Adverse Childhood Experiences (ACEs Scale)

## Overview

Adverse Childhood Experiences (ACEs) have been quantified as a score that was derived from the study Felitti et al. (1998) in their article *Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults*.The Adverse Childhood Experiences (ACE) Study.  In this study they surveyed a vast number of children and found there was a significant relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults. They created the ACEs assessment that are given to children prior to their 18th Birthday. The assessment is comprised of 10 questions that are asked in a yes or no answer way. ACEs score is derived by calculating the number of questions a child answers yes to from this questionnaire. Below are the administered questions:

1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
2. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or ever hit you so hard that you had marks or were injured?
3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touched their body in a sexual way? or Attempt or actually have oral or anal intercourse with you?
4. Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
5. Did you often or very often feel that …You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
6. Was a biological parent ever lost to you through divorced, abandonment, or other reason?
7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
9. Was a household member depressed or mentally ill?  or Did a household member attempt suicide?
10. Did a household member go to prison?

The ACEs question are broken down into three categories; abuse, neglect, and household dysfunction. The types of abuse include physical, emotional, and sexual abuse. In addition, neglect is measured as both physical and emotion. Lastly, household dysfunction is described as mental illness in the home, abuse of the mother, an incarcerated family member, substance use, and divorce.

The ACEs pyramid, as seen in the diagram, represents how negative life experiences in childhood compound the likelihood of additional risk factors in adulthood that lead to early death. This provides a visual representation of how as ACEs build in childhood the impacts continue to felt throughout the rest of a person's life.

## ACEs and Foster Care

Approximately 6% of children in the United States will be involved in one way or another with the foster care system between their birth and their 18th birthday.This represents a reasonable portion of children in the United States as well as a particularly vulnerable subset of the population. Research has shown that children in foster care are at a greater risk for ACEs as compared to the general population of children not in foster care.Children in foster care are already at risk of significant trauma and foster care puts them at greater risk of additional ACEs.Furthermore, children with higher ACEs were significantly more likely to experience instability in their placement homes. The importance of studying the number of ACEs especially in foster care cannot be understated because higher ACEs are linked with higher levels of psychological distress later in life.Examples of psychological distress that children in foster care with high ACEs are more susceptible to include behavioral issues and attachment disorders which impact their quality of life.

Due to the fact that there are myriad of negative social, emotional, physical, and mental ramifications that are associated with higher ACEs scores, specifically in children in foster care, there is a need to implement ways to address ACEs in childhood. A study by Liming et al. reported that their findings on the negative health consequences based on ACES and instability in foster care can begin to provide the basis for creating legislation and social work guidelines to help protect foster children. Additionally, the Bruskas et al. study asserted that based on their research there needs to be further training and education for social workers to give them the resources to help children in foster care with their complex needs.Overall, this population is at a greater need for care, particularly trauma informed care, that is standardized and lawful in order to have a better quality of life after all of the trauma they have endured in childhood.

## ACEs and the LGBTQPIA+ Community

When comparing ACEs scores of members of the LGBTQPIA community to their heterosexual peers there are trends that emerge.One statistic that is particularly jarring is that of the surveyed population 25% of heterosexual children reported 4 or more ACEs whereas 41.6% of LGBT children reported 4 or more ACEs.Further studies have supported this reality that children in the LGBTQPIA+ community are likely to have higher rates of ACEs than heterosexual children. In a study by Andersen et al. they found that LGBTQPIA children have increased exposure to multiple developmental risk factors like physical abuse, sexual abuse, and emotional abuse which increases their ACEs score.Furthermore, there is research that shows that LGBTQPIA children showed a greater risk for suicidal behavior.  They additionally showed a relationship between the number of ACEs and suicidal behaviors.  All of these studies paint an ugly picture that depicts a disproportionate number of ACEs in the LGBTQPIA community.

Given that children in the LGBTQPIA community typically report higher ACE scores they are risk of high rates of poor mental health in adolescences and adulthood. Furthermore, due to the fact that children in the LGBTQPIA community are at a greater risk there needs to be further research conducted into have to address the high ACEs score in order to inform policy and standards of care.  One suggestion made in the study by Clements et al. suggests that there is a need from trauma-informed interventions for children in the LGBT community. In addition, the ACEs score is beneficial in informing care providers with a better picture of the the difficulties a a child is experiencing. Lastly, additional recommendation is that care providers give all children in the LBGTQPIA community the ACEs assessment in order to gain a better understanding of the children trauma then be able to create a more individualized treatment plan. The children in the LGBTQPIA community are in need of better care that hopefully future research and policy can help to provide.

## Limitations of ACEs

The ACEs study was a groundbreaking study when it first came out and has been an instrumental first step into understanding childhood trauma but this measure is not without flaws or limitations. The first limitation of the the ACEs score is that is based on only 10 Questions which limits the scope of information. Furthermore, the questions are normed based on White, middle-class families which is not representative of general population. This norming population has provides a base line but there is a need for expansion.

Another area that needs to be expanded upon in the ACEs is the element of gender in the assessment and scores. Currently the measure accounts that males and females would rate an experiences the same event with the same score. This is a major flaw in the system because different gender experience life in different ways but that it is reflected in the scores. In addition, another flaw regarding gender the wording in question number seven on the assessment. This question ask if only mom being abused. At this time there are families with that have two fathers and a child still may witness domestic violence between the two but the index does not account for these child. Furthermore, there are cases where the mother is the abuser to the father is the victim but the ACEs wording does not include this situation.

Furthermore, the ACEs measure does not include questions that relate to culturally sensitive circumstances. An example would be there is not a question that related to the trauma of the fear that having immigration status has on a child because they may feel uncertain about the living situation.In addition, there is not a question related to if a child witness or was involved with a family member being detained or deported by ICE.There may also be situations where a guardian is separated because of migration which impacts the child's ability to have a stable home life. There are many cultural factors that are overlooked and not accounted for in the initial measure that was created by Felitti et al,

Lastly, an additionally overlooked area that is not accounted for is time.The ACEs scale is only yes or not and does not ask for further explanation of frequency, duration and time frame of the experience.  The ACEs measure currently does not ask how often an experience is occurring which could help to indicate the severity of the situation. Furthermore, there are not questions that address how long the experience was whether it lasts for a few days or a few years is potentially crucial information. In addition, there is not a consideration for when the event occurred and the time frame can impact the affect of the experience. If the experience happened when a child was three would be different if the same event occurred when a child was seventeen. Lastly, it is hard to compare ACEs scores because there is no way to know if a child with two ACEs that has been on going for years or if the child with five ACEs has all occur when the child was two.

Overall, the ACEs has provide a substantial baseline for the past almost 25 years but there are holes that need to be addressed in future assessment.  Furthermore, there is a push to use the research on ACEs to advocate for trauma informed care because the ACEs scores provide data that children are experiencing trauma on all levels.The need for trauma informed care will only be more essential as the world collectively is experiencing a global trauma of the COVID-19 pandemic. While there have been strides made to incorporate ACEs into policy, as of 2018 only 37 states have enacted ACEs related legislation. There is hope that advancing the ACEs measure and incorporation ACEs into legislation can further improve the quality of life for children and adults with childhood trauma.

## References

1. ↑ 1.0 1.1 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. *American journal of preventive medicine*, *14*(4), 245–258.
2. ↑ 2.0 2.1 2.2 https://www.cdc.gov/violenceprevention/aces/index.html
3. ↑ 3.0 3.1 3.2 https://www.ncsl.org/research/health/adverse-childhood-experiences-aces.aspx
4. ↑ 4.0 4.1 Turney, K., & Wildeman, C. (2017). Adverse childhood experiences among children placed in and adopted from foster care: Evidence from a nationally representative survey. Child Abuse & Neglect, 64, 117-129.
5. ↑ 5.0 5.1 5.2 Bruskas, D., & Tessin, D. H. (2013). Adverse childhood experiences and psychosocial well-being of women who were in foster care as children. *The Permanente journal*, *17*(3), e131–e141.
6. ↑ 6.0 6.1 Liming, K. W., Akin, B., & Brook, J. (2021). Adverse Childhood Experiences and Foster Care Placement Stability. *Pediatrics*, *148*(6), e2021052700.
7. ↑ https://txicfw.socialwork.utexas.edu/aces-foster-care-rethinking-trauma-informed-care/
8. ↑ 8.0 8.1 https://californialgbtqhealth.org/wp-content/uploads/2019/12/LGBTQ-ACES-Fact-Sheet-FINAL.pdf
9. ↑ 9.0 9.1 9.2 Andersen, J. P., & Blosnich, J. (2013). Disparities in adverse childhood experiences among sexual minority and heterosexual adults: results from a multi-state probability-based sample. *PloS one*, *8*(1), e54691.
10. ↑ Clements-Nolle, K., Lensch, T., Baxa, A., Gay, C., Larson, S., & Yang, W. (2018). Sexual Identity, Adverse Childhood Experiences, and Suicidal Behaviors. *The Journal of adolescent health : official publication of the Society for Adolescent Medicine*, *62*(2), 198–204.
11. ↑ 11.0 11.1 Clements-Nolle, K., Lensch, T., Baxa, A., Gay, C., Larson, S., & Yang, W. (2018). Sexual Identity, Adverse Childhood Experiences, and Suicidal Behaviors. *The Journal of adolescent health : official publication of the Society for Adolescent Medicine*, *62*(2), 198–204.
12. ↑ 12.0 12.1 Schnarrs, P. W., Stone, A. L., Salcido, R., Georgiou, C., Zhou, X., & Nemeroff, C. B. (2020). The Moderating Effect of Resilience on the Relationship between Adverse Childhood Experiences (ACEs) and Quality of Physical and Mental Health among Adult Sexual and Gender Minorities. *Behavioral medicine (Washington, D.C.)*, *46*(3-4), 366–374.
13. ↑ 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 13.11 Anda, R. F., Porter, L. E., & Brown, D. W. (2020). Inside the Adverse Childhood Experience Score: Strengths, Limitations, and Misapplications. *American journal of preventive medicine*, *59*(2), 293–295.
14. ↑ Cronholm, P. F., Forke, C. M., Wade, R., Bair-Merritt, M. H., Davis, M., Harkins-Schwarz, M., Pachter, L. M., & Fein, J. A. (2015). Adverse Childhood Experiences: Expanding the Concept of Adversity. *American journal of preventive medicine*, *49*(3), 354–361.
15. ↑ 15.0 15.1 15.2 15.3 Flores, G., & Salazar, J. C. (2017). Immigrant Latino Children and the Limits of Questionnaires in Capturing Adverse Childhood Events. *Pediatrics*, *140*(5), e20172842.
16. ↑ Oral, R., Ramirez, M., Coohey, C., Nakada, S., Walz, A., Kuntz, A., Benoit, J., & Peek-Asa, C. (2016). Adverse childhood experiences and trauma informed care: the future of health care. *Pediatric research*, *79*(1-2), 227–233.