Are you screening for ACEs?

 The National Crittenton Foundation's(TNCF) family of 26 agencies across the country provide services and supports to girls and young women who are impacted by violence, childhood adversity and who strive to recover from complex trauma.  In 2013, working with Dr. Vincent Felitti, Crittenton agencies conducted a pilot administration of the ACE in 18 states in a wide array of services settings from residential treatment to after school programs. This included girls and young women involved with the child welfare, juvenile and other systems of “care” such as mental health. Many were young mothers, had experienced homelessness, or were domestic minor sex trafficking survivors, and more.  The results of the pilot were summarized in several blog posts on ACE’sConnection. The report for young mothers featured at a Hill event in Washington, DC can be found here (link to first pilot findings).  

Based on the pilot experience of administering the ACE, many of the agencies are consistently screening new clients for adverse childhood experiences and using the results to inform service delivery.  They are also using it to inform policymakers and the community about Adverse Childhood Experiences and the importance of trauma informed services and supports to help girls and young women heal and build resiliency.  

Currently, the Crittenton family of agencies is involved in the second administration of the ACE across the country. Based on the experience with the pilot administration, enhancements were in the process and data gathering this time around including:

• An enhanced survey instrument that includes extensive demographics about the young women and information about systems involvement and services received  
• An administration protocol was developed to ensure more consistent administration of the survey;
• Use of the REDCap database to input and analyze survey responses for individual agencies as well as across agencies was adopted.
• The addition of well-being questions which are being pilot tested by 6 of the agencies. This is administered upon entry into services and again at discharge and can be linked to the results of the ACES.

TNCF is working with Dr. Roy Wade at Children's Hospital of Philadelphia to analyze the data.  The results will be released at a briefing in Washington, DC in the fall of 2015.  TNCF will also be releasing a provider toolkit on ACES in the summer of 2015.  The toolkit will include the survey instrument, protocol; tip sheets for using ACES for program and policy impact, and case studies of Crittenton agencies and how they are using ACEs in their work.  

Finally, in late 2015 TNCF will work with Dr. Wade, Dr. Vincent Felitti and the family of agencies to craft a youth informed new survey based on the ACE that factors in the lived experiences of young women, including factors not covered by the ACE, such as bullying, etc. Through focus groups and additional research a “girl” informed survey will be created and tested in Crittenton agencies in 2016. 

This child was being cared for by his birth mother until 3 years. He was removed by Child Welfare and custody terminated for maternal drug use, domestic violence, mental health issues, severe physical and emotional abuse, emotional neglect.  He also suffered from the  loss of a parent – his biological mother and recently his biological grandmother and grandfather who had adopted him. His biological grandmother had recently passed away of cancer and the Boy’s biological grandfather felt he was getting too old to care for the boy and was interested in  travel.  Grandfather then passed care of the child to his Biological father and his new wife. Due to severe aggression at school and in the home, the child has been recently seen by CMH and was been placed on stimulant medications for ?ADHD.  Due to persistent aggressive and externalizing behaviors, along with nightmares and becoming hysterical when separated from his grandfather, CMH placed the boy on a Mood Stabilizer, one week before I see this child in the pediatric clinic.   The parents are hoping that I can help with his behaviors and wonder about my thoughts about a child this young being placed on a mood stabilizer.

This boy is obviously experiencing severe trauma. We stopped the mood stabilizer but continued the stimulants.  The first step in cases like this is to educate the entire family (including the grandfather, father, and step-mother) on toxic stress, childhood adversity and developmental trauma.  The family is given two parent friendly videos by child psychiatrist Bruce Perry and I actually take time out of my work schedule  to review  these videos  with the parents educating them about normal behaviors in  children exposed to severe trauma and attachment disruption.  As grandfather wants to travel and transfer care to the child’s father, I ask them to go slowly in the transition and have the child and grandfather stay at the father’s home. We schedule weekly follow-up visits to continue education about the affects of trauma on young children and answer questions that come up.   I help the family understand that the acting out behaviors aren’t purposeful but based out of fear of abandonment. We get the child enrolled in karate lesions after school and encourage lots of exercise.  His teachers are educated about trauma reactions and his trauma exposure.  He does great with parental psycho-education on ACEs and toxic stress, with significantly decreased aggressive outbursts at school and at home.   He is also does very well in school and is in fact no longer considered delayed.

My hope is that this child has been given the opportunity  to pursue whatever career he wishes including becoming a physician.  If he were to become a pediatrician, I believe he certainly would understand the obstacles millions of our pediatric patients experience every year.  Regardless of his adult educational pursuits, I believe his adult potential in life has been strengthened by recognizing and treating his severe early childhood trauma. 

STEP-MOTHER’S NOTE TO ME:

Hi Tina you saw my son at ARMC. You are truly an amazing person and  doctor…….. We recently got sent to u of m and as we already knew they said everything you did. You have a gift that a lot of doctors don't have, you care.   (This really made my day and it is the type of reward that recognizing and not being afraid to take on trauma can offer anyone willing to learn and willing to care). 

Jane - this is so very needed!  I just attended the IHI (Institute for Healthcare Improvement) conference in Dallas this week, and ACEs came up in two keynote presentations.  Health care now needs guidance on how to implement, and I'm glad you are pulling together just such a resource about who is screening, and how.

Sincerely,

Melissa L. Baker, MPH

Mountain Area Health Education Center (MAHEC)