Keywords

Assessing Adverse Childhood Experiences (ACEs) in Health and Human Service Settings

The link between early childhood adversity and negative physical and mental health outcomes has been established for decades. While Felitti’s seminal study in 1998 first evaluated ACEs in relation to medical outcomes, researchers and clinicians alike had previously noted the impact of negative life experiences, such as child maltreatment or family disruptions, on youth development and adult outcomes. Over time, accumulated data revealed how common early adversity actually is. For example, the prevalence of childhood sexual victimization has been identified globally as 12.7% (Stoltenborgh et al., 2015), and youth exposure to family disruption factors occur at rates of around 25% (Dong et al., 2004; Felitti et al., 1998). Further, a dose response exists between ACEs score (i.e., the number of prior adverse events endorsed) and risk for negative mental and physical health outcomes, a finding that has been replicated across time, samples, and in participants of varying developmental phases, with emerging evidence for synergistic effects as well (e.g., Briggs et al., 2021; Cprek et al., 2020). ACEs screening can provide critical information needed to identify resources to address the consequences of the ACEs exposures (e.g., Child Protective Services in the case of child maltreatment) as well as how this history may influence a person’s ability to engage with current health and human services resources and recommendations (e.g., a female with sexual assault history from a male perpetrator may respond more positively to a female medical provider).

Once a cross-cutting explanatory impact on child development has been identified, it is logical and ethical to incorporate screening and assessment of this factor into regular practice. For example, when links were identified between smoking tobacco and lung cancer, evaluation of patient smoking became a standard of care for cancer treatment. In 2022, screening for tobacco use is a preventative approach in pediatrics, primary care, emergency medicine, and mental health settings. Despite sufficient evidence that ACEs are linked to adverse outcomes, health and human service settings have demonstrated relatively slow uptake of systematized ACEs screening and assessment (Bora et al., 2021). Given recognized associations between ACEs and a range of health outcomes, service provision dedicated to health care and human welfare should seek to evaluate and address the potential influence of ACEs to advance comprehensive and effective service delivery. Improved implementation of ACEs screening and assessment requires thorough understanding of contextual features that matter for effective assessment and identification of barriers to effective assessment that may exist within specific settings. This chapter will describe the conduct of ACEs screening and assessment within health and human service settings, discuss barriers and implementation factors for consideration within these settings, and provide recommendations to enhance effectiveness of screening and assessment to promote positive intervention outcomes and well-being. For the purposes of this chapter, the terminology of health and human service settings will be inclusive of social assistance programs such as foster care and community mental health programs, as well as health-care settings such as emergency care and substance use treatment.

The Why, What, Who, When, Where, and How of ACEs Screening and Assessment

Why Do We Need ACEs Screening and Assessment?

As noted above and in previous chapters, one of the first large-scale studies to methodically categorize ACEs and ask about them in a health-care setting was conducted between 1995 and 1997 in a collaboration between the health maintenance organization Kaiser Permanente and the Centers for Disease Control and Prevention (CDC). Dr. Vincent Felitti noted the high rates of childhood adversity within obese patient populations and associations with treatment adherence. This was one of the earliest acknowledgments of the importance of assessing for ACEs in a health-care setting due to their potential influence in adverse health outcomes and reduced treatment adherence. Since Felitti’s seminal publication (Felitti et al., 1998), exposure to childhood adversity has become a well-documented risk factor for a range of negative outcomes. Evidence continues to advance through multidisciplinary research on how ACEs can prompt individuals to be more susceptible to disease through differences in physiological development and health behaviors (see Chap. 1 for more details). As an example, a 2017 meta-analytic review of over 250,000 adult participants identified the most strongly associated outcomes linked to ACEs as problematic drug use, interpersonal violence, sexual risk taking, mental health disorders, and alcohol misuse, and more moderately associated outcomes as smoking, heart disease, and respiratory disease (Hughes et al., 2017). ACEs are an important part of one’s medical history as they provide context for current health conditions and are predictive of health outcomes (Glowa et al., 2016; Kalmakis et al., 2018) and health-care utilization (Diaz et al., 2022; Okeson et al., 2022). ACEs have also been associated with developmental outcomes, such as social, developmental, or behavioral delays (Cprek et al., 2020).

Beyond the direct link to health outcomes, it is widely understood that screening of ACEs is necessary to inform effective and equitable health care (see Chaps. 11, 12, 13, 14, and 15). For example, ethnic and racially minoritized populations who experience discrimination have increased risk for ACEs (Liu et al., 2019; Merrick et al., 2018). The screening process itself can be therapeutic for individuals when they are able to open up about their experiences and feel understood by someone else (Felitti et al., 2010). Moreover, research has documented how youth and families are willing to report experiences to providers and find ACEs assessment to be an appropriate part of care that can improve family–provider relationships (Rariden et al., 2021). Routine, universal screening of ACEs within service delivery settings can thus help professionals provide comprehensive and effective care while improving treatment of youth social, behavioral, and health conditions, as well as family–provider relationships (Bodendorfer et al., 2020).

While evidence-based responses to extreme ACEs scores need continued development, acquiring an ACEs score is not the end goal of screening. Rather, the ACEs screening process allows providers a way to open the door for further conversation with youth and families about past adverse experiences and assessment of impacts, which, in turn, leads the way to accessing the most appropriate interventions available as well as understanding confounding issues relevant for medical and behavioral care (Watson, 2019). Following the public health framework, ACEs screening can also serve as a secondary intervention by indicating individuals who could benefit from parenting programs or mental health services as well as identifying those who may need additional supports to attend medical visits or address other barriers to treatment adherence. ACEs screening in health and human service settings can thus serve to promote resources for resilience and decrease risk of negative health outcomes.

Screening and follow-up assessment of ACEs serves as a necessary gateway to identification of resources needed for successful implementation of health care and social services. A youth experiencing adversity during engagement with health and human services may require immediate intervention to reduce future risks (e.g., involvement of Child Protective Services in the case of ongoing child maltreatment), and health and human service personnel may be uniquely situated to identify and address that need through screening. Similarly, a person’s history of ACEs exposure may impact their ability to access or engage with health and human services (e.g., youth with an incarcerated parent fearing systems involvement). Assessment of factors associated with ACEs can position workers in health and human service settings to recognize these potential risks to enhance service provision.

The links established between ACEs exposures and medical, behavioral, and social outcomes highlight the foundational nature of assessment of ACEs for effective care across medical and social service settings. The various ACEs categories associate differentially with outcomes, however. Thus, recognition and understanding of subtypes of ACEs may be important for further assessment and intervention in distinctive ways across service settings.

What are the Components of ACEs Screening and Assessment?

Felitti and colleagues extended their work to better understand which adverse childhood experiences could potentially impact other developmental outcomes by pulling from the nascent base of existing literature on ACEs to identify two main groups of adverse experiences: abuse and household challenges. Abuse was further subdivided into physical, sexual, and emotional abuse, and household challenges (or household dysfunction) was separated into presence of a mentally ill or suicidal household member, incarcerated household member, substance use in the household, and mother being treated violently (Felitti et al., 1998). In 2001, a second study expanded the scope of ACEs categorization to include neglect, encompassing both physical and emotional neglect, and added parental separation or divorce to the household challenges group (Dube et al., 2002). The categorization strategy outlined in the later wave of the Kaiser Permanente and CDC study is still one of the most used frameworks in contemporary research and practice, with the exception of the “mother treated violently” subcategory often modified to include exposure to domestic violence in the home more generally. Table 4.1 provides examples of ACEs screeners used across settings with the type of ACE category assessed (see Chap. 3 for additional information). A closer examination of the various categories of ACEs and direct applications within health and human services is described below.

Table 4.1 Example ACEs screeners and implementation factors
Full size table

Abuse

Research has consistently shown abuse in childhood as predictive of a myriad of adverse outcomes (Norman et al., 2012; MacIntosh & Ménard, 2021). Beyond the direct impact of abuse on physical health (e.g., injuries from physical abuse or malnourishment due to neglect), research has demonstrated links to a range of outcomes following prolonged exposure to stressful environments contextualized by fear of injury/harm hypothesized to be driven by physiological changes that occur due to toxic stress (Shonkoff & Garner, 2012). Given the impact of abuse on child development and its association with other ACE categories, abuse should be a core component of ACEs screening, and this can be seen through measures described in Table 4.1. Universal ACEs screening can serve as a standardized and nonintrusive way to gather information and identify which individuals may require more targeted assessment. Some fields have developed standards of practice for abuse screening, with associated models for management of positive screens. For example, the SEEK (Safe Environment for Every Kid) model has been implemented and tested in a range of pediatric (university and community based; serving rural and urban populations; Eismann et al., 2019) and social service settings (e.g., child advocacy centers; Letson et al., 2022), with positive results related to reduction of child maltreatment and cost-effectiveness (Lane et al., 2021). This model includes training for providers around identification of and response to associated risk factors for child abuse, implementation of routine screening tools, and consultation with social workers to address needs and issues. Despite availability of responsive models and professional guidelines designed to promote screening, routine screening of child abuse continues to evade most health and human service providers (Kerker et al., 2016).

Across all settings, screening for abuse should be incorporated into standard routines of practice and follow-up assessment should be comprehensive enough to determine if mandated abuse reporting or referral to a physical or psychological health-care provider is necessary. Global ACEs screening is an efficient and effective way to determine if further abuse assessment is needed. However, beyond these foundational expectations, different settings may enact different procedures in response to positive screening. For example, in medical settings such as emergency departments, providers may devote less time to delving into narrative details on sexual abuse incidences and increase focus on outcomes related to physical well-being (e.g., exposure to sexually transmitted infections, genital and general body injuries). Alternatively, mental health providers may devote more time to understanding impacts of sexual abuse on psychological and emotional well-being. Intensive review of the experience, scope, and impact of sexual abuse with a child may be impractical, unnecessary, and possibly ill-advised in non-mental health-care settings due to the sensitive nature of the topic and its association with mental health symptoms.

Neglect

Neglect, such as physical and sexual abuse, has a high level of co-occurrence with other types of ACEs and can amplify negative effects when paired with other early life adversities (Briggs et al., 2021). Moreover, neglect can indicate environmental barriers to access to other services (e.g., transportation or financial limitations), impacting a family’s ability to engage with supports. Thus, neglect is another critical component of ACEs screening for health and human service settings, also noted in Table 4.1. The two subtypes of neglect (physical and emotional) have been considered differently depending on the setting. Within medical settings, evaluation of neglect has been tied to indicators of physical and emotional well-being for pediatric patients as well as increased risk for other forms of child maltreatment. Neglect is complicated to assess given that, by nature, it assumes the absence of provision of needed emotional, relational, or physical resource. Despite this, screening tools have been implemented in health and human service settings with success. For example, the Well-Child Care Visit, Evaluation, Community Resources, Advocacy, Referral, Education (WE-CARE) screen has been utilized in pediatric settings, with positive outcomes identified around provider comfort in screening for neglect and increased social work referrals for families identifying with screening scores indicating risk for neglect (Zielinski et al., 2017).

Awareness of the clinical presentations of physical neglect (e.g., weight loss, child being dressed inappropriately for the weather, poor hygiene) may support a health-care provider in recognizing the potential for ACEs in a child and proceeding to further screening. Physical neglect is associated with a myriad of adverse developmental outcomes that would be of particular interest in medically oriented settings; however, clinical judgement must be used in all settings to determine the appropriate response depending on circumstances surrounding physical neglect. The nutritional and material hardships associated with physical neglect can be related to familial poverty, parenting characteristics, or combination of both (Slack et al., 2004). If a provider deems poverty to be the principal cause, referral to case management or social work services may be more appropriate than engagement with Child Protective Services. Further, in-depth evaluation of emotional neglect may be ill-advised in most settings due to time or training limitations. If emotional neglect is identified through screening, referral to Child Protective Services and/or therapy is likely the most appropriate response.

Household Dysfunction

Household dysfunction encompasses a wide range of interpersonal and structural stressors in a child’s life, and indicators of household dysfunction are strongly linked to increased risk for exposure to other categories of ACEs (e.g., family conflict and parental substance use as risk factors for child abuse; Stith et al., 2009). Household dysfunction may be an area where health and human service workers experience limited resource in their ability to intervene beyond screening and referral. Despite this, models such as the WE-CARE screen described above enables more efficient referral to supportive services, such as social work, where preventative services may be more readily employed to reduce family stress impacts around poverty, substance use, and incarceration. Social service systems such as foster care may represent settings where knowledge of a child’s exposure to this category of experiences could be vital. Foster care is a system designed to prevent continued child maltreatment through removal of youth from abusive or neglectful biological caregivers to placement within a safer environment such as kinship care (placement with a relative), foster home care (placement with a foster family), or residential care (placement within a group home or larger facility with paid staff). Upon entry to foster care, assessment of a child’s background with regards to ACEs, including family structure and adversity, is crucial in understanding a child’s potential for integration with and stability in foster care placements as ACEs score has been linked to placement stability (Liming et al., 2021). Youth in foster care report prevalence rates of household dysfunction that are similar to prevalence rates of abuse; therefore, system-involved youth may need intervention support to address trauma related to maltreatment experiences as well as family adversities. Furthermore, if placement with family in kinship care is considered for a child in foster care, providers must be cognizant of the dynamics in both the immediate nuclear family and extended family to ensure the safety and well-being of the child. Thus, evaluation of household dysfunction could inform the type of foster care placement for a child as well as resources needed for that child’s safety and success within foster care.

Within psychological health-care settings, understanding a child’s experience of household dysfunction may support or enhance the involvement of parents or guardians in the treatment process. This involvement could be as minimal as transportation to appointments or provision of technology to engage with telehealth services, or it could be a more formal involvement prescribed in treatment protocols (e.g., Parent-Child Interaction Therapy; McNeil & Hembree-Kigin, 2011). Parent/guardian engagement with therapy may consist of attitudinal (e.g., motivation and expectations for treatment) and behavioral (e.g., attendance, active participation, and help-seeking behavior) components, each with unique potential impacts on treatment efficacy in children (Staudt, 2007; Haine-Schlagel & Walsh, 2015). Attitudinal and behavioral components of parental engagement with therapy may be impacted by household dysfunction, and information obtained through ACEs screening could be leveraged to improve treatment planning and treatment efficacy if features of dysfunction are addressed early on in the process.

Other Adverse Experience Categories

Some studies have promoted additional categories of adverse childhood experiences. Teicher and Parigger suggest emotional abuse may be further subdivided into verbal and nonverbal emotional abuse (2015). Verbal emotional abuse encompasses swearing at, insulting, or humiliating the child, while nonverbal emotional abuse encompasses behaviors such as being made to shoulder adult responsibilities or feeling as if their parent was excessively difficult to please. Other studies have proposed including themes such as bullying and rejection by peers (Hertz et al., 2015; Finkelhor et al., 2013) community and neighborhood level dysfunction and community violence (Finkelhor et al., 2013, 2015; Lee et al., 2020), and exposures to natural disaster (Choi et al., 2020) as unique ACEs categories. Children may also experience negative life events such as war, sociopolitical instability, serious illness, and racial and other historical forms of harm, which have been linked to negative outcomes as well. It is likely not feasible or necessary for a provider to assess all of these categories in every individual, yet providers should have some awareness of these potentially traumatic and harmful experiences and their capacity to serve as latent factors in adverse health-related outcomes. Health and human service settings rarely universally screen for all of these specific events, but location (e.g., areas that are tornado prone, with refugee populations, or with high community violence) may inform whether or not certain items should be assessed regularly in standard practice. The amount of data required may also vary; depending on the goal, providers may limit screening to number of ACEs categories experienced or may opt for screening of specific types of abuse and details of the experiences (Schulman & Maul, 2019).

To address issues related to question burden, some have recommended use of open-ended questions to capture any potentially traumatic events not addressed in a formal screening tool. In higher-risk groups, such as youth in the foster system, the American Academy of Pediatrics has suggested incorporating open-ended questions into routine care, including “Do you know of any really scary or upsetting things that happened to you/your child either before or after he/she came to live with you?” and “Since the last time I saw you/your child, has anything really scary or upsetting happened to you/your child or anyone in the family?” (Barnes et al., 2020). Further, use of an ACEs conversation rather than an independently completed screening tool may serve as a way to circumvent limitations of formal ACEs screening (Bodendorfer et al., 2020).

Who Should Report on ACEs Exposure?

In addition to what types of ACEs are assessed, interventionists within health and human service settings should consider the reporting source as well. ACEs screening began through use of retrospective self-report in adults; yet, screening can be done across the lifespan, with greater preventative impact if initiated at the earliest stage possible. Some have suggested that screening for maternal ACEs exposure should begin at prenatal visits, as an example (Sherfinski et al., 2021; van Roessel et al., 2021). Screening for ACEs in children is complicated by which reporter is utilized (i.e., caregiver or child). Screening of ACEs in children is somewhat less common, however, with 19.4% of providers asking children directly for their own ACEs and 16.7% of providers asking caregivers for children’s ACEs (Bora et al., 2021). Younger children may not be able to understand and report upon ACEs or may be uncomfortable reporting in the presence of a caregiver (Bright et al., 2015), while caregivers may not be the most accurate reporters, particularly if they are implicated by any responses. Research has suggested that, due to low concordance between parent, child, and caseworker report of ACEs, multi-informant approaches may be best (Lombardi et al., 2022).

Screening type may also vary depending on the age and developmental status of the reporter and whether reports are self-reports or on behalf of another (Schulman & Maul, 2019). It is not recommended to directly screen youth below the age of 8 (Bethell et al., 2017), and most clinicians reported only asking parents, not children, about household dysfunction items (except for divorce; Bright et al., 2015). Parents have expressed discomfort reporting for children on items related to sexual abuse, separation from caregivers, and community violence (Koita et al., 2018). Previous research suggests that adversities may also have critical developmental periods. Specifically, family-related factors (e.g., family separation, economic stressors, parent mental health) appear to be more influential for younger children, and community and peer-related factors (e.g., community violence, assault with injury, interpersonal loss) appear to be more influential for older children (Turner et al., 2020). A related developmental consideration concerns at what ages youth, versus their parent or guardian, can provide reliable and valid self-reports about their adverse experiences. Older children may forget or misremember adversities from their younger years and, unintentionally, may report more proximal adversities (Bethell et al., 2017). Further, youth may have difficulty reporting adversity they are experiencing in the present, especially if that report may result in their removal from their biological home or retainment within foster care (Felitti et al., 1998). There are also difficulties inherent in translating questions that ask about abuse/neglect and substance use for younger populations.

Often parents complete ACEs screeners as proxy for young child report. Parents who provide reports of their children’s experiences may underreport certain ACEs either because they do not know of the exposure or they may be unwilling to report exposures that involve a parent. Their answers could be potentially self-incriminating and thus unreliable, particularly if they perceive they will have negative consequences, such as a referral to child welfare or negative outcomes related to current child welfare involvement (McKelvey et al., 2017). Some researchers have attempted to replicate the original ACEs studies as closely as possible with parent reporters (Bucci et al., 2015; Marie-Mitchell & O’Connor, 2013). Others have asked proxy questions (e.g., asking parents if they had ever “spanked” their child as opposed to if they “physically abused” their child) to maintain a positive relationship with the parent for the purpose of future parenting intervention (McKelvey et al., 2016). Determination of the best reporter for ACEs screening should be informed by the purpose of the screening, the age/developmental status of the youth being screened, and the youth and family relationship with the person conducting the screening.

When Should ACEs be Assessed?

As noted above, ACEs screening originated as adult retrospective reporting on childhood experiences. Given what is known about the exponential negative impact of dosing of ACEs, early and repeated assessment of ACEs exposures may reduce recurrence of ACEs across developmental phases. Thus, screening of ACEs at baseline service entry (i.e., intake for human services) can serve to define the etiology and prognoses of problems, both behavioral and physical. Repeated evaluation of ACEs across service delivery can also ensure ongoing safety and improvement of environmental factors. Within outpatient therapeutic settings, negative life events are often discussed broadly, but routine monitoring of ACEs exposure for youth and baseline evaluation of ACEs exposure for adults would assist in diagnostic formulation and evaluation of treatment progression.

Youth involved with human service systems tend to have more severe histories of ACEs and are at increased risk of maladjustment in adulthood (e.g., Turney & Wildeman, 2017). Within some human service settings, the goal of the intervention is to reduce ACEs exposure – namely youth are placed in foster care as an intervention for lack of safety in the biological home setting. Within foster care services, routine monitoring of ACEs exposure for youth in foster care should be a minimum requirement. Youth in foster care with greater ACEs exposures are also at increased odds of experiencing placement instability; therefore, it is important to address ACEs history at entry into care and throughout care (Liming et al., 2021). Some states, such as Kansas, explicitly screen all youth who enter the foster system for ACEs (Liming et al., 2021). Unfortunately, there exist no universal guidelines (defined and measurable standards for when and how assessment should occur) for assessing ACEs among youth involved in the child welfare system nor for monitoring future exposures during their time in the system.

ACEs can influence developmental trajectories as well, and, as such, ACEs scores may have different impacts depending on the developmental timing of occurrence (e.g., Hambrick et al., 2019). Relatedly, exposure to one type of adversity increases risk for ACEs exposures within other categories. Thus, a positive ACEs screen at 5 years of age may have greater impact and association with outcomes as compared to a positive ACEs screen at 18 years of age. For these reasons it has been suggested that thresholds are set differentially across ages, with a lower threshold for positive screen for younger children (Barnett et al., 2021).

Where and How Should ACEs Screening Occur?

Research suggests that ACEs screening is most likely to occur in medical or mental health-care settings and most commonly involves adult retrospective report (Bora et al., 2021). However, ACEs screening may be better suited for behavioral health settings, given the potential for more intensive therapeutic support and intervention. ACEs screening in behavioral health settings may be more appropriate once rapport is established, and families may be more likely to disclose prior ACEs within an established therapeutic relationship (Schulman & Maul, 2019). Conversely, some have said that in the absence of rigorous psychometric evaluation, ACEs screening should not be universally adopted in place of a comprehensive evaluation of current psychosocial factors and may not have independent clinical benefit (Racine et al., 2020). ACEs screening, particularly for children, may best be done amid general history-taking and health-promotion discussions as part of standard care (Bethell et al., 2017). Many have spoken to the value of conversation around these questions to gather information about context (e.g., Barnes et al., 2020; Bethell et al., 2017). Providers and families have described these conversations as supportive and amenable, and this approach to ACEs assessment can serve as a complement or replacement for formal screening by increasing awareness of related issues and providing psychoeducation and resources (Bodendorfer et al., 2020). Alternatively, emergency departments appear to utilize short, formal ACEs measures more often than other settings (e.g., Koball et al., 2021). This approach is likely impacted by the time-limited nature of the provider–patient relationship and lack of established rapport to facilitate informal discussion within emergency settings.

In terms of physical context for screening, youth and families report feeling most comfortable completing ACEs screeners in private rooms (as compared to waiting rooms; Rariden et al., 2021; Schneider et al., 2021) and during visits without an abundance of other paperwork (Kia-Keating et al., 2019). Most parents did not express a preference for modality of screening, but those who did indicated face-to-face screening and assessment would facilitate more trust and comfort (Conn et al., 2018). A number of ACEs measures exist, with some described in Table 4.1. Depending on the setting and population served, factors that may influence measure selection can include clinical utility, identification of potential barriers to services, age range of respondent, or the time it takes to complete the measure.

Other suggestions related to ACEs screening implementation from youth and families include provision of an explanation for the purpose of the questioning and emphasis on the individual’s right to not disclose (Conn et al., 2018). In a military setting, individuals further emphasized the importance of confidentiality assurances (Robinson et al., 2008). At the practice level, factors identified to improve implementation of ACEs screening include electronic medical record integration of ACEs measures, clinician training in the importance of and how to do ACEs screening and follow-up assessment, and integration of behavioral health services to promote access to follow-up resources (Barnes et al., 2020).

Challenges and Barriers to Effective Assessment

Despite widespread agreement regarding the importance of screening for ACEs, clinician use of validated ACEs screening tools may be as low as 2% (Bora et al., 2021). Indeed, many caregivers report never discussing their child’s ACEs with primary care providers (Okeson et al., 2022), highlighting the need for this screening to occur across health and human service settings. Studies suggest, though providers understand the importance of childhood stress on youth outcomes, they rarely conduct comprehensive ACEs assessment (Kerker et al., 2016). Informal or incomplete assessment of ACEs is much more common, but still only reported in up to 50% of providers (e.g., Bright et al., 2015; Kerker et al., 2016). This may be a product of the differential uses of child versus adult ACEs reports; youth report of ACEs facilitates prevention of future ACEs (thus improving quality of life and adult outcomes), while adult report of ACEs facilitates more targeted care and prevention of ACEs-related mental and physical health problems.

Systematic integration of ACEs screening into standard practice could improve ACEs identification, yet disagreement remains within health and human service settings as to whether ACEs screening should be integrated as routine practice. Some have expressed concern that universal ACEs screening may result in more referrals and increased burden to other systems (e.g., child protective systems, behavioral health care; Barnett et al., 2021) or that screening in the absence of identified support services may be unethical (Finkelhor, 2018). Others reference barriers to universal screening such as limited knowledge about ACEs and the efficacy of screening, lack of training for providers, potential harm to youth, and the exclusion of additional adverse experiences beyond the 10 original ACEs (Barnes et al., 2020; Byatt et al., 2020; Maunder et al., 2020). Additionally, researchers have questioned the psychometric properties of the original ACEs questionnaire, failure to address synergistic effects of ACEs with just a cumulative score and cutoff (Briggs et al., 2021), and the sufficiency of evidence-based interventions for high ACEs scores (Finkelhor, 2018). It has also been noted that ACEs screening can be time-consuming and may even increase stigma related to trauma (Finkelhor, 2018). Unfortunately, research to support adopting universal, routine ACEs screening is still in its infancy, which has also been used as an argument against widespread implementation.

Fortunately, most identified barriers to ACEs screening can be mitigated through training to increase provider confidence in their ability to sensitively screen and education on available resources and support in response to disclosures (Rariden et al., 2021). Increased provider comfort around screening may also further reduce discomfort for the individual being screened (Mersky et al., 2019). Successful ACEs screening implementation may include educational resources for individuals who report ACEs, readily available referral sources for positive screens, and provider training in the provision of trauma-informed care. Research to date suggests that most people express willingness to discuss these topics with providers (e.g., Ford et al., 2019; Rariden et al., 2021). Moreover, in some cases, ACEs screening resulted in increased trust in providers (Flanagan et al., 2018). Medical providers have also reported that implementation of ACEs measurement is both a feasible and acceptable part of care (Gillespie & Folger, 2017). Taken together, these barriers to ACEs screening can be addressed in ways that mitigate discomfort to support improvement of health and human service delivery.

One methodological concern around the standardization of ACEs screening is whether to include experiences beyond the 10 recognized in the original ACEs measure, such as community violence, poverty, and more (Finkelhor et al., 2015). The type of ACEs evaluated should likely be informed by the population being served. For example, for special youth populations, such as youth in foster care, it may not be sufficient to simply assess for a sum score of ACEs, which fails to account for the complexity of and possible synergy across the exposures (Briggs et al., 2021). All youth in foster care have had some level of previous ACEs, which prompted their placement into care, their exposures to adversity such as child maltreatment tend to be chronic and complex in nature, and they may be at increased risk for further unique adverse experiences within foster care (e.g., placement instability; educational disruption). Thus, further assessment of other features of the exposures (i.e., severity, frequency, chronicity) may be important for identification of needs and design of prevention and intervention services.

Current Status of Assessment Efforts within Health and Human Service Settings

Though barriers limit implementation of ACEs screening within health-care settings, successful implementation examples exist within the medical field (Kia-Keating et al., 2019). Gillespie and Folger (2017) employed ACEs screening within a pediatric setting and found that parents were receptive to conversations about past adversity and clinic visits were improved. Recognition of ACEs detrimental health effects on children and adults led California to become the first state to adopt ACEs screening for all children on Medi-Cal (state health insurance for low-income individuals; Loveday et al., 2022). As of 2021, through the ACEs Aware initiative, the state of California has allocated over $45 million in funding for ACEs screening with over 50,000 youth and adults having been screened thus far. They are among the first in the nation to implement ACEs assessment within primary care settings. Expansion of child ACEs screening may also be facilitated through existing well-child surveillance mechanisms. Some examples include HealthySteps (a nonprofit committed to promoting a strong start for babies and infants), which has ACEs-specific guidance for providers having conversations with caregivers about ACEs (Barnett et al., 2021; Briggs et al., 2016) and Bright Futures (an American Academy of Pediatrics program), which provides guidelines for discussion in situations of positive screens, overlapping with ACEs categories (Barnes et al., 2020). Both HealthySteps and Bright Futures also include guidance on discussing caregiver adverse experiences in recognition of the importance of parent mental and physical health for child well-being. In sum, successful implementation of ACEs screening across settings is possible when resources are available and clinicians receive the appropriate education and training needed (Rariden et al., 2021). Within these settings, the most frequently used screener for adults is the original 10-item ACEs survey from Felitti and colleagues’ (1998; Barnett et al., 2021) and an extended pediatric version by the Center for Youth Wellness (Barnett et al., 2021; Purewal et al., 2016; see Table 4.1).

Research has also identified youth engaged in human service settings as a population with increased risk for ACEs, and higher numbers of ACEs can result in interference with youth engagement in and response to social services. For example, ongoing family conflict and child maltreatment in the home may prevent a youth from participating fully in a weekly therapeutic process. Extreme poverty and features of household dysfunction may impair a family’s ability to find and engage with supportive services in the community. Identification of ACEs as well as how ACEs may interfere with service engagement is an important first step to effective service provision. The Family First Prevention Services Act represents a promising national approach that requires trauma-informed prevention programming with an aim to reduce foster care placements and the subsequent need for residential facilities. Within this prevention framework, ACEs screening has clear relevance; yet among states with approved plans as of 2021, only some have plans to monitor specific ACEs among youth involved in the child welfare system such as maltreatment and parental mental health and substance use. Further, inconsistency exists between what ACEs are assessed state by state. Currently, the most widely used measure within the child welfare system is the Child and Adolescent Needs and Strengths – Trauma Comprehensive (CANS-Trauma; Kisiel et al., 2018). The CANS-Trauma assesses a range of adversities, not all of which are considered in the original ACEs measure. For example, the CANS-Trauma leaves out experiences such as parent mental health and substance use but includes other experiences such as community violence, natural disaster, terrorism, and more. The CANS-Trauma tool has been used to improve assessment, individualized services, and treatment planning across human service settings (Kisiel et al., 2018). The CANS-Trauma has been well validated in the existing literature as an approach for informing service planning and offers a method for routine ACEs assessment within human service settings where child adversity exposure may be a primary target for intervention.

Recommendations for ACEs Screening in Health and Human Service Settings

Factors to enhance implementation of ACEs screening should be considered in response to identified barriers that exist. Provider training and knowledge, reporter age, time availability, practice culture, follow-up resources for positive screens, and lack of standardization for best practices in ACEs screening contribute the effectiveness of ACEs screening. For example, if providers ask questions in an insensitive way or fail to provide needed resources to address ongoing ACE exposures, the screening process could do harm. Recommendations to promote effective ACEs screening in health and human services settings include: use of a developmentally tailored approach to screening, triangulation of data sources (or reporters) to assist in comprehensive identification of ACEs, structured follow-up on relevant ACEs features depending on the service setting, monitoring of ACEs exposures across time, trauma-informed methods for assessment, and interdisciplinary approaches to response to positive screens.

Developmental Tailoring of Assessment Methods and Questions

Effects of ACEs exposure during critical developmental periods, developmental differences in the occurrence of specific ACEs, and/or the proximal impact of ACEs across ages are critical features important for consideration during ACEs assessment. Providers engaging in ACEs screening within health and human service settings should attend to these issues when choosing their screening method and interpretating results. As noted above, young children will need proxy reporters, such as parents, to indicate their exposure to adversity, but parents may experience reporting biases that influence their responses. If youth are assessed directly (recommended when possible) questions need to be tailored to the child’s developmental level for understanding. For example, from the CDC ACEs screener, a young child may need explanation of words such as “alcoholic” or “depressed.” Further, early exposure to adversity can impact developmental trajectories (Hambrick et al., 2019). If the goal of ACEs screening is to intervene to prevent future ACE exposures and mitigate the impact of ACE exposure, any ACEs in early childhood should be addressed as soon as possible. Thus, if using cutoff scores for ACEs screening, one may need to adjust cutoffs downward for younger children, as noted above (Barnett et al., 2021).

Triangulation of Data Sources for ACEs Evaluation

Effective ACEs screening is dependent upon who can offer the best report (e.g., parent of a young child) as well as how information can be most effectively obtained (e.g., self-reported questionnaire versus clinician interview). Because of the diversity of populations served and intervention aims across health and human service settings, there is no gold standard tool to assess adverse life events. Thus, triangulation of data sources and methods will support obtainment of accurate estimates of a person’s ACEs exposure (Barnett et al., 2021; Lombardi et al., 2022). Parent report of a child’s ACEs exposure can provide relevant information on adversities that occurred in early childhood, whereas youth self-report of ACEs exposure may provide additional information beyond what parents know or feel comfortable disclosing. If medical records are available, record review might reveal information disclosed to other providers or information available from prior medical history (parental incarceration or physical injuries). Comparisons of youth self-report versus case file review within youth in foster care have revealed that differences in report of child maltreatment across reporter are common (Hambrick et al., 2014). For comprehensive assessment of ACEs exposure, use of multiple data sources will provide the most reliable and complete information.

Universal Screening and Repeated Monitoring of ACEs Exposures

Despite a strong foundation for the importance of ACEs screening and follow-up within health and human service settings, at best, clinical services may screen for ACEs at intake, while at worst, many service settings do no standard or repeated evaluation of ACEs. As noted above, some types of ACEs have greater likelihood of occurrence at different phases of youth development. Thus, a singular capture of ACEs early in childhood would likely miss the recurrence of ACEs or dosing of additional ACEs across time. Furthermore, exposure to one type of ACEs category may increase risk for exposure to additional ACEs (Dong et al., 2004; Finkelhor et al., 2009). Health and human service systems could incorporate ACEs screening into semi-regular (e.g., yearly) visits to assess and monitor adversity exposure, and regular evaluation of ACEs could reveal dosing patterns and changes in risk levels over time. Social service settings, such as foster care, may seek to assess ACEs on a more frequent basis as relevant for the population served.

Guidelines and Training for Effective ACEs Screening and Assessment

In our review of available ACEs screening tools, almost all have a prespecified set of ACEs categories as were described above. Unfortunately, most ACEs measures do not account for severity and duration of the events, repeated/chronic exposure to adversities, or interpersonal components (e.g., parent as perpetrator of maltreatment). Identification of ACEs exposure is best when organizations utilize empirically supported screening tools and then follow up on relevant ACEs features as appropriate for the particular health and human service setting. Further, any ACEs screener can be supplemented with an open-ended question such as, “Is there any other negative life experience that you feel is important for me to know/important for your services here?”

Generally, specific training in trauma-informed care (TIC) may be needed to prevent re-traumatization, and excessive inquiry into ACEs may not always be advised (Finkelhor, 2018; Oral et al., 2016). However, evidence-based protocols for intervention in posttraumatic stress disorder (PTSD) and other clinical impairment following trauma exposure that involve in-depth processing of the experience do exist, including trauma-focused cognitive behavioral therapy (TF-CBT; Cohen et al., 2012). TF-CBT protocols include guided development of a trauma narrative and in vivo mastery of trauma reminders among other therapeutic techniques over the course of many weeks. It may be most appropriate to wait for the development of therapeutic rapport to delve into details related to severity or chronicity of ACEs events later on in treatment. Within pediatric settings, appointments often only last 15–20 min, and a rushed evaluation of severity of events or perpetrators of abuse may cause emotional harm or impact accuracy of reporting. Thus, service settings should develop standards of practice around positive ACEs screens and follow-up evaluation based on clinician competencies and available referral sources. Further, providers within health and human service settings who engage in ACEs screening should rely on empirically supported screening tools and an organizational policy for referral to indicated follow-up specialty services (e.g., child protective services and/or mental health services with clinicians trained in empirically supported trauma treatments).

Best practices for methods of ACEs screening are nascent, but several studies have identified promising approaches. When agencies incorporate ACEs screening into standard practice, attention needs to be given to the training of service providers who will be interpreting and responding to the screen. As noted earlier in the chapter, providers engaging in ACEs screening have noted a lack of training around how to conduct ACEs screening and how to respond to positive screens. Other barriers identified included concerns about time management and risk of harm through the screening and assessment process. Interestingly, previous research has shown that positive screens in ACEs evaluations have minimal impact on clinical workflow and providers can manage risk of harm of assessment through simple interpersonal techniques (e.g., framing the purpose of the screening and assessment) and universal screening (to reduce stigma related to the inquiry; Mishra et al., 2021). Implementation of ACEs screening in practice can be improved through education of providers on how to screen, preidentified referral resources for positive screens, and setting specific feasibility planning to minimize impact on workflows.

Interdisciplinary Approach to ACEs Assessment and Response

Lastly, the ACEs literature has benefitted from a strong interdisciplinary approach to identifying links between ACEs and outcomes, relevant for physical, behavioral, and social health. Because of this, ACEs screening has been identified as a key feature for standard practice across settings. Given the range of ACEs categories (e.g., abuse, household dysfunction), some with direct implications for physical and behavioral diagnoses, an interdisciplinary approach to ACEs evaluation and intervention for positive screens would likely produce the best long-term outcomes. For example, evidence on the intergenerational transmission of risk for ACEs exposures reveals that primary prevention of youth risk for ACEs likely involves behavioral and health interventions at the parent level (e.g., referral for parental substance use, mental health, or legal services; Narayan et al., 2021). The SEEK model described earlier in the chapter provides a framework for linkage to community resources and social work support in the case of positive screens (Eismann et al., 2019). Management of risk related to child abuse and neglect will likely require community level intervention as well as social service interventions to address stressors such as poverty, community violence, and access to effective supports.

Access to appropriate resources following a positive ACEs screen appeared consistently in research on barriers to implementation of ACEs screening in practice, yet systematic guidelines for how to respond to positive screens are difficult to establish given the varied nature of available supports across locations. In parallel with implementing routine ACEs screening in health and human service settings, preidentified referral sources as well as decision pathways to mandated reporting can support clinician comfort with engaging in ACEs screening universally (Barnes et al., 2020). Access to interdisciplinary supports that can alleviate family stress on the whole is most effective in reduction of risk for recurrent ACEs exposures.

In summary, early adversity has impact on physical and mental health outcomes relevant for practice within health and human service settings. While notable barriers exist to effective implementation of universal screening and monitoring of ACEs, the cost of not asking about ACEs likely far outweighs the cost of addressing these barriers. Specifically, establishment of standards for routine screening of ACEs across the lifespan, triangulation of data sources for reporting, utilization of developmentally tailored and setting-specific ACEs screeners, structured pathways for follow up on positive screens, and interdisciplinary approaches to management of positive screens will enhance ACEs screening uptake and response in health and human service settings.