Pediatric ACES assessment within a collaborative practice model: Implications for health equity.

Abstract

It is now well understood that exposure to Adverse Childhood Experiences (ACEs) is negatively linked to health and well-being across the lifespan. In an effort to disrupt ACEs exposure and its effects, there is a nationwide movement to screen for ACEs in primary care, despite a lack of wellestablished guidelines for assessing and responding to risk within routine care. Additionally, developing culturally responsive models of ACEs assessment is imperative, particularly because racial and ethnic minority populations face disproportionate risk of exposure to ACEs and disparities in quality of health care. Using mixed methods, we explored the feasibility, acceptability, and utility of conducting ACEs routine inquiry with an ethnically and economically diverse pediatric population through a unique collaborative practice model (CPM) consisting of an integrated, multidisciplinary team within primary care. In the CPM study, 163 children from a safety-net health system were enrolled; of those, an ACEs questionnaire was collected from 158 (97%) study participants as part of their mental health evaluation. The sample was highly ACEs exposed, with 40% of children and 56% of teens having scores of four or more. There were significant associations between level of ACEs exposure and degree of mental health impairment in both children and teens. Providers viewed the ACEs assessment process as feasible, acceptable, and to have utility for the care of the study's diverse pediatric population. Findings highlight benefits, challenges, cultural considerations and recommendations for promoting health equity through a primary-care integrated ACEs assessment model. Public Policy Relevance StatementRacial/ethnic minority and low socioeconomic status populations face disproportionate exposure to ACEs and barriers to accessing treatment. Results of a mixed methods study found that a multidisciplinary, team-based approach to assessing ACEs in primary care is feasible, acceptable, and useful to providers working with diverse and highly stressed children and families. This model of routine ACEs inquiry can inform earlier recognition and individualized treatment to improve health and healthcare equity and outcomes for trauma-exposed youth. aaa A dverse childhood experiences (ACEs), historically defined as exposure to abuse, neglect, and household challenges, are common across the United States. Nationally representative findings from the 2011/12 National Survey of Children's Health (NSCH) indicate nearly one-half of U.S. children are exposed to at least one ACEs, with higher rates among older, lower-income, racial/ethnic minority, and uninsured or publicly insured youth (Bethell et al., 2017). An abundance of research with adults illustrates a robust dose-response relationship between This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Utility of screening for adverse childhood experiences (ACE) in children and young people attending clinical and healthcare settings: a systematic review

“… 41 For most studies using the ACE questionnaire, a score of ≥4 ACE was used to indicate high ACE exposure. Of the studies that did not use a version of the ACE questionnaire, 2 used the Post-Traumatic Stress Disorder section of the Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (to assess for domestic violence and exposure to sexual and/or physical abuse) and the European Addiction Severity Index (to assess parental employment status) 44 45 ; 2 used the interRAI Child and Youth Mental Health Assessment; 1 used an adapted version of the Traumatic Event’s Screening Inventory 40 ; 1 used the Center for Youth Wellness ACE Questionnaire (17-item child and 19-item teen) 49 ; 1 used the Traumatic History Profile 8 ; 1 developed and used the Whole Child Assessment which included ACE questions 50 ; and 1 employed seven measures including the Childhood Trauma Questionnaire-Short Form, Trauma Experiences Checklist, Parental Nurturance Scale, Parental Harsh Discipline Scale, Violence Exposure Scale, Friends’ Delinquent Behavior Scale and School Connectedness Scale. 52 …”

“…One study used the ACE 10-item questionnaire (completed by parents of infants; n=151, infant M age=5.77 months, SD=1.98, 49.7% male) while the other used the ACE 17-item (completed by parents of children; n=114, child M age=8.4 years, SD=2.5, 57% male) and 19-item questionnaires (completed by adolescents; n=49, M age=14.7 years, SD=1.3, 40.8% male). Both studies found administering the ACE questionnaire to be highly feasible with 92% 47 and 97% 49 of potential participants completing the questionnaire. Given the small number of studies looking at the administration of ACE in health settings and that both studies were undertaken in the USA, further research is indicated for generalisability.…”

“…Twenty-four studies included in the review used a tool to assess for ACE as part of clinical enquiry 4 5 7 8 38–57. Of these, 3 studies also assessed for SDH 8 40 52.…”

“…Two studies examined the feasibility of ACE questionnaire administration in a health setting 47 49. Both studies were conducted in the USA.…”

“…Eleven studies were identified that explored health practitioner knowledge and acceptability of ACE screening 26–31 47 49 50 55 59. Ten studies were undertaken in the USA while one was conducted in Australia.…”