Debate: Is ACE screening doing more harm than good? Bridging the gap between ACE measurement and conceptualization

Abstract

The rapid expansion of adverse childhood experience (ACE) screening in pediatric care has largely been driven by strong evidence linking childhood adversity to later physical and mental health outcomes. Proponents argue that ACE screening offers a pragmatic approach to identifying psychosocial risk factors that may otherwise remain undetected in routine healthcare encounters. Yet, concerns have emerged regarding whether cumulative ACE scores provide sufficiently precise information for individualized clinical interpretation. In this debate article, we argue that clinical implementation of ACE screening may have advanced more rapidly than conceptual consensus regarding what ACE scores actually represent. Current cumulative scoring models often compress heterogeneous experiences into a single metric, limiting their ability to capture meaningful variation in severity, timing, chronicity, relational context, and protective factors. Consequently, individuals with identical ACE scores may have fundamentally different developmental histories and clinical needs. Although ACE screening may retain value as a population-level indicator of risk, its application within individualized care contexts raises unresolved concerns regarding interpretive precision and clinical utility. We conclude that future approaches to adversity assessment may require multidimensional conceptualizations that better align with support more nuanced patient-level interpretation.