ACEs and Trauma-Informed Practice: Using the Research Carefully

“Adverse childhood experiences”, or ACEs, has become a familiar phrase in UK schools, social care and health services, and some settings have asked families to complete ACE questionnaires. The research behind the term is important. It is also often misread, and the researchers themselves have published warnings about how it is being used.

The original ACE study

The ACE study was a collaboration between the US Centers for Disease Control and Prevention and the health organisation Kaiser Permanente. The first major results were published by Vincent Felitti, Robert Anda and colleagues in 1998 in the American Journal of Preventive Medicine.

Adults attending a medical clinic in San Diego for routine health assessments were sent a questionnaire about their childhood. Of 13,494 adults, 9,508 responded. The questionnaire asked about seven categories of experience before the age of 18:

• psychological abuse
• physical abuse
• sexual abuse
• violence against the mother
• living with someone who misused alcohol or drugs
• living with someone with mental illness or who had attempted suicide
• living with a household member who had been in prison

Each category counted as one point. Later analyses of the study added emotional and physical neglect and parental separation or divorce, which gives the familiar 10-item version.

What it found

Adverse experiences were common. Just over half of respondents reported at least one category, and about 6% reported four or more. The study found a graded relationship: the more categories people reported, the higher their rates of later health problems and risk behaviours. Compared with those reporting none, people reporting four or more categories had between four and twelve times the odds of alcoholism, drug use, depression and suicide attempts.

These findings reshaped public health thinking. They showed that childhood adversity is widespread, that it often clusters, and that it is linked with health across the whole lifespan. A 2017 systematic review and meta-analysis led by Karen Hughes and Mark Bellis in The Lancet Public Health found similar associations across many later studies.

The limits of an ACE score

The original study was designed to understand patterns across a population. It was not designed to assess individual children. Several limitations follow.

• The score counts categories, not severity, frequency, duration or timing. A single frightening incident and years of abuse can both count as one point.
• It leaves out many adversities, such as bullying, racism, poverty, bereavement, community violence, serious illness or being in care.
• It does not measure protective factors: a trusted adult, a stable school place, good friendships.
• The original data came from adults recalling their childhoods, all members of one US health plan.

Rebecca Lacey and Helen Minnis (2020), reviewing twenty years of research in the Journal of Child Psychology and Psychiatry, noted that the simplicity of the ACE score is part of its appeal for policy, but that it risks oversimplifying risk and cause, encouraging determinism and creating stigma.

Population prediction is not individual prediction

The most direct test of individual prediction came from Jessie Baldwin, Avshalom Caspi, Terrie Moffitt, Andrea Danese and colleagues (2021) in JAMA Pediatrics. They used two long-running cohort studies, the E-Risk study in the UK and the Dunedin study in New Zealand. Higher ACE scores were linked to poorer average health outcomes across groups. But the scores were poor at identifying which individuals would go on to have problems: screening would miss many people who later struggled and flag many who would not. The authors concluded that using ACE screening to target interventions is likely to be ineffective.

The original researchers have said the same. Robert Anda, Laura Porter and David Brown (2020) wrote in the American Journal of Preventive Medicine that the ACE score “is neither a diagnostic tool nor is it predictive at the individual level”, and that no score or range of scores should be used as a cut-off for decisions about individuals.

For schools, this means: do not use ACE questionnaires to screen pupils or families, and do not describe a child as “having four ACEs” as a shorthand for their needs or prospects. A number cannot tell you what a child has lived through, how they experienced it, or what is helping them now.

What trauma-informed practice means

Trauma-informed practice is a different idea from ACE screening. It describes how an organisation works, not a test applied to individuals.

The most widely cited framework is from the US Substance Abuse and Mental Health Services Administration (SAMHSA, 2014). It describes a trauma-informed organisation as one that realises how widespread trauma is, recognises its signs, responds by building that knowledge into policy and practice, and actively seeks to avoid re-traumatising people. It sets out six principles:

1. Safety
2. Trustworthiness and transparency
3. Peer support
4. Collaboration and mutuality
5. Empowerment, voice and choice
6. Attention to cultural, historical and gender issues

The value of this approach for schools is that it does not require knowing who has experienced trauma. Practices that help a traumatised child feel safe, such as predictable routines, calm adults, clear explanations and a chance to repair after conflict, also help everyone else.

What it looks like in school

• Predictability: visual timetables, warnings before change, consistent routines at transition points such as arrival and lunch.
• Relationships: every pupil known well by at least one adult; time built in for relationship repair after incidents.
• Regulation before reasoning: when a pupil is highly distressed, help them calm down first. Discussion of what happened can follow.
• Curiosity about behaviour: asking “What might be going on for this child?” alongside “What did they do?”
• Voice and choice: involving pupils in decisions about their support, and explaining the reasons for rules.
• Staff wellbeing: supervision and support for adults who work with distressed children.

Trauma-informed practice does not mean removing boundaries. Clear, consistent expectations are part of what makes a setting feel safe.

For parents

If your child has been through something frightening or distressing, you do not need to calculate a score. Consistent care, a predictable routine, and a parent who listens and stays calm are among the most protective things a child can have. Let the school know about significant events, in as much detail as you are comfortable sharing, so staff can respond with understanding.

When to seek help

If you are worried about a child’s safety, speak to the school’s designated safeguarding lead or contact your local authority children’s services. If you are concerned about a child’s emotional wellbeing or signs of trauma, talk to the school’s SENCO or pastoral team and to your GP, who can refer to NHS Child and Adolescent Mental Health Services (CAMHS) where appropriate. In an emergency, call 999.

Further reading

• Anda, R. F., Porter, L. E. and Brown, D. W. (2020). Inside the adverse childhood experience score: strengths, limitations, and misapplications. American Journal of Preventive Medicine.
• Baldwin, J. R. et al. (2021). Population vs individual prediction of poor health from results of adverse childhood experiences screening. JAMA Pediatrics, 175(4), 385-393.
• Felitti, V. J. et al. (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(4), 245-258.
• Hughes, K. et al. (2017). The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. The Lancet Public Health, 2(8), e356-e366.
• Lacey, R. E. and 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(2), 116-130.
• Substance Abuse and Mental Health Services Administration (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884.