Why you need to remain critical of ACEs (Adverse Childhood Experiences)

Why you need to remain critical of ACEs (Adverse Childhood Experiences)

Jessica Eaton

15th March 2019

Lots of people have been asking me why I am critical of the ‘ACEs’ movement. Before I explain why I remain wary of such an approach to human development, for the followers of this blog who don’t know much about ACEs, I will briefly explain it.

ACE stands for Adverse Childhood Experiences.

Essentially, adverse childhood experiences in your own life might include sexual or domestic abuse, neglect or physical abuse, emotional abuse, living with a parent who was in addiction, one of your parents going to prison, being frequently bullied, losing one of your parents to divorce, illness or suicide and so on.

The approach suggests that if you have multiple ACEs, you might require support, therapy, trauma-informed interventions and specialist provision. This is being used to build services, policies, strategies, research and interventions in the UK and around the world.

Many professionals, organisations, governments and universities are also embracing ACEs as the ‘explanation’ for mental health issues in adulthood, criminal behaviour, drug addiction, physical illness, disability, suicide attempts, self-harming and even – being raped. (Yeah you read that right, apparently its your ACEs that cause rape, now).

Maybe you are already beginning to smell a rat. If you are, good. If not, read on.

ACE has been widely used in research to try to understand the correlation between childhood trauma and poor outcomes. Whilst this is important, the way ACEs is being used already holds frightening potentials and actual impacts on traumatised groups.

Below, I will outline my main concerns about ACE approaches. But before I begin, please take a minute to calculate your own ACE score out of 10. It will help you to understand how damaging ACEs can be.

Calculate your ACE score

At any point prior to your 18th birthday:

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?

If Yes, score 1 point

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?

If Yes, score 1 point

Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?

If Yes, score 1 point

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?

If Yes, score 1 point

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?

If Yes, score 1 point

Were your parents ever separated or divorced?

If Yes, score 1 point

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?

If Yes, score 1 point

Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

If Yes, score 1 point

Was a household member depressed or mentally ill, or did a household member attempt suicide?

If Yes, score 1 point

Did a household member go to prison?

If Yes, score 1 point

Now add up your “Yes” answers. This is your ACE Score

 

For transparency, my ACE score is 7. According to all ACE studies, that is very high.

So now you know your score, you might like to know that if you score is 4 or higher, you are the target of the ACEs approach. Keep that in mind as you read on.

 

Reasons we need to remain critical of ACEs

ACEs is being used as a predictive model to forecast outcomes of abused and harmed children

 

My largest concern by far is the way ACEs is being used as a predictive model. That means, your score is being used to predict your potential, your outcomes, your lifestyle, your health, your wellbeing, your mental health and your criminality. Therefore, those of us with ACE scores over 4 are reportedly much more likely (and I’m talking stats between 400%-1222% more likely) to commit suicide, have Hepatitis, commit domestic violence, have heart disease, have liver failure and even *be* raped by someone.

ACEs is literally being used to crystal ball our outcomes – and the outcomes of children all over the world. These approaches pathologise and label children, arguing that those kids with the high ACE scores are destined for doom, drugs, prison, illness and early death.

Maybe you are reading this and thinking, ‘Well, that’s true isn’t it? Abused and traumatised children go on to have such poor outcomes.’

But do they? Do they really? Can we really generalise this much?

Let’s have a think about some basic logic and stats.

If 1 in 5 British adults said they were abused in childhood in the last CSEW (2017), why hasn’t our population literally collapsed under the weight of suicides, chronic illness, criminality and serious mental health issues? Why are there so many ‘successful’ people who were abused in childhood? Why are so many kids making it out of the ghetto and out of the council estates and being able to go to university, get careers, bring up their own kids and live a safe and happy life?

If ACEs was correct, are all of these success stories just ‘anomalies’? Are they all just the exception to the rule?

Okay, maybe they are.

But then can you explain why 51% of the children’s social work workforce were abused in childhood (Eaton and Holmes, 2017)? How can 51% of the UK social work workforce all be exceptions to the rule? How come so many abused and traumatised children can go to university, get a social work degree and work in child safeguarding and protection if they are so damaged by their ACEs?

The reality is, you cannot predict outcomes for humans. Humans are complex, weird and wonderful. Sometimes a kid who escapes trafficking and slavery goes on to become a lawyer and a national advocate – but ACEs would argue that this person should be ill, dead, on drugs or committing violent crime. However, you can also meet people with extremely low to zero ACEs scores (around 20-30% of the population) who have mental health issues, have attempted suicide, are addicted to drugs, are violent criminals or have become very unwell.

This stuff cannot be explained by the individual alone. Scoring systems will always fail us. Quantifying human experience and predicting human behaviour will never work. We are too unpredictable and too diverse.

 

ACEs is not strength-based, it is another predictive deficit model

I hear lots of people hailing ACEs as a ‘trauma informed approach’. However, true trauma-informed philosophies are strength based. This means that if you truly adopt a trauma-informed approach to your work or your understanding of human development and suffering, then you do not label that human with diagnoses or numbers based on what other people have done to them. You will notice of course, in the quiz above, that ACEs are largely things other people did to us, or we witnessed being done to others.

Trying to predict the outcomes of children based on harm committed towards them by a third party is NOT strengths based or trauma-informed.

The trauma-informed approach to trauma and suffering would be to support the human with the reactions, responses and consequences of being traumatised and harmed by others or by an event. We would not then use those events to predict their future. We would argue from a strengths-based, trauma-informed approach that no matter what shit that kid lived through, they are capable of anything. They could be a famous dancer, a genius engineer, a CEO of a company, a doctor, a politician or an author. We would argue that their ‘ACEs’ do not define them and cannot be used to predict their wellbeing, worth or behaviours.

ACEs is therefore a wolf in sheepskin clothes. It is a true deficit framework that calculates the horrible things that have happened to kids or been done to kids, in order to try to predict their futures, as if they are not changeable or recoverable.

Look back at your own life. Think about your ACE score. Are you doomed? Are you in prison? Do you have heart disease? Are you addicted to drugs? Are you beating your partner?

And EVEN IF YOU WERE ANY OF THESE THINGS – would it be because you were harmed in childhood, or are you the master of your own decisions and your own behaviours?

Should dangerous criminals be able to say ‘The reason I did it was because of my ACEs’?

Nah, didn’t think so.

 

ACEs is already being used in harmful and dangerous ways around the world

 

I will give you two examples of how ACEs is currently or has recently been used to harm victims and survivors of abuse. The first example comes from Australia. In recent news, insurance underwriters for life insurance and buildings insurance have started to use ACEs as a way to make decisions on policies and insurance decisions. That’s right. If your ACE score is too high, maybe you are uninsurable. See, ACEs positions you as a risk to that company. What if they insure your life for £500,000 and then you commit suicide with your 1222% change of suicide as put forward by the ACEs study?

The second example comes from a local authority in the UK who made me aware of how ACEs were being used before they found out and commissioners pulled the pilot. In one area of the UK, ACEs scores were being used on pregnant women when they went to antenatal classes or scans, to decide whether to begin pre-birth assessments to check their capability of being a safe mother. You read that right. Women were being asked to fill in an ACEs quiz the same to the one above, and if their score reached a threshold, they were referred to social care for an assessment on their capability to be a mother. This was pulled after 12 months and never spoken about again.

Those of you who support ACEs, had you considered what might happen if we started to label people with numbers based on their traumas? How those numbers might be used against them?

 

ACEs creates some serious cognitive dissonance in professionals

One of the most interesting things I have been doing over the last couple of years (and I encourage all professionals in teaching, training and leadership to do the same) is to get your entire team to privately fill in an ACE quiz to obtain their own score, and then to show them the predictions based on their score. About them being bad employees, skipping work, being unreliable, being ill all the time, being more likely to be in prison, more likely to be addicted to drugs, more likely to die young, more likely to beat their partner.

Let it sink in with them. Let them realise that they too, have high ACE scores. In an average room when I give a speech and I say these things, I watch the faces of the people who know what would have happened if someone had predicted their outcomes. I asked yesterday as I gave a speech in Canterbury, ‘What would someone say about you, if they knew your childhood? What would your score be? Where would they predict you would end up? Do you think they would have predicted you would be sat here listening to me give this speech? No, they wouldn’t.’

Therefore, professionals using ACEs need to be reminded that the ACEs theory applies to adults as it applies to children. If a room of 200 social workers and police can all have high ACEs and yet work in such high-risk, skilled jobs – what does this really say about ACEs?

Does it truly have the predictive power it claims to have?

How can professionals keep using it, making these comments about the outcomes of children, when they know they lived those same lives?

 

ACEs is not accepted by many psychologists, academics, victims and survivors

 

Finally, and thankfully, I am not the only person saying this. Many of us working in psychology, social work, criminology and even victims and survivors themselves – are very wary of the ACEs approach. For detailed, peer reviewed work, look up Professor Sue White and her co-authors. Also, look at the conferences that are springing up around the UK to challenge the way ACEs pathologises children and adults who have been abused. Third, look at organisations like Drop The Disorder (A Disorder for Everyone).

If you are concerned about the way ACEs can be used, you are not alone. Far from it.

 

My final words to you are these:

If you work in social care, policing, psychology, therapies, charities or any other helping profession – most of you came into this work because you believed that these kids were NOT doomed. You believed humans CAN change. You believed that with support, compassion and time, you could help humans to find their strengths and feet again. Deficits models work against you. Deficit models pose that these humans are a product of their trauma, and their outcomes are all affected because they are damaged for life.

I’m not standing for that pessimistic shit and nor should you.

 

Written by Jessica Eaton

15/03/2019

Email: Jessica@victimfocus.org.uk

www.victimfocus.org.uk

Tweet: @JessicaE13Eaton

23 thoughts on “Why you need to remain critical of ACEs (Adverse Childhood Experiences)

  1. Even if ACEs were a reliable guide to adult outcomes, the list above is not very comprehensive. It mentions ‘household’ but does not seem to define what that is; I was in a boarding school and some of those things happened very frequently. And why does sexual assault only count as an ACE if the perpetrator was more than five years older? Sexual assaults happen in institutions a lot and often the perpetrators are only slightly older than the victim but a lot more advanced than them in development. At my school the average boy in year 8 was pre-pubescent; most of the boys in year 10 were as tall as adults although it was common for boys to be held back a year although this usually happened in year 8 or 9.

    I’ve seen ACEs discussed among friends on Facebook in regard to their own divorces, by way of trying to blame the parents for getting divorced (or their ex for getting divorced from them). It’s obviously ridiculous that parental divorce has the same score as rape; the conflicts leading to divorce and the custody disputes that follow may well be more traumatic. A relative of mine is going through a divorce now and to my knowledge there has been nothing traumatic about it that could affect the children; the husband does not spend enough time with them, it’s gone on for too long and the wife wants out but both are trying to protect the children’s feelings and welfare. He’s not a good husband or father, but he’s not foul-tempered or violent.

    Liked by 1 person

  2. Again well said Jessica. I am also a 7! A professional within social care … over 19 years … now its aces what next!
    #stereotypes #assumptions
    We are people, we are human we are not a number, our life experiences can make us stronger .. keep challenging #timetochange

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  3. This is really misleading and factually incorrect, which is a shame as I think there is a legitimate point that you are trying to make that I would support (that deficits based approaches can be pathologising, and that the ACEs model has occasionally been misused in a way that is victim-blaming).

    You appear to have fundamentally misunderstood the nature of what risk means statistically. It is misrepresenting the data to say things like ACEs mean people with high scores have “1222% chance of suicide”. They may have 122 times higher rate than general population, but that would still be a very small minority of people. If one person per 10,000 dies by suicide, then what they are saying is that one person per 82 people with a complex trauma history dies by suicide. 81 people don’t, so if you have a high ACE score and no suicidal intent you are in the majority, not the exception that proves the concept to be wrong. Likewise saying some people with high ACEs do not go on to prison, addiction or violence disproves the whole concept is like saying there is no point treating asthma because most people with asthma won’t die of an asthma attack. A statistical increase in risk is not an inevitability. Likewise if 1 person per 200 in the UK is homeless, then if a person with 4+ ACEs has a 50 times higher rate of homelessness, that means 1 in 4 of them would become homeless at some point in their life. 3 in 4 will never be homeless. If you are not homeless it doesn’t prove it wrong.

    I think the legitimate core of your complaint is about people misinterpreting what increased risk means, as if it’s within each person in a group, rather than a statistical quality of a population group within which a minority of people (but more than in general pop) will go on to a particular outcome. The problem is that you are doing this yourself, through holding the very same misconception that you are accusing others of. And by putting such utter misrepresentation of what the ACEs model tells us out there, you undermine the genuine criticism that it is yet another deficits based model that is being inappropriately used in some contexts to pathologise victims.

    I would argue that trauma history is worth asking about, as it helps others to understand how a person has arrived at their current place psychologically. Understanding that some experiences increase risks help us justify services to prevent those experiences and help people recover from them. In my case, recognising level of need amongst children in Care should mean we provide better mental health input and carer training, for example. I think it can be helpful to have the level of vulnerability childhood trauma confers recognised, along with fact that these early experiences often have lasting outcomes. Much better than claiming that the mental health sequelae of abuse are an unrelated chemical imbalance or a problem inherent in the individual’s psyche, rather than their experiences. But language should be about risk/vulnerability, as many people with these experiences don’t get these outcomes.

    And we need to be clear that increasing risk does not make something causal. Like cannabis and heroin, many people who check the box for the former don’t go onto the latter, but almost all who check the box for the latter had experienced the former – and there are many other variables and choices at play. The incidence cited depends from which end you look at the data. As a trauma survivor the odds are in favour of you going on to have a healthy happy life (even though the incidence of many kinds of later problems is higher than in the general population).

    However, like screening for cervical cancer, screening can be done without pathologising, and help us to understand the variables that really matter (like HPV) and allow protective interventions to be developed. With trauma and abuse, there is a definite dose effect – and that means that the earlier you pick up problems the more you can do to help. If one group is much more likely to have difficulties, we need to shape services to reflect that and meet need. So to me, recognising that some groups of children, such as those that I work with in the Care system, are likely (on average) to have greater mental health needs is a rationale to fund/provide better services for these groups, and to ensure carers have skills to recognise and meet these needs. For the record: I don’t ever count ACEs or use them to determine services, pathologise people or assume they will be in negative outcome groups and I’ve never seen that done in any of the multitude of services I’ve been involved in. But I do like the fact people are becoming aware of ACES, as to recognise risks allows us to tailor services, offer support to those who want it and reduce risk of negative outcomes.

    Finally, let us not forget that the reason the whole ACEs research program came into being was to reduce stigma and victim blaming. Vince Filetti was screening people for bariatric surgery when he started hearing tales of child abuse amongst the patients, and realised that many “medical/biological” problems were in fact much more complex and related to past experiences. ACEs were developed from his finding morbid obesity isn’t due to gluttony, in many cases it reflects deeper feelings about body based on traumatic experiences, and his growing awareness that this complex interplay of experience and physical health was also true in numerous other conditions. I think that is a body of work he can be exceptionally proud to have catalysed, and it would be absolutely wrong to attempt to discredit it on the basis of some hokey maths and two examples of bad practise.

    Liked by 5 people

    1. That was an extraordinarily long way of saying ‘I don’t use ACEs scores and they shouldn’t be used to pathologise children but I still think ACEs is useful’

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    2. May I also add, I’m disappointed you are so sure ACEs is being carefully used as I have just got in from driving 4 hours and my inbox is filled with British men and women telling me stories of how local authorities and service providers have told them their ACEs scores and made them read information telling them they will die 15 years earlier. These emails confirm exactly what I have been saying.

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      1. I’m sure you are misrepresenting what the risk means, and making the very problem you are complaining about worse, and I suspect that you’ve added to the distress people experience when learning about ACEs worse. I don’t doubt there are some examples of bad practice, but they would exist with or without the ACEs research/model. You need to attack the bad practise and not the model, especially as you profoundly misunderstand and misrepresent what risk multipliers mean.

        Liked by 4 people

      2. Interesting how these comments appear to be attacking me as a person and my ‘understanding’ rather than my opinions on ACEs. Your comments give you away.
        To suggest that I am actually adding to people’s distress by criticising a quantitative model of human trauma is a low blow and totally uncalled for.
        I have given extremely serious examples of ACEs being misused both in the blog and in my comments back to you but you brush them off like those people don’t matter. Oh it doesn’t matter that some people are being pathologised and labelled with ACEs and being told they will die early. Oh it doesn’t matter that women were targeted every day for 12 months in a local authority using ACEs to remove their newborn babies. It doesn’t matter that ACEs are being used to refuse life insurance – because they are all one offs? All those examples, are ONE OFFS? Right.
        I’ve woken up to even more emails from members of the public writing to tell me how their ACEs score has been used against them. But that’s all a one off right?
        I’m just misrepresenting ACEs for some random reason. My concerns aren’t valid.

        Finally, could you PLEASE stop explaining basic maths to me. The article uses the percentages that are used in the original studies. The fact that you think I lack the understanding of incidence, percentage versus ratio and risk is a massive assumption based on your personal opinions of me – and again, gives you away.

        You are absolutely entitled to disagree with what I write about. But just remember your own words – you commented here that you don’t use ACE scores and you don’t like the way they label and that you agree that are contributing to a deficit model.
        So maybe ask yourself why you spent all evening trying to belittle me on this post if you actually agree with the main concerns.

        If you have an issue you are absolutely welcome to email me directly or call me. The next comment you leave here that doesn’t focus on this blog and starts to become personal (or explains maths to me like I’m thick) will be deleted.

        Sound.

        Liked by 1 person

  4. ACE scores are very limiting in terms of a person’s potential and resilience levels and in the wrong hands these scores could be damaging. With the right support, access to high quality services and opportunities targeted at enabling the individual to move on in life, individuals can overcome negative childhood experiences: however these ACE scores could eventually be used like SATs and used for outcome predictors and long term labelling.

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  5. Thank you so much for this. I work in a service trying to get us as practitioners to use this. After reading it and scoring myself, I refused to go on the training. It raises all sorts of questions and issues about my own childhood and it made me feel a failure. As a worker. How the hell woukd this then make a victim of any type of abuse feel? And how could I support that victim feeling that I was a damaged individual with bad parents? The parent blaming that will likely come from this tool will help no one. It’s a negative tool, a blunt tool and a hatful tool. In my personal and professional opinion. I’m glad someone has the guts to say this. Thank you.

    Liked by 1 person

  6. Bless your heart Jessica!!!! My being abused by my spouse was blamed on my ACE’s!!!!!! then I really felt traumatised!!!!!

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    1. Same thing happened to me. I’d love to add to this article in terms of how complicated things are. How a one size fits all model never does. How we have no childhood history that informs our everday life but that it is all pathologicalized if discusses in negative ways which totally discounts the history of children in terms of human rights, slavery, labor, forced education and religion and numerous systematized political problems in regards to children as property of parents and state. We’ve only opened up the door to begin to discuss the reality of children’s lives and a good percentage of adults have never self examined their own lives enough to understand themselves. But I get overwhelmed at thinking of writing an article which, btw, is based on actual careful research. Let’s just say we got lots more wrong systematically in our beliefs than we got right. The best thing is to keep open and keep learning and suspend judgment on hard lines right or wrong. One person’s treasure is another person’s trash. One person’s up is another person’s down. One person’s hope is another person’s devastation. That’s because location, time, place, actual circumstances, make differences as to how one experiences their own life compared to others. We aren’t machines and we aren’t objects…we are living beings!

      Liked by 1 person

  7. My only encounter with ACE was a sports coaching thing where the coaches were being told about ace and then pointing out that kids under these lists may be better sports folk, work harder put up with pain more and ‘need’ to be part of a team better 😦 Ugly and foul thing it was, and thankfully it didn’t get rolled out but it was discussed! every person is unique, individual, has every chance they can! some less chances than others but they also deserved more! ACE is a simplistic patronizing short hand to put down folk and keep them down!

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  8. Could the ACE questionare be used to keep students from lets say care based proffessions? (eg in addition to SAT’s the univescities can ask one to do a ACE score questionare ) If one wishes to study Medicine, social work . teaching , Psychology ect..
    If one scores above a 6 lets say.. The uni or college can refuse them entry?

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      1. I do believe that ACE can be used under certain circumstances by professionals to explain certain behaviors.
        I do believe that certain behaviors are a coping mechanism to cope with ACE and by using certain therapeutic techniques one can learn to overcome (IE CBT)
        Humans especially kids are resilient..
        One should not ignore ACE but take it with a grain of salt IMHO

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  9. I find it really concerning that whilst you appear to understand the potential trauma that can occur from completing an ACE score questionnaire you have published it on a public forum where anyone could complete it and indeed then suffer trauma!
    Best practice within the ACEs movement does NOT focus on completing a questionnaire to find out your ACEs score as those that understand the research properly will get that you don’t need to experience 4 ACEs for it to have an impact, it can just be 1 experience alone. It is how the person perceives this experience, the support they have in place to buffer the impact and indeed their own levels of resilience. Best practice promotes professional curiosity…i.e encouraging all to think around what may have happened to someone who needs the support of services, finding out what they feel their need is to best support them and then providing the appropriate support within a trauma informed way. Resilience here is key, it is the reason why many professionals within the field can experience numerous ACEs and bounce back to hold successful jobs, have a healthy lifestyle and happy family. Wouldn’t it be great if everyone within a community could understand the potential effects of early trauma (ACEs) and work together to mitigate the impact of adversity, forming a healthy and resilient community that gives everyone a chance in life. ACEs used in the right way i.e alongside a resilience based trauma informed model ( not completing a ACEs questionnaire and focusing upon the deficit) can go a long way to preventing harm to others.

    Liked by 1 person

  10. Excellent summary. I can’t stay long because I’ve just realised my life is a sham and I should have died long ago, or at least beaten my kids, and probably let all those families I was social worker for off the hook (or not) because of my high ACE score.

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