Family crossing stream together

Inside the ACE Score Strengths Limitations and Misapplications with Dr. Robert Anda

Dr. Robert Anda, Co-Principal Investigator and designer of the ACE Study, explains strengths and limitations of the ACE Score. He explains why the growing popular movement to use the ACE Score for screening patients, assigning risk, and making clinical decisions for individual patients is a misapplication of the ACE Study findings. 

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Why is the ACE Study and Building Resilience Important for Providers?

Understanding the life history of the people you serve, no matter what services you provide will help your services be more effective. Asking about their personal experiences with adversity will build your relationships and understanding your own experiences will help build your empathy and ability to respond. Knowing how those experiences have an impact, and the variety of responses, will frame the services you provide to truly meet peoples’ needs.

What is the ACE Study?

In the Adverse Childhood Experiences Study, the Kaiser-Permanente (KP) Health Maintenance Organization (HMO) and the US Centers for Disease Control and Prevention (CDCP) collaborated in surveying over 17,000 HMO members about their experience of a variety of adversities as 0-18 year olds and their subsequent health histories. They found a strong relationship between the number of ten categories of adversities experienced ((physical abuse, emotional abuse, sexual abuse, physical and emotional neglect and experience of parental domestic violence, substance abuse, incarceration, mental illness, and separation/ bereavement) and risk of a variety of negative behavior and health outcomes, including “the leading causes of morbidity, mortality and disability in the USA: cardiovascular disease, chronic lung disease, chronic liver disease, depression and other forms of mental illness, obesity, smoking and alcohol and drug abuse.”

Initially eight and then ten categories of adversity were included in the study because of their high prevalence in the KP weight reduction program: five directed toward children (physical abuse, emotional abuse, sexual abuse, and, later, physical neglect, emotional neglect) and five household issues (domestic violence to mother, separation, substance abuse, incarceration, significant psychiatric illness). Although other risk factors such as poverty, political and cultural trauma, etc. also affect illness and wellness, they were not analyzed in the ACE Study of KP members.The number of adversity categories experienced in childhood significantly predicted negative health and behavior outcomes, but it did not appear to matter much which categories were involved. The number of experiences within categories was not counted.

What Can I Do About ACE's?

ACEs can be taken into account when considering service delivery system arrangements, workforce development, family support, community development, and the potential healing power of social networks in preventing ACEs and ACE consequences. The National Center for Trauma-Informed Care seeks to change the paradigm from one that asks, “What’s wrong with you?” to one that asks, “What has happened to you?”

Four Ways the ACE's Findings Make a Difference

  1. Provides a better understanding of why children and families make the choices they do and why they react a certain way
  2. Helps to inform services/practices
  3. Promotes/reinforces strength based approach
  4. Problem behaviors recognized as ways of coping

What about Resilience?

  • It is important to build the capabilities of caregivers and strengthen the communities that together will form the environment of relationships that are essential to children's lifelong learning, health and behavior.

  • Resiliency can overcome ACEs

What Can be Done about ACEs?

  • Provide safe, nurturing relationships
  • Understand coping strategies
  • Identify and reinforcing child and family strengths
  • What has helped the individual to “not be bothered” by their experience?
  • Enhance knowledge (parenting skills)
  • Identify and access supports - Informal and natural; who do they go to in times of need?
  • Provide Evidence Based Programs/treatments or promising practices (age and developmental appropriate)

Where Can I Get Training and Support?

  • How do I start the conversation with families about ACEs?
  • What does trauma-informed mean?
  • How can my agency/organization become more aware of ACEs and identify ways to enhance resiliency?
  • Where can I find training on ACEs for staff?

Please contact the Maine Resilience Building Network  at for training information or questions. MRBN can partner with your school, organization, or business to train about understanding ACEs and resilience, and provide Technical Assistance if you need help adapting your work to incorporate ACEs and resilience. MRBN members come from a broad range of local organizations that specialize in trauma-informed care, and have member providers and educators who can share their research and best practices.

The ACEsConnection website is an online network where you’ll find articles, blog posts, opportunities to connect with professionals from around the world. They’ve published a Roadmap to Resilience that features best practices from around the country. Maine was involved in building this Roadmap!

Roadmap to Resilience

Will People be Disturbed by Taking the ACE Questionnaire?

When the HMO members completed the four-page ACE questionnaire, a clinician was available for phone support 24 hours a day for the three years of the study, in order to assure patient well being. In three years, the clinician did not receive a single call and no complaints about the survey were filed. In fact, many expressed appreciation for having been asked and for the opportunity to briefly discuss the how the experiences affected their health

The ACE questions are now integrated within the overall KP health history and over 400,000 adults have completed them without report of difficulty. Dr. Felitti emphasizes that resistance to the ACE questionnaire is an issue for service providers, but not patients.

If the ACE questionnaire is administered in an office setting or is not part of an overall health assessment process, the comfort level and interpersonal dynamics are different than the experience at KP. Other clinics have reported that some respondents are reluctant to answer questions about trauma in the context of mental health screening. Within focus groups on trauma screening for their children, parents have expressed concern about survey questions about a children’s ACE history leading to a mandated report to child welfare. Likewise, youth have reported reluctance to share their trauma history with strangers or to list it on a form where they are not sure where it would go or what the service system response would be.

Additional research studies indicate that people typically do not mind being asked within professional relationships about their trauma histories and often expect it. Many victims of interpersonal violence describe feeling supported by having their primary care provider screen for safety.

How can ACEs and their Outcomes be Prevented in Children?

Data from the National Child Traumatic Stress Network and the Family Research Laboratory indicate that many children exposed to cumulative trauma or victimization will show negative health and behavior outcomes, even before they reach the age of 18. Yet the majority of these children do not develop the significant health and behavior outcomes identified in the ACE Study. How might that happen and how can this be extended to the more vulnerable children? Many children experience family and community settings that are “good enough” to protect them from the impact of trauma and to support adequate resilience development and healthy coping. Interventions are emerging which help prevent children and families from being overwhelmed by their exposure to one or more ACEs.

Opportunities to prevent ACEs include:

  • Parents managing their marital, mental health, substance use, criminal, violence, and maltreatment risk issues before causing ACEs in their children.
  • Parents reflecting on their own ACE histories, identifying what still bothers them and strengthening healthy ways to cope and to protect and support their children.

The #1 predictor …that a child will develop socially, emotionally, cognitively, etc. is the parent’s self- understanding, or how you have made sense of your own…experiences, good or bad…It’s never too late to make sense of your life and what happened to you.

Dr. Daniel Siegel, Co-author of Parenting From the Inside Out:
How a Deeper Self-Understanding Can Help You Raise Children Who Thrive.

From a lecture at Parents as Teachers National Conference, 4-5-07

For children exposed to ACEs, opportunities to reduce negative outcomes include:

  • Identifying ACEs and providing protective/promotive family and community experiences and enhancing resilience before the child develops impairment (e.g. to maintain child feeling safe, lovable, capable, meaningful; to make sense out of the adversity and how to cope; to enable parent availability to support the child, etc.)..
  • Identifying ACEs and impairment and providing intervention for impairment, before it leads to unhealthy coping or negative outcomes. Screening for cumulative risk across categories (not just the major identified adversity) is important for developing a trauma-informed intervention plan. Trauma-focused cognitive- behavioral therapies for individuals or groups are available to treat impairment, PTSD, depression, loss, internalizing and externalizing behavior problems, etc.
  • Taking a trauma-informed approach to dealing with unhealthy coping strategies and illness, such as assessing for trauma which may have led to impairment which the unhealthy strategies are being used to cope with or which exacerbate illness.


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