Screening for Adverse Childhood Experiences (ACEs) in Primary Care [jamanetwork.com]

 

By Thomas L. Campbell, JAMA, May 28, 2020

Adverse childhood experiences (ACEs), such as experiencing or witnessing violence or abuse or living with a parent with mental illness or substance use disorder, have been shown to have a powerful influence on subsequent mental and physical health and life expectancy. Exposure to ACEs has been linked to more than 40 negative health conditions, including poor mental health, substance use disorder, adverse health behaviors, chronic physical disease, and shortened life span. A meta-analysis of 37 studies that examined 23 health outcomes found that individuals who reported more than 4 ACEs had higher odds of cancer, heart disease, respiratory disease, and poor self-rated health (odds ratios ranging from 2 to 3); mental illness, alcohol use disorder, and risky sexual behavior (odds ratios ranging from 3 to 6); and drug use disorder and interpersonal or self-directed violence (odds ratios greater than 7). Early childhood adversity and high levels of β€œtoxic stress” have been found to have widespread and longstanding effects on multiple systems, and have been associated with reduced immunity, high levels of inflammation, shortened telomeres, subsequent poor health outcomes, and premature mortality.

As a result of this extensive body of research, many have recommended that clinicians, especially those in primary care, screen for ACEs and intervene to prevent some of these adverse health effects. The state of California recommends routine screening for ACEs, and has allocated $40 million in 2020 to reimburse clinicians who screen patients in the Medi-Cal program. The American Academy of Pediatrics recommends that β€œPediatric practices [should] consider implementing standardized measures to identify family and community-level factors that put children at risk for toxic stress,” but does not specifically recommend screening for ACEs. The US Preventive Services Task Force has not published recommendations on screening for ACEs, and no major medical organizations have specifically recommended it. Before advocating widespread screening for ACEs, a careful assessment of the risks and benefits of such screening should be done, and the established principles for preventive screening should be applied to ACEs.

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