Adverse Childhood Experiences Screening Research Articles

Adverse Childhood Experiences and Patient-Reported Outcome Measures in Critically Ill Children.

Adverse childhood experiences (ACEs) are linked to adverse health outcomes for adults and children in the United States. The prevalence of critically ill children who are exposed to ACEs is not known. Our objective was to compare the frequency of ACEs of critically ill children with that of the general pediatric population of Georgia and the United States using publicly available National Survey of Children’s Health (NSCH) data. The impact of ACEs on patient-reported outcome measures of emotional, social, and physical health in critically ill children is not known. We sought to determine whether a higher total number of ACEs was associated with poorer patient-reported measures of emotional, social, and physical health. We conducted a prospective cross-sectional study of children < 18 years of age who were admitted to a 36-bed free-standing, quaternary academic pediatric intensive care unit in Atlanta, Georgia from June 2020—December 2021. Parents of patients who were admitted to the pediatric intensive care unit completed a survey regarding their child’s ACEs, health care use patterns, and patient-reported outcome measures (PROMIS) of emotional, social, and physical health. Prevalence estimates of ACEs were compared with national and state data from the NSCH using Rao-Scott Chi-square tests. PROMIS measures reported within the PICU cohort were compared with population normed T-scores. The association of cumulative ACEs within the PICU cohort with patient-reported outcomes of emotional, social, and physical health were evaluated with a t-test. Among the 84 participants, 54% had ≥ 1 ACE, 29% had ≥ 2 ACEs, and 10% had ≥ 3 ACEs. Children with ≥ 2 ACEs had poorer anxiety and family relationship T-scores compared to those with ≤ 1 ACE. Given the high burden of ACEs in critically ill children, screening for ACEs may identify vulnerable children that would benefit from interventions and support to mitigate the negative effects of ACEs and toxic stress on emotional, social, and physical health.

Adverse Childhood Experiences, Domestic Violence and Substance Misuse: An Action Research Study on Routine Enquiry and Practice Responses.

The long-term impacts of Adverse Childhood Experiences (ACEs) are of increasing interest to researchers and practitioners, including the effectiveness of screening for ACEs to improve health and social outcomes. Despite a focus on implementing such practices, there has been little focus on ACEs experiences for women experiencing domestic violence and substance use, or consideration of practice responses around ACEs routine enquiry for domestic violence and related services. The Irish study discussed in this paper used an action research approach to implement ACEs routine enquiry within a domestic violence service for women accessing the service (n = 60), while also utilizing co-operative inquiry groups for practitioners both within the organization (n = 10) and with those working in associated fields of infant mental health, child protection, substance misuse and welfare and community support (n = 7). Of the 60 women who completed the ACEs routine enquiry in the study, over one-half (58 per cent) reported experiencing at least two ACEs in their childhood, including one-third of all respondents reporting experiencing four or more; service users reported significant levels of overlap between direct child maltreatment and adverse home environments. Reported parental substance misuse with the home environment was substantially higher than in general population studies. These findings offered early indications of both ACEs prevalence as well the types of ACEs that most define the experiences of the women presenting to a domestic violence service that supports women with substance misuse and other related issues. This paper discusses the ways in which the co-operative inquiry groups used this information and other processes to enhance practitioner, organizational, and inter-agency understanding and service responses. The practitioners felt that this form of ACEs routine enquiry, while not an end in itself, was a useful tool to engage women in conversations about trauma and intergenerational patterns and a basis for developing trauma-informed interventions. We conclude with discussion about: considerations of the risks of “individualizing” women's traumatic experiences; skills and supports for practitioners; and resource implications.

Pediatric Functional Neurological Disorder: Demographic and Clinical Factors Impacting Care.

This is a multicenter retrospective EMR-based chart review of 88 patients aged 3-21 years admitted for evaluation of functional neurologic disorder (FND). We sought to establish characteristics associated with FND, calculate incidence of abnormal neurodiagnostic findings, and determine features associated with variability in workup and treatment. FND patients were 65% female, 40% White, 33% Hispanic, and 88% primarily English speaking with median 13.9 years. We detected variability in management by age, ethnicity, psychiatric comorbidity, and hospital site. Our findings suggest limited utility to CTs in this setting (100% normal) and that workup can be safely informed by physical exam, which predicted abnormal MRI and LP results. We favor screening for adverse childhood experiences in FND patients. Hospitalization may be a rare opportunity for psychiatry contact.

Is ACEs Screening for Adolescent Mental Health Accurate and Fair?

Increasingly, adversity-focused assessment tools are being introduced into preventive mental health screening protocols. However, few studies have explicitly examined whether use of these instruments serves as equitable, clinically useful measures of mental health risk in adolescents. In response, the present study examined whether an adverse childhood experiences (ACEs) measure was accurate and fair as an index of environmental risk for adolescent mental health diagnoses. Secondary data analyses were conducted on the National Comorbidity Survey-Adolescent Supplement. Adolescents (N = 10,148; AgeMean = 15.20; 51.3% male; 65.6% White, 15.1% Black, and 14.4% Hispanic) answered ten questions concerning childhood adversities and completed diagnostic interviews for PTSD, depression, and externalizing disorders. In the overall sample, ACEs showed some clinical utility (e.g., area under the curve (AUCs) ≥ 0.64), diagnostic likelihood ratios (DLRs) > 4.0) and acceptable calibration (i.e., expected/observed indices' confidence intervals included 1) across diagnoses. Within subpopulations, however, predictive validity varied. The AUCs were lower for multiple diagnoses in Black male and Hispanic female adolescents and DLRs suggested greater clinical utility for indexing mental health in White, female adolescents. Finally, models were not well-calibrated between adolescent subpopulations, suggesting recommended ACEs screening can potentially produce biased results when used to inform mental health policy and prevention. Reasons for why results from ACEs screening may vary across adolescent subpopulations and the importance of testing statistical fairness for preventive mental health screening are discussed.

Characterising a syndemic among black women at risk for HIV: the role of sociostructural inequity and adverse childhood experiences

Objectives Black women disproportionately experience STIs (including HIV/AIDS), gender-based violence, substance misuse and mental health conditions. Addressing a gap in syndemic research, we characterised comorbidity overlap within the context of...

Intergenerational transmission of trauma: unpacking the effects of parental adverse childhood experiences

ABSTRACT Background: Existing research documented the connection between individuals’ childhood trauma exposure and adverse health and behavioural health outcomes. However, less attention has been paid to understanding trauma in an intergenerational context. Objective: This study aims to fill this research gap by (1) exploring the association between parents’ trauma histories and child behavioural outcomes; (2) unpacking the effects of different types of parental trauma on child behavioural outcomes; (3) examining whether these associations vary by parental roles. Participants and Setting: This study recruited 202 parents from an online data collection platform – Amazon Mechanical Turk. Methods: We conducted regression analyses to examine the associations between parental adverse childhood experiences (ACEs) and their child’s behavioural problems and functioning. Results: Findings showed that only parental childhood maltreatment ACEs, but not family dysfunction ACEs, were significantly associated with child behavioural problems and functioning. The impact of parental child maltreatment ACEs on child behavioural problems was equally significant between fathers and mothers. In contrast, mothers’ childhood maltreatment ACEs exerted a more potent effect on child functioning. Conclusion: Study findings highlighted the need for child behavioural health services to incorporate the screening and treatment of parental ACEs in treatment programmes to break the cycle of intergenerational trauma.

The impact of adverse childhood experiences on adolescent health risk indicators in a community sample. Correction to Meeker et al. (2021).

The sample included 1,532 adolescents who completed the Youth Risk Behavior Surveillance Survey in their local high schools. By local consensus, this national survey was augmented with questions exploring prevalence of 11 commonly identified ACEs. After controlling for age, gender, and race, youth with multiple ACEs reported 3 to 15 times the odds of a range of negative health experiences. Findings indicate a serious burden of ACEs on adolescent social emotional well-being. This study did not include youth in out of school placements or who were not present the day the survey was given, and thus represent youth who may benefit from universal prevention and intervention programs. Universal screening of ACEs and health-related outcomes suggests that reporting multiple ACEs is strongly related to a wide range of mental health, violence, and substance use histories. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Implementation of an adverse childhood experiences screening protocol for adults at an outpatient medical psychology practice

Objective: Despite an abundance of evidence supporting screening adults for adverse childhood experiences (ACEs), the gap between this knowledge and screening persists. Evidence suggests that screening is warranted, feasible, and desired by patients. This feasibility study aimed to educate and train staff and providers on ACE screening and implement an ACE screening policy and protocol at an outpatient medical psychology practice. The two expected outcomes of this project, provider knowledge after ACE training and provider compliance with the ACE screening protocol, were measured to determine if a clinical practice change occurred.Methods: A quasi-experimental design with a pre-test/post-test was used to determine increases in provider knowledge following an ACEs training intervention. Additionally, post-intervention only data collection was used to determine compliance with ACE screening protocol, to determine practice change and feasibility of continued protocol use.Results: The project results indicated that the implementation of the ACE screening protocol was feasible. Thirty-three adult clients new to the practice completed the ACE screening. Of the 33 clients screened during the 12-week study, 26 clients had an ACE score of three or higher, and 14 (42%) received therapy referrals based on their ACE score after education and discussion by the intake therapist. Weekly chart checks revealed that 100% of clients screened received, at a minimum, the educational packet regarding the impact of ACEs on physical and mental health. The protocol encouraged providers to promote evidence-based interventions to mitigate the potential untoward outcomes associated with ACEs.Conclusions: These findings reflected a change in knowledge based on education and indicated that educational intervention was effective.

Adverse childhood experiences, diabetes and associated conditions, preventive care practices and health care access: A population-based study

Our objective was to examine how Adverse Childhood Experiences (ACEs) are associated with diabetes mellitus, diabetes-related conditions, and preventive care practices. We used data from the Behavioral Risk Factor Surveillance System (BRFSS) 2009–2012, a cross-sectional, population-based survey, to assess ACEs, diabetes, and health care access in 179,375 adults. In those with diabetes (n = 21,007), we assessed the association of ACEs with myocardial infarction, stroke, and five Healthy People 2020 (HP2020) diabetes-related preventive-care objectives (n = 13,152). Healthcare access indicators included lack of a regular health care provider, insurance, and difficulty affording health care. Regression analyses adjusted for age, sex, and race. The adjusted odds ratio (AOR) of diabetes increased in a stepwise fashion by ACE exposure, ranging from 1.2 (95% CI 1.1–1.3) for 1 ACE to 1.7 (95% CI 1.6–1.9) for ≥4 ACEs, versus having no ACEs. In persons with diabetes, those with ≥4 ACEs had an elevated adjusted odds of myocardial infarction (AOR = 1.6, 95% CI 1.2–2.0) and stroke (AOR = 1.8, 95% CI 1.3–2.4), versus having no ACEs. ACEs were also associated with a reduction in the adjusted percent of HP2020 diabetes objectives met: 72.9% (95% CI 71.3–74.5) for those with no ACEs versus only 66.5% (95% CI 63.8–69.3%) for those with ≥4 ACEs (p = 0.0002). Finally, ACEs predicted worse health care access in a stepwise fashion for all indicators. In conclusion, ACEs are associated with greater prevalence of diabetes and associated disease conditions, and with meeting fewer HP2020 prevention goals. Implementing ACE screening and trauma-informed health care practices are thus recommended.

Insights from Expanded Adverse Childhood Experiences Screening in a Hospital-Based Outpatient Psychiatry Service.

Adverse childhood experiences (ACEs) are associated with poor mental health in adulthood. Comprehensive prevalence data encompassing all 10 ACE questionnaire items has not previously been described in a hospital-based outpatient psychiatric clinic. This study assessed the prevalence of 10 ACEs in such a clinic and correlated ACEs with indicators of case severity. For 252 patients newly evaluated in an urban clinic, a retrospective chart review was completed and data was collected on ACE questionnaire responses, psychiatric, substance-related, and medical diagnoses, psychiatric hospitalizations, suicide attempts, and suicide and violence risk. Patients in the clinic had an average of 3.4 ACEs, higher than national community sample averages of 1.6. The percentages of patients with at least one, two, and four ACEs were 82% (n = 207), 68% (n = 172), and 42% (n = 106) respectively (compared with 61%, 38%, and 15% nationally). ACEs had statistically significant correlations with an increased number of psychiatric diagnoses, substance use disorders, medical illnesses, suicide attempts, and suicide risk level. This study demonstrated that patients seeking psychiatric care from a hospital-based outpatient clinic are likely to be traumatized to a degree far exceeding what is typical in the general population. While a high prevalence of ACEs in a psychiatric population is an expected finding given the literature to date, this is the first study presenting data on the prevalence of ACEs in such a hospital-based community clinic. Additionally this study reinforces prior research correlating childhood adversity and case severity.

Adult Daughters of Alcoholic Parents-A Qualitative Study of These Women's Pregnancy Experiences and the Potential Implications for Antenatal Care Provision.

The adult children of alcoholic parents are at increased risk of having health problems compared to the adult children of nonalcoholic parents. Little is known about how growing up with alcoholic parents affects women’s experiences when pregnant. The objectives of this study were to explore how adverse childhood experiences related to parental alcohol abuse affect women during their pregnancy and to assess the potential implications of women’s experiences for antenatal care provision. Twelve in-depth interviews were performed with women who were brought up by an alcoholic mother and/or father. Systematic text condensation was used to analyse the data. Two main categories were identified: ‘establishing relationships and having social support’ and ‘antenatal care encounters and concerns during pregnancy’. Women’s trust in others in adult life was impacted by their upbringing. Strained relationships with their parents and few friends meant that the women primarily relied on their partners for support. Neither antenatal care providers nor women talked about women’s childhood experiences at the visits. The women described concerns related to the baby’s health, lack of predictability and control during the pregnancy, as well as apprehensiveness regarding birth and motherhood. The potential implications for practice include systematic screening for adverse childhood experiences, antenatal preparation classes, parenting courses, and post-graduate training.

The Impact of Adverse Childhood Experiences and Community Violence Exposure on a Sample of Anxious, Treatment-Seeking Children.

Screening for adverse childhood experiences (ACEs) can help prevent and reduce adverse outcomes on child development, including increased risk for anxiety disorders. Emerging studies strongly support the inclusion of community-level adversities in ACE screeners to consider diverse contexts and populations. Recent studies suggest that community violence exposure (CVE) may have a distinct impact on youth mental health. Although recent studies have examined the association between ACEs, CVE, and mental health in primary care settings, this association has not been examined on treatment-seeking children in urban mental health settings. The present study employs a mediation model using the PROCESS macro to examine community violence exposure mediating the effect on the association between ACEs and somatic symptoms (SS) on a sample of anxious treatment-seeking children. A total of 98 participants (Mage = 11.7, SD = 3.79, 51.6% males, 54.1% ethnic minority children) who sought services at a specialized anxiety clinic completed self-report measures. Results indicated that exposure to ACEs is associated with endorsement of somatic symptoms as a result of reporting hearing, witnessing, or experiencing CVE. Evidence of mediation was found in a statistically significant indirect effect of ACEs on SS through CREV (Effect = .17, 95% CI = .069-.294). These findings support recent evidence that CVE is a distinct ACE as it contributes to toxic stress similar to individual-level ACEs. The use of a comprehensive ACE screening that includes CVE is warranted, particularly when working with culturally and socioeconomically diverse populations, as it would better capture a broader range of adversities across demographic groups.

Adverse Childhood Experiences and Diabetes: Testing Violence and Distress Mediational Pathways in Family Medicine Patients.

Type 2 diabetes mellitus (diabetes) is increasing in frequency and creating a significant burden on the United States healthcare system. Adverse childhood experiences (ACE) and interpersonal violence (IV) have been shown to have detrimental effects on mental and physical health. How ACE can influence IV as an adult and how this can influence the management of diabetes is not known. The purpose of the current study is to understand the relationship between violence and social determinants of health (SDoH), and its effect on patients with type 2 diabetes mellitus. A practiced-based research network (PBRN) of family medicine residency programs was utilized to collect cross-sectional data from seven family medicine residency program primary care clinics. In total, 581 participants with type 2 diabetes were recruited. A serial/parallel mediation model were analyzed. The majority of participants (58.3%) had a Hemoglobin A1c (HbA1c) that was not controlled. ACE was associated with an increase in Hurt-Insult-Threaten-Scream (HITS) scores, which in turn was positively associated with an increase in emotional burden, and finally, emotional burden decreased the likelihood that one's HbA1c was controlled (Effect = -.054, SE = .026 CI [-.115, -.013]). This indirect pathway remained significant even after controlling for several SDoH and gender. The impact of ACE persists into adulthood by altering behaviors that make adults more prone to experiencing family/partner violence. This in turn makes one more emotionally distressed about their diabetes, which influences how people manage their chronic condition. Family physicians should consider screening for both ACE and family/partner violence in those patients with poorly controlled diabetes.

Screening for Adverse Childhood Experiences in Children: A Systematic Review.

Adverse childhood experiences (ACEs) are associated with increased risk of poor mental health outcomes. Although there is interest in screening for ACEs for early identification and intervention, it is not known whether screening improves outcomes for children. To systematically review whether screening for ACEs in children leads to an increase in (1) identification of ACEs, (2) referrals to services, (3) increased uptake of services, and (4) improved mental health outcomes for children and parents. Ovid Medline, PsycINFO, CINAHL, and Center for Clinical and Translational Research electronic databases were searched between 2009 and 2021. Studies were included if researchers screened for current ACEs in children aged 0 to 12 years and they had a control comparison. Information was extracted, including study characteristics, sample demographics, screening tool characteristics, referral rates to services, uptake rates, and mental health outcomes. A total of 5816 articles were screened, with 4 articles meeting inclusion criteria. Screening for ACEs increases identification of adversity and may increase referrals to services. There are limited data about whether this leads to an increase in referral uptake by families. There are no reported data addressing mental health outcomes. There are few published control trials of moderate quality. There is limited evidence that screening for ACEs improves identification of childhood adversity and may improve referrals. If we are to realize the hypothesized benefits of ACEs screening on child and parent mental health, it is essential to understand the barriers for families taking up referrals.

Maximizing the Benefit of Screening for Adverse Childhood Experiences.

Adverse childhood experiences (ACEs), first described by Felitti et al1 in 1998, affect over two-thirds of US adults2 and have been linked to numerous deleterious longitudinal health, mental health, and social outcomes, including cancer,3 pulmonary disease,3 liver disease,4 autoimmune dysfunction, depression, anxiety, psychopathology, and suidicality.5 A growing awareness of ACEs’ impact on child health has given way to initiatives to screen for ACEs in clinical settings and, especially, in primary care, with the assumption that such screening can ameliorate health outcomes.In this issue of Pediatrics, Loveday et al6 present results from a systematic review of screening for ACEs in children. The goals of this study were to review the rationale for screening for ACEs and examine impacts of screening on access to referrals and services for identified needs. This is an important clinical question because new efforts to mandate ACEs screening are being adopted in states such as California.7 Cautions about such implementation have been raised, even by one of the original ACE study authors.8 Critics have warned that population level ACE questionnaires being used are not validated screening instruments and that they do not have predictive value at the individual level9 and can induce an expectancy effect, in which identified problems may lead to unnecessarily proactive identification of future toxic stress and resultant problems.10In their systematic review, Loveday et al6 identified a dearth of studies relevant to child ACEs screening and point out that none of the studies reported on child or parent mental health outcomes. We know from our previous work that there is an intergenerational effect of ACEs11 and also a possible hesitancy to answer questions that are sensitive and potentially retraumatizing.12 Having only 4 studies of this systematic review that meet moderate criteria speaks to the limited evidence for the value of ACEs screening and a lack of evidence that screening improves access or receipt of necessary services. Indeed, although combined in this study, there may be a qualitative difference between screening for a need for resources (broader social determinant of health screening) and for exposure to adversity within the caregiving relationship (eg, abuse, neglect, exposure to intimate partner violence). For the latter, without linking exposure questions with mental health symptom screening, the opportunity to refer appropriately those who could benefit most from evidence-based trauma therapy or other appropriate mental health services may be lost.As primary care providers for children and families who suffer from the burden of ACEs, we recognize that having a framework for understanding ACEs and identifying symptoms within a safe and responsive relationship with patients and families is critical to providing trauma-informed care in the pediatric medical home.13 We understand that there are many barriers to ensuring that those with identified adversities are linked to community resources, such as limited time, staff resources to reach beyond the clinical space, and competing clinical demands,14 especially with the current pandemic in which acute COVID-19 concerns are taking precedence over preventive care.15Consensus has highlighted the need to focus on safe, stable, and nurturing relationships and change the paradigm from simply identifying ACEs to promoting resilience.16 Resilience-informed relational care15 allows pediatricians to provide support for all children from the pediatric setting. Providers should create a safe and empowering environment to raise and respond to a family’ specific social determinants of health (SDOHs) or ACE concerns. When needs exceed capacity to address these within the medical setting, pediatricians can partner with community organizations to link children to resources and trauma-informed services. This work includes preparing the next generation of providers to respond sensitively and appropriately to toxic stress symptoms and the SDOHs17 and understanding the intersectionality of ACEs with SDOHs to promote equity.18 Screening without appropriate office-based guidance and supported linkages to community resources appears to have limited evidence of benefit, as noted in the Loveday et al6 review and may be potentially harmful; yet, pediatricians can use a resilience-informed team-based and community approach to assist families in navigating their most pressing health and social needs.

Researching Adverse Childhood Experiences in a Domestic Violence service: The role of co-operative inquiry groups in practice development and change

The long-term impacts of Adverse Childhood Experiences (ACEs) are of increasing interest to researchers and practitioners. While attention is being paid to the effectiveness of screening for ACEs to improve health and social outcomes, how to implement such practices has become key. The Irish study upon which this article is based used an action research approach to implement ACEs routine enquiry within a domestic violence service, while also utilising co-operative inquiry groups for practitioners within the organisation (n=10) and those working in associated fields of infant mental health, child protection and welfare and community support (n=7). This article documents the process of enacting the co-operative inquiry groups and outlines learning points, challenges and lessons. Drawing on Finlay’s (2002a, 2002b) theories on the variants of reflexivity in research processes, six themes emerged on the research process: insider and outsider status; the structure and approach to the groupwork process; participation in the group process; addressing fears; practice concerns; and motivations to act. We conclude with suggestions for effective co-operative inquiry processes and highlight the factors related to groupwork that may contribute to improvements in practice, organisational and community change.

Associations of Adverse Childhood Experiences with Frailty in Older Adults: A Cross-Sectional Analysis of Data from the Canadian Longitudinal Study on Aging

Introduction: Frailty in older adults, characterized by a decline in multiple physiological systems and increasing vulnerability to loss of independence, disability, and death, is a public health priority in developed countries. Etiology of frailty extends across the lifespan and may begin in early life, but empirical evidence for this association is scarce. In this study, we examined whether adverse childhood experiences (ACEs) are associated with frailty in later life. Methods: We conducted a cross-sectional analysis of data for a population-based sample of 27,748 adults aged 45–85 years from the Canadian Longitudinal Study on Aging. The frailty index (FI) was computed with 76 health-related characteristics of physical and cognitive performance, self-rated health, chronic conditions, visual and hearing ability, activities of daily living, and well-being. Self-reported exposure to ACEs included physical, emotional, and sexual abuse, neglect, and witnessing intimate partner violence prior age of 16 and parental death, divorce, and living with a family member with mental illness prior age of 18. Generalized linear regression models with gamma error distribution and identity link function, adjusted for age and sex, were used to examine associations of each ACE type and the number of ACE types (0, 1, 2, or 3+) reported by an individual with FI. All models were adjusted for income, education, smoking, and alcohol consumption in sensitivity analysis. Results: Individuals exposed to ACEs had elevated levels of FI (mean = 0.13, SD = 0.09) than those unexposed, with the largest difference observed for neglect (B [95% CI]: 0.05 [0.04, 0.06]) and the smallest for parental death and divorce (0.015 [0.01,0.02]). The ACE count was associated with frailty in a graded manner, with the FI difference reaching 0.04 [0.037, 0.044] for participants exposed to 3+ ACE types. The association between ACEs and frailty tended to be stronger for women than men and for men aged 45–64 years than older men. Conclusions: Our study supports previous studies showing that exposure to ACEs is associated with frailty in adults. Our findings suggest that screening for ACEs involving childhood maltreatment may be useful for identifying individuals at risk of frailty and prevention of ACEs may have long-term benefits for healthy aging.

Using a participatory method to test a strategy supporting the implementation of a state policy on screening children for adverse childhood experiences (ACEs) in a Federally Qualified Health Center system: a stepped-wedge cluster randomized trial

BackgroundAdverse childhood experiences (ACEs) are potentially traumatic events occurring before age 18, such as maltreatment or exposure to violence. ACE screening is increasingly recommended to prevent and address physical and mental health conditions associated with ACEs. To promote ACE screening uptake, the state of California issued the “ACEs Aware” policy that provides Medicaid reimbursement for ACE screening annually for child primary care visits. However, policy directives alone often do not translate into effective screening efforts and greater access to care. Few rigorous studies have developed and tested implementation strategies for ACE pediatric screening policies. This study will fill this gap by testing a multifaceted implementation strategy in partnership with a Federally Qualified Health Center (FQHC) system serving low-income families in Southern California to support the ACE Aware policy.MethodsWe will use Implementation Mapping, with study process and consideration of determinants and mechanisms guided by the EPIS framework, to co-create and refine an implementation strategy. The proposed strategy is comprised of online training videos, a customized algorithm and use of technology to improve workflow efficiency, implementation training to internal FQHC personnel, clinic support and coaching, and written implementation protocols. A hybrid type 2, stepped-wedge cluster randomized trial design with five primary care clinics will test whether a multifaceted implementation strategy improves (a) fidelity to the ACE screening protocol, (b) reach defined as the proportion of eligible children screened for ACEs, and (c) the impact of the ACE policy on child-level mental health referrals and symptom outcomes. The study will use mixed methods with data to include electronic health records, surveys, and interviews with clinic personnel and caregivers.DiscussionThis study is designed to increase the capacity of FQHCs’ inner context to successfully implement an outer context-initiated ACE policy designed to benefit pediatric patients. It capitalizes on a rare opportunity to use a co-creation approach to develop, adapt, refine, and pilot test an implementation strategy to maximize the impact of a new state-wide policy intended to improve ACE assessment and subsequent care to improve child health, particularly those from underserved communities.Trial registrationTrial # NCT04916587 registered at ClinicalTrials.gov on June 4, 2021.

Barriers to Screening for Adverse Childhood Experiences

This pilot study provides a baseline understanding of nurse practitioners’ (NPs’) and NP students’ current knowledge and reported barriers to screening for adverse childhood experiences. A 23-question survey was distributed by email to NP and NP student members of 2 local chapters of a state NP organization. Results showed that a significant number of practitioners understood the importance of adverse childhood experiences screening but failed to perform screening due to multiple barriers. A review of barriers identified a need for improved screening methods, provider education, allocation of time, and follow-up resources as essential to improve current screening practices.

Lessons Learned from a Quality Improvement Initiative: Adverse Childhood Experiences Screening in a Pediatric Clinic.

We used quality improvement methods to establish ACEs screening in a busy pediatric clinic that serves primarily Medicaid-insured and Spanish-speaking patients. The final Plan-Do-Study-Act cycle included the screening of both the patient and his/her caregiver(s). ACEs scores were a process measure; balancing measures were the average time to screen, the number of referrals generated, and qualitative caregiver reception. We screened 232 families, and the process maintained a ≥ 80% completion rate of ACEs screening for 1-month-old children and their caregivers during the final 10 weeks. 23% of caregivers had an ACEs score ≥ 4; overall, 6% were referred for further resources. The average time to discuss the screen was 86.78 seconds. The general caregiver reception was gratitude; 2% refused screening. This study demonstrates the feasibility of initiating ACEs screening of 1 age group and their caregivers using quality improvement methods.