Screen for Adverse Childhood Experiences (ACEs) in all medical encounters
From an article in the
American Journal of Preventive Medicine
An editorial by
Dr Jeoffry B. Gordon and
Dr Vincent Felitti stresses that the practical, insightful value of individual ACE screening in the GP surgery to preventive and clinical medicine is profound.
[To put the report in context, in the UK,
NSPCC report that it is difficult to measure exactly how many children in the UK experience neglect. However, their research with 2,275 young people aged 11-17 about their experiences of neglect suggests around 1 in 10 children in the UK have been neglected. In the editorial below, in the USA, the prevalence of identified child abuse or neglect is at least 1 in 8.]
In the USA, there are over 600,000 substantiated cases of child abuse or neglect each year, including at least 1700 child maltreatment homicides annually - about as many deaths as are caused by childhood cancer. In children below age 18 the population prevalence of identified child abuse or neglect is at least 1 in 8.
Among USA adults living in the community the prevalence of an ACE Score of 4 or more is 15.6% or 1 in 6 adults. [A 2014
UK study on ACEs estimated that 9% of the population had 4+ ACEs.]
An ACE Score is not a diagnosis but is a proven screen for assessing contributors to many physical and mental illnesses. The ACE Score reflects the number of categories (not events) of adverse childhood events experienced in the first 18 years of life. Many, but not all, persons who experience the circumstances shown by the ACE Score will develop damaging outcomes. [To find your ACE score and further information, go
here.]
The effects of trauma can be mitigated by
“positive childhood experiences” which strengthen integrity and resilience. The biomedical and economic benefits of ACE screening have been sufficient to result in
supportive legislation in 39 US states.
For children brought to a GP, the routine ACE screen has the red flag significance of identifying concurrent child abuse or neglect or suicidal thoughts or intent. For adults, according to Government analysis, significant trauma is associated with substantial mental, physical, and social illness and disease. Nonetheless, the vast majority of medical practitioners in all specialties do not fully appreciate the prevalence of child abuse trauma, nor its association with mental and physical illness, especially among adults.
Doctors have perceived that questions about domestic violence, suicidal intentions, and sexual abuse could be upsetting or “triggering” even though they are now documented as necessary for quality care.
Such concerns reflect discomfort by clinicians rather than patients.
Dr Felitti and his department initially had to overcome medical staff hesitancy, but then
had no negative experiences in screening 440,000 adult patients undergoing a comprehensive medical evaluation. Indeed, it was common to hear spontaneous patient expressions of appreciation for the opportunity to open up for the first time about their adverse childhood experiences, creating new intimacy in the doctor-patient relationship.
An important aspect of any screening is that it leads to effective treatment. The underlying contributions to disease and psychological distress uncovered by ACE screening expose complex bio-psycho-social medical problems that may challenge the clinical practitioner unless prior attention is given to planning an efficient appropriate therapeutic response. Multiple compilations of evidence based treatments and resources are currently available in the USA and routinely taught and used across the nation.
As clinicians, we, among many others, have found the individual ACE screen to be important, practical, functional and acceptable in the clinic. Furthermore, the reputation of the ACE screen makes it the perfect tool for motivating the majority of medical practitioners - who have yet to recognize the clinical significance of child maltreatment across the life span - to introduce this risk assessment into routine practice and use the resulting knowledge for effective treatment.
Read the full article here.
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From an article in the American Journal of Prevent, 02/04/2025