Determinants Public Health

the problem with ACEs. A critique of the critique


People being critical of the ACE framework seems increasingly common.

The criticism comes from several perspectives, often well founded. Andy Turner offered a rapid canter through the criticisms in this thread. All valid points. I’m also aware of a prominent criticism from Prof White and others. See here for one of the papers. Again, all valid.

Here put up a critique of the critique and a counter narrative. I’m aware it may get me into hot territory. It is structured around three themes – framing, research, implementation with some of the common criticisms I hear in each of those themes.

1. Concept and framing

ACEs explains population risk, not individual stories

ACE is the risk factor, and was always supposed to be a risk factor way of thinking about the world, or a framework for research agenda, rather than something around which to design services

Many with significant ACEs also have no issues and problems, and vice versa – many with significant problems have no ACEs.

For sure.

Ecological fallacy is as much in play here as any other construct.

ACEs is an explanatory factor at cohort level.

Take great care applying this at individual.

Can lead to medicalisation of social construct & There is often enthusiasm as an answer to all social ills


I don’t think anyone is actually doing this medicalisation in practice, not what I see.

Of course there is Potential for a narrow conceptualisation of social problems.

Nobody is arguing with the fact that poverty, poor housing etc isn’t important, and more important.

ACEs are an upstream issue in some contexts (to treatment and punishment), but downstream in others (eg poverty and marginalisation) lies further upstream,

Of course we need to take great care to not victimise people, it would be easy to do so

Narrow construct. The ACE framework is relatively narrow, it only covers certain events

Of course. There are events not identified in the ACEs research which will impact in the same way 

Most are not only rigidly sticking to what ACEs were identified in the original studies. It’s toxic stress that matters and how this cumulated over time; and the long term impact of this. This video from Bruce Perry on ACEs, brain development, trauma and importance of relationship, early years and trauma debriefing is worth a watch.

A narrow concept of ACEs is just wrong. Bruce also challenges the narrow concept of how ACEs research is being used in a very clear way based on the neuro-science. He brings together brain development, early years, trauma and ACEs research and the key protective factor being the quality of relationships, particularly in the first year of life, and why we need to be careful in how we offer support in the aftermath of traumatic events

Negative framing.

We tend to think about ACEs (whether narrowly or broadly defined) as the positive presence of some bad things. We forget at our peril that equally (?more) important is the positive presence of good things, the importance of assets, single anchoring relationship, its not what happened to you but how you have managed to process what has happened – quality of relationships it the key buffer.

Early years determinism.

The early years DO matter. Science overwhelming!

The rest of young lives also matter. The rest of whole lives matter. Early good work can be undone by toxic influences later in life. Nobody arguing otherwise. But the early years ARE the most impactful.

Bruce Perry (and plenty of others) have clearly articulated the research evidence that children who have had a good enough experience in the first year of life are much more likely to have better outcomes even if they then experience a number of years of trauma ‑ they will have better outcomes then children who have had significant trauma in the first year of life but are then placed in much more stable environments i.e. we really need to focus on the 0 ‑ 2 age range to make the most difference

2. Research and evidence base

The ACEs evidence base for interventions has limitations that have not been fully addressed.


See here (plus tables with supporting evidence) for an excellent summary from Prof Bellis and others. I do see a lot of the narrative, and evidence summaries for interventions, seemingly over focus on interventions delivered to individuals rather than creating environments, communities and contexts that support well being.

Often that’s a problem inherent with the paradigm and evidence question generating processes and a reflection of the social complexity (and thus difficulty of succinctly summarising evidence of what do “do”). Often also this is compounded by a need to focus evidence towards recommendations for practitioners rather than at policy makers across many different national actors.

There’s a risk that this document may be seen to perpetuate a model of evidence rooted in individuals and not structural determinants.

Evidence of effectiveness of interventions affected by bias of who is framing it and summarising it.


Same can be said of anything.

We over extrapolate from animal studies on cortisol, toxic stress etc.

Disagree here. Nobody is doing this. There’s plenty of biological plausibility and real world observational evidence. I don’t think anyone is over extrapolating. Back to Bradford Hill.

We do misconstrue epidemiological and direct clinical evidence, that is different.

Research in this space can be obscuring cause and effect, confounding, random variation.


Will never be smoking gun linking risk to outcome over long latency periods, Apply Bradford Hill criteria – strength of association, temporal nature, biological plausibility etc. The same issues are inherent in many other concepts that are framed as big threats.

Recall bias can be an issue

3. Implementing

ACEs are not evenly distributed,

All risk factors are unevenly distributed

Act accordingly

Some frame ACE as a diagnostic tool, or a diagnostic label.

Agree. Need to be careful here.

Its an explanatory factor not a diagnosis

The negative consequence of using this as a diagnostic framework often not acknowledged.

Screening and counting

Personally my view is the case for screening is nowhere near met

This shouldn’t exclude judicious enquiry, followed by appropriate response. This is tricky.

I’m no fan of the enthusiasm for “counting and scoring”.

Not just children

Of course early years matter, primary, secondary and tertiary prevention

Adversity in childhood has lifelong impact. The right response in adulthood also matters, a lot. In this case the clue isn’t in the title.

Over hope in rapid results, magic bullets and simplistic solutions.

Agree. Nothing new here, nothing special to ACEs on this one

nobody saying there are magic bullets inherent in a response to ACEs and nobody is over simplifying this.

Its really rather complicated in some respects, but paradoxically simple in others. There IS a need for a different response – what happened to you vs what matter with you etc.

Any response will be varied across different sectors and service areas, probably with commonality and strong crossovers into other spaces, for example person centredness, asset or strengths based approaches. There’s also a tricky thing on how you view the world – some people will see the world through the ACE lens, some through different lens.

3. Bottom line

ACEs is well intentioned but problematic model. Tell me a model that isn’t problematic. Implementation without critical analysis is a mistake

Nobody is saying that cuddles are the answer to toxic stress or the long term consequences arising from poverty or other factors upstream of individual adversities.

However the framework and thinking that ACEs can give us can certainly open up new responses to (and reasons for) improving our primary prevention and improving resilience and our response across multiple settings and across a whole life course. There are plenty of opportunities for “better”, some of which we are capitalising on, some we are not.

The bottom line is that we ignore trauma at our peril – the important message from ACEs research is that is has a huge impact on people’s outcomes and then we need to be very mindful as to how we apply this knowledge.

Thanks to Dr Zoe Brownlie for helpful comments on an earlier draft.





1 reply on “the problem with ACEs. A critique of the critique”

This is a welcome addition as a mediation between the polarity in the debate around aces. Would love to see this more dialogically constructed.


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