Increasing the effectiveness of the client’s Adverse Childhood Experiences (ACEs) assessment
Internship report of Anuja Bhandari who interned in early 2022.
When I first started working at Wellness Space as an intern, my role was to go through client consultation files (especially self-assessment of ACEs) and check if there were any changes to the ACE (adverse childhood experiences or traumatic events that occur before a child turns 18) in the self-assessment after the client consultation (personal interview, online or offline) . According to research, ACEs have a significant impact on mental health, and detecting ACE is a crucial task for a therapist. However, only 22% of the mental health service users report being asked about child abuse. Hence, there is an opportunity to highlight and promote the identification of adverse childhood experiences for mental health centres/therapists.
I found out while talking to many therapists and going through files that many ACEs are missed out while filling the form which can have an effect on further therapy sessions. And then I began to go through files and consultation notes to see the revision and some of the potential reasons might be how a few experiences like physical abuse or emotional abuse are normalised in India or people might block some memories which might be traumatic for them. Further in the report we will look at what are the major ACEs client miss out filling, what is the impact of it in adulthood and how it will be useful in the therapy afterwards.
1. ACE revisions after the personal interview:
The very first session of the client before therapy is like a personal interview in which the client gives each and every information about their childhood and current issues and before that, they fill up the forms for anxiety, depression, wellbeing, sleep and ACE and After going through more several hundred files and collecting the data we have come to the conclusion which is mentioned in the above data. As per the data, the highest no of ACE revisions happens in physical abuse, the second-highest in emotional abuse, 3rd peer victimisation and parents’ fighting (Figure 1 has the details).
Figure 1 – Revision in Adverse Childhood Experience score (% of individuals whose records changed after the personal interview as compared to self-assessment)
2. Potential reasons for not filling up the ACE form correctly:
- As mentioned earlier, beating up a child in order to discipline them or punish them is so normalised in India that people think it is acceptable and does not consider it to be worth mentioning.
- There are clients above the age of 50 who does not remember much about their childhood so miss out on filling in the information.
- When you have a traumatic experience, your brain tends to block the painful memories which need deep work to let it out thus they miss out to fill them.
- Another possible reason might be repressed memories, the memories which are those you unconsciously forget. 
- One more possible reason can be that early childhood memories lack emotional significance and it is said that memories become much stronger when they have an emotional component. Very young children do not have a fully developed range of emotions hence these childhood experiences may not get stored with the same emotional significance as an adult or adolescent. And as they carry less weightage, they fade away easily with your age.
3. How missing out on ACE affects therapy:
- According to research most of these abuses are linked to PTSD. When compared to other types of childhood maltreatment, emotional abuse is the most strongly related to the severity of PTSD symptoms among the four key ACEs that are overlooked. Hence, identifying and assessing these missed out ACEs is critical for PTSD interventions and will further help in therapy.
- Data at Wellness Space shows that frequently missed out ACEs like emotional abuse or physical abuse are linked to higher sleep issues, anxiety and depression.
- Therapy based on current relationship issues requires special attention to how the client witnessed their parent’s relationship as a child.
- Peer victimisation is linked to low self-esteem; hence it is important to work upon it in therapy.
To summarise, these four ACEs (emotional abuse, physical abuse, peer victimisation, and parental fight) are usually missed out during the self-assessment process and play a key role in PTSD, anxiety, depression, sleep issues, and a variety of mental health diseases. After reviewing the quantitative ACE, I shifted my focus to the qualitative ACE, which describes the client’s current issues. The goal was to find a link between the client’s childhood trauma and current concerns. We analysed over 150 files and came to some conclusions on the significant difference between the high and low ace. According to the findings:
- People with high ace scores are more likely to do self-harm and have a lesser ability to focus than people with low ace scores.
- Another interesting finding includes that people with both high and low ace scores are equally suffering from sexual blockages.
4. How this data is useful further in therapy:
As a result of the findings on self-assessment scores and revision after a personal interview in the ACE, the suggestions I made are:
- Focusing on the effectiveness of the consultation by adding more questions on the few aces that are being missed out frequently.
- We also made a video regarding this information and revised the form for better clarity for the prospects who are preparing for consultation.
- We altered a few processes in the system to emphasise the client codes that require PTSD assessment in order to accurately verify PTSD.
- We have also implemented this new process where aces that are common in PTSD and revision after personal interview which are Emotional abuse, Physical abuse, Emotionally neglect, Peer victimisation, Peer isolation, and Parents fighting and will be probed more in future consultations.
By Anuja Bhandari, Psychology Graduate and Intern @ Wellness Space.
 Trivedi, G. Y., Pillai, N., & Trivedi, R. G. (2021). Adverse Childhood Experiences & mental health – the urgent need for public health intervention in India. Journal of preventive medicine and hygiene, 62(3), E728–E735. https://doi.org/10.15167/2421-4248/jpmh2021.62.3.1785
 Read, J., Harper, D., Tucker, I., & Kennedy, A. (2018). Do adult mental health services identify child abuse and neglect? A systematic review. International Journal of Mental Health Nursing, 27(1), 7–19. https://doi.org/10.1111/inm.12369
 Boag, Simon (2006). Freudian Repression, the Common View, and Pathological Science.. Review of General Psychology, 10(1), 74–86. doi:10.1037/1089-26184.108.40.206
 s Hoeboer, Carlijn de Roos, Gabrielle E. van Son, Philip Spinhoven, Bernet Elzinga, The effect of parental emotional abuse on the severity and treatment of PTSD symptoms in children and adolescents,Child Abuse & Neglect,Volume 111,2021,104775,ISSN 0145-2134,