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“The ACE score is a powerful tool for describing the population impact of the cumulative effect of childhood stress and provides a framework for understanding how prevention of ACEs can reduce the burden of many public health problems and concerns. However, the ACE score is neither a diagnostic tool nor is it predictive at the individual level. Thus, great care should be used when obtaining ACE scores for children and adults as a part of community-wide screening, service, or treatment.
Inferences about an individual’s risk for health or social problems should not be made based upon an ACE score, and no arbitrary ACE score, or range of scores, should be designated as a cut point for decision making or used to infer knowledge about individual risk for health outcomes. California’s recent release of statewide guidelines for Medi-Cal patients as part of the ACEs Aware initiative provides a useful example for consideration of these issues.
The ACEs Aware initiative reimburses providers for screening children and adults using questions about ACEs and guides providers in administering ACE questions and applying ACE score cut points. Client ACE scores are combined with the presence or absence of a list of 35 health conditions using an algorithm to group clients into low-, medium-, and high-risk categories for what is termed toxic-stress physiology that informs counseling, follow-up, treatment planning, and support services. Many of the health conditions included in the list have complex etiologies rather than developing from a single cause, making the ACE and Toxic Stress Risk Assessment Algorithm employed in the ACEs Aware initiative problematic. Attributable risks are relatively small for ACEs and health conditions such as cardiovascular disease, cancer, diabetes, kidney disease, and others on the list for adults. Although the health conditions listed within the algorithm have been associated with ACEs in epidemiologic studies, most occurrences of many listed conditions are caused by factors other than ACEs.
Given the limitations of the ACE score and its lack of standardization in combination with a list of health outcomes with widely varying etiologies, this algorithm will inherently lead to both over- and underestimation of individual risk. Although there are potential benefits for clients in the intent of this initiative, in its current form, the algorithm may stigmatize or lead to discrimination based upon an ACE score, generate client anxiety about toxic-stress physiology, or misclassify individual risk, which could result in the withholding of useful, necessary services or, alternatively, steer clients toward unnecessary services.
The understanding of childhood adversity and its long-term effects continues to evolve. More research is needed to explore innovative assessment approaches that address the limitations of the ACE score. Until the evidence base further develops, the authors caution against misapplications of ACE scores that assume an ACE score associated with risks derived from epidemiologic studies can sensibly be used to infer risk or make decisions about services, treatment, or care of individuals.
The authors encourage continued efforts by policymakers and legislators to provide knowledge and resources for human service systems as part of the rapidly growing movement to provide trauma-informed care and promote accurate and compassionate public understanding of ACEs as an endemic public health problem. At the same time, providers and patients deserve the kind of rigor that would be provided by a USPSTF review before promulgating community-wide screening, service, or treatment recommendations that use ACE scores.
