So You’ve Screened for ACEs… Now What?

by Maggie Wayne, Docs for Tots Health Liaison

Docs for Tots has partnered with the Center for Youth Wellness (CYW) to bring together diverse pediatric offices across Long Island and assist them in implementing universal ACEs screening. CYW, national experts on ACEs, has demonstrated that by addressing ACEs and building resilience through community resources, behavioral therapy, and support, the health outcomes of individuals can improve. A key goal of CYW is to have every pediatrician universally screening for ACEs in order to identify risks early and empower families to take action to address toxic stress in their lives.

However, screening for ACEs can be difficult because the screen addresses topics that some professionals do not feel comfortable discussing. Specifically, it asks about past abuse and neglect. This is of particular concern for providers who have the responsibility of being mandatory reporters.

Q: Can I completely rule out abuse and neglect? When do I report?

Your professional judgment always takes precedence over what the screen states. As pediatricians, you are already checking in with how your patients’ home lives are. This means you would know if abuse or neglect were part of the child’s life in the past, and that you will know when to report, independent of ACEs screen. The ACEs screen is a screen for toxic stress and does not replace your professional judgment regarding abuse or neglect and your patients.

Q: If that’s the case, why screen at all?

Data shows us that the toxic stress that results from experiencing ACEs has long-term negative health outcomes. This can be especially harmful if a child experiences ACEs from birth to age five due to the impact on a child’s rapidly developing brain.

Universal screening is important because ACEs do not discriminate. They affect every race and every socioeconomic status equally. Asking the questions opens up the conversation, which can in itself be an intervention. It is important to note that ACEs cannot be fixed in a single visit.

Q: I’ve ruled out abuse and neglect. Where can I refer my patients?

It all depends on what your patients’ symptoms and needs are. If they have a low ACE score and a caregiver states they are already in family therapy, your role is to educate on toxic stress and assure your patient that you are there if they need additional assistance. Research indicates that a strong bond between children and their parents is a great way to combat adversity. Sometimes parenting classes or encouraging family activities, like family dinners or community programs, are all that are needed.

Referrals should be based on the patient’s score and symptoms. For low scores, education and community resources are sufficient. Once a child starts presenting with symptoms of toxic stress (irritability, behavior problems, frequent or uncontrolled illnesses) a mental health referral may be needed in addition to education and community resources. For higher ACE scores, consider a mental health referral before community referrals. However, you need to meet your patients where they are. If they are not ready to accept help or guidance, schedule a follow up visit or phone call (a way to avoid a repeat copay) to check in and assess their needs.

To combat the effects of toxic stress, you and your child can work together to build and foster resilience.

Q: What is resilience and how can I foster resilience in my patients?

Resilience is when you acknowledge you may be struggling and cultivate your well-being despite these struggles by building trusting relationships and restoring your physical and emotional health through a healthy lifestyle. Sometimes, providing medical intervention or referring to behavioral health can help your patients manage stress, but there are lots of things they can do at home to help build resilience with their child. For ideas on how to build a healthy lifestyle, have your patients check out StressHealth.org for ideas promoting good nutrition, exercise, and sleep habits. There are also suggestions on how to build a better relationship between your patients and their caregivers, and mindfulness activities to teach them how to manage stress. Check them out yourself as well! Self-care is important when discussing trauma in your office.

 

Q: What about other types of adversity?

The ten ACE categories we screen for were identified in the original Kaiser/CDC study and were associated with long-term health consequences in a population of 17,000 adults. Subsequent research has explored the relationship between other childhood adversities and health. Evidence shows that factors such as bullying, community violence, death of a parent or guardian, discrimination, or separation from a caregiver to foster care or immigration may also lead to a toxic stress response.

Research is ongoing on how to address all forms of adversity in children. The ACEs screen provides us with a starting point and is based in research. The adaptability of the tool from the Center for Youth Wellness allows for each office to ask about adversity that may be of particular concern to their population, such as concerns over deportation or racial discrimination, in addition to the original ten ACE factors.

Q: What about Social Determinants of Health?

This is an ongoing area of discussion and research in the field of toxic stress management and trauma informed care. Docs for Tots is working closely with national experts at the Center for Youth Wellness to dive further into the intersection between ACEs and Social Determinants of Health.

Maggie Wayne is a Health Liaison with Docs for Tots, working with our partners on incorporating into pediatric practices screenings for Maternal Depression and Adverse Childhood Experiences (ACEs).