A Health Problem and An Opportunity: Screening for Adverse Childhood Experiences
A consensus of scientific research demonstrates that cumulative adversity, especially when experienced during critical and sensitive periods of development, is a significant contributing factor to some of the most harmful, persistent, and expensive health challenges facing our nation. Adverse Childhood Experiences (ACEs) are highly prevalent, experienced in all communities, and are likely to increase during the COVID-19 emergency [i] [ii] [iii] [iv] [v]. ACEs and the potential resulting toxic stress physiology are strongly associated, in a dose-response fashion, with some of the most common and serious health conditions facing our society today, including nine of the 10 leading causes of death in the United States.
On these key facts, many of us in the scientific community agree that next step is to identify and implement the best ways to interrupt the intergenerational effects of trauma and create a healthier future for the next generation. I want to recognize and applaud the recent article in the American Journal of Preventive Medicine, authored by Robert Anda, Laura Porter, and David Brown for its role in stimulating dialogue, among the ACEs and trauma-informed community, as we push toward reducing the incidence of ACEs in half within one generation.
It will take more than one method of intervention to wrestle this public health crisis down and ensure that resilience (and the buffering supports that encourage it) wins the day. For the purpose of this piece, I’m going to focus on California’s ACEs Aware Initiative (which I serve on as an advisor), clinical interventions, and address some concerns raised by Anda, Porter, and Brown.
One of the goals of the ACEs Aware initiative is to provide clinicians with education and training, clinical protocols, resources, and tools they need to engage with their patients and provide education on ACEs, toxic stress, and buffering factors. Led by the Office of the California Surgeon General and the California Department of Health Care Services, the initiative offers educational forums and clinical resources, such as clinical workflows, screening tools, response algorithms, and educational materials. Screening for ACES in adults and children is reimbursable, but not mandatory [vi].
The initiative recognizes that it is important to integrate what we know into clinical practice now, as trauma is pervasive, and we’re likely to see incidences of early childhood adversity rise during the COVID-19 emergency.
ON SCREENING FOR ACES IN A CLINICAL SETTING
As a primary care pediatrician and researcher, I worked with colleagues to create a screening tool for ACEs, released in 2018. My colleagues and I created a tool that was specifically designed for use in pediatric practice. The Pediatric ACEs Screening and Related Life-events Screener (PEARLS) was developed in partnership with the Center for Youth Wellness, University of California, San Francisco (UCSF), and UCSF Benioff Children’s Hospital Oakland. We created this not as a diagnostic tool but as a way to make our clinical assessment more robust and to help us more consistently include these really important issues in conversations with our patients. When used in a clinical setting, the purpose of the PEARLS tool (and other ACEs tools) is to identify the likelihood that a patient may have underlying or be at risk for developing toxic stress physiology. The clinician in response can offer anticipatory guidance about ACES and toxic stress as well as link patients to resources and support as part of their treatment planning.
The PEARLS tool has published face validation and the biometric and psychometric validation is currently underway. However, as the science and practices continue to evolve, the ACEs tools we have now can inform how a clinician thinks about the entirety of a patient’s presentation and whether they may have underlying toxic stress physiology, and recommend that the physician place an increased emphasis on ensuring that interventions include buffering supports.
Individual ACE screening is not meant as a replacement for a full clinical work up or to explain the full etiology of a disease, but rather as another important piece of information to be included in the physician’s decision-making. The ACEs Aware-developed ACEs and Toxic Stress Risk Algorithm shows how an ACE score is used in combination with a clinicians’ assessment of an individual’s health conditions to guide anticipatory guidance and treatment plans.
Scores on ACEs tools alone should not be the only indicator determining therapeutic interventions or treatment plans, but without them, we may fall short of considering an important piece of information that could be missed otherwise.
Several implementation studies have established the feasibility and utility of ACE screening and treatment in pediatrics[vii] [viii] [ix] [x] [xi] [xii], maternity care[xiii] [xiv], family practice [xv], and internal medicine [xvi] [xvii] [xviii]. These implementation studies have found that ACE screening usually adds less than five minutes to the visit, is acceptable to both patients and providers, and is associated with improved patient satisfaction and health care utilization[xix] [xx] [xxi]. As outlined in the ACEs Aware provider toolkit, education about the relationship between adversity and health is appreciated by patients, increases trust in the provider, and improves the quality of the relationship. With appropriate provider-patient engagement/education, screening is also welcome by patients as a bridge to needed services.
BUILDING THE SCIENCE
The science is robust, evidence-based and clear on the impact of outcomes, as outlined in countless articles and reports, including the National Academies of Sciences, Engineering, and Medicine report Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. This has given us the ability to start to tackle the impacts of adversity and the toxic stress physiology in patients. That said, there is absolutely work to be done to develop and refine the tools that screen and assess for ACEs and toxic stress physiology, and as with any new medical practice, physicians have the option to move forward with evidence-informed practices as they develop, understanding that the effort for advancing the science must continue.
Specifically, more work needs to be done around the interpretation of ACE scores. As mentioned, the score is an important descriptive piece of data. It informs providers about the life experiences of patients that can contribute to health concerns. We do need to know more about the variance in the scores themselves; a person with a score of 1 may indeed signify persistent trauma linked to a poor health and toxic stress physiology, and a person with a score of 4 may not be linked to symptomatology and toxic stress physiology. We need more evidence-based research and standardization in this area, and that work is underway.
At the same time, the clinical algorithm provided by the ACEs Aware initiative is an important way to start ensuring that clinicians have access to this descriptive information. California has taken the brave step forward to lead the science and drive the policy while holding and caring for our community.
Another contribution of the ACEs Aware initiative lies in its commitment to advancing learning and implementation in multiple areas. The state of California is working with the University of California San Francisco on the California ACEs Learning and Quality Improvement Collaborative (CALQIC), an 18-month learning collaborative of pediatric and adult clinics to identify best practices in implementing ACES screening in primary care. It will include up to 15 organizations representing at least 50 sites that provide comprehensive primary care services to Medi-Cal adult and pediatric patients across the state.
ON THE APPLICATION OF POPULATION-BASED RISK FOR HEALTH OUTCOMES TO INDIVIDUAL CLINICAL SCREENINGS FOR TOXIC STRESS PHYSIOLOGY
The purpose of public health is to improve the health of communities. To improve the health of communities, you must improve the health of the individual people in those communities. This implicit relationship drives any number of public health interventions designed to educate patients and their families, and provide information and context for treatment options and wiser decisions. A clear, current example is individual physicians applying epidemiological data about which populations face increased mortality due to COVID-19, and taking that into consideration when crafting public health recommendations and treating patients in those populations. Another example is the association between tobacco use and adverse health outcomes driving decades-long public health and individual clinician interventions to encourage smoking cessation. We have to be careful about how we explain individual risk based on a screening tool, but our intervening clinical behaviors can be modified to take these epidemiologic risks into consideration.
As physicians collectively work to improve the health and well-being of their patients, more and more data becomes available about which interventions are beneficial and which are harmful, especially if these efforts are well coordinated, funded, and given the appropriate research attention. In cases where a body of research is developing, a promising clinical practice not yet officially recognized as a public health screening measure can be used effectively in clinically appropriate cases and with proper education and resourcing.
CONCLUSION
There is a lot more work to do, and much of it is ongoing. The state of California has chosen a deliberate approach to ACEs screening that includes education for providers, engagement for communities, and a commitment to collaboration, learning, and advancing the science. The goal is to offer providers, patients, and families the opportunity to interrupt harmful intergenerational cycles, and ensure that people have access to information they need to understand how ACEs and toxic stress may be impacting their health, and the protective and buffering practices that can help us all heal.
Citations
[i] Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998; 14: 245–58.
[ii] Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. The Impact of Adverse Childhood Experiences on Health Problems: Evidence from Four Birth Cohorts Dating Back to 1900. Preventive Medicine 2003; 37: 268–77
[iii] Anda RF, Felitti VJ, Bremner JD, et al. The Enduring Effects of Abuse and Related Adverse Experiences in Childhood: A Convergence of Evidence from Neurobiology and Epidemiology. European Archives of Psychiatry and Clinical Neuroscience 2006; 256: 174–86.
[iv] Merrick MT, Ford DC, Ports KA, et al. Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morb Mortal Wkly Rep 2019; 68. DOI:10.15585/mmwr.mm6844e1.
[v] Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of Adverse Childhood Experiences from the 2011–2014 Behavioral Risk Factor Surveillance System in 23 States. JAMA Pediatr 2018; 172: 1038–44.
[vi] https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2019/APL19-018.pdf. Accessed April 17, 2020.
[vii] Gillespie RJ. Screening for Adverse Childhood Experiences in Pediatric Primary Care: Pitfalls and Possibilities. Pediatr Ann 2019; 48: e257–61.
[viii] Purewal SK, Bucci M, Wang LG, et al. Screening for Adverse Childhood Experiences (ACEs) in an Integrated Pediatric Care Model. Zero to Three 2016; 36: 10–7.
[ix] Marsicek SM, Morrison JM, Manikonda N, O’Halleran M, Spoehr-Labutta Z, Brinn M. Implementing standardized screening for adverse childhood experiences in a pediatric resident continuity clinic: Pediatric Quality and Safety 2019; 4: e154.
[x] Kia‐Keating M, Barnett ML, Liu SR, Sims GM, Ruth AB. Trauma‐Responsive Care in a Pediatric Setting: Feasibility and Acceptability of Screening for Adverse Childhood Experiences. American Journal of Community Psychology 2019; 64: 286–297.
[xi] Marie-Mitchell A, Lee J, Siplon C, Chan F, Riesen S, Vercio C. Implementation of the Whole Child Assessment to Screen for Adverse Childhood Experiences. Global Pediatric Health 2019; 6: 2333794X1986209.
[xii] Choi KR, McCreary M, Ford JD, Rahmanian Koushkaki S, Kenan KN, Zima BT. Validation of the Traumatic Events Screening Inventory for ACEs. Pediatrics 2019; DOI:10.1542/peds.2018–2546.
[xiii] Flanagan T, Alabaster A, McCaw B, Stoller N, Watson C, Young-Wolff KC. Feasibility and acceptability of screening for adverse childhood experiences in prenatal care. Journal of Women’s Health 2018; 27: 903–11.
[xiv] Young-Wolff KC, Alabaster A, McCaw B, et al. Adverse childhood experiences and mental and behavioral health conditions during pregnancy: the role of resilience. Journal of Women’s Health 2019; 28: 452–61.
[xv] Glowa PT, Olson AL, Johnson DJ. Screening for adverse childhood experiences in a family medicine setting: a feasibility study. The Journal of the American Board of Family Medicine 2016; 29: 303–7.
[xvi] Goldstein E, Topitzes J, Birstler J, Brown RL. Addressing adverse childhood experiences and health risk behaviors among low-income, Black primary care patients: Testing feasibility of a motivation-based intervention. General Hospital Psychiatry 2019; 56: 1–8.
[xvii] Goldstein E, Athale N, Sciolla AF, Catz SL. Patient Preferences for Discussing Childhood Trauma in Primary Care. permj 2017; 21: 16–055.
[xviii] Chandler GE, Kalmakis KA, Murtha T. Screening Adults With Substance Use Disorder for Adverse Childhood Experiences: Journal of Addictions Nursing 2018; 29:172–8.
[xix] Gillespie RJ. Screening for Adverse Childhood Experiences in Pediatric Primary Care: Pitfalls and Possibilities. Pediatr Ann 2019; 48: e257–61.
[xx] Felitti VJ, Anda RF. The Lifelong Effects of Adverse Childhood Experiences. In:Chadwick’s Child Maltreatment: Sexual Abuse and Psychological Maltreatment.
[xxi] Ford K, Hughes K, Hardcastle K, et al. The evidence base for routine enquiry into adverse childhood experiences: A scoping review. Child Abuse & Neglect 2019; 91: 131–46.
