Rationale for ACEs Screening

Screening can improve clinical decision-making and prevent negative health outcomes

Many of the foundations of health in adulthood are laid during childhood and adolescence. Though there are children who experience multiple ACEs in their first few years of life, most children accumulate ACEs over the course of their childhood. In a multisite study of children exposed to or at risk for maltreatment, it was found that by age 6 children had an average ACE score of 1.94. Between ages 6 and 12, on average they accumulated an additional 1.53 ACE, and then between ages 12 to 16 another 1.15 (Flaherty et al., 2013). The gradual accumulation of ACEs suggests that there is an opportunity to identify children at risk for accumulating ACEs and the negative health outcomes associated with them. By doing so, we can raise awareness of the importance of preventing further exposure to ACEs, identify needed specialized treatment for children who have been exposed, and better tailor health care measures based on an understanding of the child’s odds of illness or disease. In addition, while the plasticity in the brain during early childhood and adolescence is a source of vulnerability to ACEs, it is also an opportunity for intervention and treatment.

Pediatric primary care setting is an ideal setting for universal screening, health promotion and disease prevention

The primary care medical home is uniquely positioned to be the site for routine universal screening for ACEs. Primary care physicians are trained in disease prevention and to understand the important role of parents and communities in determining a child’s well-being. Interacting with children and their families at regular intervals can allow patients and providers to develop a trusting relationship, which can facilitate the disclosure of ACEs. In a survey of 302 pediatricians, 81% agreed screening for family social emotional risk factors is within their scope and 79% agreed that their advice can impact how parents care for their children (Kerker et al., 2015).
Universal screening for ACEs is critical. For some children the effects of toxic stress are seen in externalizing behaviors, such as poor impulse control and behavioral dysregulation. In these children, externalizing behaviors may be symptoms of the neurodevelopmental impacts of toxic stress. Routine screening offers the opportunity to identify individuals at high risk and offer Anticipatory Guidance before the child becomes symptomatic. In addition, there are also individuals who do not exhibit any externalizing behaviors, and are still at increased risk of developing poor health outcomes.

The American Academy of Pediatrics (AAP) calls on pediatricians to identify and treat adversity and toxic stress

Particularly harmful and stressful relational experiences such as child abuse and neglect can compromise healthy development and negatively impact health in both childhood and later during adulthood (Johnson, Riley, Granger, & Riis, 2013; Felitti et al., 1998; Flaherty 2013; Kalmakis & Chandler, 2015; Oh, et al., 2016). A dose-response relationship between the number of adversities and likelihood of disease has also been substantiated with children experiencing a greater number of adversities being at greater likelihood of negative health outcomes (Bethell et al 2016; Bright et al., 2016). Given the tremendous research on the negative impacts of adversity on child health and opportunity for meaningful prevention, the American Academy of Pediatrics has called on pediatricians to play a role in identification and treatment of adversity and toxic stress (Garner et al., 2012).

ACEs screening accepted by patients and can improve health care utilization

Research has shown that screening for adversity is acceptable among patients. In an adult primary care setting, 79% of patients were comfortable being asked about ACEs and 86% felt comfortable being screened for ACEs (Goldstein, Athale, Sciolla, & Catz, 2017). Inquiry of early adversity can also be met with appreciation; in a pediatric setting, parents were reported to be engaging in conversations about trauma and found the topic to be of value to their child’s care (Gillespie & Folder, 2017).

Addressing childhood adversity in the medical setting has great potential to improve health care utilization. One year after screening for Adverse Childhood Experiences (ACE) in the Health Appraisal Clinic at Kaiser Permanente of San Diego, clinicians saw a 35% decrease in office visits and an 11% decrease in emergency room visits among participants compared to the prior year. In comparison to a control group that did not undergo screening, screened participants saw an 11% decrease in office visits (Felitti & Anda, 2014).

Clinical integration of ACEs screening into workflow is feasible

Pediatric clinics implementing adversity screening have found that screening can be feasible in a limited resource setting. For example, in an outpatient pediatric setting, office visits improved without impeding factors such as limited time or resistance from caregivers or providers (Gillespie & Folder, 2017).

References

Bethell CD, et al. Health Aff (Millwood). Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience. 2014 Dec;33(12):2106-15.
Bright MA, et al. The Comorbidity of Physical, Mental, and Developmental Conditions Associated with Childhood Adversity: A Population Based Study. Matern Child Health J. 2016 Apr;20(4):843-53.
Garner, A. S., Shonkoff, J. P., Siegel, B. S., Dobbins, M. I., Earls, M. F., McGuinn, L., … & Committee on Early Childhood, Adoption, and Dependent Care. (2012). Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics, 129(1), e224-e231.
Felitti, V. J., & Anda, R. F. (2014). The lifelong effects of adverse childhood experiences. Chadwick’s child maltreatment: sexual abuse and psychological maltreatment, 2, 203-15.
Flaherty, E. G., Thompson, R., Dubowitz, H., Harvey, E. M., English, D. J., Proctor, L. J., & Runyan, D. K. (2013). Adverse childhood experiences and child health in early adolescence. JAMA pediatrics, 167(7), 622-629.
Gillespie, R. J., & Folger, A. T. (2017). Feasibility of Assessing Parental ACEs in Pediatric Primary Care: Implications for Practice-Based Implementation. Journal of Child & Adolescent Trauma, 1-8.
Goldstein, E., Athale, N., Sciolla, A. F., & Catz, S. L. (2017). Patient Preferences for Discussing Childhood Trauma in Primary Care. The Permanente Journal, 21.
Johnson, S. B., Riley, A. W., Granger, D. A., & Riis, J. (2013). The science of early life toxic stress for pediatric practice and advocacy. Pediatrics, 131(2), 319-327.
Kalmakis, K. A., & Chandler, G. E. (2015). Health consequences of adverse childhood experiences: a systematic review. Journal of the American Association of Nurse Practitioners, 27(8), 457-465.
Kerker, B. D., Storfer-Isser, A., Szilagyi, M., Stein, R. E., Garner, A. S., O’Connor, K. G., … & Horwitz, S. M. (2016). Do pediatricians ask about adverse childhood experiences in pediatric primary care?. Academic pediatrics, 16(2), 154-160.
Oh, D.L., Jerman, P., Silverio Marques, S., Koita, K., Ipsen, A., Purewal, S.K., Bucci, M, (2016). Systematic review of pediatric health outcomes associated with Adverse Childhood Experiences, American Academy of Pediatrics National Conference & Exhibition San Francisco, CA
Sills MR, Shetterly S, Xu S, Magid D, Kempe A. Association between parental depression and children’s health care use. Pediatrics. 2007;119(4):e829–e836
Stein RE, Hurlburt MS, Heneghan AM, et al. Chronic conditions among children investigated by child welfare: a national sample. Pediatrics. 2013;131(3):455–462.