Adverse Childhood Experiences

Adverse Childhood Experiences (ACEs) are used to explain and predict the health issues people will experience as a consequence of circumstances or events in their childhood. This perspective has a growing popularity in Scotland over a whole range of settings including health, education and criminal justice.

The evidence base for ACEs is chiefly the original ACE Study conducted at Kaiser Permanente from 1995 to 1997. Over 17,000 Health Maintenance Organization members from Southern California received physical exams, completed surveys about their childhood experiences and current health status and behaviour.

The data by which an ACE score is determined are simply the number of ‘yes’ responses to ten questions about what happened to someone before their 18th birthday:

1. Emotional abuse by a parent, step-parent or adult living with the child involving feeling physically threatened
2. Physical abuse by a parent, step-parent or adult living with the child that left marks or injury
3. Sexual abuse of any kind by any person 5 or more years older than the child
4. A mother or stepmother who was violently abused by her partner
5. A member of the household who had a substance use problem
6. A member of the household who had a mental health problem
7. A member of the household who was imprisoned
8. Parental separation or divorce
9. Emotional neglect defined as family not being a source of strength and support
10. Physical neglect defined as family / household member not taking physical care of the child

All adults, then, can receive an ACEs score of 0-10

This, and subsequent studies, show links between the ACEs score and health outcomes, including problem substance use. Perhaps not surprisingly to people experienced in meeting or working with people who have a substance use problem, or to people who have experienced problem substance use, the higher someone’s ACE score, the more likely it is that they have a substance use problem in their adult life.

This analysis and insight is useful but it is limited. It is open to criticism because the ACEs study ignores the social context and conditions in which people are born, grow up and live their adult life. It focusses on parental behaviour and circumstances within the family home only – ignoring, for example, unemployment, acts of violence perpetrated outwith the home, poverty, education, sexism, racism and class. (see poverty)

It also relies entirely on self-reporting. It depends on adults being able to recall, and being willing and able to disclose, the existence of painful episodes from their childhood reliably. Even when this is possible, people may well recall their childhood in ways that explain their current situation. For example a healthy and happy adult may not report or even recall their father’s one-off act of extreme violence in the family home as they view it as insignificant or not worth mentioning; whereas someone who has faced difficulties in their adult life including poor health may report the same childhood experience as they feel it is significant or helps explains or ‘justify’ their current situation – they may have revisited this experience as part of their engagement in treatment and it may now have significance for them.

The ACEs questionnaire is simple and crude. The subsequent work implies that -

• all abuse and neglect; all parental separations; all household substance use issues have the same traumatic impact on a child no matter how the child is otherwise supported
• all childhood trauma has the same impact whether the child is a few months old, a
• young child or a young person aged up to 18
• all violence within a home has the same impact whether it is a single incident or repeated and no matter the degree of violence involved.

Many people, and other evidence, would contest these implications of the ACEs research.

The discourse that has developed around ACEs lays responsibility for health in adulthood almost entirely on the child’s household. Wider community and society are ‘let off’ any responsibility or role. This is a political view that ignores much of the long-standing and well- researched evidence on wider determinants of health. While ACEs is a more
sophisticated analysis it suffers shortcomings similar to the shortcomings of the political notion that substance use and by implication problem substance use is a lifestyle choice
(see lifestyle choice).

The ACEs research has been useful in helping some people who have a substance problem to understand the connection between experiences in childhood over which they had no control and their current issues. This has been empowering for people who were otherwise left to feel guilt or that they were somehow inadequate or different from other people. (see addict; see disease model)

The ACEs research also contributes to understanding of why problem drug use may occur in families and why some people who have a substance problem have had a parent or a sibling with a substance problem. It therefore counters the notion that problem substance use is hereditary. (see could happen to anyone)

The ACEs research has similarly helped address some stigma by demonstrating that people who have a substance problem are not ‘bad’ or ‘lacking willpower’ or making ‘bad choices’ or choosing to ‘indulge themselves’; that their problems are rooted in situations in their past which most people will regard as unpleasant and unfortunate and with which some people will empathise. (see stigma) However, some people may be less empathetic. Reactions like ‘well my father was violent and I didn’t become a heroin user’ illustrate this and are based on both misinterpretations of the ACEs evidence and the shortcomings of the ACEs analysis.

The ACEs research is a very good basis from which to advocate early intervention and support for vulnerable households.