Assessing for Adversity

Considerations and Resources

Buy-in and Design

Kids Doctor Checkup

Screening for ACEs: Why and How 

In her TED talk, “How childhood trauma affects health across a lifetime,” Nadie Burke Harris gives a call to action for the use of ACEs screening in pediatric primary care, stating “when we understand the mechanism of a disease, when we know not only which pathways are disrupted, but how, then as doctors, it is our job to use this science for prevention and treatment.”  

Exposure to ACEs increases the risk of health problems across an individual’s lifetime. This is a dose-gradient response, meaning the more ACEs a person experiences, the greater that risk. Experiencing four or more ACEs is associated with significantly increased risk for 7 out of 10 of the leading adult causes of death, including heart disease, stroke, cancer, COPD, diabetes, Alzheimer's, and suicide. Prolonged exposure to toxic stress leads to changes in brain structures as well as hormone levels in the body and can negatively impact the immune system. These changes can impact all areas of health, from food cravings and metabolism to emotional regulation and decision-making to sleep. understanding what a person has been through can provide greater understanding for risk factors as well as care plan needs.  

 

In youth, screening for ACEs and responding with early intervention and resources present opportunities to mitigate the impact of ACEs on future health concerns. Once the presence of ACEs is identified, resource connection and building, prevention, and intervention can begin. Childhood is a critical time to buffer the impact of toxic stress on long-term health. This time is an opportunity to support the developing brain, immune, and hormonal systems of the body. By decreasing the amount of toxic stress impacting the body and increasing positive childhood experiences and building resilience, brain structure and body systems can regulate and ultimately decrease negative health outcomes in adulthood. Additionally, screening presents an opportunity to support families and communities in addressing concerns that contribute to ACEs and with an aim of decreasing the likelihood of more ACEs occurring over time. 

Young Man in Therapy
 

Screening Tools 

 

There are a variety of screening tools available for screening youth and adults for ACEs. When selecting a screening tool, consider the following: 

Who is being screened (parent or patient)? 

  • In addition to (or instead of) screening children for ACEs, some pediatric practices screen parents for ACEs since the presence of these may impact outcomes for their own children (similar to the reasoning for routine maternal depression screening in pediatric settings) 

 

Who is filing out the ACEs screening (parent or patient)? 

  • Parents are most likely to fill out the ACEs by selecting the answers that apply for experiences their child has had, until the child reaches adolescence. 

  • A self-report version may be used for youth who are old enough to complete other screenings (depression, anxiety, and substance use) on their own. 

 

What languages is the tool available in? 

  • Some have been translated already.  

 

Is the screening tool ”identified” or “deidentified”?  

  • “Identified” means that the patient’s yes/no answers to each question will be seen by the appropriate clinic staff, meaning what specific adverse experiences they say “yes” to will be known. Clinic staff who review the screening will be able to see which ACEs a patient has/has not experienced. It is possible that patients may not respond accurately if they know their responses will be seen.  

  • “De-identified” means that only the patient’s total ACEs score will be seen by the appropriate clinic staff. Staff will not know which questions a patient responded “yes” to, only how many. This may increase likelihood of accurate ACEs disclosure / screening tool completion. Clinic staff will not have knowledge of which ACEs a patient has experienced (unless the patients responds “yes” to all). 

 

Other considerations:  

  • Ensure patients and clinic staff are aware of mandatory reporting as it relates to ACEs disclosures. For identified screenings, these means a report is necessary for a ‘yes’ response to any adverse experiences indicating possible maltreatment. For de-identified, a report is necessary if the score reflects the patient responded ‘yes’ to all questions.  

  • ACEs screenings indicate number of experiences, not impact of these experiences. ACEs screening is not the same as trauma screening. Individuals with ACEs may or may not report their experiences as traumatic.  

  • It is critical to use screening tools as a spring board to validate and learn from patients to understand how toxic stress may have impacted them rather than making assumptions such as "it was just a divorce" or "parental substance use must have been traumatic." 

 

Screening for Resilience 

  • In addition to learning about the impact of ACEs, there are screening tools to guide providers to learn about patient resilience. These screening tools can support conversations to build resilience and provide quick references for areas of strength, support, and motivation.  

  • Resources for screening tools: 

 
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Creating Workflows 

 

1. Identifying Barriers and Establishing Buy-in 

Workflows for implementing ACEs screening begin with the establishment of larger organizational attention to all workflows to include trauma-informed and Healing Centered Engagement practices. ACEs screening is an extension of this work. Prior to adding ACEs screening to the workflow, it is necessary to educate all SBHC staff on the purpose of adding it as well as to understand and address any hesitance. This will help inform a workflow that fits the unique needs of your SBHC.  

A common barrier to administering ACEs screening is time. SBHCs are limited on the time they have with patients and staff capacity to meet multiple needs as they are already doing a host of screenings. When, how, and why should the clinic take on more are some of the most common questions asked when a practice considers ACES screening. Rather than start with this question, begin by establishing the value and purpose of adding the ACEs screening to the clinic workflow. Perspectives on the time it takes to implement screening are likely to change when all staff are invested in the value of the screening. This staff buy-in will in turn inform the design of the screening workflow. 

Ask staff members “how will ACEs screening improve patient care?” and note barriers and resistance and identify what is needed to resolve these. This might involve staff training in trauma-informed care, education on the physical health impacts of ACEs, research into how other pediatric and SBHCs have implemented the tool, evaluation of other screenings being done, and further work on community resource engagement and referral systems.  

A key to addressing ACEs is consistency, which is optimally created by training staff before you begin doing screenings and incorporating workflow design into the training process. Selecting a screening tool will both impact and be impacted by your workflow for administering the tool. 

2. Designing the Workflow: from screening to follow-up 

The Center for Youth Wellness provides a useful template (see Appendix A: ACEs Screening Decision Making Inputs Worksheet) for creating ACEs screening workflows and more resources can be found through ACEs Aware’s ACE Screening Clinical Workflows, ACEs and Toxic Stress Risk Assessment Algorithm, and ACE-Associated Health Conditions: For Pediatrics and Adults. When designing a workflow, consider the following elements, which overlap with one another and are best thought through as a whole. 

Process: 

  • Create the workflow for ACEs screening at your SBHC.  

  • Ahead of time: determine appointment types when screening will be administered, such as annual well visits, and process for staff to know when to have screening ready for a visit (how to track when screenings are needed and when they have been completed) 

  • During the appointment: when is screening done (at what stage of the appointment process), who administers the screening (and how do they preface it – including limits of confidentiality/mandated reporting), where does the patient complete the screening (consider confidentiality and trauma-informed space), who reviews it (may be multiple staff), who is consulted (what determines this, is there a base standard?), what are the expectations, how are needed referrals/follow-ups handled? 

  • After the appointment: what follow-up processes are in place for referrals (internal and external both clinical in nature and non-clinical), reporting, and follow-up appointments.  

People: (see Sample Staff Roles in Responding to ACEs - also found under General Resources)

  • Who is responsible for what, when and how  

  • Consider the role of each SBHC staff member in the ACEs screening process. (how might these roles/responses change based on the level of concern identified).  

  • Identify outside stakeholders and resources who will likely be involved and create relationships and plans for connecting patients when appropriate.  

  • Ensure staff have the resources and training they need to fulfill their role, prior to implementing ACEs screening, 

  • Provide ongoing training opportunities and avenues for input from staff on the process and adapt as needed. 

Plan: 

  • Screenings require a review and response, including those that score 0. What is the plan for responding to ACEs?

  • Consider who will be involved in this response: SBHC staff and outside resources 

  • Prior to implementing screening, ensure staff are prepared to respond to ACEs appropriately and are clear on their roles in the process.

  • Also consider what resources are needed for outside referrals (creating referral lists, building community partnerships, vouchers for patients, etc.) and have them prepared and on hand.  

 
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