The 2016 movie Resilience is making the rounds here in Durham. A few weeks ago, it was shown at my daughter's school. I really like the movie. What I don't like, however, is being handed 10 questions from the ACE Questionnaire when I settle into my seat. Being handed those questions reminded me of a frequent conversation I have.
I am often asked if I would recommend an organization using the ACE Questionnaire. Generally folks are asking because they are interested in screening for trauma in some way. Which is so fabulous! The question is a great one. But here's why using the ACE questionnaire is not a good idea.
1. It's VERY dated.
Here's the question asking about domestic violence:
"Was your mother or stepmother:
often pushed, grabbed, slapped or had something thrown at her?
or
sometimes or 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?"
This language is gendered and very problematic. I've worked with survivors for almost fifteen years. And I've heard my share of stories of physically abusive moms. But that's not the only way the ACE questionnaire is dated. Here's the question screening for addiction issues:
"Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?"
What's missing here? Can you tell?
Prescription drugs are just as addicting today as they were when my parents were growing up. In the past, they have been seen as "safe" but that is no longer the case. These are just a few examples.
2. It's not trauma-informed.
The 100+ questions (and that's on the "Family Health History" questionnaire!) are exhausting and overly invasive. Any form that ask about sensitive topics like rape, domestic violence, incest or suicide must give participants a warning before doing so... and an option to opt out. The original ACE Study participants didn't get either but we know better now. It can be shocking to go from a question asking about close friendships to the question asking about living with someone who used "street drugs". Invasive questions without any kind of warning do not build trust and can actually inhibit trust building.
3. It's not patient-centered.
Some of the questions are asked in such a way that the respondent can reflect on how they felt about a certain situation. This is excellent. But some of them are asked in a way where an experience outside the one that is described wouldn't
count". Here's a good example:
"Did an adult or person at least 5 years older than you ever...
touch or fondle you or had you touch or fondle them in a sexual way?
or
try to or actually have oral, anal or vaginal sex with you?"
Clearly if my brother/cousin/friend 4 years old than I did any of those things with me, they would not "count". But that doesn't mean that I was not a victim of sexual abuse. The other challenge is while the questionnaire is about determining how childhood trauma affected patients, the reality is adults can also be raped. But those questions aren't asked. Instead, patients get questions about drinking and exercise instead of what they should be asked about. Patient centered care prioritizes the patient’s needs, experience, and values in clinical care. This would include allowing them to define their experience as abuse or not.
Last reason: the ACE questionnaire is not a screening tool! It was intended for research only.
Yes, the ACE Questionnaire may get you a lot of information about the person in front of you. But more than data, you need trust. Asking only what you need to (especially in the early stages of a relationship) builds trust more effectively than almost anything else you can do.
What are you using to screen for abuse, childhood trauma or as a general intake form? Leave a comment below.
PS. Need a tool to screen instead of the ACE? My 2018 session of When Survivors Give Birth talks about what to ask and how to ask. Click here for more details.