What are the reasons that parents or caregivers do not fully disclose their own or their young children’s ACEs when asked to fill out an ACE screening form in their child’s pediatrician’s office?
That was one of the many questions raised in a recent webinar: Screening for Adverse Childhood Experiences in the Pediatric Primary Care Setting: Practical Considerations and Lessons Learned.
Dr. Kavitha Selvaraj, an attending physician at the Ann & Robert H. Lurie Children’s hospital in Chicago, presented a number of practical lessons she and her colleagues learned at four medical institutions in Chicago. They were all part of a toxic stress collaborative network screening for adverse childhood experiences (ACEs) in pediatric clinics.
A multidisciplinary team of doctors, social workers, psychologists and researchers from pediatric clinics at the Ann & Robert H. Lurie Children’s Hospital of Chicago, the University of Illinois at Chicago Hospital, Rush University Medical Center, and the John H. Stroger Hospital of Cook County joined forces to create a 13-item screening tool for both ACEs and unmet social needs (USN) called the Addressing Social Key (ASK) Questions for Health Questionnaire, according to the webinar registration page. The four institutions screened and studied the feasibility, efficacy and acceptability of using the ASK questionnaire between August 2016 and July 2017.
It was clear that patients were not fully disclosing ACEs during the screening, according to Selvaraj. Less clear were the reasons why — and which logistics would invite or discourage full disclosure.
“When you give the screen, where is it going to be given — in the waiting room? [or] In the patient room?" says Selvaraj’s colleague and co-presenter, Dr. Stan Sonu, an attending physician in internal medicine and pediatrics, and attending medicine fellow at Cook County Hospital.
“Is your [medical assistant] going to do it? Or is the nurse going to approach the screen with your family, or will it be done privately?” adds Sonu.
“The context could be a barrier,” continues Sonu, noting that their surveys were filled out in the waiting room. “That may have been a barrier for us, why ACE disclosure was so low,”
Selvaraj agrees. She says that with the help of a grant, their team is now questioning parents to find out what the barriers were to disclosure of ACEs, and they’re already finding a common theme.
“They [parents] have all these papers to fill out, they’re sitting in the waiting room, it’s chaos, their three kids are running around and they’re trying to fill out three forms for them, and all of a sudden there’s a question about sexual abuse. And they’re like, ‘What is this, it’s coming out of nowhere.’”
Because of their workflow, Selvaraj says, “There’s not really a person sitting down and saying, ‘Hey here’s why we’re asking, we’re not trying to pry. We’re not trying to get anyone in trouble. We want to help.” Selvaraj said that specific language was in the handout, but nobody was reading it.
Leena Singh is the program director of the Center for Youth Wellness’ National Pediatric Practice Community on ACEs (NPPC), which is training pediatric practices nationally in how to implement ACEs screening. She said they’re hearing about the same problem of very low ACEs scores for children 0 to 5 in the NPPC pilot sites. Their clinical team is convening a 0 to 5 screening work group to investigate it.
“So part of that is trying to figure out why that is,” said Singh. Does the form need additional sensitivity for those younger ages? Is it because parents and caregivers feel that even if something has been experienced by the child, that the child is experiencing child amnesia, which we know is not true. Even if the child doesn’t remember, we know there’s a physiological response. And they still have that experience and that can lead to issues down the line for their health. “
Selvaraj also said that the entire project was done using fellowship time. For pediatrician Dr. Elizabeth Grady with the Daly City Health Center, that is significant. “I particularly appreciated that they had done this whole project with no outside funding, because one of my goals is whatever we’re going to do to address this in pediatric clinics as a part of primary care, we have to make it replicable — which is make it not cost anything.”
Here are some of the lessons learned culled from the Webinar powerpoint:
- Setting up a screening protocol takes a lot of time
- Choose your team wisely
- Train everyone and offer regular training
- Figure out the best time to offer the screening
- Have someone explain the purpose of the screening
Selvaraj also shared excerpts from exchanges with participants
In response to a request for training materials on ACEs, Selvaraj recommended an ACEs training series developed by Dr. Dipesh Navsaria on the American Academy of Pediatrics website. She also referred participants to the National Pediatric Practice Community on ACEs.
A webinar participant asked: "We are developing online modules for PCPs to be able to effectively do this and would love to see what you use to teach others how to frame ACEs in the clinic setting. Here's a link to our project."
Another webinar participant told Selvaraj about the Partnership for Resilience, “an organization formed with ICAAP and a number of educational organizations to 'to transform and integrate education, health care and community organizations to create a trauma-informed, family-focused system that measurably improves academic, health, and social outcomes for children.”
For articles and other material related to neurodiversity, neurobiology and ACEs, Selvaraj’s co-presenter, Dr. Audrey Stillerman, recommended The Center for the Collaborative Study of Trauma, Health Equity and Neurobiology.
Selvaraj also recommended to participants interested in collaborations with schools the Center for Childhood Resilience, which is based at Lurie Children’s Hospital in Chicago.
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