Misapplying The ACEs Trauma Study: A SSWN Research Brief
“If you put this science into the hands of the people, they will do very wise things with it.”–Laura Porter, quoted in the Resilience documentary*
*https://www.aceinterface.com/Laura_Porter.html [accessed 02/05/20]
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.
What is the Article About?
Professor Robert Anda is one of the authors of the original ACEs study (Felitti et al 1998). Together with colleagues Laura Porter and David Brown, Anda recently intervened in the debate around the use of ACE scores in a way that is both helpful and extraordinary. In a recent article for the American Journal of Preventative Medicine, the authors confirm that the usefulness of ACE scores are limited to research, public health surveillance and promoting accurate and compassionate public awareness of ACEs. This is a helpful confirmation. The extraordinary part is that the authors have spelled out in no uncertain terms how the ACE score can be misapplied and the serious risks of doing so.
Why is the Article Important?
The authors remind us that population-based studies should not be used to make inferences about individuals. Making this error is known as the ‘ecological fallacy’: a basic principle of social science research. In short, aggregate population-level data tells us precisely nothing about individual people. This principle appears to have been overlooked by some proponents of the ‘ACEs movement’. This means that ACE studies and the scoring method are not suitable for screening, or for informing decisions about services, treatment or care. Doing so could have harmful consequences for individuals including stigmatization, discrimination, creating anxiety, misclassifying risk, withholding necessary service or steering clients towards unnecessary services (Anda et al 2020).
The opening quotation from one of the co-authors, Laura Porter – “If you put this science into the hands of the people, they will do very wise things with it” – must now be seen as a case of misplaced confidence, and a stark reminder that researchers cannot know in advance precisely how any work they produce might be (mis)used or (mis)interpreted. In the case of the ACEs model and in particular its main methodological feature – the ‘ACE score’ – the authors are unequivocal that it should only be used for the purposes for which it was created, and that misusing ACE studies or the ACE score can have seriously harmful consequences. Others have been warning of these risks before now (see White et al 2019). However, a clarification such as this from one of the co-authors of the original ACE study is a noteworthy and welcome intervention.
What Can School Social Workers Do With This Article?
- Share it (we attach a free PDF of it below to read and download)
- Use it to inform efforts to make your school’s trauma-informed approaches more focused on designing settings and specific clinical services that are trauma-informed and rooted in the best available evidence (see our recent work at SSWN on this here and here, without using the ACEs study and the scale as the driver of your efforts.
- Continue to seek universal and Tier 2-level screeners that account for trauma and other coexisting mental health conditions for your school student population (our article here at SSWN “SSWN Open Access Project: 21 Free Measures of Risk and Protective Factors for Youth” is a good place to start)
- Consult the Hopeful Childhoods website that I (Gary Walsh) and other UK scholars created to address these issues (more info on our project is below in this article) and share your own perspectives on these issues there and via the Twitter hashtag #HopefulChildhoods
Andaetal-ACEs-article
More Information On Our Hopeful Childhoods Site
In October 2019, I created the Hopeful Childhoods website alongside colleagues Professor Jane Callaghan (University of Stirling), Dr Emma Davidson (University of Edinburgh), SallyAnn Kelly (Aberlour), Satwat Rehman (One Parent Families Scotland) and Professor Morag Treanor (Heriot Watt University). The main motivation for doing this related to our concerns about the popularisation and potential misapplications of the ACEs model in Scotland and further afield. As a response, we wanted to:
- Provide a source of critical information in relation to the ACEs model.
- Share alternative models of support for children and families.
- ‘Flip the narrative’ from a deficit view of adversity and risk to a hopeful perspective.
My colleagues and I are profoundly aware that many children currently experience a broad range of adversity, and that many adults have experienced adversity in the past which can have lasting and devastating consequences. However, this does not mean that we should see everything through the frame of adversity and risk. Allowing a deficit frame to take hold risks defining the identities of people affected in such terms, as well as any supportive measures, treatment or care put in place for them. Additionally, such a frame is individualistic, locating problems within people themselves and not their social or economic circumstances, which are often ignored altogether.
Our website is designed for practitioners, policy makers and researchers working with or on behalf of children and families in social work, education, health and other sectors. We aim to share thoughts, ideas and materials that can help to change our thinking in relation to support for children and families, creating a shift from a deficit view of adverse childhoods to a broader, transformative understanding of hopeful childhoods.
Selected References
Anda, R. F., Porter, L. E. and Brown, D. W. (2020) ‘Inside the Adverse Childhood Experience Score: Strengths, Limitations, and Misapplications’, American Journal of Preventive Medicine. DOI: 10.1016/j.amepre.2020.01.009.
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P. and 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. DOI: 10.1016/s0749-3797(98)00017-8.
White, S., Edwards, R., Gillies, V., & Wastell, D. (2019). All the ACEs: A Chaotic Concept for Family Policy and Decision-Making? Social Policy and Society, 18(3), 457-466. DOI:10.1017/S147474641900006X.
