Considering the Unintended Consequences of ACEs Screening

The blockbuster Adverse Childhood Experiences (ACEs) Study has become the fulcrum of a powerful and diverse consortium of interests bent on preventing and addressing childhood trauma.

Groups ranging from pediatricians and charitable foundations to politicians have increasingly asked how this growing body of research—which clearly shows how bad events experienced as a youngster can negatively affect adult health—can be applied to policy and practice.

While a politically viable and economically feasible strategy to lift up the lives of millions of children has been elusive, the interim step of using the study’s Adverse Childhood Experiences (ACEs) questionnaire as a screening tool is gaining traction.

But as more agencies and systems are poised to screen children for experiences ranging from sexual abuse to parental divorce in a bid to better direct therapeutic services and other resources, a vexing question remains. Will a headlong rush to use ACEs as a screening tool trigger unintended consequences, such as increasing the need for intervention from child protective services?

Originally created for the 1997 study that found hard to dismiss correlations between early experiences of trauma during childhood and later health problems in adulthood, the ACEs screening tool asks respondents 10 questions about their experiences as children, including questions about abuse and parental presence.

clipboard_stethoscopeThanks to the work of pioneering Harvard researcher Jack Shonkoff and others, the effect of trauma and toxic stress on the brain has created calls for increased intervention. As agencies and providers pivot to address childhood trauma, screening tools like ACEs are becoming widespread.

According to a recent report issued by Futures Without Violence in collaboration with several notable advocacy organizations, at least 23 states and the District of Columbia have collected ACEs data.

One example is the California Department of Justice, a recent recipient of a grant with the federal Defending Childhood initiative. Aimed at addressing the impact of violence on children, the Defending Childhood initiative in California will rely on ACEs-driven screenings to recognize and diagnose childhood trauma.

“When [California children] have been exposed to trauma, [under the initiative] they will be ensured that they will be screened at school, at their pediatrician’s office, or wherever they enter the child welfare or juvenile justice system,” said Harris at a press conference in February.

Christopher Blodgett is director of the Area Health Education Center and the Collaborative Learning for Educational Achievement and Resilience Trauma Center at Washington State University, Spokane. One of the first researchers to explore the implications of the adoption of ACEs screening and assessment by child-serving systems, Blodgett’s research has seen the deployment of ACEs  in the education system and considered the potential of using ACEs as a policy planning tool.

Blodgett says that as screening for trauma moves into new settings, there are serious concerns about how to handle reports for trauma, particularly when individuals in child-serving institutions are bound by mandatory reporting requirements for incidents of abuse and neglect.

“Before you ask these [ACEs] questions, you have to have a plan of action when the answer is yes,” said Blodgett. “Screening for trauma is more dicey where you get into education settings, where there’s a big conversation around this right now.”

“Most schools don’t have the capacity to figure out how to respond if there are identified ACEs,” he said. “These systems weren’t designed as identification and treatment systems. That’s when issues about potentially increased reporting become much more serious.”

For Robert Anda, a co-author of the influential 1997 ACEs study, the ACEs questionnaire is more about taking a public health approach than a tool for mandatory reporting. In screening parents, he suggests that other measures could be developed to measure risk of maltreatment without compelling pediatricians to turn to child protective services.

“ACEs can be measured safely in parents to give you an index of what may be a risk for the parents and the whole family and the child,” said Anda in an interview The Chronicle of Social Change at the One Child, Many Hands conference earlier this year at the University of Pennsylvania. “You can get other indirect measures that aren’t going to [lead to] mandatory reporting, including, I think, measuring some of the developmental functions as a proxy and stay away from the mandatory reporting.”

“We have to dig deeper and say ‘what’s going on,’ before making a decision about adjudication.”

The Center for Youth Wellness has spearheaded the use of ACEs screening tools in its pediatric clinic in the Bayview Hunters Point neighborhood of San Francisco. The California Department of Justice has looked toward the center as a model in creating its statewide trauma screening efforts, according to staff in the office of California Attorney General Harris.

The center uses the 10 questions from the original ACEs study, but has also added seven more factors that contribute to toxic stress for the low-income population served by the clinic, including homelessness, involvement in the foster care system, community violence and discrimination, among others.

But the Center for Youth Wellness’s Cecilia Chen cautions that the tool that the center uses is only designed for a specific context.

“Our screening tool is designed to be used by pediatric health care professionals,” said Chen, interim director of policy at the center. “We don’t advocate for its use in the juvenile justice and education systems. Tools don’t always translate across different sectors, and we really don’t know what the unintended consequences would be in other settings.”

Since the center has been using the ACEs tool, it has not seen an increase of children reported to child protective services, Chen said. But even in a pediatric setting, she says, training is necessary to administer ACEs and not jump to conclusions after reviewing the results.

“An increase of reporting is a concern that people have with the possible universal administration of ACEs screening,” she said. “We’ve found that the use of the tool has to be coupled with training of the tool.”

Blodgett of Washington State agrees that putting the ACES tool in the hands of professionals without training would be “irresponsible.” As part of a research study that used the ACES screening tool in an early education program, his team spent over a year training staff members about how to approach parents and how to responsibly ask questions with the appropriate level of detail without triggering mandatory reporting obligations.

“If we ask the three original questions [from the original ACES study] that are about physical abuse, sexual abuse or neglect, if a parent said yes to any of those questions, as a mandated reporter, we’re required to call CPS,” he said. “It’s not a discretionary issue.”

Like the Center for Youth Wellness, Blodgett’s team also tweaked the original ACEs questions.

“What we did is we dropped those questions [about abuse and neglect], and replaced them with a global question: ‘Since your child was born, has your family had any contact with child protective services?’” he said. “We don’t ask any follow up questions. Just asking that question gets at the accumulated dose question of risk of trauma.”

The possible uptick of children entering the system may not be the only unintended consequences of the wider use of ACES. For a system perennially starved of resources, the child welfare system could be tasked with difficult decisions if caseloads increased as a result of ACEs screening.

According to Jill Duerr Berrick, co-director of the Center for Child and Youth Policy at the University of California, Berkeley, ACEs might force administrators and policymakers to make wrenching decisions about the worthiness of children in the system.

“It’s already the eye of the needle to try and get services in the United States anyway, compared to a European country where they have a much broader framework of looking at things like child well-being,” Duerr Berrick said. “I’m a little reluctant to see us move to develop a system where we’re somehow [saying] that one type of trauma is worse than another and that one is less deserving than the other.”

“I wouldn’t want to see a system where we’re now deciding we’re going to triage Johnny over Sally who were both physically beaten by a caretaker because Johnny’s score was an ACE higher in order to manage these incredibly scarce resources.”

That scenario may seem far fetched, but it’s a reminder that as ACEs continue to transform policy debates, there are still a few questions left to answer.

Chronicle Publisher Daniel Heimpel contributed to this story.

Note: in a previous version of this story, Jack Shonkoff was incorrectly identified as a neuroscience researcher. While his work at the Harvard Center on the Developing Child incorporates neuroscience research, he is a pediatrician.

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Jeremy Loudenback
About Jeremy Loudenback 267 Articles
Jeremy is the child trauma editor for The Chronicle of Social Change.

3 Comments

  1. I’m a little confused about the premise of this article. It makes it sound like an increase in mandatory reporting would be unequivocally a bad thing – which, if there is an actual incident that needs to be reported, it absolutely would not be.

    Furthermore, there seems to be an assumption that a report automatically leads to an investigation and CPS intervention which automatically leads to child removal from the home or similar. That is a pretty big stretch.

    A particular answer may automatically lead to a mandatory report. But that’s it. A report is merely a trigger that *may* result in an investigation, but that report is screened in by trained workers and the determination regarding whether to investigate is based on a myriad of factors, not just a single report.

    And even if an investigation is triggered, the decisions regarding the level of involvement of CW in the family’s life is also based on a myriad of factors – most notably whether there are *still* conditions in the family that *currently* endanger a child. A possible incident from years ago that has since been resolved is not going to alone result in a child being sent to foster care. Again, there is nothing automatic about this process.

    There should be education and discussion about how these types of reports should be handled, of course. And if there are concerns that CPS involvement always leads to negative outcomes for families that is an entirely different discussion. But I find it a little troublesome that practitioners – and even researchers – are trying to skirt their mandatory reporting duties based on what appear to be false assumptions regarding the process.

  2. 1. Dr. Abramovitz, in my state of Michigan, when a child is identified as having suffered psychological trauma, there is a 10 – 12 month wait time to be seen in our only NCTSN site in Kalamazoo at Western Michigan University. That is a pretty long weight. They are also only being referred the “tip of the iceberg”.

    2. This year in January,, I went to the Academy on Violence and Abuse Conference in San Diego and the annual Chadwick Child Abuse Conference. My hotel was expensive and there were very expensive boats in the Marina, a lot of them. It did not slip my mind that there were homeless camps close to the hotel. The problem in our country is that we care more about our own Mercedes or our own 1 million dollar boat than other people.

    I grew up on welfare. My sister was put in foster care. I was made an emancipated minor by a system that asked me “What did you do to make your parents so angry?” and I experienced all 10 ACEs.

    What we need is a few less expensive boats and a few more services for kids. We talk in pediatrics about wanting to prevent suicide, obesity, and on and on and we know how we can do a better job than what we are doing — screen. Any pediatrician however can clearly state the woeful inadequacy of child welfare, especially one that was personally involved with that system. However it is equally not appropriate to say well we cannot screen more because there are no services. There may not be many but having a kid be a part of a serviceless organization can mean keeping health care untill 26 easier and can help that individual not to have to beg their child abusing welfare parents to fill out the FAFSA so their accepted daughter can go to medical school at the University of Michigan.

    3. Bottom Line is that we as a society say we love our children but I must ask do we really? I see very poor evidence that we do.

    Hope you will forgive me for my forward nature but as a member of the NCTSN, I am sure you know of the pain and frustration experienced by those discarded by our society.

    Thanks Dr. Hahn

  3. Dear Mr Loudenback,
    I appreciate your important commentary about the unintended consequences of stimulating interest in knowing ones ACEs score (i.e ACES too high). This knowledge can be valuable in stimulating trauma prevention policy efforts.

    However, as you indicate, it can’t be done in the absence of having clearly defined follow-up and treatment resources, which is why I write to call your attention to the your commentary’s omission of any mention of the National Child Traumatic Stress Network.

    The NCTSN’s network of 78 programs located all across the country serve “To raise the standard of care and improve access to services for traumatized children, their families and communities throughout the United States”. Its success is exemplified the many NCTSN member’s accomplishments mentioned in the commentary, without acknowledging its key role. Three senior NCTSN members were part of the Task Force that produced the Defending Childhood report and Dr Blodgett is a long standing NCTSN member. NCTSN members have developed and widely disseminated many of the evidence based child trauma treatments for received by thousands of children exposed to more than 20 types of traumatic events that include those covered in the ACES questions.

    The NCTSN funded program I co-direct has implemented its mission of “creating and sustaining the next generation of trauma-informed social work practitioners” by disseminating the NCTSN’s state-of the-art Core Curriculum on Child Trauma in partnership with faculty at 52 school of social work. We have now trained more than 3500 social work students and several hundred of their agency based field instructors.

    The NCTSN also focuses on policy, resilience and prevention and promotion by the constant collaborative effort of its work groups and task forces where the hundreds of members and affiliate members collectively go beyond the mandate of their funded programs to produce valuable resources for parents, teachers, child welfare workers and mental health workers. Since it inception it has formed close productive collaborative working relationships with the Children’s Bureau, and the Departments of Justice and Education, as well as numerous State-wide trauma coalitions.

    Sincerely,

    Robert Abramovitz, MD
    Distinguished Lecturer
    Co-Director National Center for Social Work
    Trauma Education and Workforce Development
    Silberman School of Social Work at Hunter College
    2180 Third Avenue @ 119th Street
    New York, New York 10035
    r.abramovitz@gmail.com
    347 292 9260
    Member National Child Traumatic Stress Network
    http://www.ncswtraumaed.org

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