Debate: Is ACE screening doing more harm than good? Beyond the ACE score - towards more personalised approaches to risk prediction.

Adverse childhood experiences (ACEs) are strongly associated with later mental and physical health problems, prompting growing interest in ACE screening to identify vulnerable children and adults who may benefit from interventions to prevent or mitigate these outcomes. However, evidence supporting routine ACE screening in clinical practice remains limited. Although cumulative ACE scores demonstrate robust population-level associations with health outcomes, their individual predictive accuracy is consistently poor, with substantial false-positive and false-negative classifications and potential for inequitable outcomes across demographic groups. Existing screening approaches also fail to capture important contextual differences among reported ACEs, as well as factors that may promote resilience. Furthermore, positive screening results are not currently linked to clearly established, evidence-based clinical pathways, raising wider concerns around labelling stigma and missed needs. Therefore, widespread implementation of ACE screening in its current form cannot be recommended to prevent poor health. However, future approaches that move beyond cumulative adversity counts towards more nuanced, personalised and proportionate ACE measures, which also consider broader developmental, social and protective factors, have the potential to inform more personalised risk assessment following childhood adversity.