Moving upstream: The case for ACEs screening

I thank the authors for their thoughtful letter and invigorating critique of routine screening for adverse childhood experiences (ACEs). This is a rapidly developing field, and one that warrants urgent attention to ensure best practices and effective interventions. ACEs are a growing public health priority due to their high prevalence and serious sequelae in childhood and across the lifespan. The brief ‘Practical Tips for Paediatricians’ format of the initial article did not allow for an exhaustive review of the evidence of the toxic effects of ACEs, but this has been well established elsewhere (1), motivating governmental bodies and professional practice associations such as the American Academy of Pediatrics to call for ACEs screening in conjunction with other initiatives to educate and support clinicians (2).

Screening is indicated for ACEs because, unlike developmental delays, ACEs typically go undetected in childhood (3,4). Pediatric ACEs screening has been shown to be feasible by clinicians and acceptable to patients (5,6). The authors state that there are “no evidenced-based interventions tied to scores on an ACEs checklist.” However, as described in the Practical Tips column and other literature (7,8), simply arriving at an aggregate ACE score is not the goal; rather, screening is intended to prompt and inform a subsequent conversation with the child/youth and their caregiver about their specific experiences and needs. This conversation then guides the “pathway to accessing evidence-based child and parent mental health interventions”.

The authors note a “lack of evidence-based programs that map onto high ACE scores”, as per Finkelhor (9). In the same issue, however, Dube questions Finkelhor’s critique of the diagnostic use of ACE scores (8), noting instead their importance in guiding clinical conversations and providing public health data. In fact, there are evidence-based interventions for specific ACEs such as parental mental illness, parental substance misuse, and family dysfunction (10,11), which comprise the bulk of the ACE questions. Other questions ask about severe abuse or dangerous neglect, which paediatricians agree is relevant to their practice (3). Anticipatory guidance may also increase resilience, because simply having the conversation may be beneficial: evidence from adult trauma literature and early ACE study findings show that being asked sensitively about adverse experiences is perceived as useful and beneficial by patients (12–15), and simply disclosing these experiences can positively impact health (16). The authors rightly note that there are resource challenges, with limited access to specialized services. However, the economic and social impacts of ACEs themselves are massive (17), and also strain an already-burdened system. Identifying and addressing toxic exposures hold the promise of improving child health (18), and thereby decreasing lifetime economic burdens.

The ACE questions have been adapted for paediatric use. Validated paediatric trauma instruments can be unwieldy in routine clinical care, so validation of a brief paediatric-adapted ACEs screen is needed, along with longitudinal studies of early intervention. As with any screening instrument, the risks associated with screening must be weighed against the benefits of screening and the risks of nondetection. Not asking the questions maintains the status quo. The adult ACEs research details the later disastrous consequences of early toxic exposures; paediatric ACEs research guides us to mitigate and reduce these exposures as they are happening, to move ‘upstream’ to the source of these serious lifelong consequences.