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State PACEs Action

As we move towards working with state legislatures, or thinking about this, I believe it is important to devise the best screening scale.  This should take into account rural vs urban ACEs. I believe we should seriously consider this because we don't want to have folks (especially the professionals who would be required to start this screening and who don't know of or are dubious of the efficacy of ACEs screening or especially pharmaceutical companies with deep pockets) questioning the screening instrument we use.  

In fact we want to be well positioned and with 10 years plus behind us --- we on ACEsconnection should be thinking hard .... what are the best screening questions that will "get the job done well?"

1. obtain the most accurate response

2. have the best specificity with best sensitivity....with the best positive predictive value... I am not a statistician!!!! But the point remains. It is time to think about our questions.  

I believe that we should have questions that cover the diversity of our population. A Harvard researcher is currently looking at this question...

My question is what do you think? 

If we move too quickly with the wrong screening instrument we could suffer a setback.

It is obvious that poverty, social isolation, lack of eduction are important ACEs (intuitively speaking) 

What do you think (my Myers Briggs is INFP and strongly so... Just an FYI.) ? This is no research article....It is a question.....That I consider seriously......Though this is a complex subject... I don't think we should wait to screen but I do believe we should pool our knowledge NOW to create the best screen to propose to the public.... If we are looking at legislative efforts in states but we do not have the best screen that we can have.... We may set ourselves back by decades and this has already been a decades long struggle. Thanks Tina

Improving the Adverse Childhood Experiences Scale


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But if you are asked, "What is your evidence behind your screening tool?" Ask "What is the evidence behind yours?"(for example for pediatric bipolar).

You will find that the DSM is a group of academic doctors getting together to decide these symptoms mean this diagnosis. The evidence is slim at best.  They can give not genetic, epigenetic, demographic or you name it ... answers....However an association called "The Directors of State Mental Health Providers asked them to put Developmental Trauma Disorder in the DSM - 5 (it has the most evidence base as it is associated with the  National Child Traumatic Stress Network and they worked overtime to get this dx in - only problem is -- it encompasses so many trauma associated diagnoses and so the tx would be trauma focused therapy - no drugs ---). So no dx.

The evidence base behind the association between childhood adversity and severe adverse mental, physical, and societal outcomes is clear----- (You don't have to have 5 million ACE studies to come to the conclusion that there is a significant link)... and that society will save in term of money spent and human suffering......

however beware.... if ACEs were to become a reality...a business that makes lots of money on drugs and a profession who learned only to give out drugs may fight back and they fight HARD.....

They have the money and the resources to do so... 

I did cancer research before medical school... we studied a cancer drug that is now making big money for a drug company... I am not 100% sure but I do believe most of the grant funding came from the NCI (National Cancer Institute) little from the drug company but that company is currently reaping the profits of my and our lab's work


in Vermont, we are working with our legislature. Elizabeth Prewit did two (?) pieces about the Vermont activity, which I'm sure you can find on the ACEs Connection website. I took issue with them on prescisely this issue - the screening. The ACE study is an incredibly valuable study. It is a watershed moment in the childhood trauma world. It did not, however, develop screening tools, and it is not "trauma informed." The ten-item ACE questionnaire is not a validated screen - it came out of the ACE study. It is an event-based questionairre that trauma experts have great concern about  - asking questions about events is often triggering for trauma survivors. I am well aware that for the ACE study someone carried a cell phone 24/7 in case anyone who went through the much more intensive questioning for the study needed support afterwards. No one ever called that cell phone, and therefore, the presumption is that no one was triggered. This is an impossible assertion to make - we cannot draw conclusions from data that does not exist. Trauma experts say that it is very likely that many people were triggered, and the significant drop in primary care visits that the ACE study documented in the year following the study may well have been, at least in part, due to triggered patients not wanting to go back to the place that triggered them.

It is important to note that this may not have been conscious on the part of the patients. They may just have avoided the practice and not, themselves, known why. It is also important to note that a trauma survivor who is triggered may not themselves be aware that they were triggered - the response ( which may be severe dissociation, with a range of consequences, for the trauma survivor him/herself, and for that person's family and friends, perhaps also for coworkers) may not really "kick-in" until a week or two later (or longer?). That same person may well avoid the place that triggered them, but never realize, in any conscious way, that they were triggered or who triggered them. So to say that the fact that no one called the 24 hour hotline number means no one was harmed by the event-based questions is double-jeopardy. No data does not provide us a conclusion in any situation, and then when we're in the world of childhood trauma and it's attendant psychological ramifications, the ACE study is well out of it's depth.

This is all to say that any screen must be validated. It should be a symptom-based screen if non-trauma-trained professionals are administering it. 

In Vermont we are looking at the 4 question PTSD screen for adults, and for children using a question that was suggested in a recent JAMA article: "Since the last time I saw you, has anything really scary or upsetting happened to you?"

We have a workgroup focused on this issue that is working with representatives from two primary care practices. 

Addressing childhood trauma, with adults and with children, is of critical importance, and it is the ACE study that made that clear.  It is imperative, however, that any work to address childhood trauma relies on the experts in childhood trauma - those psychiatrists and psychologists who have made early toxic stress, it's prevention, intervention and treatment, their focus. MDs are experts in their fields, but unless they're MDs in psychiartry who have focused on childhood trauma, it is as irresponsible to rely on them for addressing this as it would be to ask a cardiologist to advise on treatment for an endrocrine disorder.

You might check out the National Child Traumatic Stress Network and SAMHSA for resources for screening for trauma. Both have compiled screens and the research behind them that would be very helpful. 



Kathy, I very much appreciate the clarification of concerns, and objections you noted above. I wish that I had seen it sooner. I've had periodic discussions with one Vermont House member-who's a retired School Principal- and he didn't clarify the concerns as well as your post above. I believe you have articulated a reasonable argument as it applies to both the 2013 Vermont House Bill 762, and use of the ACE questions in the annual State BRFSS (Behavioral Risk Factor Survey Study)-even though not all 50 states may be trying to ascertain ACE data in their BRFSS. 

I am curious whether the World Health Organization (WHO) considered such factors when they adopted the ACE screening tool which they used in their 2013 assessment of the world's healthiest children.

The current WHO ACE International Questionaire , and accompanying guidebook, seem to have differently worded questions, which are arranged sequentially depending on previous answers, and seem to consider additional events and circumstances that might cause "toxic stress"-which were not among the CDC/Kaiser-Permanente original [8-10] questions. It is also available in a multitude of languages, on the WHO website.

Can we members ascertain if our home state BRFSS personnel have also addressed similar concerns, as well as ascertain what alternative strategies may be being used to administer such questioning ? ? ?

Thank You Kathy, for addressing this matter.

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