ACEs…Great in Poker not in Childhood

Adverse childhood experiences (ACEs) are classified into three categories of events: abuse, neglect, and household dysfunction.  The experiences are measured from an individual’s childhood until the age of 18 into the ACEs questionnaire, which is 10 questions, to determine their exposure to harmful experiences to determine an overall score.  The higher the ACEs score (or number of adverse experiences), the more exposure a child has had to trauma with immediate and proven longstanding consequences.  Examples of questions on the questionnaire include:

Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?

Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

via ACEs Too High

Drs. Felitti and Anda, along with colleagues, in their groundbreaking research entitled “Relationships of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death The Adverse Childhood Experiences (ACE) Study” in 1998 in the American Journal of Preventive Medicine examined the impact of ACEs on physical health.  In the study sample of 9,508 adults who responded to the survey, a stratified relationship was found between the number of adverse childhood experiences and adult physical health.  The more traumatic events experienced during childhood, the worse off their health was in adulthood, often leading to premature death.  The researchers attributed premature death in adulthood to use of maladaptive coping behaviors of adults to deal with symptoms related to the traumatic event.  Some examples of these coping skills are an increase in high risk sexual behaviors, drug use, smoking, and overeating.  The study yielded results that individuals who experienced four or more adverse childhood experiences had a 12-fold increase in health risk.  Below is the graphic from this study that demonstrates the impact of adverse childhood experiences and its impact on physical health into adulthood.

Today, through the Brief Risk Factor Surveillance System (BRFSS), a telephone survey, the ACE study continues.  Adverse experiences are being tracked for adults across the United States with approximately 400,000 interviews each year.  The graphics below compare the findings between the original ACE study in the late 1990’s and the ongoing ACE study in 2010.  In the years between the first study and the findings of 2010, there were slight changes in each category; however, it is to be noticed that a large portion of the sample population in each year, 64% and 59%, have experienced between one and four adverse childhood experiences.

via CDC


via CDC










As one would assume, due to the nature of being involved with the child welfare system, children in foster care have experienced adverse childhood experiences.  But to what extent? Kristin Turney and Christopher Wildeman in a recent study entitled “Adverse Childhood Experiences Among Children Placed In and Adopted From Foster Care:  Evidence from a Nationally Representative Survey” examined this very question.  The authors used data from the 2011-2012 National Survey of Children’s Health which tracks health status of children living in the United States who are not in out-of-home placement.  They compared this group to children in and adopted from foster care to determine the prevalence of exposure to adverse experiences.  The study yields three major findings that are imperative pieces of knowledge for those who practice in the field of child welfare.

Children in foster care were exposed to ACEs at a much greater frequency than children in the general population…therefore showing that adverse experiences are linked to foster care entry (p. 124).

Children in foster care are about 7 times more likely than other children to experience parental incarceration or household member substance abuse (p. 124).

Children in foster care are more likely than children in poverty and children in nearly all types of complex family structures to be exposed to ACEs…this suggests that children in foster care are uniquely disadvantaged relative to a host of other types of children who have elevated risk of ACEs such as children in poverty or children living with single mothers  (p. 124).

Foster care placement, although not counted on the ACEs questionnaire as an event, is a traumatic event nonetheless.  Foster care children and adolescents who already have been deemed a more vulnerable population than those living in poverty, according to the study cited above, have the cards stacked against them when it comes to experiencing traumatic events.

In my practice, I administer the ACEs questionnaire with every child and adolescent to assess the number and severity of adverse experiences encountered to provide a framework for our work together. The findings provide me insight into the child’s lived traumatic experiences and serves as a starting point of my understanding of their lived experience before foster care and while in foster care.

Practicing from a strengths based perspective, I would be remiss in this post not to mention resilience.  According to the American Psychological Association, resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress — such as family and relationship problems” and “it means “bouncing back” from difficult experiences”.  I have witnessed resilience in children and youth over and over in my practice.  In a recent post I shared an interview with Sam who demonstrated resilience in the face of great adversity from severe emotional and physical abuse to the toll of being involved in state systems.  On the website ACES Too High cited above, a resiliency questionnaire is shared which provides protective factors that are building blocks for a child and/or adolescent’s work in the therapy room.  I have recently added this into my practice as well.  Examples of questions are:

When I was a child, teachers, coaches, youth leaders or ministers were there to help me.

My family, neighbors and friends talked often about making our lives better.

When I felt really bad, I could almost always find someone I trusted to talk to.

In therapy with children in foster care placement, it is imperative to examine and understand the past and present that affects the work we do.  However, having a greater understanding of the impact that we are attempting to have on their future is the most difficult part of the work.  Balancing the impact of the adverse childhood experiences with building resilience is and should be the expectation from everyday conversations with children and adolescents in foster care placement all the way up to the creation of policies and systems.

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