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Information Sheet #202E
Screening or Not Screening? Unresolved
Debates on the Use of the Adverse
Childhood Experiences Questionnaire in
Routine Screening
Delphine Collin-Vézina, Denise Brend & Barbara Fallon
July 2020
Introduction
The Adverse Childhood Experiences (ACE) Study is a landmark study conducted by Kaiser Permanente and
the Centers for Disease Control and Prevention. It was the first large scale, non-clinical study to document ten
categories of adversity in childhood (covering both child maltreatment experiences and household challenges)
and to assess their relationship with health outcomes in adulthood. These categories were sexual, physical, and
psychological abuse; physical and emotional neglect; parents’ mental illness and substance abuse issues;
parent’s incarceration; domestic violence; and divorce.
About 17,000 adults took part in the initial study and reported retrospectively their experiences before the age
of 18 about these 10 conditions (Felitti, Anda, & Nordenberg, 1998). Key findings were:
- ACEs occur frequently: two-thirds of participants had experienced at least one ACE category and one
in eight individuals had experienced four or more ACEs.
- The higher your ACE score, the higher the likelihood of developing long-term mental and physical
health problems, as well as social and relational challenges.
These findings have led to the adoption of the Adverse Childhood Experiences questionnaire (ACE
questionnaire) as part of routine screening and assessment in various health and mental health settings. While
this practice appears well aligned with recommendations put forth by leading mental health organizations (e.g.
SAMHSA) on the importance of recognizing trauma, there is an ongoing controversy regarding this practice.
Between November 2019 and February 2020, several papers were published commenting on this debate. The
objective of this information sheet is to summarize recent findings presenting the benefits and limitations of
using the ACE questionnaire as part of routine screening in community and clinical samples.
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Information Sheet #202E
Studies highlighting benefits of using the ACE questionnaire in
routine screening
Kia-Keating, Barnett, Liu, Sims and Ruth (2019) conducted a study that focused on
implementation processes, and facilitators and barriers to ACEs screening. More specifically, it
examined the feasibility and acceptability of a parent and child screening questionnaire among
predominantly low-income, Latinx patients in four community-based health clinics in California.
This project was part of a larger initiative that aimed to assess the impact of screening for ACEs
in pediatric settings in order for wellness navigators to assist families to connect to resources, when
parents reported two or more ACEs for themselves or one ACE exposure to their infant.
Feasibility was assessed based on information gathered from parents of infants 4-12 months old
who were visiting the clinics for the first time and completing the ACE questionnaire to report on
their own adverse experiences and the ones their infants had been exposed to since birth. In order
to examine the acceptability of the tool, service providers participated in semi-structured
interviews about their receptivity, experience, and problems or benefits with the addition of the
ACE screening in the pediatric clinics.
Feasibility: Out of 164 parent-infant dyads that were recruited, 151 completed the parent and child
versions of the ACE questionnaire. The mean age of infants was 5.8 months and 50.3% were
females. Over three-quarter of this sample (76.8%) identified as Latinx. Parents’ age and gender
were not presented in the article. A first indicator of feasibility that the authors noted was the high
percentage (92.1%) of all patients recruited who agreed to complete the questionnaire. They also
noted that 39.1% of parents reported two or more ACEs and 18.6% of infants were exposed to one
or more ACEs since birth, according to their parents. In total, 47% of parent-child dyads met the
criteria for service referral (2 ACES for parents and/or 1 ACE for infants) through the wellness
navigator service in these pediatric clinics. Of those, the majority (77.4%) consented to receive
services. In total, this process allowed 55 families out of 151 to be screened for ACEs and to be
referred to services, which according to the authors lend support to using this questionnaire in
routine assessment.
Acceptability: Nine service providers participated in semi-structured interviews: three
pediatricians, three medical assistants, two wellness navigators, and one licensed clinical social
worker. Participants’ demographics were not presented in the article. Data was analyzed using a
‘rapid qualitative analysis approach’, which involved the research team in reviewing all interview
transcripts and producing a matrix of common themes. Screening benefits identified by the
providers included: (1) facilitating a deeper alliance with patients through acknowledging their
own path and life challenges; (2) helping to draw connections between health and mental health
issues that patients were presenting with; and (3) highlighting the necessity to adopt a holistic,
whole-person approach. Some of the challenges identified included: (1) feeling nervous about
asking these sensitive questions, (2) having to make it fit in an already long assessment process,
(3) recognizing the needs for further training to be offered to staff in order to maintain best
practices for introducing and discussing ACEs with patients. The findings also suggested that
acceptability improved over time and that practitioners shifted their attitude – which was
ambivalent to begin with – towards a stronger acceptance of the process as they observed the
positive impact on their relationship with patients.
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Information Sheet #202E
Overall, this study is suggesting that there are potentials benefits to include the ACE questionnaire
as part of routine screening in health care settings – both from a feasibility and acceptability
perspectives. Limitations of the study include: small sample sizes, both for parent-infant dyads and
for service providers; the limited information on participants’ demographic; the absence of a robust
qualitative method used to analyze the interview data; the lack of findings’ generalizability to other
social contexts and service settings; and the lack of information on whether the service referral
was effective in preventing the sequelae of trauma.
Choi, Wang and Jackson (2019), examined whether exposure to adverse childhood experiences
(ACEs) by the age of three among children living in poverty resulted in behavioural problems at
ages three, five, nine and fifteen; after controlling for mothers’ socioeconomic status and their
children’s characteristics. The long-term effects of ACEs when poverty and ACEs co-occur is less
known. The sample of children consisted of 2750 children and their parents from the Fragile
Families and Child Wellbeing study. The study was limited to low-income families that had
experienced poverty at any time during the first three years of a child’s life. Logistic regression
modelling was used to obtain odds ratios of ACE categories predicting behavioural problems after
accounting for family socioeconomic position.
The findings indicated that experiencing ACEs in early childhood was significantly associated
with later behavioural outcomes from children to adolescence. Exposure to multiple ACEs before
the age of three was significantly associated with the top-risk behaviour group at age five and at
both ages nine and fifteen, children experiencing two or more ACEs had 1.9 to 3.2 times higher
odds to be placed in the top 10th percentile of behaviour problems. Among covariates, mothers’
education, race and children’s gender and temperament were identified as significant factors to
determine behaviour problems. The researchers noted that their findings support policies and
programs for families with children who have experienced economic disadvantages and early
childhood adversity, and government responses that aim to mitigate child poverty are critical and
should be encouraged.
There are several limitations noted by the authors. Sexual abuse was not included because of low
frequency. Cumulative risk scores may not reflect distinctive experiences. Family processes such
as supportive co-parenting, parenting efficacy, and the quality of care were not included in this
study. These protective factors may mitigate the negative effects of ACEs on child behaviour
problems. Sibling and peer victimization, property crimes, parental death were also not assessed.
Studies pointing to limitations of the ACE questionnaire in
practice and research
McLennan, MacMillan and Afifi (2020)’s commentary offers insights regarding four psychometric flaws of
the10-item ACE questionnaire. The first problem they highlight pertains to the tool’s item coverage. Although
the ACE questionnaire covers 10 types of adverse childhood experiences that are widely accepted as potentially
detrimental to the well-being of children and youth, it fails to include other types of victimization that have
garnered much attention in the past decade, including peer and community violence, that have been shown to
predict poor adolescent health (Finkelhor, Shattuck, Turner, & Hamby, 2015). The ACE tool does not capture
the impact of exposure to poverty, which is an important marker of child and youth well-being. McLennan and
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Information Sheet #202E
colleagues question the use of single items to measure each of the 10 adverse childhood experiences that are
complex and multifaceted.
The second problem they discuss relates to the item construction. The authors question the use of a
dichotomized ‘yes-no’ response options that do not allow for severity ranges. In addition, several of the 10
items include double-barrelled questions, that make the ‘yes-no’ response options difficult to interpret. For
example, ‘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 Acting a way that made you afraid that you might be physically hurt?’ An additional
concern is the lack of contextual information that the authors argue should precede the asking of sensitive,
potentially triggering questions. The preamble that has been added to the children and youth version of the
ACE questionnaire comments on the link between stressful events and physical and mental health. These
critiques lead the authors to have concerns about the validity, reliability and response interpretation of the tool.
The third concern relates to item scoring. McLennan and colleagues highlight that summing responses by
giving equal weight to each item may be erroneous. They advocate for a more sophisticated approach for the
interpretation of the ACE item score that is applicable at the epidemiological level and an individual level.
Indeed, although it is well established that higher scores on the ACE questionnaire leads to poorer outcomes, it
is yet to be determined whether any combination of the 10 items produce the same negative impact.
The authors conclude with their concerns about the lack of rigour in the instrument development. They
highlight that other tools developed in recent years have gone through rigorous evaluations of their
psychometric properties and could be considered for screening. They conclude that the ACE questionnaire
continues to be used due to its simplicity despite lacking some of the most basic quality criteria that are expected
in psychosocial measures and should not be used in clinical practice and research.
Using an interview grid rather than the original ACE questionnaire, Negriff (2020) examined more
closely the relative contribution of the household dysfunction items versus the childhood
maltreatment items for predicting adolescent mental health outcomes, and the utility of a cut-off
score for ACEs in predicting mental health. Data were from the fourth assessment in a longitudinal
study examining the effects of maltreatment on adolescent development. The maltreatment group
(n = 219) was recruited from active cases in the Children and Family Services agency of a large
American city. The comparison group (n = 128) was recruited from school lists of children’s names
in the same 10 zip codes as the maltreated sample. At Time 4, the participants (n = 347) were a
mean age of 18.49 years (SD = 1.41), approximately evenly split between males and females, and
primarily African American (43%) or Latino (34%).
Individual ACE items were assessed using the Comprehensive Trauma Interview (CTI; Noll et al.,
2003). Items from the CTI were mapped onto the original ACEs items, parental mental health was
dropped as there was no approximate item on the CTI. This resulted in a total of nine items on two
subscales. The Household dysfunction subscale included: divorce, household member
incarceration, witnessing domestic violence, and household member substance use (range 0–4).
The maltreatment subscale included: sexual abuse, physical abuse, physical neglect, emotional
abuse, and emotional neglect (range 0–5). Four mental health symptom types were measured: 1.
Depressive symptoms, using the 27-item Children's Depression Inventory about their feelings in
the past two weeks (Kovacs, 1981, 1992); 2. Post-traumatic stress disorder symptoms, using the
Youth Symptom Survey Checklist (Margolin, 2000); 3. Anxiety, using the 39-item
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Information Sheet #202E
Multidimensional Anxiety Scale for Children (March et al., 1997); 4. Externalizing problems,
using the Youth Self Report (Achenbach and Rescorla, 2001).
MANCOVA and Sidek were used to account for correlations between the four outcomes in mental
health symptoms for those endorsing versus not endorsing each ACEs item, controlling for age,
sex, race/ethnicity, household income, and maltreatment group status (maltreated versus
comparison). Independent main effects of household dysfunction, child maltreatment, and ACEs
total score on the four mental health outcomes were then estimated using linear regression.
Interaction effects were tested using the nested χ2 difference test comparing each parameter set to
equality versus freely estimated across groups. Lastly, to examine the support for an ACEs cut-off
score, four different categorical groupings were created based on prior research with ACEs scores
and MANCOVA was used to examine the group differences.
Maltreatment items and witnessing domestic violence were found to be the best predictors of the
mental health outcomes they measured. They also found the more expansive definition of
emotional neglect used by the CTI to be a better predictor of mental health than the original ACE
item. Their results did not support the use of a cut-off score for clinical decision-making or referral
to mental health treatment. Based on their findings they advocated for witnessing domestic
violence to be adopted as a maltreatment factor and noted the importance of further work to gather
more complete evidence on the impacts of each ACE on diverse outcomes (e.g., physical health,
substance abuse, sexual risk-taking). The absence of a parental mental illness item, the use of the
CTI rather than the original ACE questionnaire, the measures being self-report, and the limited
scope of symptoms addressed are the acknowledged limitations of this study.
Opinion papers making specific recommendations
Racine, Killiam and Madigan (2020)’s opinion paper highlights ‘screening for ACEs is only appropriate if a
TIC approach to patient care is implemented (p.6)’. They suggest that filling out an ACE questionnaire or a
similar tool without organizational and systemic structures to prevent and intervene on ACEs is not
recommended.
Lacey and Minnis (2020) echo this recommendation and suggest areas for improvement for the future of
ACEs research and its application to practice and policy. They can be summarized as follow:
- To be clear and specific on the definitions of ACEs that are used in research rather than to refer to this
broad term without specifying which ACEs are considered or not.
- To consider including other ACEs, such as poverty.
- To use alternative approaches that go beyond summing up items: clustering, weighing, recording
severity and developmental period when the adversity occurred.
- To favor longitudinal studies to assess impacts of ACEs over the life course.
- To assess cost-effectiveness and safety impacts of routine screenings for ACEs.
These authors also recommend practitioners remain cautious when generalizing population-based research
data to individual risk–although research has shown that more ACEs lead to poorer outcomes, this may not
translate directly to one client’s risk and individual challenges. They also urge practitioners to consider larger
systemic and structural causes of ACEs and determinants of health, such as poverty, when developing practice
and policy initiatives.
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Information Sheet #202E
Conclusion
Twenty years of research using the ACE questionnaire has allowed the field of childhood trauma
to gain significant momentum and social recognition. Studies using this questionnaire have
confirmed the high prevalence of childhood adversities in various populations, and their short and
long-term impacts on people’s physical and mental health. This is an important legacy to celebrate
and acknowledge.
However, there have been growing concerns expressed by researchers, practitioners, and policy-
makers regarding the use of the original ACEs questionnaire for routine screening. The aim of this
paper was to review recent papers that studied and discussed the benefits and drawbacks of its use
in clinical and community settings. On the one hand, Kia-Keating and colleagues (2019)’s study
suggests that routine screening of adversity leads to service referral and that these needs could have gone
undetected. Choi et al. (2019) also showed that screening before the age of three could facilitate detection of
high-risk children and early service provision to support effective policies and programs to prevent negative
outcomes across the lifespan. On the other hand, McLennan et al. (2020)’s commentary offers insights
regarding four psychometric flaws in the ACE questionnaire: the lack of full coverage of potential childhood
adversity; weaknesses in item construction; lack of sophistication regarding item scoring; and lack of rigour in
the instrument development. Negriff (2020)’s study also points to issues regarding item scoring, even when
using instruments other than the original ACE study, and suggests that maltreatment items, including exposure
to domestic violence, have unique and more detrimental impacts on individual well-being than household
dysfunction items, including substance abuse, parent’s incarceration, and divorce.
Racine and colleagues (2020)’ and Lacey and Minnis (2020)’ opinion papers both emphasize the importance
of considering the use of the ACE questionnaire in routine screening alongside a broader societal discussion
on structural factors that influence childhood adversity’s exposure and its impact on individuals over their
lifecourse. There is a clear call to refine our use of the ACE questionnaire and other childhood adversity
detection tools to go beyond simply documenting the hardships children encounter, and preferably to use this
information as a leverage to create a true societal TIC movement whereby childhood adversity will be fully
addressed and, hopefully, prevented in the first place.
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References
Choi, J.-K., Wang, D., & Jackson, A.P. (2019). Adverse experiences in early childhood and their
longitudinal impact on later behavioral problems of children living in poverty. Child
Abuse & Neglect, 98, advance online publication. DOI: 10.1016/j.chiabu.2019.104181
Felitti, V., R. Anda, & Nordenberg, D. (1998). Relationship of childhood abuse and household
dysfunction to many of the leading causes of death in adults: The Adverse Childhood
Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245-258. DOI:
10.1016/S0749-3797(98)00017-8
Finkelhor, D., Shattuck, A., Turner, Hamby, S. (2015). A revised inventory of adverse childhood
experiences. Child Abuse & Neglect, 48, 13-21. DOI:10.1016/j.chiabu.2015.04.011
Kia-Keating, M., Barnett, M. L. Liu, S. R., Sims G. M., & Ruth, A. B. (2019). Trauma-responsive care in
pediatric settings: Feasibility and acceptability of screening for adverse childhood experiences.
American Journal of Community Psychology, 614, 286-297. DOI: 10.1002/ajcp.12366
McLennan, J.D., MacMillan, H.L., & Afifi, T.O. (2020). Questioning the use of adverse childhood
experiences (ACEs) questionnaires. Child Abuse & Neglect, 101, advance online publication. DOI:
10.1016/j.chiabu.2019.104331
Negriff, S. (2020). ACEs are not equal: Examining the relative impact of household dysfunction versus
childhood maltreatment on mental health in adolescence. Social Science & Medicine, 245, advance
online publication. DOI: 10.1016/j.socscimed.2019.112696
Lacey, R.E. & Minnis, H. (2020).Practitioner review: Twenty years of research with adverse childhood
experience scores – Advantages, disadvantages and applications to practice. Journal of Child
Psychology and Psychiatry, 61, 116-130. DOI: 10.1111/jcpp.13135
Racine, N., Killiam, T., & Madigan, S. (2020). Trauma-informed care as a universal precaution: Beyond the
Adverse Childhood Experiences questionnaire. JAMA, 174, 5-6. DOI:
10.1001/jamapediatrics.2019.3866
Suggested Citation: Collin-Vézina, D., Brend, D., & Fallon, B. (2020). Screening or Not
Screening? Unresolved Debates on the Use of the Adverse Childhood Experiences Questionnaire
in Routine Screening. CWRP Information Sheet #202E. Toronto, ON: Canadian Child Welfare
Research Portal.
