JOINING FORCES

Joining Families

Volume 18, Issue 1 • Summer 2018

R E A L W O R L D R E S E A R C H F O R F A M I LY A D V O C A C Y P R O G R A M S

F E AT U R E D I N T E R V I E WAdverse Childhood Experiences: Promises, 			
Risks, and Cautions
An interview with David Finkelhor, PhD
David Finkelhor, PhD

David Finkelhor, PhD, is the Director of the
Crimes against Children Research Center, CoDirector of the Family Research Laboratory, andProfessor of Sociology at the University of New
Hampshire. He is well known internationallysince 1977 for his work on child victimization,
child maltreatment, and family violence. He has
written extensively on child sexual abuse, childhomicide, missing and abducted children, children exposed to domestic and peer violence, andIn This Issue
This issue of Joining Forces Joining Families (JFJF) features an interview
with David Finkelhor, PhD, on adverse childhood experiences (ACEs). We
provide a brief summary of Dr. Finkelhor’s recent article questioning thewisdom of screening for ACEs in healthcare settings. Other articles on
ACE screening include a review of the concept of resilience as it relates
to adversity in development. In our regular research methods article, we
describe differences in screening methods. Websites of Interest features the
Crimes Against Children Research Center, which Dr. Finkelhor directs, andtwo additional sources of information about ACEs: SAMHSA and the CDC.
All of these contain online resources that educate about ACEs and childhood
victimization.
CONTENTS
Adverse Childhood Experiences: Promises, Risks, and Cautions…………… 1
Should There Be Screening for Adverse Childhood Experiences?………… 4
Adverse Childhood Experiences and Resilience…………………………… 5
Social Support, Self-Esteem, and Peer Attachment in Adolescents
Decrease Adverse Effects of Childhood Maltreatment……………………… 7
Building Bridges to Research: What is Screening and How Does It
Apply to Adverse Childhood Experiences?………………………………… 8
Websites of Interest……………………………………………………… 12

other forms of family violence. Dr. Finkelhor is
editor and author of 11 books and over 150 journal articles and book chapters. He has received
grants from many institutions and received avariety of professional achievement awards. Dr.
Finkelhor is also a singer and songwriter, largely
about research and researchers.

Dr. McCarroll: This is the 20-year anniversaryof the study of adverse childhood experiences(ACEs) (Felitti, et al., 1998). Has interest in
ACEs increased?
Dr. Finkelhor: Enormously. It is a very big
focus for a lot of people in research and policy.
The fact that maltreatment and other childhood adversities have long-term effects has
been widely accepted in the social sciences
and policy areas for years. But, the ACEs study
added an on-ramp to involving the medical andthe public health communities because of theapparent evidence that child maltreatment was
related to risk for certain important chronic
health conditions such as heart disease, asthma,and so forth, and the related hope that we could
save money on health care costs through childmaltreatment and childhood adversity prevention.
Dr. McCarroll: People in many fields are
writing about as well as attempting to screen
for ACEs.
Dr. Finkelhor: Oh, yes. There are lots ofscreening efforts going on. Some pediatricpractices have started to screen for ACEs: somescreen the kids, some screen the parents. It is avery widespread initiative.
Continued on page 2

An interview with David
Finkelhor, PhD, from page 1

One alternative to ACE
screening is symptom
screening. Symptoms
are known mediators in
the causal chain between
adversity in childhood
and later healthproblems and they may
be better predictors thanthe ACEs themselves.

It seems to me that the interest in ACEs
went in two main directions. The first direction
was a policy-advocacy argument, which was,“Look. If childhood adversities are associatedwith these health problems, there is really agreat deal of benefit to try to prevent themfrom occurring. So, let’s invest in adversity prevention programs: parent training, family andprenatal education and those types of things.”
The second direction was, “Oh, these adversities seem to predict bad outcomes. Wouldn’t
it be helpful for us to know who are the highrisk people in our patient population so let’s
start screening everyone for these risks?” That
is where the screening initiative developed. I
am more enthusiastic about the first initiative
than I am about the second. My concern has
developed from my review of the literature on
universal screening in general and the prospects and perils of that kind of an effort. I am
concerned that there is a certain amount offuzzy thinking that has infused this screening
mania right now.
Dr. McCarroll: How has screening been
conducted and with what success?
Dr. Finkelhor: When people talk about ACE
screening, it is not always about using the classic ACE inventory that Felitti and colleagues
developed (Felitti, et al., 1998). A lot of thescreening efforts have adapted it or developed
their own inventories. There is a diversity of

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2 • Joining Forces/Joining Families

Editor-in-Chief
James E. McCarroll, PhD
Email: James.McCarroll.ctr@usuhs.edu
Editorial Consultant
Joshua C. Morganstein, MD
Captain, US Public Health Service
Assistant Director
Center for the Study of Traumatic Stress
Associate Professor & Assistant Chair
Department of Psychiatry
Uniformed Services University

things that are being screened for and that is areflection of one important problem, which isthat there is no consensus based on scientifictesting on exactly what to screen for. Whatkinds of adversities and other indicators aremost likely to predict high risk? We haven’t
settled this question.
There is another problem you need to
anticipate in any screening effort, even withfairly good general screening tests, is that they
produce a lot of false positives. A lot of people
may have this elevated score, but they are really
doing fine. You can get a lot of people who arethen sent for treatment who turn out not to
actually have problems. That can overwhelm thetreatment system with low priority cases. Withchildhood adversities, this can also possibly
mean more referrals to child protection authorities and investigations of families who do notneed it or benefit from it and, in fact, resent it.
Dr. McCarroll: That may suggest the needfor good instruments. Do you find much
psychometric data on the screening that isbeing conducted? Or is it based on people
thinking this would be important to do?
Dr. Finkelhor: There is some psychometricdata, but it is mostly just to show that the items
that people are using are associated with diseaseor problem behavior and that the accumulation of these is associated with more problem
behaviors. But, that tends to be a very easy test.
You generally can show that the more items thatare responded to, the more bad things are likely
to be happening. There are dozens and dozensof things that we could screen for. You could
start with a big universe of them and then narrow it down to the ones that are the best, a small
number, but we really haven’t done that. Also,that does not necessarily tell you very efficiently
who needs referral and treatment.
Dr. McCarroll: Who should refer and whoshould treat often depends on the cutoff
values. A lot of screening work ignores
psychometric issues like cutoff points andfalse positives. It is never really conclusive;
there is always error.
Dr. Finkelhor: Exactly.
Dr. McCarroll: You brought up important issues
about the screening of children. Is that being
done?
Dr. Finkelhor: It is being done, but one ofthe problems the field is wrestling with is theContinued on p. 3
Summer 2018

An interview with David
Finkelhor, PhD, from page 2

The best reason forscreening for thesymptoms rather thanthe ACEs, in my view,is that we actually
have evidence-based
treatments for most ofthese symptoms.

existence of mandatory reporting laws requiring the reporting of even a “suspicion” of maltreatment. In a pediatric practice or behavioral
health practice, if you ask about the child being
physically abused, sexually abused, neglected,
or exposed to domestic violence, a “Yes”
requires a report to a child protection system.
A lot of the systems adopting these screens
do not want to trigger those reports. This is areally big issue. They recognize that triggering those reports might be counterproductivein that they would create reports of low-levelepisodes that do little to help the family andmight destroy the rapport between the family
and the provider. One of the things that somepeople have done is to give the parent, or insome cases the youth, a list of adversities andsay, “Don’t tell me which adversities, just countup the number that have happened to you andwrite the number down.” The idea is that thehigher numbers will correlate with more risk,
which they do. The problem there, as I see it, is
if one of your goals is to provide help for highrisk people, then any person trying to prescribe
an intervention would have to get the history tofind out for sure what specific adversities triggered the referral. They would need to answer
the question, “What are the problems we are actually dealing with here?” So, you may be blind
to reportable problems in the initial screening, but that blindness cannot be sustained
throughout the referral process so reporting is
still likely to be an outcome.
Dr. McCarroll: Is their idea that sometreatment is effective for all the ACE
conditions and you do not need to know thespecifics? Is that the theory they are workingon?
Dr. Finkelhor: That may be the theory, butthat is not what research on practice says needs
to happen. Various available interventions
are geared to specific different kinds of family problems. Obviously, an intervention for afamily where domestic violence is occurring
would be different from the intervention where
the child may have been sexually abused. So
ultimately you need this differentiated information.
One of the key problems that has beenfound in universal screening in general is that
there are negative effects to universal screening that need to be factored into any equation
about whether it has overall system-level benefits. In the case of universal prostate screening,

http://www.CSTSonline.org

for example, the negative effects were that a
lot of men get biopsied and most turn out not
to have cancer, but the biopsy can sometimes
result in serious complications. For every person you save from cancer, how many did you
expose to this procedure and may have actually
given them a bad outcome that they would nothave otherwise had. The outcome studies on
prostate screening have not shown that they arereally saving lives.
Similarly, in the case of universal ACE
screening there are people who may be subjected to investigations and other kinds of aversive
events, who might not have needed it, mightfeel alienated as a result, and it might disturb
the relationship they have with their provider.
Those are all potentially negative outcomes thatmight result from this universal screening. We
have to assess how often that occurs and weighit against any benefit that we find to the screening. We just do not know what those parameters
are right now and the people who are doing
screening are not mostly doing it in the context where they can assess fully those potential
negative outcomes.
Dr. McCarroll: What would a provider do witha child that comes up with an ACE score of six,for example.
Dr. Finkelhor: That is kind of a black box in
my understanding. They basically make a referral to a behavioral health specialist. That could
help if there is a rich supply of diverse family
and youth services in the practice or the community to make referrals to, people with a lot ofknowledge about evidence-based interventions.
But in most places in the country, a referral tobehavioral health may or may not send you to
somebody who really knows a lot about how totreat the specific childhood adversities, like exposure to domestic violence. They may or may
not have training in evidence-based treatments,
and in some cases the wait lists for referral
are very long. Until we know exactly what weneed to do, with which kinds of families, andare confident that the services will be available,
we cannot be confident that screening will bebeneficial. There are no clear protocols for how
to handle the referrals, or how to triage the referrals that we know will result in benefit. Also,in the case of disease screening, we know how
the disease will progress. With an ACE score ofsix, we do not know if the person will get heartdisease, COPD, or any other condition.
Continued on p.10

Joining Forces/Joining Families • 3

Should There Be Screening for Adverse Childhood
Experiences?
By James E. McCarroll, PhD, and Joshua C. Morganstein, MD

While the study of
ACEs has produced
significant advances inthe study of their effects
on health, much more
research needs to bedone before screening
can be implemented ona large-scale basis.

Adverse childhood experiences (ACEs)
can have significant effects on child and adult
health. In addition to programs that attempt
to prevent these events, issues of screening
for those exposed are important. Felitti, et al.
(1998) related ACEs to health outcomes. Seventeen questions were grouped in two categories: abuse (psychological, physical, and sexual)and household dysfunctions (mother treatedviolently, and anyone living in the household
who was a substance abuser, was mentally illor suicidal, or ever imprisoned). Adult respondents in a health maintenance organization
were asked to respond to the 17 questions aspart of a standardized medical evaluation.
Over nine thousand responded to the questionnaire. The results showed that there wasa graded relationship between the number of
items endorsed and risk factors that contributed to major causes of illness and death in
the U.S. An increase in the number of ACEs is
associated with a greater likelihood of negative
adult physical and mental health outcomes.
Since this study was conducted there have been
many hundreds more with similar results.
It has been suggested that primary care providers screen adolescents and emerging adults
for ACEs, but clinically efficient tools for such
screening are currently lacking (Pardee, Kuzma,
Dahlem, Boucher, & Darling-Fisher, 2017).
However, screening is a complex undertaking,both scientifically and clinically. For example,
Finkelhor (2017) has suggested that screening
for ACEs might be premature. He noted thathigh ACE scores (e.g., number of items endorsed) are non-specific and that this proceduredoes not meet the model for effective screening.
To be effective as a medical procedure, screening requires the existence of a specific risk factor
that can be treated. Likewise, there should be a
specific intervention that would be done basedon the results of the screening. Finkelhor raised
other questions such as whether negative effects
involved in screening (e.g., time, cost, training,
stigma, and false positives) would outweigh thepositive ones.
The items that are useful in ACE researchfor prediction of adverse outcomes are unclear.
In an effort to test and improve on the classic
ACE items, Finkelhor, Shattuck, Turner, and4 • Joining Forces/Joining Families

Hamby (2013) suggested deleting some items andadding new ones. The items recommended forremoval included parental separation or divorce
and incarceration of a household member. New
suggested items included parents always arguing, having no good friends, having someone
close with a bad illness or accident, below average
grades, peer victimization, property victimization, exposure to community violence, andlow socio-economic status. Other authors havealso suggested additional items such as family
financial problems, food insecurity, homelessness,parental absence, parent/sibling death, bullying, and violent crime (Mersky, Janczewski, &Topitzes, 2017).
While the study of ACEs has produced
significant advances in our understanding of theeffects of ACEs on health, much more researchneeds to be done before screening can be implemented on a large-scale basis. Finkelhor (2017)
suggested that the most effective screening
program would be for the conditions for which
established and effective treatments exist.

References

Felitti VJ, Anda RF, Nordenberg D, ... Marks JS.
(1998). Relationship of childhood abuse andhousehold dysfunction to many of the leading
causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4): 245–258.
Finkelhor D. (2017). Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse & Neglect; doi: 10.1016/j.
chiabu. 2017.07.016.
Finkelhor D, Shattuck A, Turner HA, & Hamby SL.
(2013). Improving the adverse childhood experiences study scale. JAMA Pediatrics; 167(1):70–75.
Mersky JP, Janczewski CE, & Topitzes J. (2017). Rethinking the measurement of adversity: moving
toward second-generation research on adverse
childhood experiences. Child Maltreatment;
22(1): 58–68.
Pardee M, Kuzma E, Dahlem CH, Boucher N,& Darling-Fisher CS. (2017). Current stateof screening high-ACE youth and emerging
adults in primary care. Journal of the American Association of Nurse Practitioners. Nov 15.
doi:10.1002/2327-6924.12531.
Summer 2018

Adverse Childhood Experiences and Resilience
By James E. McCarroll, PhD, and Joshua C. Morganstein, MD

Resilience is theability of the individual
to continue a normallife trajectory in spiteof adversity, not a
fixed invulnerability or
superior functioning.

Adverse childhood experiences (ACEs)
have been associated with a wide variety ofnegative health and behavioral outcomes inadults (Felitti et al., 1998). This important
insight has led to a wide body of research tounderstand how to prevent the effects of ACEs
and to treat negative outcomes when theyoccur in both children and adults. However,an early assumption that ACEs are universally
associated with negative outcomes is not accurate. Adversity is associated with wide variations in outcomes following exposure to different types of adverse events (Rutter, 2012).1 Thisobservation led to attempts to discover what
accounts for positive changes in the face ofadversity. Many concepts have been put forthto account for this fact such as competence, thecapacity for adaptive behavior (Masten & Tellegen, 2012), and positive psychology, a conceptthat includes building valued subjective experiences and individual traits, and institutions toimprove quality of life and prevent pathologies(Seligman, 2000).
More recently, the concept of resilience has
drawn much research attention. While there
is no consensus on a definition of resilience,
Rutter (2006) described it as an interactive
concept of relative resistance to environmental
risk experiences, or the overcoming of adversity. The important point is that resilience isinteractive [author’s italics] in that it has to
be inferred [author’s italics] from individual
variations in outcome among those who haveexperienced significant adversity (Rutter, 1987).
This description emphasizes that resilience is aprocess, not the fixed invulnerability of an individual. Resilience also should not be thought ofas superior functioning, but rather the ability of
the individual to continue a normal life trajectory in spite of adversity (Rutter, 2013).
Rutter’s (2013) review of resilience reveals
that adversity is an environmentally as wellas genetically mediated risk. Mediated meansthat “something” works differently in people
between facing adversity and the outcome. This
“something” that mediates is the subject of
1. This review borrows heavily from the work of
Michael Rutter, who has researched developmental
psychopathology since the 1970s and has produced
some of the most thoughtful papers on resilience.

http://www.CSTSonline.org

research. In other words, what factors interact
between the exposure to risk and the outcome?
Another route to reducing risk impact as wellas promoting resilience is the alteration ofenvironmental exposure (Rutter, 1987). For
example, parental supervision and the regulation of children’s activities can reduce exposure
to high-risk community environments as wellas promote pro-social activities. Exposure toadversity may result in sensitization, which
increases vulnerability, or decreases vulnerability through a “steeling” (author’s quotes) effect.
Steeling can occur as a result of manageable
challenges or small doses of stress. This meansthat risk factors may actually be strengthening if they occur in a way and at a time during
development when the individual can cope withthem, physically and psychologically (Rutter,2013). Such experiences, although multi-determined through the interaction of biologicalfactors, such as genetics, and environmental
effects can result in increased self-efficacy andresilience to later stresses.
Research on risk and protective factors
often seems to assume that they work the same
way and that risks are the same in non-stressedgroups as they are in those who are stressed.
This is also not always the case because risk
and protective factors are identified because of
their effects, not their nature. Not all individuals
respond to stress in the same way and outcomescannot be understood as the balance between
risk and protective factors (Rutter, 2013).
Two dynamic processes underlie resilience:(1) those that operate prior to adversity topromote resilience (e.g., maternal warmth, sibling warmth, and a positive atmosphere in thefamily) and (2) those that operate after adversity to restore good functioning (Rutter, 2013).
Examples of the first are taking responsibility
and successfully coping with challenges. The
implication of this second mechanism underlying resilience is the possibility that early adverse
experiences in childhood can be corrected in
adults, that of turning point effects in adultlife. Such turning points involve a “knifing off ”[author’s quotes] of the past and the opening ofopportunities for the future. Positive adult experiences can provide a major discontinuity withpast adversities and open up fresh opportunities for success. Examples are positive external
Joining Forces/Joining Families • 5

Adverse Childhood
Experiences andResilience, from page 5

Resilience is aninteractive process
between the individual
and the environment andhas to be inferred in theoutcome among those
who have experienced
significant adversity.

interventions such as mentorship by individuals who have overcome their own adversities
such as substance abuse or crime and personalactions such as entering into a good marriage.
Prevention factors promoting resiliencecan be thought of as features that act differently depending on the presence or absenceof environmental risk. An example is child
adoption, which has no benefits to the childin the absence of adversity, but is protective
when there is an environmental risk, such asremaining in a family when the child has been
abused or neglected or there are serious family
conflicts. It is important to keep in mind that
resilience is multi-determined and depends onthe context of experiences, biological factors,
and environmental factors. Resilience as well as
adversity should be seen as lifelong factors that
can influence and be influenced by changes.
Assessment of the effects of adverse experiences, whether they occurred in childhoodor later life, is more complex than screening.
Much needs to be done to understand theinterplay between adversities and outcomes.
Biological effects on resilience require better
understanding. The brain is largely the arbiterof the body’s response to all life events. Stressupsets the body’s homeostasis through a variety of genetic and environmental interactions,but the body adapts during these changes. How
these functions occur has been the subject of
an increasing volume of mind-body researchallowing more understanding of adversity andresilience at all levels of the body, neurobehavioral and physiological (Karatoreos & McEwen,2013). More needs to be learned about critical
periods when stress occurs, the mediators that
occur to protect the body against overload
and disturbances to homeostasis, how negative changes can be mitigated, how the brainchanges in response to stress and recovery, andhow to address long-term negative effects suchas severe child abuse and neglect.
There are also public policy implications to
the increased use of the concepts of childhood
adversity and resilience across disciplines suchas health, education, and social welfare. There
are many arenas of policy recommendations toimprove resilience such as strengthened families, increased counseling and mental healthservices, supportive school environments, community programs, socioeconomic improvement, and a more comprehensive conceptionof resilience (Ager, 3013). The complexity ofthese challenges includes the need for more

6 • Joining Forces/Joining Families

and better qualitative and quantitative researchthat engages a research-policy linkage, analysis
at multiple levels, and engagement in knowledge transfer initiatives.
Adverse experiences and their effects upondevelopment and outcome are complex, involving practices and policies that intend to betterthe lives of people. Both adversity and resilience
have effects that are multi-determined, the outcome of which depend on the interplay of manyfactors. As is the case with many of the efforts toimprove lives, particularly for children, one size
does not fit all when it comes to understanding risk and protective factors in the context ofadverse experiences and resilience.

References

Ager A. (2013). Annual research review: Resilience and child well-being – public policy
implications. Journal of Child Psychology andPsychiatry; 54(4): 488–500.
Felitti VJ, Anda RF, Nordenberg D, ... Marks JS.
(1998). Relationship of childhood abuse andhousehold dysfunction to many of the leading causes of death in adults: The Adverse
Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4):245–258.
Karatoreos IN & McEwen BS. (2013). Annual
research review: The neurobiology and physiology of resilience and adaptation across thelife course. Journal of Child Psychology andPsychiatry; 54(4): 337-347.
Masten AS & Tellegen A. (2012). Resilience indevelopmental psychopathology: Contributions of the Project Competence Longitudinal
Study. Development and Psychopathology; 24:
345–361.
Rutter M. (1987). Psychosocial resilience andprotective mechanisms. American Journal of
Orthopsychiatry; 57: 316–331.
Rutter M. (2006). Implications of resilience concepts for scientific understanding. Annals of
the New York Academy of Sciences; 1094: 1–12.
Rutter M. (2012). Resilience as a dynamic concept. Development and Psychopathology; 24:
335–344.
Rutter M. (2013). Annual research review: Resilience – clinical implications. Journal of Child
Psychology and Psychiatry; 54(4): 474–487.
Seligman MEP & Csikszentmihalyi M. (2000).
Positive psychology: An introduction. American Psychologist, 55, 5–14.

This review borrows heavily from the workof Michael Rutter, who has researched develSummer 2018

Social Support, Self-Esteem, and Peer Attachment in
Adolescents Decrease Adverse Effects of Childhood
Maltreatment
By James E. McCarroll, PhD, and Joshua C. Morganstein, MD
Social support cansometimes act as ameans to decrease
adverse psychologicaloutcomes andenhance social andacademic functioningof abused andneglected children.

http://www.CSTSonline.org

Effects of adversity are often negative.
However, and fortunately, such effects can be
mitigated under some circumstances. Research on the effects of child abuse and neglectsearches for such circumstances as interventions that can be applied in prevention as wellas treatment. Among such circumstances are
mediators, links between adverse experiences
and outcomes. Mediators are opportunities forintervention. For example, in a study of adults
with a history of child abuse and neglect, social
support mediated the relationships between
child maltreatment and adult anxiety anddepression (Sperry & Widom, 2013). Higher
levels of social support were associated withlower levels of anxiety and depression.
Research to improve the lives of maltreatedchildren has often focused on families andfriends as well as schools as sources of positive
experiences that promote resilience. In a groupof 101 adolescents, the effects of parental maltreatment and being the victim of peer bullying
on severity of depression in adolescents wereassessed (Seeds, Harkness, & Quilty, 2010).
Parental maltreatment was defined as(a) antipathy, (b) indifference, and/or (c) physical abuse. Peer bullying was defined as verbal
and/or physical harassment by a same-age peer.
Mediators examined were appraisal (availability of others for support), belonging (availabilityof others for companionship), and tangible support (availability of material aid or instrumental support), and the number of close friends
reported by participants. Father-perpetrated
maltreatment and bullying were mediated bylower perceptions of both tangible support
and belonging and thus resulting in greater
depression severity. Contrary to expectations,severe mother-perpetrated abuse was mediated by higher perceptions of tangible support
and lower depression severity. Severe maternal
maltreatment was associated with more peer
confidants. The authors suggested that motherperpetrated abuse led some adolescents to seekout other sources of practical aid that somewhat protected them from depression.

Maltreatment has been found to have many
complex effects on school achievement andadjustment of children and adolescents. (Lim& Lee, 2017) In a study of 2,351 Korean middle
school students, parental neglect was negatively
related to school adjustment. Self-esteem andpeer attachment mediated the relationshipbetween child neglect and school adjustment.
In other words, higher self-esteem and peer
attachment were associated with better school
adjustment. Peer attachment and self-esteem
were also significantly positively correlated.
The search for mediators is often the route
to interventions for abused children. However,the complexity of human development requiresthat individual differences in experiences andreactions must be considered in such programs.
Educators, social service workers, healthcare
providers and policy makers should further efforts to reduce exposure of children to parental
maltreatment and peer bullying as well as enhancing social support as a means to decrease
adverse psychological outcomes and enhancesocial and academic functioning.

References

Lim Y, & Lee O. (2017). Relationships between
parental maltreatment and adolescents’ school
adjustment: Mediating roles of self-esteem andpeer attachment. Journal of Child and Family
Studies; 26: 393–404.
Seeds PM, Harkness KL, & Quilty LC. (2010). Parental maltreatment, bullying, and adolescentdepression: Evidence for the mediating roleof social support. Journal of Clinical Child &Adolescent Psychology; 39(5): 681–692.
Sperry DM & Widom CS. (2013). Child abuse
and neglect, social support, and psychopathology in adulthood: A prospective investigation.
Child Abuse & Neglect; 37(6): 414–425.

Joining Forces/Joining Families • 7

BUILDING BRIDGES TO RESEARCH

What is Screening and How Does It Apply toAdverse Childhood Experiences?
By James E. McCarroll, PhD, and Joshua C. Morganstein, MD
Screening as a
primary prevention
approach to ACEs
would involve
administeringa standard setof questions toeveryone, regardlessof their clinicalpresentation. It
generally fails tomeet the criteria
established forscreening in clinicalpractice.

In the medical field, screening is a methodof detecting disease or adverse exposuresassociated with high risk for disease (leadpoisoning in children, for example) in persons
assumed to be healthy and, thereby, reducemorbidity and mortality. Screening is notdiagnostic. That is done by additional tests andfollow-up evaluation for those whose screening is positive. Many health conditions can bescreened and preventive actions taken with theassurance that the benefit to society and the patient are substantial (see Grade A recommendations at https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions).
Some examples of routine screening aresome cancers (coleorectal, lung, cervical),osteoporosis, abdominal aortic aneurism, andmany more health-related conditions including
behaviors such as alcohol misuse and tobacco.
Among the criteria for the effectiveness ofa screening test are that (1) there must be an
accurate screening test for the condition, and(2) evidence exists that screening can prevent
adverse health outcomes (Cole, 2000), (3) that
it is reasonably quick to perform, (4) it is safe
and acceptable to the person being screened
and to the person performing it, and (5) thestatistical properties of the test (sensitivity,
specificity, positive predictive value and others)
are known and are acceptable (Jekel, Katz, &Elmore, 2001).
Research over decades has shown correlations between exposure to adverse childhood
experiences (ACEs) and negative medical andbehavioral outcomes for children and adults.
A review of 35 studies found that ACEs wereassociated with asthma, infection, somatic
complaints, sleep disruption, and delays incognitive development (Oh, et al., 2018). Given
this history, it is not surprising that many havesuggested screening for ACEs in an attempt toprevent negative outcomes for children (McKelvey, Selig, & Whiteside-Mansell, 2017) andadults (Glowa, Olson, & Johnson, 2016).
Screening as a primary prevention approach to uncovering ACEs is less formal andgenerally fails to meet the criteria establishedfor clinical practice. Universal screening would

8 • Joining Forces/Joining Families

involve administering a standard set of questions to everyone, regardless of their clinicalpresentation. An example would be to usesome or all of the 17 items from the Felitti, etal. (1998) study, asking these questions of all
patients who come to see a provider. There
are many other ways for a provider to consider how to work with individuals who havea history of ACEs, such as exposures to childhood traumas. Among these are an awarenessof the correlation between ACEs and negative outcomes and sensitive history taking todetermine if such an association exists.
The question of whether and how toscreen for ACEs is the subject of debate. Arguments are made for and against it in termsof whether it should be performed and, if so,
its effects on providers, children, adolescents,
parents and patients. There are barriers toscreening by providers and to methods ofclinical inquiry. In a review of qualitative
studies of the experiences of professionals
who work with children and adolescents,
many expressed discomfort in inquiring
about childhood adversity (Albaek, Kinn, &Milde, 2017). Three themes were found: (1)feeling inadequate and unequipped to workwith childhood adversity, (2) fear of making
it worse for children due to their inability to
predict consequences that may result frominquiry, and (3) facing the horrors of childhood abuse. The authors described this process as walking children through a minefield.
Additional barriers are largely about provider
time, lack of training and familiarity with theconcepts of ACEs, and how these are related
to health outcomes (Tink, Tink, Turin, &Kelly, 2017).
On the other hand, Glowa, Olson, &Johnson (2016) reported that ACE screeningof adult patients by providers was feasible
in that it did not interfere with the visit and,in the opinion of the provider, was acceptable to the patient. When parents of children
six years or younger were asked about theirperceptions of their ACEs screening, they
accepted and appreciated the screening in thepediatric setting and believed it could lead to
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Knowledge of ACEs
can give medical andsocial service providers
a better understandingof the relationshipof trauma or otheradversity to patients’
health and risks ofnegative health andbehavioral outcomes.

http://www.CSTSonline.org

needed services (Conn, et al., 2017). They also
viewed the screening as a motivating factor
and that the provider could help them learn
the necessary skills and obtain resources.
The American Academy of Pediatrics
provided a document for pediatric providers
to consider when addressing ACEs in theirpractice: Addressing Adverse Childhood
Experiences and Other Types of Trauma in
the Pediatric Setting (https://www.aap.org/
en-us/Documents/ttb_addressing_aces.pdf).
This guide uses the medical home model forchildren and youth with special health careneeds. The model provides coordinated care
and a family-centered approach for children
who have been exposed to ACEs. Children
are identified through routine screening or
surveillance. Suggestions are given on how
to ask about ACEs and what to do once an
exposure is found. This document provides
a reasonable discussion of how to consider
ACEs in a pediatric practice.
Given this brief description of screening,
what can be done in addressing how to assess
for ACEs? Dr. Finkelhor (2017) discusses
three important issues on screening for ACEs:(1) What should be screened for? (2) Whatinterventions should be in place for those
who screen positive for a given ACE? and(3) What are the possible negative outcomes
and costs of ACE screening? These should
be considered prior to instituting informal
screening or case finding.
Knowledge of ACEs can give medical andsocial service providers a better understanding of the relationship of trauma or other adversity to patients’ health and risks of negative
health and behavioral outcomes. However,
the road to this goal is not well understood as
it depends on many individual (patient andprovider), family, institutional, community,
and societal factors. Training of providers,costs incurred and anticipated, maintenanceof the program, and dealing with unanticipated outcomes must all be considered in
the implementation of programs that seek to
identify and mitigate the impact of ACEs inorder to improve health outcomes.

References

Albaek AU, Kinn LG, & Milde AM. (2017). Walking children through a minefield: How professionals experience exploring adverse childhood experiences. Qualitative Health Research.
doi: 10. 1177/1049732317734828.
Cole TB. (2000). Is domestic violence screening
helpful? Journal of the American Medical Association, 284(5):551–553.
Conn AM, Szilagyi MA, Jee SH, Manly JT, Briggs
R, & Szilagyi PG. (2017, December 7). Parental
perspectives of screening for adverse childhood experiences in pediatric primary care.
Families, Systems, & Health. doi: 10.1037/
fsh0000311.
Felitti VJ, Anda RF, Nordenberg D, … Marks
JS. (1998). Relationship of childhood abuseand household dysfunction to many of theleading causes of death in adults: The Adverse
Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4):245–258.
Finkelhor D. (2017). Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse & Neglect. doi: 10.1016/j.
chiabu.2017.07.016.

Glowa PT, Olson AL, & Johnson DJ. (2016).
Screening for adverse childhood experiences
in a family medicine setting: A feasibility study.
Journal of the American Board of Family Medicine. doi: 10.3122/jabfm.2016.03.150310.
Jekel JF, Katz DL, & Elmore JG. (2001). Epidemiology, Biostatistics, and Preventive Medicine,
2d Edition. Philadelphia, PA: Saunders, pp.
261–273.
McKelvey LM, Selig JP, & Whiteside-Mansell L.
(2017). Foundations for screening adverse
childhood experiences: Exploring patterns of
exposure through infancy and toddlerhood.
Child Abuse & Neglect; 70: 112–121.
Oh DL, Jerman P, Marques SS … Bucci M. (2017).
Systematic review of pediatric health outcomes
associated with childhood adversity. BMC
Pediatrics. doi: 10.1186/s12887-018-1037–7.
Tink W, Tink JC, Turin TC, & Kelly M. (2017).
Adverse childhood experiences: Survey of resident practice, knowledge, and attitude. Family
Medicine; 49(1): 7–13.

Joining Forces/Joining Families • 9

An interview with David
Finkelhor, PhD, from page 3

The most important
thing, from my pointof view, is to go backto the original insightfrom the ACEs, whichis that we have lotsof justification now
to engage in primaryprevention.

Dr. McCarroll: In the child maltreatment
literature, people make the case that it is notnecessarily the single type of maltreatmentthat is always harmful, but the combination ofmaltreatment.
Dr. Finkelhor: Poly-exposure does increase
the likelihood of a negative outcome, but it
depends. If you are just screening adults onthat and you are not really trying to remedy thesource of the problem that is one thing. But, if
you are treating juveniles where the problems
may be ongoing, there is a very different set of
responsibilities.
One alternative to ACE screening is
symptom screening. You might want to screen
all adults and all children for certain typesof current symptoms — depression, anxiety,substance usage — because we know these
symptoms to be mediators between adversity
in childhood and later health problems andthey may be better predictors than the ACEs
themselves. We do not know for sure thatsymptom screening is better than adversity
screening, but it is a possibility. But, the best
reason for screening for the symptoms rather
than the ACEs, in my view, is that we actually
have evidence-based treatments for most ofthese symptoms. If you are screening for posttraumatic stress symptoms or for depression
or for hyperactivity or acting out behavioral
problems, for drug abuse, these are all things
for which we have treatments. They are also
known mediators in the causal chain from
ACEs to later health problems. And, to someextent they are less complicated. We knowmuch more about how to screen for them and,to some extent, they are less complicated. A
lot of medical practices already do ask about
depression, and they ask about substanceabuse. The question for me is not whether
ACEs show who is at risk, but does it do a
better job of predicting risk than some of thesymptom screening measures that perhaps
have clearer implications for referral andtreatment? This is an important practice issue
that needs to be settled. My hypothesis is thatyou might be able to do just as well or even be
more successful by screening for symptoms
alone. Screening for symptoms might be precise. Some of the stress response mechanisms
may show up in biological mechanisms likecortisol levels. To the extent that we can measure those kinds of things in laboratory tests,
they might be very good predictors of later
health problems. They may be the exact things
we want to be measuring that show whether

10 • Joining Forces/Joining Families

somebody’s childhood adversity is affecting
them currently.
Dr. McCarroll: Who should be concerned about
ACEs? Would that be anyone who deals withfamilies and children? There is an argument
for universal screening in places like schools
and sports activities. Where would that go?
Dr. Finkelhor: I am increasingly nervous totake this universal adversity screening beyond
the medical/public health sector. The potential
for stigmatization is really pretty intense once
you start doing this is other places like schools
and day care. My basic point is that I just think
we have to be cautious and not jump into
practices without some evidence basis for them.
Just the knowledge that ACEs predict outcomes
does not necessarily mean that there is going tobe benefit to asking everybody about it.
Dr. McCarroll: But, is it not also true that ACEs
do not have to lead to a bad outcome?
Dr. Finkelhor: Many people are resilient. Although the number of ACEs is correlated with
bad outcomes, the point is rarely made that you
still can find people with high ACEs scores who
do not seem to have any problems. That is very
reassuring.
Dr. McCarroll: The topic of resilience isperhaps another facet of the ACE business.
Is that something you have seen in theliterature?
Dr. Finkelhor: There are people who havetaken that insight and now they are trying not
to just screen for ACEs, but for resilience factors
as well. We should be interested in improving
prediction as much as possible, and resilience
factors may help prediction, but how we should
use that in a clinical way is not yet clear. I am
not sure that it is a solution to the ACEs screening dilemmas to say, “Oh, we are screening for
ACEs, but we are also screening for resilience
factors.” If you do not yet know with some confidence what exactly to do with the results you
get from screening because there is no kind ofclear evidence-based model, then you have notchanged the equation very much by just adding
the resilience items as well.
I have a couple of bottom lines on this.
One is that to the extent that people want to doscreening, they should start with a very simple
model and they should use the evidence base as
guidance. We have, for example, interventions
for abusive parenting. If you want to screen forparents that are using coercion and yelling to
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An interview with David
Finkelhor, PhD, from page 10

Moreover, toengage families inthese programs,
you don’t have tonecessarily screen
for ACEs. It is often
sufficient to appeal
to people’s desire
to be good parents,
to enjoy theirchildren and family,
to promote healthy
development, and tohelp them overcome
the frustrations they
face.

manage their kids, you can then connect themto parent education programs that have been
proven to reduce that kind of problem. That is agood place to start, it is pretty straightforward,
and you can evaluate it. It is better not to throw
the whole kitchen sink in at the beginning.
Another thing that can be less problematicis not to start with screening everybody, but totrain the clinical staff to look for the kinds offamilies that might most benefit from havingsome additional questions asked about what isgoing on with them and then give them some
information.
The most important thing, from my pointof view, is to go back to the original insightfrom the ACEs, which is that we have lots ofjustification now to engage in primary prevention. In the larger community, not justhealthcare, we ought to be focusing on developing family enrichment, parenting programs,
household safety programs, prenatal education,school safety programs, and anti-bullying programs, all of which are known to reduce the occurrence of these toxic childhood experiences.
We are moving in that direction, and we have a
lot of promising findings in this area, but there
is where I would like to see us concentrate ourefforts.
For example, home visitation programs
have been greatly expanded over the last 20
years, and especially since the passage of the
Affordable Care Act. We can build on that
infrastructure to create and implement training modules that are maximally engaging forparents and convincingly effective for preventing adversities. How to manage inconsolable
infants? How to select responsible caregivers?
How to avoid blow-ups and domestic violence?
How to prevent sibling abuse? We know a lot
about the parenting skills that are protective.
There are many good parenting programs.

Much of the challenge is making the acquisitionand deployment of these skills easy, enjoyable,
and long-lasting. A similar strategy applies tothe increasing use of family life specialists inprimary care medical practices.
Moreover, to engage families in these
programs, you don’t have to necessarily screen
for ACEs. It is often sufficient to appeal topeople’s desire to be good parents, to enjoy
their children and family, to promote healthy
development, and to help them overcome thefrustrations they face. This is an exciting time
for positive parenting, but we need to remember to use the tools of evaluation to build out
our knowledge base and keep on improving.
Dr. McCarroll: Prevention rather than
remediation.
Dr. Finkelhor: Not that we should abandon
remediation, but I am just afraid that with the
ACE screening, we are getting too far awayfrom the original prevention orientation.
Dr. McCarroll: Looking at the ACE items andthinking about how you would prevent them is
one way of thinking about it.
Dr. Finkelhor: Yes. Exactly.
Dr. McCarroll: Thanks again for your time andyour thoughts.
Dr. Finkelhor: You are welcome. Good talking to you.

References

Felitti VJ, Anda RF, Nordenberg D, ... Marks JS.
(1998). Relationship of childhood abuse andhousehold dysfunction to many of the leading causes of death in adults: The Adverse
Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4):245–258.

Until we know exactly what we need to do, with which kinds of families,
and are confident that the services will be available, we cannot be
confident that screening will be beneficial. There are no clear protocols
for how to handle the referrals, or how to triage the referrals that weknow will result in benefit

http://www.CSTSonline.org

Joining Forces/Joining Families • 11

Websites of Interest
Three websites have important information about
adverse childhood experiences (ACEs).
Crimes Against Children Research Center— at the University of New Hampshire, directed by Dr.
Finkelhor, has an extraordinary number of resources
about children including adverse childhood experiences, bullying, technology in youth harassment victimization and many, many more.
(See: http://unh.edu/ccrc/).

The Centers for Disease Control and Prevention (CDC)
also provides material on the nature of ACEs, prevention tips, and possible outcomes. It also provides an
excellent video that can be used for educational purposes. (See https://www.cdc.gov/violenceprevention/acestudy/index.html)

The Substance Abuse and Mental Health Services
Administration (SAMHSA) also provides a tab for ACEs
in addition to their many other programs such as suicide prevention, and other topics of trauma. Searchhttps://www.samhsa.gov/capt/practicing-effectiveprevention/prevention-behavioral-health/adversechildhood-experiences to find this specific information.

12 • Joining Forces/Joining Families

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