How to Administer a Trauma Screening Using the ACEs Questionnaire
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By Patrick Tennant, Ph.D., LMFT-Associate
Important to Know:
- Ask all clients about trauma history using validated scales like the ACEs questionnaire
- Retrospective recall isn’t ideal, but is still useful
- Be aware of link with co-morbidities (particularly suicidality) and be prepared to screen for risks
- Refer clients with trauma history to trauma-informed treatment using empirically supported protocol (i.e., Trauma-focused CBT or EMDR)
ACEs may inform some or all of the reasons that a client is seeking treatment and can be clinically useful in treatment planning and provision. This article briefly reviews the importance of screening for trauma, how to do so using the ACEs questionnaire, factors to consider when implementing this screening, and how to best use data gathered through the screening.
Why do it?:
A high proportion of the population has at least one ACE in their history. Client’s entering mental health treatment are even more likely to have ACEs than the general population and the association between the presence of ACEs and negative psychological health outcomes follow a dose-response pattern (i.e., as the number of ACEs increases, psychological health decreases). It is also important to remember that, even if ACEs do not appear to be directly related to the primary presenting issue, they may complicate attempts to treat these “unrelated” issues. Given this, We should screen all clients for ACEs in the early phases of treatment.
How to do it:
Clinicians often express trepidation at screening for trauma, but published research to date indicates that it is not only acceptable but actually quite important to do a thorough trauma screening with every client. Concerns over re-traumatizing clients are valid, but the risk can be mitigated through observance of several simple guidelines. For instance, though it is important to screen early in the treatment process, the clinician should always preference the client’s safety by balancing the need for this information with the client’s trust in and comfort with the clinician. The clinician should introduce questions on the trauma history carefully, stating the importance of these questions while also acknowledging that they may be distressing. It is also important to use a screening tool that is sufficiently comprehensive and provides guidelines for determining the need for further assessment (such as the ACEs questionnaire; revised version provided here; seehere for differences between the revised and the original version). Depending on client and contextual factors (e.g., the absence of space for a private conversation), it may be better to have client complete the ACEs questionnaire on paper rather than verbally through an interview and doing so does not jeopardize the validity of the results. The client should understand that they free to decline to answer any question and, whether conducted aloud or on paper, the clinician should non-judgmentally attend to client signals of distress. In addition to protecting the client from overwhelming emotions that they may not yet be equipped to handle, this can provide clinically useful information on the level of impairment related to the trauma. Finally, it is critically important that the clinician confirms that a client with trauma history feels safe and regulated before leaving the office. There are many “grounding techniques” that can be used to bring the client’s awareness back to the safety of the present moment.
What to do with the information:
Like all screenings, a trauma screening such as the ACEs questionnaire is meant to be used only to indicate the need (or lack thereof) for further assessment and does need constitute a thorough assessment in-and-of itself. It is also important to remember that no screening tool represents an exhaustive list of traumas that your client may have experienced and so it is essential to continue to explore the potential presence and impact of other traumas as your work with a client progresses. Similarly, the presence or absence of any particular experience is never “the whole story, largely” and each client’s idiosyncratic responses must be considered. Said another way, completing the ACEs questionnaire with your client is a good place to start your trauma screening, but an insufficient place to stop. At this point, some clinician’s may wonder if a client’s retrospective recall of childhood experiences is entirely accurate. There is some disagreement in the research literature on this topic, but the conclusion is generally that retrospective recall should be used and trusted by clinicians when higher quality data is not available (as it often will not be in outpatient treatment). This is because, while retrospective recall is not perfectly accurate when compared to prospective reports and may be shaped by the client’s current disposition (e.g., neurotic clients may be more likely to recall adverse childhood experiences than highly agreeable clients), it is mostly accurate and is associated with a wide variety of co-morbidities. If the screening indicates that further assessment is needed, the clinician should warmly but directly investigate the client’s trauma history (again, preferencing directness over avoidance, but allowing the client decide if/when the questions become too distressing) and formulate a trauma-informed treatment plan. It is critical that clinicians be aware of co-morbidities associated with the ACEs (especially the increased risk of suicidality and self-harm) and of the requirements of their mandated reporting status that may arise from assessing trauma history. Being prepared to offer (or offer referrals to) empirically supported trauma-informed treatments (i.e., Trauma-focused CBT, EMDR, or possibly exposure therapy) is also advisable. In the end, the great depth and breadth of research done on the ACEs and associated outcomes present clinicians with a major set of resources that are most accessible if the clinician conducts a screening using the ACEs questionnaire.
Further Reading:
Briere, J. (2002). Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model. In J.E.B. Myers, L. Berliner, J. Briere, T. Reid, & C. Jenny (Eds.). The APSAC handbook on child maltreatment, 2nd Edition. Newbury Park, CA: Sage Publications.
Centers for Disease Control and Prevention. (2010). Adverse Childhood Experiences (ACEs). Retrieved from https://www.cdc.gov/violenceprevention/acestudy/
Edwards, V. J., Dube, S. R., Felitti, V. J., & Anda, R. F. (2007). It’s ok to ask about past abuse. The American psychologist, 62(4), 327-8.
Reuben, A., Moffitt, T. E., Caspi, A., Belsky, D. W., Harrington, H., Schroeder, F., … & Danese, A. (2016). Lest we forget: comparing retrospective and prospective assessments of adverse childhood experiences in the prediction of adult health. Journal of Child Psychology and Psychiatry, 57(10), 1103-1112.
Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014
Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. The Journal of Clinical Psychiatry, 74(6), 541-550.
More articles in this issue:
Adverse Childhood Experiences (ACE) Study: The evidence behind what we know
How to Create Trauma-informed Systems of Care within Organizations
Social Workers Can Collaborate with Physicians to Create Aces-informed Healthcare
ACE’s in Foster Care: Rethinking trauma-informed care