Should Services Ask About ACEs?
Adverse Childhood Experience (ACE) studies have been carried out in a number of countries since the original study was published in 1998 in the United States. These population health studies have found links between adverse experiences up to age 18 and later health and wellbeing.
As part of the ACE study, a questionnaire was developed for use with adults participating in the study. 10 types of childhood adversity were included in the ACE study, including
- types of personal experiences - such as physical, emotional and sexual abuse
- experiences related to family members - such as growing up in a household where there is drug, alcohol or domestic abuse.
It is not recommended that anyone uses ACE questionnaires with children or adults to gather “ACE scores” (e.g. in schools). This could lead to unhelpful labelling and stigmatisation and potentially upset or unsettle children, families or adults.
NHS Health Scotland and partner organisations advocate a public health approach to childhood adversity. This focuses on the prevention of childhood adversity where possible as well as supporting families and individuals who have experienced adversity and trauma. Approaches which are adversity and trauma-informed and build resilience (e.g. nurture approaches in early learning and school settings) are important, alongside prevention on the causes of childhood adversity for population health.
NHS Education for Scotland has produced a Trauma Training Framework, which is designed to support the planning of training for a trauma and adversity informed workforce. More information about this can be found on the NHS Education website (external site).
When working with children and young people, assessment practices should always be person-centred and in line with the Getting it Right for Every Child National Practice model. More information can be found on the Education Scotland site (external site).
The original ACE questionnaire was developed for use in a population health research study and not as a tool to be used in clinical, educational or other service settings. Questionnaires used in ACE studies have a number of limitations when used to understand the experience of an individual or small group of individuals.
The ACE questionnaire doesn't consider for example
- experiences of bullying at school
It also doesn't take into account the context of a person’s life, such as
- their age
- the duration and intensity of trauma and adversity
- whether there were any safe and supportive relationships.
An individual’s response to the questionnaire may not accurately reflect the range and relevance of their experiences. An individual's adverse experiences, the length and severity of the experiences, and protective factors all vary, so the ACE questionnaire is not predictive of an individual’s health or life chances.
Enquiry about childhood adversity
An enquiry about childhood adversity involves a practitioner (e.g. a doctor) asking adults about adversity they may have experienced in childhood – often using a questionnaire – and how this adversity may impact on their lives now. This would take place as part of a conversation to inform the most appropriate support and treatment for the adult if required.
This type of enquiry is commonly referred to as either ‘routine enquiry’ or ‘ACE enquiry’.
‘Routine enquiry’ specifically refers to a clinician asking all adults about childhood adversity within a service; such as Health Visitors asking all new mothers at their six-week contact. This is different from targeted approaches which involve practitioners asking specific adults about their experiences as part of a therapeutic conversation based on their clinical judgement.
‘ACE enquiry’ can be used to refer to both routine and targeted approaches to asking about childhood adversity.
Neither approach – routine or targeted – to asking about childhood adversity should involve ‘ACE scoring’. The scoring of ACEs was only ever used as part of a population health research study. Any enquiry about ACEs should be used to start a therapeutic conversation that considers what (if any) response or support will be required by the person rather than a form of problem categorisation.
Appropriate training should be undertaken so that practitioners have the skills to respond appropriately to the information in a person-centred, trauma-informed way. It should only be used in settings where there has been an assessment of organisational readiness to undertake ACE enquiry. It should also be used within the context of clear organisational plans about how this information will be used to support an individual or as part of a wider assessment.
ACE Enquiry pilots
New pilots of enquiry of adverse childhood experiences have been carried out in England and Wales with promising findings, but there is a need to further develop the evidence base on enquiry of childhood adversity and to test it in a Scottish context.
NHS Health Scotland is supporting a pilot on enquiry on adverse childhood experiences with adults across a small number of GP practices. An evaluation will explore whether this is safe, effective and acceptable to both patients and staff. It will look at whether it improves health and wellbeing for patients and does not cause harm. Training and support has been put in place for those undertaking enquiries.
NHS Health Scotland has held seminars to share learning on routine enquiry about ACEs. You can access the slides and reports from the seminars below.
You can contact the Childhood Adversity team for more information about our work.