Assessment of Screening for Adverse Childhood Experiences and Receipt of Behavioral Health Services Among Children and Adolescents

Abstract

ImportanceScreening for adverse childhood experiences (ACEs) in primary care settings has been increasing as a response to the overwhelming and consistent evidence of the deleterious associations between ACEs and later physical and mental health. However, there is little empirical guidance on the appropriate implementation of ACEs screening in pediatric primary care.ObjectiveTo test the use of a pilot intervention for ACEs screening and referral on the receipt of behavioral health care for children and adolescents within a large integrated health care delivery system.Design, Setting, and ParticipantsA retrospective cohort study was conducted in a large integrated health care system serving Southern California. Child and adolescent members of the target health care system younger than 18 years between July 1, 2018, and November 30, 2021, who received a positive screening for ACEs at the pilot clinic were included. This pilot clinic implemented an intervention that included additional screening questions and incorporated social workers into the process of evaluation and referral for behavioral health needs following ACEs screening.ExposuresACEs screening.Main Outcomes and MeasuresVisit to a behavioral health care service within 90 days of a positive ACEs screen determined as a score of 1 or higher and behavioral symptoms.ResultsThe cohort consisted of 4030 children (mean [SD] age, 9.94 [4.55] years) with positive ACEs screening, 48% adolescents (11-17.99 years), approximately equal gender (51% females), 73% Hispanic, and 33% with Medicaid insurance. After the intervention, children were more likely to have a behavioral health services visit within 90 days of the screening than before the intervention (from 4.33% to 32.48%; incidence rate ratio, 7.50; 95% CI, 1.55-36.2).Conclusions and RelevanceIn this cohort study, the implementation of a new ACEs screening and referral process was associated with increased receipt of behavioral health services among children with a positive ACEs screening. This could be useful strategy for other health care systems responding to state and local mandates to screen and provide care for children with ACEs.

Physical, mental, and behavioral health after adverse and benevolent childhood experiences: A comparison of two adversity conceptualizations.

“…The present findings indicate public health responses to ACEs (e.g., public awareness, routine enquiry, trauma-informed treatment; Lacey & Minnis, 2020) should consider both the accumulation and co-occurrence of ACE exposure. Specifically, as routine ACEs screening, referrals, and follow-up services in health care systems become more widely implemented (Negriff et al, 2022), clinicians should monitor and anticipate client needs across different health domains based on both the number of ACEs and the types of adversities experienced (e.g., instability vs. violence). Further, having a high number of BCEs was protective for mental and behavioral health.…”

Conceptualizing adverse childhood experiences as a latent factor: Tests of measurement invariance across five racial and ethnic groups

“…Mei et al (2022) replicated this three-factor model across age, race, sex, socioeconomic status, gender identity, and sexual orientation. However, both studies were conducted among adults, resulting in meaningful opportunities to continue exploring measurement invariance related to ACE items among children and youth (Negriff et al, 2022). Moreover, extant invariance tests also do not account for the statistically different patterns that have emerged in recent scholarship attending to racial and ethnic differences in ACEs among youth through multiple-group latent class analysis (Parnes & Schwartz, 2022;Zhang & Monnat, 2022).…”

“…Yet, evidence to support the utility of an ACE screening tool has been equivocal at best (e.g., Campbell, 2020; Dube, 2018). Others have also echoed concerns regarding the translational nature of ACE research into practice and have highlighted that the relatively narrow range of ACE items conventionally examined in research lack sensitivity and specificity (Finkelhor, 2018; McLennan et al., 2020), and that the simple additive scoring approach may overlook the differential impact of specific ACEs on health (Negriff et al., 2022). ACEs research has clearly illuminated the fundamental importance of childhood trauma and adversity on population health and human development; however, in some ways, the translation of ACEs research to practice has outpaced psychometric work to develop and confirm robust measurement approaches.…”

Does screening for Adverse Childhood Experiences in pediatric patients increase referrals to community services or engagement with behavioral health services compared to no screening?

“…A 2022 retrospective cohort study assessed the rate of successful engagement with behavioral health services for children and adolescents (n=4,030), using a pilot intervention of ACE screening and referral. 2 The researchers extracted data from electronic medical records of patients in an integrated healthcare system in Southern California that served more than 4.7 million people, including 1.5 million children. Patients had a mean age of 10 years (range 2–18 years), 51% were female, and reported race/ethnicity was 73% Hispanic, 14% Black, 6% White, 4% Asian/Pacific islander, and 4% other or unknown; 33% had Medicaid insurance.…”