Practitioner Review: Twenty years of research with adverse childhood experience scores – Advantages, disadvantages and applications to practice

Abstract

Background: Adverse childhood experience (ACE) scores have become a common approach for considering childhood adversities and are highly influential in public policy and clinical practice. Their use is also controversial. Other ways of measuring adversity -examining single adversities, or using theoretically or empirically driven methods -might have advantages over ACE scores. Methods: In this narrative review we critique the conceptualisation and measurement of ACEs in research, clinical practice, public health and public discourse. Results: The ACE score approach has the advantagesand limitationsof simplicity: its simplicity facilitates wide-ranging applications in public policy, public health and clinical settings but risks over-simplistic communication of risk/causality, determinism and stigma. The other common approachfocussing on single adversities -is also limited because adversities tend to co-occur. Researchers are using rapidly accruing datasets on ACEs to facilitate new theoretical and empirical approaches but this work is at an early stage, e.g. weighting ACEs and including severity, frequency, duration and timing. More research is needed to establish what should be included as an ACE, how individual ACEs should be weighted, how ACEs cluster, and the implications of these findings for clinical work and policy. New ways of conceptualising and measuring ACEs that incorporate this new knowledge, while maintaining some of the simplicity of the current ACE questionnaire, could be helpful for clinicians, practitioners, patients and the public. Conclusions: Although we welcome the current focus on ACEs, a more critical view of their conceptualisation, measurement, and application to practice settings is urgently needed. Researchers need to be clearer about their definitions of adversitywhat constitutes an adversity and what does not?Researchers should consider including additional ACEs other than the 10 frequently investigated ACEs from the Kaiser Permanente Study and justify these clearly.Researchers should explore the different ways in which ACEs tend to cluster cluster and, individually and together, predict outcomes Longitudinal studies are required, particularly those which are able to consider the co-occurrence, timing, frequency, duration and severity of ACEs, and which have high quality prospective ACEs data. Key practitioner messagesTwenty years of adverse childhood experiences (ACEs) research has shown a graded relationship between the number of adversities (ACE score) and health and other outcomes in many different populations, with important implications about the potential impact of ACEs in clinical practice, public policy and public health initiatives.

Contrasting cumulative risk and multiple individual risk models of the relationship between Adverse Childhood Experiences (ACEs) and adult health outcomes

“…Despite the additional information gained from application of a multiple individual risk model, it is virtually absent from the literature, despite the long history of research into the effects of specific abuse types ('single adversity approaches' [6]). For example, there is substantial theoretical and empirical support for childhood sexual abuse specifically (compared to other childhood adversities) as most strongly predictive of several outcomes including suicidality [32], cardiopulmonary symptoms, and obesity [33].…”

“…An example of the logistic regression model is represented in eq. (1) for the i th participant, assuming a binary outcome and continuous ACE Score (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11), and with the same set of covariates (not represented in the model equation).…”

“…However, there are instances that it makes theoretical sense (either for certain types of adversity or for certain outcomes) to consider that an accumulation of adversity might not be the only model to consider. The review of Lacey and Minnnis provides an overview [6].…”

Contrasting Cumulative Risk and Multiple Individual Risk Models of the Relationship Between Adverse Childhood Experiences (ACEs) and Adult Health Outcomes

“…but with a restrictive assumption about linearity of the effect (that each additional ACE has an equal impact). An example of the logistic regression model is represented in equation 1for the i th participant, assuming a binary outcome and continuous ACE Score (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11), and with the same set of covariates (not represented in the model equation).…”

“…Differences in operationalization may impede efforts to synthesize the literature and differences in conceptual models of how adversity impacts outcomes have high stakes as policy and intervention programming depend on this body of literature. There has been some recent criticism of the use of the 'ACE Score' (4)(5)(6), some of it from within the original Kaiser ACEs Study team (7). Such criticism tends to focus on using a 'crude' or oversimpli ed measure in policy-making.…”