Screening for Adverse Childhood Experiences (ACEs)

As adults, we’re often advised that our daily choices in diet, exercise, and lifestyle influence our physical and mental health. While it’s true that our health is a reflection of our cumulative choices and behaviors, it’s also true that our health as adults is significantly impacted by our past, especially our childhood.

Adverse Childhood Experiences (ACEs) are stressful or potentially traumatic events that occur in childhood (0-17 years). ACEs can affect anyone, regardless of gender, socioeconomic status, ethnicity, or location. 

In 1995, the CDC-Kaiser ACE study released a landmark investigation exploring the relationship between early adversity and its impacts on adult health outcomes. The study revealed major findings, including: 

• ACEs are extremely common. 64% of Americans have experienced at least one ACE, and 13% have experienced four or more.
• As the number of ACEs increases for any given individual, so does the risk for negative physical and mental health outcomes. 
  

The ten categories of ACEs include: 

• Abuse — physical, emotional, or sexual
• Neglect — physical or emotional
• Household dysfunction — parental incarceration, mental health conditions, substance use disorders, parental separation or divorce, or domestic violence
  

ACE “scores,” or the number of adversities a person has experienced, range from 0 to 10. An ACE score is calculated by the total reported exposure to the 10 ACE categories. 

How does an ACE score impact overall health?

Some stress in life is normal. Unfortunately, the type of stress that occurs during an ACE can become toxic, especially if the stress is intense, frequent, or prolonged. This repeated activation of stress hormones can affect the way a child’s brain develops, as well as their immune, nervous, and hormonal systems. 

The ACE score is a good starting point for patient assessment and treatment plans, but it should also be evaluated within the context of the patient’s health condition(s) and if there are any ACE-associated health conditions (AAHCs) present. In general, AAHCs include cardiovascular, pulmonary, immune, metabolic, mental health, and substance use conditions. An extensive list of AAHCs for both children and adults can be found here.

Are there any protective factors? 

While having ACEs can influence a child’s life and health trajectory, ACEs do not guarantee negative outcomes in life. Protective factors, like having an important adult figure in life, can buffer children from the negative influences of ACEs. 

Assessing patient resilience and protective factors is another crucial component in the overall ACE screening. A number of resilience surveys can be utilized, including The Child Youth Resilience Measure (CYRM-28) for children (5-9 years), youth (10-23 years), and adults (24+), which can be found here.

For all ages and risk levels, education about ACEs, toxic stress, and how to develop resilience and increase protective factors is recommended. ACES Aware, an initiative led by the Department of Health Care Services (DHCS) and the Office of the California Surgeon General (CA-OSG), recommends providing patients with education that includes strategies to help regulate the stress response, such as:

• Supportive relationships
• High-quality, sufficient sleep
• Balanced nutrition
• Regular physical activity
• Mindfulness and meditation
• Experiencing nature
• Mental health care, including psychotherapy or psychiatric care

Screening for ACEs at your practice

The health care setting offers a unique opportunity to help patients and families understand the impact of ACEs on their overall health. ACE screening also improves clinical decision-making and treatment of serious and difficult-to-treat health conditions. 

A complete ACE screening involves assessing for the triad of:

• Adversity (i.e., ACE score)
• Clinical manifestations of toxic stress (i.e., ACE-Associated Health Conditions, or AAHCs)
• Protective factors (i.e., PCEs)
  

Discussing childhood adversity can be difficult for some patients, and they may not feel comfortable disclosing specific details. As a result, there are two options for ACE screening, depending on your patients’ comfort levels and preferences:

• De-identified screening tool: Counts the number of experiences from a list without specifying which adverse experience happened.
• Identified screening tool: Patients specify the experience(s) that happened to their child or themselves. 
  

Once a patient has completed a screening, you can assess their risk for toxic stress:

• Low risk for toxic stress - Score of 0-3 (Without associated health conditions)
• Intermediate risk for toxic stress - Score of 1-3 (With associated health conditions)
• High risk for toxic stress - Score of 4+ (With or without associated health conditions)
  

A comprehensive list of ACE screening tools for children and their caregivers, and screeners in different languages can be found here.

Developing routine screening 

Toxic stress can be treatable and preventable — with proper guidance, education, and connection to care. Developing routine screening for ACEs can become another protective factor and improve health outcomes through prevention, early detection, and intervention.

For many children, ACE-associated health conditions may not be present yet, so there is more emphasis on anticipatory guidance, education, and routine ACE screening as a method of prevention and early intervention.  

If you're interested in connecting your patients with therapists specializing in trauma or learning more about how to implement ACE screening at your medical practice, reach out to [email protected].