The Importance of Screening for Adverse Childhood Experiences (ACE) in all Medical Encounters

Such high hopes are being pinned on screening for adverse childhood experiences…also on treating and healing young people and adults who have experienced aces.

Are these high hopes warranted?

Folks’ reactions confuse me because you can’t get around the fact that it’s very difficult, expensive, time consuming, and resource consuming to try and help people who have experienced unsupportive and harmful parenting. Isn't it always better to prevent a problem than to try and fix it after the fact?

The most important and least discussed takeaway from the ACE Study is that there needs to be an entirely new kind of parenting education that reaches everyone, everywhere. If this isn’t realized, the Study will eventually be forgotten and chalked up as the greatest lost opportunity ever.

@Molly Peterson posted:

We truly appreciate your support of screening for ACEs, Drs. Gordon & Felitti. The Center for Youth Wellness is leading a project with the New Jersey AAP, funded by HRSA, to provide guidelines for screening in the pediatric primary care setting in a report to congress. We have completed working with two cohorts of 30 practices to help them start screening, and they have given us extremely positive feedback on this program and the process of screening itself. Please feel free to find out more here: The TASIE Project - NJAAP. We are also in the process of recruiting for practices for our 3rd cohort if you know any practices that might be interested. All information can be found in the above website.

!!!!! Bravo for the work you do. If we cannot accomplish systemic appreciation we will have to change one clinic at a time!

We truly appreciate your support of screening for ACEs, Drs. Gordon & Felitti. The Center for Youth Wellness is leading a project with the New Jersey AAP, funded by HRSA, to provide guidelines for screening in the pediatric primary care setting in a report to congress. We have completed working with two cohorts of 30 practices to help them start screening, and they have given us extremely positive feedback on this program and the process of screening itself. Please feel free to find out more here: The TASIE Project - NJAAP. We are also in the process of recruiting for practices for our 3rd cohort if you know any practices that might be interested. All information can be found in the above website.

@Mike Flaningam posted:

(Sorry for the late and long comment). Thank you, Drs Felitti and Gordon, for your important rebuttal to last year's AJPM position statement. Your comment about how the statement "creates a comfortable incentive for many clinicians to avoid addressing child abuse and neglect" absolutely nails it.

It's all the more frustrating because we know the authors of the position statement are PACEs-informed and I believe to be genuinely interested in advancing the movement. I see their holdup as being from a trap most of the medical field, especially academia, has fallen into - the rigid need to be evidence-based. As a physician, I appreciate how much our profession's pursuit of evidence-based decision making has largely improved the care we provide. However, a downside is how this emphasis pushes the humanity out of what we do (along with electronic health records). The older I get, the better I understand the art of medicine seasoned clinicians talk about. Ultimately, the healing we provide is largely from the relationship with have with our patients. From an evolutionary standpoint, we humans, like all mammals, are social creatures, and our ancestors survived because they were part of a tribe who supported each other.

At their root, ACEs are caused by relational trauma, so healing from them requires relational healing. Physicians have the potential to be part of that, but this is less likely if we see the patient as a widget to plug into an evidence-based algorithm, and not as a person whose lived experience makes them unique and as someone who is wanting to be heard and validated. We docs are trained infinitely more on basing our clinical decisions on evidence-based studies than how to relate to patients, including the patient who has shared a traumatic experience with us. As we're burned out and just trying to survive each workday with our sanity intact, most docs absolutely are happy to follow the position statement and avoid addressing ACEs.  Though because the statement endorsed the status quo and therefore wasn't newsworthy, most docs will never hear about it. This lost opportunity to effectively raise awareness is what frustrates me most about the position statement.

Thanks for your very cogent comments. I agree 100%. The trouble with ACPM and USPSTF is - while they have a correct and valid perspective - they like us would like to have impact and outcomes proofs as well! Of course neither they nor anyone else (in their ignorance) will fund such a big study because there is no money to be made from it. Meanwhile, ACEs and other tools provide the means we clinicians use here and now to help our patients and are necessary to provide the best care possible.

(Sorry for the late and long comment). Thank you, Drs Felitti and Gordon, for your important rebuttal to last year's AJPM position statement. Your comment about how the statement "creates a comfortable incentive for many clinicians to avoid addressing child abuse and neglect" absolutely nails it.

It's all the more frustrating because we know the authors of the position statement are PACEs-informed and I believe to be genuinely interested in advancing the movement. I see their holdup as being from a trap most of the medical field, especially academia, has fallen into - the rigid need to be evidence-based. As a physician, I appreciate how much our profession's pursuit of evidence-based decision making has largely improved the care we provide. However, a downside is how this emphasis pushes the humanity out of what we do (along with electronic health records). The older I get, the better I understand the art of medicine seasoned clinicians talk about. Ultimately, the healing we provide is largely from the relationship with have with our patients. From an evolutionary standpoint, we humans, like all mammals, are social creatures, and our ancestors survived because they were part of a tribe who supported each other.

At their root, ACEs are caused by relational trauma, so healing from them requires relational healing. Physicians have the potential to be part of that, but this is less likely if we see the patient as a widget to plug into an evidence-based algorithm, and not as a person whose lived experience makes them unique and as someone who is wanting to be heard and validated. We docs are trained infinitely more on basing our clinical decisions on evidence-based studies than how to relate to patients, including the patient who has shared a traumatic experience with us. As we're burned out and just trying to survive each workday with our sanity intact, most docs absolutely are happy to follow the position statement and avoid addressing ACEs.  Though because the statement endorsed the status quo and therefore wasn't newsworthy, most docs will never hear about it. This lost opportunity to effectively raise awareness is what frustrates me most about the position statement.

@Jill Obremskey posted:

All agree that home visiting is an affective means to address  families who have been identified as high risk.  However, what we need is prevention.  The AAP recommends incorporating social and emotional health assessment and parenting support by a child's primary care provider at all well child visits as per bright future guidelines.  There is significant research on how optimization of early relational health is an effective tool for prevention of behavioral and emotional problems in later childhood and adolescents.  The Child and Adolescent Health Measurement Initiative's ENACT! framework is a possible systems approach to supporting caregivers, families and communities in reaching this goal.

https://cahmi.org/our-work-in-...24C019#COE_Resources

Of course, you are right on and CAHMI is an exemplary model and program. The problem that I am appreciating is that in many places pediatricians are overworked and underpaid. Many circumstances, including the FFS system, high Medicaid population, rural and inner city sites cannot maintain the team/ancillary services necessary to implement such a top notch program. Also we need an outreach component to find families that hesitate to access a pediatric clinic. We are all on the same wave length. Thanks for your comment and the link.

All agree that home visiting is an affective means to address  families who have been identified as high risk.  However, what we need is prevention.  The AAP recommends incorporating social and emotional health assessment and parenting support by a child's primary care provider at all well child visits as per bright future guidelines.  There is significant research on how optimization of early relational health is an effective tool for prevention of behavioral and emotional problems in later childhood and adolescents.  The Child and Adolescent Health Measurement Initiative's ENACT! framework is a possible systems approach to supporting caregivers, families and communities in reaching this goal.

https://cahmi.org/our-work-in-...24C019#COE_Resources

@Jill Obremskey posted:

David Dooley is spot on - primary prevention through parenting and support of care takers should be our focus.  There are not enough resources for evidence based home visiting nor mental health providers to meet this growing "epidemic".

There is no conflict here. Primary prevention of maltreatment and parental education are both optimally provided by (nurse or community health worker) home visiting programs to higher risk pregnant families and continuing for 3-6 months, supplemented with community parent education groups. See "Hello Baby" in Allegheny County, PA.

You wrote, "David Dooley is spot on..."

Dr. Bruce Perry used the exact same wording when I asked him about an entirely new kind of parenting education that reaches everyone, everywhere.

David Dooley is spot on - primary prevention through parenting and support of care takers should be our focus.  There are not enough resources for evidence based home visiting nor mental health providers to meet this growing "epidemic".

Home visiting is wonderful. It benefits moms and infants, but there still needs to be an entirely new kind of parenting education that reaches everyone, everywhere.

One that teaches parenting behaviors and practices generally recognized as supporting the healthy development of children.

One that reaches grandparents raising grandchildren, mature parents, young parents, single people, high schoolers, and grade school kids.

One that doesn't have an end date.

One that will become a permanent fixture of our culture.

@David Dooley posted:

I'm all for screening, but I really don't think much will change unless we redirect our focus on universal primary prevention.  Especially, an entirely new kind of parenting education that reaches everyone, everywhere.

I agree with you100%, working on it. Trying to create a universal home visiting program for all California Moms with newborn infants. This editorial was written to rebut a policy statement by The American College of Preventive Medicine which recommended against individual screening all together. I posted their statement about 6 months ago as a blog.

I'm all for screening, but I really don't think much will change unless we redirect our focus on universal primary prevention.  Especially, an entirely new kind of parenting education that reaches everyone, everywhere.