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What evidence is there to support parental ACE screening within health visiting practice? A literature review

22 November 2021

Victoria MacLellan and Peter Yates examine the experiences of parents and service providers during routine parental ACE screening.

What factors influence mothers in the UK and Ireland to wean their infants before six months of age?

Authors:

Victoria MacLellan, child protection learning and development lead, NHS Lothian.

Dr Peter Yates, programme lead for social work, Edinburgh Napier University.


Research summary

  • Adverse childhood experiences (ACEs) are associated with poor adult health and social outcomes. 
  • A parent’s ACEs can affect their parenting capacity. 
  • Research also highlights the intergenerational impact of parental ACEs that can place children at higher risk of ACEs. Hence, some researchers advocate screening parents for ACEs to identify families at risk. 
  • Health visitors are well placed to identify children at risk and may be well placed to carry out parental ACE screening. 
  • A literature review of the evidence base for parental ACE screening within health visiting practice was completed. 
  • While parental ACE screening is acceptable and feasible, some found it uncomfortable, particularly those with high ACEs.
  • Alternatively, trauma-informed conversations about ACEs may help parents make decisions regarding future support.

Key words Parent or caregivers, adverse childhood experiences, health visitor, paediatrician, midwife, community nurse. 


INTRODUCTION

Adverse childhood experiences (ACEs) were first defined by Felitti et al (1998) in their landmark study demonstrating an association between ACEs and poor long-term health and social outcomes, including ischaemic heart disease, cancer, chronic lung disease, adult alcohol or substance misuse and mental health problems (ACEs shown in Table 1). A strong and cumulative effect was found between the number of ACEs and increased risk of poor outcomes.

These sequelae may also affect future parenting capacity and parent-child relationships (Murphy et al, 2014). Evidence shows ACEs can have intergenerational effects, resulting in poor child health and developmental outcomes for the children of parents who have ACEs. Such outcomes include developmental delay over multiple domains (Folger et al, 2018), hyperactivity, emotional difficulties (Schickedanz et al, 2018), asthma, obesity, poor diet and poor dental care (Le-Scherban et al, 2018). Therefore, there may be an intergenerational ‘cycle of adversity’ linked to ACEs (Lange et al, 2016).

To break this cycle of adversity, some researchers argue the need to identify parents who have ACEs and offer support to mitigate their impact (Le-Scherban et al, 2018). Within some areas of paediatric practice in the US, routine parental ACE screening has been implemented. While there is evidence to support its feasibility (Gillespie and Folger, 2017) there is little evidence showing it has intergenerational effects (Folger et al, 2018). In Wales, the Family Resilience Assessment Instrument and Tool was introduced as part of the Universal Healthy Child Wales Programme. While this tool doesn’t measure specific parental ACEs, it aims to measure parental childhood experiences and their impact on family needs (Wallace et al, 2017). No recommendations for routine parental ACE screening are known to have been made within the UK. Public Health Scotland (2021) advises against gathering of ACE scores due to potential upset of children and adults leading to stigmatisation and labelling.

For those with ACEs, recommended interventions include trauma-focused mental health services for parents (Randell et al, 2015), strengths-based parenting interventions (Woods-Jaeger et al, 2018) and building resilience of children and parents (Le-Scherban et al, 2018). However, there is a lack of evidence-based interventions for those with ACEs (Asmussen et al, 2020). ACE screening becoming widespread practice remains a topic of debate. It may identify those at risk of poor outcomes (Dube, 2018) and have some therapeutic benefit (Gillespie and Folger, 2017), but may create stigma (Finkelhor, 2018), be inaccurate (Hardt and Rutter, 2004), and risk individualising complex social issues (Edwards et al, 2019). 

The ACE agenda involves reducing health inequality through prevention and reduction of ACEs (Asmussen et al, 2020). It has particular significance for universal services such as those provided by UK health visitors. Health visitors offer home visits to all families with pre-school children. They have a role in reducing health inequality through identification of vulnerable families and providing early intervention to meet their additional needs (Scottish Government, 2015). Health visitors may be uniquely placed to implement routine screening for parental ACEs. This would require convincing evidence that routine screening increases the likelihood of positive outcomes for families and evidence informing how routine screening should be undertaken.

There is no empirical evidence for routine screening increasing the likelihood of positive outcomes (Folger et al, 2018). A number of studies have explored the feasibility and acceptability of parental ACE screening in paediatric practice. This literature review seeks to synthesise the findings and draw conclusions for health visiting practice.


STUDY AIM/PURPOSE

This paper aims to explore the current evidence base regarding the experience of parental ACE screening from the perspective of parents and health visitors by carrying out a systematic approach to a literature review. Due to the dearth of research on this issue, specifically within health visiting, it was necessary to broaden the enquiry to investigate studies involving parental ACE screening carried out by other professionals (eg paediatricians, obstetricians and social workers).

The research question was broad:

What are the experiences of parents and service providers with respect to routine parental ACE screening?


METHOD

The following databases were searched in May 2021: CINAHL, Medline, PsychInfo, Social Science Abstracts and PTSDPubs. Google Scholar was searched for grey literature. The search terms used are outlined in Table 2.

Only primary research written in English was included. The search was carried out from 1998 onwards, when the concept of ACEs was first introduced. Studies that involved only screening children for ACEs, the association between parental ACEs and adult health outcomes or comparing child and adult ACE screening tools were excluded. This resulted in a final sample of 10 articles (as illustrated in Figure 1).

Evaluative tools for mixed-methods studies (n=5) (Long, 2005) and for quantitative studies (n=5) (Ciliska et al, 1998) were used to appraise the quality of the final sample. A data extraction tool ensured systematic extraction of relevant data which was analysed thematically. 

Systematic literature reviews do not require ethical approval (Maltby et al, 2010); however, ethical considerations pertinent to the individual studies identified were considered.


RESULTS

Ten articles contributed to answering the research question. Only one study was conducted within the UK (Hardcastle and Bellis, 2019), while nine were conducted within the US. They involved quantitative and mixed-methods designs with parents, prospective parents and service providers (results summarised in Table 3).

Table 3: Summary of Studies and Key Findings

Baseline knowledge about ACEs

From a study of 596 pediatricians working in general practice in the US, Szilagyi et al (2016) found 76% of respondents were not familiar with the original ACE study (Felitti et al, 1998). Lack of knowledge of ACEs was found to be a barrier to enquiry. Service provider education and guidance on ACE enquiry would be necessary for a screening programme to be successful. Similarly, 41% of providers in a study by Merksey et al (2019) found they were uncomfortable with the idea of ACE screening because of a lack of education on ACEs. 

Feasibility

Eight studies involved parental ACE screening using a tool. Tools were used to identify specific parental ACEs or gather an ACE score. One study also involved ACE enquiry (Hardcastle and Bellis, 2019). One study involved only having an ACE informed conversation. (Bodendorfer et al, 2020). Screening took place in either the home or clinic environment. Seven studies examined feasibility, all seven studies found screening to be feasible i.e. parental ACE screening was practicable in terms of time and resources.

Acceptability

Service providers reported feeling anxious initially about implementing ACE screening. Anxiety surrounded the perceived difficult nature of asking parents about their ACEs and the anticipated time necessary to implement screening. However, anxiety diminished with practice and, over time, practitioners became more comfortable with screening (Flanagan et al, 2018; Hardcastle and Bellis, 2019; Kia-Keating et al, 2019). 

With regards acceptability, the majority of parents reported being screened for ACEs acceptable and comfortable (Gillespie and Folger, 2017; Johnston et al, 2017; Flanagan et al, 2017; Conn et al, 2018; Kia-Keating et al, 2019. Hardcastle and Bellis, 2019; Quizhpi et al, 2019). They agreed clinicians should ask about parental ACEs and reported being happy with their clinician’s response to results (Flanagan et al, 2018; Quizhpi et al, 2019). 

In some studies, ACE screening was reported to lead to improved relationships between parents and providers by developing a trusting relationship and facilitating a deeper understanding (Hardcastle and Bellis, 2019; Kia-Keating et al, 2019; Gillespie and Folger, 2017). ACE screening was seen as a valuable step towards mitigating the impact of ACEs on parenting by linking parents with resources that may help to break the cycle of adversity (Hardcastle and Bellis, 2019; Conn et al, 2018; Flanagan et al, 2018). A UK study of 376 women that involved parental ACEs screening by health visitors, found that two-thirds of women thought it improved the help and support they received (Hardcastle and Bellis, 2019). ACE screening helped prompt parents to think about the parenting they wanted to provide in comparison to the parenting they had experienced (Hardcastle and Bellis, 2019; Conn et al, 2018).

Indeed, some parents reported ACE screening led to their first disclosure of ACEs (Hardcastle and Bellis, 2019). Others reported that screening led to spontaneous disclosures during subsequent visits (Kia-Keating et al, 2019; Gillespie and Folger, 2017; Johnston et al, 2017) and expressed gratitude for being asked and no longer feeling that they had to keep a secret (Kia-Keating et al, 2019; Gillespie and Folger, 2017). 

However, a small minority of parents felt less comfortable with ACE screening. In a study of 480 pregnant women, women with three or more ACEs were significantly less comfortable with screening. They were also less satisfied with their clinician’s response due to a perceived lack of empathy, not having enough time to discuss the responses, and a lack of resources on offer following screening. Merksey et al (2019) found higher levels of discomfort associated with disclosure of sexual abuse. 

From a small study of parents’ opinions about screening, Conn et al (2018) reported that some parents thought recalling the past could be emotionally difficult and may have the potential to retraumatise parents who have ACEs. Therefore, it might be difficult for parents to have conversations about ACEs at home if children were present, either because of the parent’s own distress or the upset the conversation might cause to the child. Likewise, practitioners in Hardcastle and Bellis’s (2019) study reported concerns about confidentiality of conversations regarding ACEs in the home, when friends and family were present. 

As an alternative to ACE screening, Bodendorfer et al (2020) sought to examine the acceptability and feasibility of offering an ACE conversation with parents that did not require ACE disclosure. Instead, the ACE conversation involved providing information to parents about available resources and the impact of high levels of adversity and trauma on children’s health and wellbeing. However, similar to other studies, while the ACE conversation was found to be acceptable by the majority of parents, a minority found the discussion about ACEs uncomfortable. Providers perceived parents to feel ‘accused’ while others appeared to take offence.

Timing

With respect to the timing of screening, in a study of a home-visiting programme for parents considered to be in ‘high risk’ groups, Johnson et al (2017) compared rates of ACEs disclosure between those who had an established relationship with their provider (n=20) with those screened on the first visit (n=90). A higher disclosure rate was found among those with an established relationship. Flanagan et al (2018) similarly found clinicians preferred to screen later in pregnancy once rapport and trust had been established with the women, and that ACE screening should also be balanced with screening for resilience. The health visitors in Hardcastle and Bellis’s (2019) study, reported screening at six weeks to be too early, but at six months too late.

ACE disclosure

In a large study, Gillespie and Folger (2017) compared the rates of ACE disclosure between those asked to disclose the detail of their ACEs (n=1308 parents) and those asked only for their total ACE score (n=975 parents). Significantly higher disclosure rates were found in the latter group (8.1% versus 11.2%), suggesting parents may be more willing to acknowledge a history of ACEs if not required to disclose the details. Hardcastle and Bellis (2019) similarly found women who disclosed ACEs through an aggregate score generally did not wish to discuss the details. However, in a study of 151 low-income parents (Kia-Keating et al, 2019), also screened using only an aggregate score, there was an example of a parent not disclosing ACEs during initial screening but doing so in a subsequent appointment prompted by earlier screening. The same mother voiced her approval of being asked about ACEs, thereby allowing a conversation to take place that could support her to provide her child with a more positive childhood experience than her own.

Parental inclusion

Variation existed across the studies regarding who was screened. Some studies involved only mothers (Hardcastle and Bellis, 2019; Flanagan et al, 2018), some included fathers only if they were present (Bodendorfer et al, 2020; Quizhpi et al, 2019; Conn et al, 2018; Gillespie and Folger, 2017; Johnston et al, 2017). Other studies did not identify parental gender or role (Kia-Keating et al, 2019; Merskey et al, 2019). Where stated, mothers (85% to 93%) represented a significantly larger proportion than fathers (7% to 18%) (Bodendorfer et al, 2020; Conn et al, 2018; Johnston et al, 2017). Within one study, on several occasions fathers asked to be included in the screening process. Health visitors expressed their view that, when appropriate, flexibility should be given to include fathers (Hardcastle and Bellis, 2019). Schickedanz et al (2018) surveyed the parents’ of 2903 children to examine the association between parental ACEs and child behavioural development. Maternal ACE score had a stronger influence on a child’s behavioural development than paternal ACE score. It was hypothesised this may be explained by most mothers being the primary caregiver within their study. While it is acknowledged that further study is required to understand the effects of both maternal and paternal ACEs on child development (Folger et al, 2018), when determining who to include in parental ACE screening, it may be helpful to consider the role of caregiver(s) including their significance to the child.


DISCUSSION 

Service providers’ initial anxieties about screening for ACEs were allayed. They found it feasible in practice and, overall, parents reported that conversations about ACEs helped deepen their relationships with service providers and facilitate ACE disclosure at the time of screening, or subsequently. While health visitors may require training in trauma-informed practice, if conversations about ACEs are managed sensitively, they may help parents reflect upon their experiences and consider how they would like their own children’s lives to be different. On that basis, there may be value in holding such conversations early in the relationship between the health visitor and parent. It may also be useful to return to such conversations later once trust and rapport has been established. Care needs to be taken around confidentiality and potential distress if these conversations take place in the home where children or other family and friends are present, particularly if those responsible for past abuse remain in contact with the family.

A distinction needs to be made, however, between routine enquiry and routine screening, as highlighted by Public Health Scotland (2021). While most parents may be comfortable with ACE screening, this review finds screening is much less acceptable to parents with high ACE scores and they may not wish to disclose or discuss their experiences. A lack of disclosure cannot be taken for an absence of ACEs. Indeed, Hardt and Rutter (2004) found one third of adults did not report childhood experiences of abuse or neglect when asked as adults. This may be for several reasons, including not remembering, not identifying the experiences as having been adverse, or not wishing to disclose. Therefore, ACEs screening may not always provide an accurate representation of parents ACEs.

With regards to the ACE score, even if accurate, it does not necessarily provide a fair reflection of parents’ level of need. An ACE score does not take account of the impact of adverse experiences on individuals that may vary significantly from person to person and be influenced by factors such as age, ACE severity, timing, frequency, resilience and protective factors (Lopez et al, 2021). 

When considering the evidence base for parental ACE screening it is helpful to consider domestic abuse routine enquiry. Exposure to domestic abuse is one of the ACEs defined by Felitti et al (1998). Domestic abuse enquiry within health visiting practice is now firmly embedded and can offer important learning that may be transferrable to that of ACE enquiry. In a systematic review of routine screening for domestic abuse in health settings, O’Doherty et al (2014) found that while it increased the identification of women who had been abused, there was no evidence of a reduction of incidence or improved health outcomes for those affected. While in a subsequent systematic review Feder et al (2019) found onward referral to services following domestic abuse screening was not as effective as self-initiated referral. There is little evidence relating to domestic abuse enquiry to support improved long-term health outcomes as a result. 

The ACE inventory developed by Felitti et al (1999) was used to screen for ACEs in the studies within this review. Some studies adapted their screening tool to include additional ACEs (see Table 4). However, this led to inconsistency in the number and type of ACEs being screened. 
 

The original inventory has been questioned in terms of its current relevance. Finkelhor et al (2015) argue that some ACEs are no longer significant (e.g. parental separation) while other ACEs (e.g. living in poverty) are not represented. Similarly, Edwards et al (2019) argue that taking a narrow view of ACEs is stigmatising and ignores some of the wider contexts affecting families, such as poverty, racism, and living in areas of multiple deprivation or high levels of crime. The original ACE inventory was designed for epidemiological purposes (Dube, 2018) (see Table 5). It seems highly problematic to use it instead as a screening tool to identify parents in need of additional support and onward referral to services. It risks individualising wider issues of social inequality that should be the responsibility of policy makers (McVarish and Lee, 2019).

In relation to parental ACE screening, there is no evidence that ACE screening produces better outcomes for parents and children and without effective interventions, routine screening is ethically questionable. In summary, there is little evidence to support the current trend of using ACE screening as a way of determining service intervention (Asmussen et al, 2020). 


IMPLICATIONS AND RECOMMENDATIONS

  • There are strong arguments against the use of ACE screening, with little and disputed evidence to support its use as a means of identifying parents’ needs, allocating resources or determining onward referral to additional services.
  • There may be value in routine enquiry, that is, holding conversations with parents about their childhood experiences and current circumstances, that extend beyond the original ACEs inventory to include other forms of adversity and wider current social circumstances that may impact upon parenting. Such conversations may help to deepen relationships and facilitate disclosure of adversity.
  • When considering who to include in parental ACE screening, consideration should be given to the role of mothers, fathers and other caregiver(s) including their significance to the child.
  • There may be value on holding such conversations early in the service provider-parent relationship as well as revisiting these conversations at later stages.
  • Care needs to be taken around the setting for such conversations, the potential for distress and breaches of confidentiality if other family and friends are present.
  • Such conversations may still be less acceptable to parents who have experienced higher levels of adversity in childhood and need to be approached with sensitivity.
  • Professionals may require training to hold such conversations, which would need to include the principles of person-centred, trauma-informed and culturally competent practice.

CONCLUSION

The research that has been undertaken with regards to ACEs has been influential and helpful in highlighting the impact of childhood adversity and trauma on long-term mental and physical health outcomes as well as the potential for intergenerational effects. There may be ongoing value in using an updated ACEs inventory as a screening tool for epidemiological purposes. An updated inventory may further our understanding of the impact of ACEs on health and social outcomes from a population perspective. However, there is significant evidence against screening for ACEs for any other purpose, and particularly for identifying families in need of additional support and associated allocation of resources. Instead, there may be value in holding trauma-informed conversations with parents about their childhood histories and wider social circumstances to deepen trust in relationships with health visitors. These conversations may help parents reflect on their parenting and consider whether they would like to initiate referrals to additional support services.


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