By Ariane Marie-Mitchell, American Academy of Pediatrics, October 2019
In the August newsletter, we provided an overview of the definition and impact of adverse childhood experiences (ACEs) (http://aapca2.org/aces). In this article, we will explore the argument in favor of screening for ACEs in pediatric practice, and describe the process and results of a California state advisory group on screening for trauma.
The American Academy of Pediatrics (AAP) recommended screening for toxic stress (negative physiologic changes that can result from severe stressors like ACEs in the absence of sufficient protective factors) (Garner et al, 20121 ). This recommendation, and the basic argument in favor of screening for ACEs, is that if we know that adults who have a history of ACEs are at increased risk of poor health and social outcomes, then there is the possibility that reducing the prevalence or impact of ACEs on children could reduce the likelihood of poor outcomes over the lifespan. In order to support the AAP recommendation and the argument in favor of screening for ACEs with evidence, research studies need to demonstrate that: 1) there are screening tools that accurately identify ACEs in pediatric patients, 2) there are interventions that will improve outcomes for children with ACEs, and 3) the potential harms of screening for ACEs are outweighed by the potential benefits. So, do we have that evidence, or do we need it before proceeding with implementing screening?
An exhaustive review of these questions is beyond the scope of this article, but here is a synopsis based upon related literature and clinical experience. There are a large number of tools that have been validated to screen for one or more ACEs (e.g. see review by Chung et al, 20162 ). Of these, only a subset have demonstrated effectiveness in pediatric practice, and an even smaller subset have included all ten ACEs (see further discussion below). Regarding interventions that will improve outcomes for children with ACEs, there is good evidence that multi-component interventions that include parenting education, social service referrals, and social support can improve early childhood health outcomes (Marie-Mitchell A and Kostolansky R, 20193 ). If the range of social determinants is expanded to include factors that increase risk of ACEs, such as poverty, then the evidence increases in support of the opportunity for pediatricians to improve child outcomes (Fierman et al, 20164 ). As for potential harms, that is difficult to assess because harms are not often measured in screening studies. What we can say is that the majority of parents believe it is important for pediatricians to know about the presence or absence of ACEs in order to provide good care for their children (Koita et al, 20185 ; Marie-Mitchell et al, 20196 ).