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ACEs screening is about building relationships, says early adopter

 

[Editor’s note: This blog post by Dr. R.J. Gillespie of The Children’s Clinic in Portland, OR, is in response to recent comments made in the ACEs in Pediatric community about ACEs screening.]

Whether or not to screen for ACEs in primary care is an important debate—and I hear and respect the passion from both sides of the argument. I fall in the “pro-ACE assessments” camp, but with some important caveats. I think that assessments for ACEs are dramatically different from screening for autism or developmental delays—with the latter types of screenings, a conversation about positive predictive value, prevalence, or sensitivity and specificity is a natural consequence. In my opinion, assessments for ACEs in primary care should be primarily about building relationships, which changes the dynamic of the conversation because it’s harder in the scientific community to define the value of these tools without numbers and data to back up their purpose. 

The concerns cited by TL Campbell about screening for ACEs (no evidence-based treatments, asking the questions would offend patients and parents, and risk of labeling people with such exposures as high risk) in the Journal of the American Medical Association haven’t really borne out in my practice. More importantly, I think those concerns miss the big picture of what happens in practice when ACEs are assessed and empathetically addressed during the course of a visit.

My practice incorporated parental ACE screening into our clinical workflows over seven years ago, and we’ve used the information to better understand early childhood health and development. Our initial intentions were simple—if a parent has experienced ACEs, what do they need or want in terms of resources and support? If a parent has experienced ACEs, how can we help them to break the intergenerational transmission of trauma? We thought the best way to figure that out was to ask if parents have experienced ACEs, and then what resources they would find most helpful.

Since then, we have learned that parental ACEs had a negative impact on their child’s developmental trajectories1, and on utilization patterns including frequency of well visits2. This makes conversations about parental trauma (and other family stressors) an important and integral part of the conversations about how we help children with developmental risk. To me, this means that ACEs assessments are really best utilized in the context of supporting a child’s development and social wellness, rather than as a one-off kind of screening tool. For example, there’s a difference in the clinical workflow for a failed developmental screen if there is a history of maternal depression, parental ACEs, or other social determinants of health versus how we respond if none of those things are present. It’s not enough to simply refer everyone for early intervention if we don’t have an idea of the factors that might make it difficult for the family to use such resources. 

Veronique Mead, who referenced us in her comments, noted that the providers here at The Children’s Clinic wouldn’t go back to our “care as usual” before we started looking at parental ACEs. And that still holds true. The realization that we’ve come to is that screening for ACEs doesn’t really change the parent but changes us as providers. When I asked our providers what screening for ACEs was like, they all responded with stories of empathy for what our families have experienced, and embarrassment at not having held parents’ histories in their minds when we’ve sometimes just plowed through our typical well care visits. Some of our advice just doesn’t make sense for our families for a lot of different reasons. Talking openly about trauma doesn’t mean that our care is now perfect—but it’s light years better than it was.

There is a big difference between screening parents and screening kids. That’s one caveat. Some people think it’s “worse” in some ways because the parents are not our patients and therefore we shouldn’t ask for that kind of history. Once you’ve been in pediatric practice for more than a minute though, you realize that kids don’t develop in a vacuum—they thrive in a healthy family and social environment. You also realize pretty quickly that all parents—no matter their background—have triggers that pop up in the weirdest ways when you’re raising a child. It’s far better to talk about those triggers—and how to be resilient and cope with them when they happen—than to pretend that they just don’t exist at all.

The families that I’ve worked with have almost universally acknowledged that they’ve had fears in the back of their minds related to their own trauma histories. They also express that they want better for their kids and don’t want to repeat the mistakes their parents made—and they’re grateful for having somewhere to talk openly about those fears, with the promise of partnership from their child’s provider. It’s never my goal to force a disclosure from a parent, or to judge someone for what they’ve been through, but to try to offer them a helping hand based on what I learn from them. Using this approach, I’ve never had a parent who expressed offense at having been asked the questions. More often than not, they express that they not only understand why we’re asking but are also grateful for the conversation. This has been shown in focus groups of parents: That when it comes to the importance of trauma, parents “get it” and see their pediatrician as a trusted change agent that can help connect them to services and supports3

I believe that harm can only be done if we don’t address every (and I mean EVERY) assessment tool in an empathetic manner. Every patient who discloses trauma to us deserves to hear why we want to know, have us answer their questions about the tool, and understand what we’re going to do about it. One of my concerns about how California is addressing ACEs screening lies in the definition of “abnormal” screen—that you need 4 or more ACEs to be considered positive. In a practice that is new to screening, this definition may create a situation where a patient or parent with one or two traumas, which can encompass some devastating and horrific experiences, might be considered “normal” by their provider. That’s why we have to address every assessment tool and treat every disclosure with the same compassion regardless of the number elicited by the tool.

Marie Archambeau presents what I think is the biggest caveat to ACE screening, which is essentially screening without a plan. I think that this type of screening can’t be just about data collection or information gathering at a population level, but about relationship-building. This was my other major concern when California moved to universal screening: how screening would be managed in a practice that was screening merely to “tick a box” on their lists of things that needed to be done that day. There is undoubtedly value in knowing the prevalence of ACEs in our communities, both for a baseline assessment and to see if interventions to address ACEs are ultimately effective in preventing ACEs. (Thank you, Dr. Burke Harris for that bit of wisdom!) [Ed. note: Dr. Nadine Burke Harris, California's Surgeon General launched the state's screening project, ACEs Aware, in January.] But in my opinion what happens at the level of the patient encounter supersedes value that is gleaned at a public health level. It’s not about labeling the parent (or the child) and never should be. It’s about helping parents when they are feeling most challenged. Ms. Archambeau rightly states that we all need training in how to compassionately address results as part of the basic process for how we do these types of assessments well.

As I write this, I’m looking at an adolescent questionnaire for a patient that I saw this afternoon. We always ask kids: “If you had 3 wishes, what would they be?” This 14-year-old wrote: “No war, no hunger, no poverty.” Without a doubt, that’s a tall order, and I think it’s what is resonating in our communities through the protests and riots that are forcing us to scrutinize the past and decide the values that will define our future. But what this also says to me is that there’s a generation of kids who are sick of living with trauma. And they’re probably sick of the adults around them pretending that the trauma doesn’t exist. ACEs assessments by themselves might not heal the world, but we can’t heal the world without an honest dialogue about ACEs either.

  1. Folger AT, Eismann EA, Stephenson NB, Shapiro RA, Macaluso M, Brownrigg ME, Gillespie RJ. Parental Adverse Childhood Experiences and Offspring Development at 2 Years of Age. Pediatrics. 2018;141(4):e20172826.
  2. Eismann EA, Folger at, Stephenson NB, Brownrigg ME, Shapiro ra, Macaluso M, Gillespie RJ. Parental Adverse Childhood Experiences and Pediatric Healthcare use by 2 Years of Age.  J Pediatr.  2019; 211:  146-151.
  3. Conn A-M, Szilagyi MA, Jee SH, Manly JT, Briggs R, Szilagyi PG. Parental perspectives of screening for adverse childhood experiences in pediatric primary care. Families, Systems, & Health. 2018;36(1):62-72.

 

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I have been thinking a lot about the current lively conversation. We have now known about the problem of the endemic of child abuse and neglect with the resulting traumatic stress contributing to mental and physical disease for a generation, but medicine has not yet dealt with it adequately.  Taking a broad view I see we are having an enthusiastic dialogue among 3 groups of clinicians about how to deal with this problem and the 4th group.

The fourth group is by far the largest - maybe 80 % of all docs - and consists of the large population of physicians in both pediatric and adult medicine who are unaware, ignorant, too busy, too organ or disease oriented, too technology enthralled, too stressed themselves, just too inattentive or who just think this problem does not impact their patient population to pay attention to the issue of child abuse.

The first group I would call the "Eager Pragmatists." They are motivated by extensive personal exposure to the breadth and depth of the problems caused by child abuse. They have an enthusiastic commitment to educating the fourth group and bringing them on board. Clinicians like Felitti, Burke-Harris, and Krugman are eager to promote universal screening with ACEs or the equivalent, not just to discover patients who would benefit from intervention, but also to universally develop sensitivity to the issue in all clinicians and in society generally.

The second group I would call the "Concerned Skeptics." Like Campbell, Anda and Finklhor, while recognizing the serious nature of the problem, they especially are concerned about the reliability of the screening instrument, the possibility of  defensive rejection by nervous patients,and lack of evidence based effective treatment protocols. I think that underlying their concerns is a recognition that child abuse often, if not always, exists in the context of major socio-economic adversity which challenges the resources and capacity of the physician and the clinic. While this group is strongly dedicated to finding solutions, their perspective is strongly influenced by non-clinicians and the academic paradigm.

The third group I would call the "Compassionate Clinicians." Like Dr. Gillespie, et al they are very invested in the issue and vocally recognize the limitations of any test or screen in clinical medicine. They advocate that the results need to be analyzed and used with appropriate technical sophistication and conveyed to the patient in the context of a compassionate, concerned, supportive therapeutic relationship. They are not put off by the fact that this pathology is not quickly dealt with using a pill or surgery, but requires access to a whole range of family and socio-economic interventions.

So here we are, the members of the three groups are having a stimulating and intense dialogue among ourselves about the best way to approach the trauma of child maltreatment in the clinic. No doubt this will lead to improved and more sensitive care by all of us. No doubt this is beneficial. Meanwhile it is important not to get too wrapped up in our own perspective and philosophy.  It is imperative that we join together and work together to promote policies and strategies to catch the attention of the large majority of physicians who are ignoring this issue all together and facilitate their education and skills.

The ultimate goal of expanding attention to child maltreatment within the medical profession is to change to attitudes and sensitivity of the broader culture to the harms caused by interpersonal violence.

 

Thank you RJ for articulating the power of partnering with parents in authentic and respectful conversations to support their foundational relationships with their new child.  The value for families and clinicians of these welcomed dialogue of hopes, dreams, worries and histories is deeply meaningful for both as they begin their journey toward advancing and assuring early relational health, from adversity to HOPE.  Thanks for clarity of your work, the caveats from discovery and the earnest championing of this movement of advanced pediatric care.    

David Willis, MD Senior Fellow, CSSP

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