Problems with the recommendation to implement ACEs screening

Clinician and Staff Perspectives on Implementing Adverse Childhood Experience (ACE) Screening in Los Angeles County Pediatric Clinics

PURPOSE

To understand clinician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care.

METHODS

We conducted a qualitative evaluation in 5 clinics in Los Angeles County, California, using 2 rounds of focus group discussions: during an early phase of the initiative, and 7 months later. In the first round, we conducted 14 focus group discussions with 67 participants. In the second round, we conducted 12 focus group discussions with 58 participants. Participants comprised clinic staff involved in ACE screening, including frontline staff that administer the screening, medical clinicians that use screening to counsel patients and make referrals, and psychosocial support staff who may receive referrals.

RESULTS

Themes were grouped into 3 categories: (1) screening acceptability and perceived utility, (2) implementation and quality improvement, and (3) effects of screening on patients and clinicians. Regarding screening acceptability and perceived utility, clinicians generally considered ACE screening to be acceptable and useful. In terms of implementation and quality improvement, significant barriers included: insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Lastly, regarding effects of screening, clinicians expressed that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening.

CONCLUSIONS

Clinic staff felt ACE screening was feasible, acceptable, and beneficial within pediatric care settings to improve trauma-informed care and that ACE screening could be strengthened by addressing time constraints and limited referral resources.

Parent Perspectives on Adverse Childhood Experiences & Unmet Social Needs Screening in the Medical Home: A Qualitative Study

OBJECTIVES

To explore parental perspectives regarding disclosure of child and parental adverse childhood experiences (ACE) and family unmet social needs (USN) and to elicit parental recommendations for screening in the pediatric medical home.

METHODS

We conducted a qualitative study using a purposive sample of English- and Spanish-speaking parents in our urban academic community clinic. Between January 2018 and March 2019, each parent underwent one semistructured interview that was audiotaped, transcribed, and independently coded in Atlas.ti by 2 study team members. Data analysis was based in constructivist grounded theory methodology to identify common themes and subthemes.

RESULTS

We interviewed 25 English-speaking and 15 Spanish-speaking parents who were mostly female, racial/ethnic minorities with ≥1 ACE. English-speaking subjects were more likely to have a high school degree and be single parents. Four themes were identified: 1) Pediatricians should ask about ACE and USN. 2) Disclosure is a longitudinal process, not a discrete event. 3) Barriers to disclosure are significant, involving concrete and emotional risks for the family. 4) Trauma-informed providers and practices support disclosure.

CONCLUSIONS

Families support pediatricians addressing ACE and USN in the medical home despite significant barriers. Even if providers screen using trauma-informed principles, parents may prefer not to disclose ACE initially because they regard disclosure as a stepwise process. These findings contribute to a new conceptual framework for thinking of ACE screening not merely as a way to generate information, but as an interactive, therapeutic relationship-building activity irrespective of whether or when it produces disclosure.

Prevalence of Adverse Childhood Experiences in the First Decade of Life: A Study in the Portuguese Cohort, Generation XXI

Adverse childhood experiences (ACEs) are a modifiable risk factor for diseases throughout life. This study estimates the prevalence of ACEs in children, addressing associated sociodemographic characteristics and examining the relationship of ACEs with the child’s health and behaviors. We used information on 5295 participants at 10 years old, of the birth cohort Generation XXI, established in Porto, Portugal. Children answered a self-administered questionnaire on ACEs, based on the original ACEs study. Principal component analysis was used to group correlated ACEs, and a score was computed to assess their cumulative effect. Overall, 96.2% of children reported having been exposed to at least one ACE. The most prevalent ACE was a household member shouting, yelling, or screaming at the child (57.7%). Boys were more likely than girls to report “abuse”, “school problems”, and “death/severe disease”. Low parental education, income, and unemployment were associated with an increased risk of “school problems”, “death/severe disease”, and “household dysfunction”. We observed that the dimensions of ACEs could be identified at 10 years of age. A disadvantaged socioeconomic environment was associated with dimensions of ACEs. These data illustrate the natural history of dimensions of ACEs and their potential social patterning.

Legislating to Prevent Adverse Childhood Experiences: Growth and Opportunities for Evidence-Based Policymaking and Prevention

Since the landmark study of Adverse Childhood Experiences (ACEs; Felitti et al., American Journal of Preventive Medicine, 14(4):245-258, 1998), there has been a significant growth in efforts to address ACEs and their impact on individual health and well-being. Despite this growing awareness, there has been little systematic review of state legislative action regarding variation in focus or scope or of the broader context impacting the introduction and enactment of ACE-related policy efforts. To inform the role of psychologists and related professionals to contribute to these legislative efforts, we conduct a comprehensive mixed-method analysis of all state bills introduced over the past two decades to investigate the use and impact of ACE research in introduced and enacted state legislative language (51 states, N_{Total Bills} = 1,212,048, N_{ACE Bills} = 425). In addition, these analyses examine congressional office communications (N = 14,916,546 public statements) and voting records (N = 1,163,463 votes) to understand the relationship between legislative members' public discussion of ACEs and their voting behavior on these bills. We find that legislators' public discourse is significantly related to ACE-related policymaking above and beyond political affiliation or demographic characteristics. Furthermore, key legislative language related to domestic violence, evidence-based practice, and prevention were significant predictors of whether an ACE-related bill becomes law-above and beyond the political party in power. These analyses highlight the ways in which ACE-related research has informed state policy. Based upon this work, we offer recommendations for researchers and policymakers.

Maternal-Child Health Outcomes from Pre- to Post-Implementation of a Trauma-Informed Care Initiative in the Prenatal Care Setting: A Retrospective Study

Background: There has been an increase in use of trauma-informed care (TIC) approaches, which can include screening for maternal Adverse Childhood Experiences (ACEs) during prenatal care. However, there is a paucity of research showing that TIC approaches are associated with improvements in maternal or offspring health outcomes. Using retrospective file review, the current study evaluated whether differences in pregnancy health and infant birth outcomes were observed from before to after the implementation of a TIC approach in a low-risk maternity clinic, serving women of low medical risk. Methods: Demographic and health data were extracted from the medical records of 601 women (n = 338 TIC care, n = 263 pre-TIC initiative) who received prenatal care at a low-risk maternity clinic. Cumulative risk scores for maternal pregnancy health and infant birth outcomes were completed by health professionals. Results: Using independent chi-squared tests, the proportion of women without pregnancy health risks did not differ for women from before to after the implementation of TIC, χ2 (2, 601) = 3.75, p = 0.15. Infants of mothers who received TIC were less likely to have a health risk at birth, χ2 (2, 519) = 6.17, p = 0.046. Conclusion: A TIC approach conveyed modest benefits for infant outcomes, but not maternal health in pregnancy. Future research examining other potential benefits of TIC approaches are needed including among women of high socio-demographic and medical risk.

Factors Related to Providers Screening Children for Behavioral Health Risks in Primary Care Settings

PURPOSE

To provide information from a large sample of pediatric and family medicine primary care providers on practices in screening children for behavioral health risks.

DESIGN AND METHODS

Participants were a sample of physicians (n=319) and nurse practitioners (n=292) from across the U.S. who completed a confidential online survey about screening practices through a computer-assisted self-interview.

RESULTS

Almost all respondents (89%) reported screening children for depression/anxiety and behavior problems. Child substance use (82%), family social support (74%), significant household changes (73%), bullying (72%), child abuse (62%) and domestic violence (52%) were also asked about regularly, although with high rates of informal screening methods. Caregiver mental health (49%), caregiver substance use (35%), family financial strain (33%) and transportation difficulties (27%) were screened less frequently. Screening was associated with higher rates of referral for risk-related problems, and was more likely when providers reported greater confidence providing support to clients, perceived community resource availability as higher, and worked in systems with integrated primary care and behavioral health.

CONCLUSIONS

Findings suggest a great amount of diversity in how providers screen for behavioral health risks. There is reluctance to screen when options for addressing the problems are seen as limited. Research is needed to better guide healthcare providers in determining the right context and methods for screening social risks.

PRACTICE IMPLICATIONS

Protocols for screening adverse childhood events (ACES) and other social risk factors should be accompanied by adequate training and efforts to improve community resource and support networks.