and considering the time it was first developed.
It is part of our kite (basket) of tools to challenge us to look wider and deeper.
Susan Smith posted:A March 4th 2018 blog in New Zealand warning about relying on ACEs checklists.
The problem with checklists in child protection work
As she finally concludes - after a considerable focus on ACEs limitations - ACEs are a tool.
We know! A very valuable tool.
What disappoints me most about the blog article is that it appears to have a number of very low expectations and assumptions about social workers who may be utilizing ACEs in their work. We do not think it is a quick fix to holistic needs assessment, we do not think it is a stand alone tool AND we do not just blindly take the results without analysis and considering the time it was first developed.
It is part of our kite (basket) of tools to challenge us to look wider and deeper.
thanks for trying to introduce us to some Maori (indigenous NZ) words -- but I thought the word for "basket" was "kete"??
also might be a good idea not to use the word "we" too often in a universal sense, applying to all members of a profession
" We do not think it is a quick fix to holistic needs assessment, we do not think it is a stand alone tool AND we do not just blindly take the results"
-- even if only one person, over-worked and underpaid, with little time for ongoing professional development and supervision, does use a tool "inappropriately" it proves the opponent correct. Best to just keep the caution in the discussion; while maintaining the educational process.
But the same precautions can be, and need to be, applied to other areas of "risk assessment and management" -- like the use to which SW's from Child Services would like reports from AOD services concerning parents' behaviours to be applied, in my experience.