Creative Commons/Flickr/Family drawing by Meggy
Since 2016, more than 12,000 children beginning at the age of 1-years-old have been screened for adverse childhood experiences (ACEs) at Montefiore Medical Center in Bronx, New York, according to Miguelina German, the director of Quality & Research in the Pediatric Behavioral Health Integration Program and project director of Trauma Informed Care at the center.
Parents of infants are asked to fill out ACE scores for themselves and their infants. If parents or their infants have ACE scores of 4 or higher, they’re automatically offered a referral to the onsite HealthySteps program, which the center says is designed “to ensure that parents and babies are started on the right track.” For children 1 year and older, a parent is asked to complete an ACE screen on their child, and if the score is 4 or higher, they’re also referred to HealthySteps. Children over the age of 5 are referred to the onsite Child and Adolescent Psychology/Psychiatry (CAPP). Both are part of Montefiore’s Pediatric Behavioral Health Integration program. Pediatricians may also elect to refer children to either program if they have any other concerns, regardless of the child’s ACE score, says German.
HealthySteps offers a wealth of support services, including a hotline for infant and toddler care questions, optional home visits, parents’ discussion groups, and onsite treatment for parents with depression, anxiety and other mental health issues.
ACEs refer to the CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study), groundbreaking research that looked at how 10 types of childhood trauma affect long-term health. They include: physical, emotional and sexual abuse; physical and emotional neglect; living with a family member who’s addicted to alcohol or other substances, or who’s depressed or has other mental illnesses; experiencing parental divorce or separation; having a family member who’s incarcerated, and witnessing a mother being abused.
Subsequent ACE surveys include racism, witnessing violence outside the home, bullying, losing a parent to deportation, living in an unsafe neighborhood, and involvement with the foster care system. Other types of childhood adversity can also include being homeless, living in a war zone, being an immigrant, moving many times, witnessing a sibling being abused, witnessing a father or other caregiver or extended family member being abused, involvement with the criminal justice system, attending a school that enforces a zero-tolerance discipline policy, etc.
The ACE Study is one of five parts of ACEs science, which also includes how toxic stress from ACEs damage children’s developing brains; how toxic stress from ACEs affects health; and how it can affect our genes and be passed from one generation to another (epigenetics); and resilience research, which shows the brain is plastic and the body wants to heal. Resilience research focuses on what happens when individuals, organizations and systems integrate trauma-informed and resilience-building practices, for example in education and in the family court system.
The ACE Study found that the higher someone’s ACE score – the more types of childhood adversity someone has experienced – the higher their risk of chronic disease, mental illness, violence, being a victim of violence and several other consequences. The study found that most people (64%) have at least one ACE; 12% of the population has an ACE score of 4. Having an ACE score of 4 nearly doubles the risk of heart disease and cancer. It increases the likelihood of becoming an alcoholic by 700 percent and the risk of attempted suicide by 1200 percent. (For more information, go to ACEs Science 101. To calculate your ACE and resilience scores, visit: Got Your ACE Score?)
Montefiore, the university hospital that is part of the Albert Einstein College of Medicine, developed an ACE survey in collaboration with the Harvard Center for the Developing Child Frontiers of Innovation Early Identification of Risk workgroup. It asks parents to count up all the ACEs that apply to their child, and put the total in a box on the form, according to German.
It raises an obvious question. What if a parent filling out the form is a perpetrator? “I think my response would be is that parents aren’t going to self disclose about their child’s welfare, if they’re being asked questions that they think will get them in trouble. So asking them to disclose the specifics is probably not going to give the data you’re looking for,” says German.
“What you’re really asking is how do we keep children safe? How do we discover if children are suffering from these traumatic experiences? During a visit, for example, if a clinician noticed bruises on a child, the child would be examined in a room separate from the parent,” she continues.
Parents or caregivers fill out the ACE surveys for their children up to the age of 18. German says there’s been some debate about letting teenagers fill out their own ACE forms separate from the ones their parents fill out as another way to gather first-hand information about adverse experiences. It’s something German says that Montefiore might consider after they analyze the results of their ACEs screening process thus far.
Still, she says, there’s good reason to have parents fill out the forms for their teenagers: “Because there are some experiences that a teenager may not be aware that they were exposed to. Things that happen to a child before they turn three years old are incredibly impactful for brain development. But most of us have no memories of things before we’re three.”
So far, German says that they know that 30 percent of the children they screened for ACEs had an ACE score of 1 or higher.
That preliminary figure squares with the 2016 National Survey of Children’s Health. It found that 38 percent of children in every state have at least one ACE.
Besides the range of ACE scores, they’re looking for their data analysis to tell them just how effective the ACEs screening process has been, and what the data will tell them about their patients. They’re also comparing ACEs screening to another tool known as the Pediatric Symptom Checklist-17.
Before starting to screen for ACEs, Montefiore had already done research to determine that HealthySteps works, said Rahil Briggs, a clinical psychologist who is director of Montefiore’s Healthy Steps program. Their research shows that mothers who are part of HealthySteps use emergency room services less, and the children have healthy social and emotional development, despite their mothers’ history of childhood trauma.
That a system as large as Montefiore — it has 85,000 pediatric patient visits annually at its 21 outpatient sites — can introduce widespread ACEs screening to its patients and services for those families was only possible because of the enthusiastic buy-in by the medical center’s leadership, says German.
Montefiore Chief Medical Officer Andrew Racine is a champion for ACEs screening and trauma-informed practices, says German. Were he not, it would have been hard to pull off.
“You can't do it without [leadership] buy in because this is hard work and it's triggering and makes your staff anxious,” she says.
To help ease the triggers that may occur among staff members involved in presenting the ACEs survey to parents, German said they offer trauma-informed trainings, along with referral to services through their health insurance or at Montefiore. And they tell them to “feel free to take a break in the middle of training. We want them to feel a sense of safety and control,” she says.
That sense of safety and control also extends to how they present the ACEs survey to patients. Instead of saying to parents that they have to fill out the survey, they’re given the option of taking it, a choice German says is critical.
“One of the key elements of trauma is you didn’t have control,” she explains. “So, for us to give an ACEs screen and not give them a choice to do it is potentially triggering their trauma.”
There were also lessons learned from when they first began screening in pediatric practices. Initially doctors handed the ACEs survey to parents, along with a cover letter.
“We learned that patients weren’t reading the cover letter,” says German. “They’d just look at the survey and it would be jarring.”
So they tweaked the approach. Before doctors hand the survey to patients, they tell them that they’re asking them to fill this out because Montefiore cares about their physical and emotional health, says German.
As they wait for the results from the data and analysis, the one thing they know for sure, says German, is that “ACEs screening is feasible.”