By Laura Shamblin, MD FAAP
Most of us have now heard of the Adverse Childhood Experiences Study published by Drs. Felitti and Anda in the American Journal of Preventative Medicine in May of 1998. The study and many follow up studies have shown a direct and dose dependent relationship between adverse childhood experiences, or abuse, neglect, and household dysfunction, and adult risky behaviors and health outcomes. As a Pediatrician and advocate for Trauma Informed Care, I’d like to take this opportunity to address some of the objections to screening for ACEs that I have come across. It is true that some areas of research are still emerging, such as protocols, but in other ways we are twenty years behind using the information we have to make a positive difference in our patients lives and in training new physicians to be more comfortable addressing social and experiential determinants of health.
Myth #1 People don’t want to talk about their personal or family traumas.
In several studies, the vast majority of patients did not mind answering a screening tool at a primary care visit. (1,2) Clinics who have adopted ACEs have found using a cover page with a short explanation of the relationship between childhood traumas and adult health outcomes to be helpful. It has also helped to have ACEs screening papers given to the patient to be filled out either at home before the visit, or in a private patient room before seeing the doctor rather than in the public waiting room. Any adoption of a new screening tool should ideally have input from a patient advisory group before implementation to account for concerns of different patient populations. (3)
Myth #2 Filling out a questionnaire may cause someone to remember suppressed memories of childhood abuse and have a sudden onset or worsening of mental health issues.
This concern has been brought up in a couple of published articles (4), however there are many more articles recording the use of ACEs screening tools in various outpatient settings without reference to this situation actually happening. The ACEs questionnaire has also been given and shown to many, many large audiences at conferences and trainings and again, there has never been a case brought to light of any major mental health consequences, to my knowledge. On the contrary, many people express appreciation and even relief to learn the associations between childhood experiences and adult behaviors and health outcomes. They know there is a problem, and it is helpful to put a name to it and therefore be able to get more information about treatment and recovery steps that can be taken. There is mention of patients being uncomfortable with the information on health outcomes being given without being accompanied by information on resilience, buffering, and positive and compensatory experiences. (5)
Myth #3 There aren’t any truly evidence-based interventions for childhood trauma. We shouldn’t make families aware of the negative health outcomes, because there is nothing proven to help them.
This assumes that all positive screens will need a behavioral health care referral. In a large study of 3 community pediatric clinics in the Chicago area, screening for ACEs only resulted in referral for mental health care in 2% of patients. (6) In a feasibility study in a family medicine practice including adults, no new referrals were made. (1) When those services are needed, there are several modalities of treatment that have good evidence for use in children and are recommended by the AAP. At the top of the list would be Trauma-Focused CBT followed by PCIT and CPP. TBRI is also a growing modality with good results among the adoption community and schools but less research funding nationally. More information about treatment modalities can be found here. https://www.traumainformedmd.com/treatments.html#/
For the many who do not need a referral, parenting resources such as local parenting classes (check with churches, hospitals, and pregnancy centers), as well as anticipatory guidance and education provided by the physician, is likely the most helpful resource and is the most asked for by parents. There is growing evidence that positive experiences in childhood as well as healthy attachment relationships with at least one adult both have a buffering effect on children who experience multiple ACEs. These positive experiences and relationships provide resilience as well as support for healing. (7,8)
Myth #4 There aren’t enough mental health professionals available to provide follow up for all of the positive screens we would get, so it’s better to just not ask the questions.
Behavioral health providers who use evidence-based methods of treatment for childhood trauma may be more available than most providers are aware. If you know the modality you would like to be used such as TF-CBT or CPP it is possible to use several search methods to find the nearest provider to your community. Links to these search sites are listed on the Treatments page of www.TraumaInformedMD.com here https://www.traumainformedmd.com/treatments.html#/. SAMHSA also has a search function you can find here https://findtreatment.samhsa.gov/ and most state Mental Health Departments also have search capabilities and resource lists. Another helpful search website is https://www.psychologytoday.com/us which has a way to filter for therapists that provide different modalities or types of therapy. By searching, you can quickly find what behavioral health resources may be near you, even in a rural location.
Myth #5 If we ask about abuse, we may uncover events that would fall under the mandatory reporting obligation. We may overwhelm the Child Protective Services and kids may be removed from the home who didn’t need to be, further traumatizing them.
First of all, if a child is in an unsafe situation there should be no problem with reporting it, despite the time and effort it may require from the provider. However, situations that are serious enough to involve your local Child Protective Services will be evaluated for safety and many of them will not require removal from the home, but they will give the family the opportunity to receive prevention services. The Family First Prevention Services Act is a federal law that was put into effect on October 1st, 2019. It allows state human services agencies to use federal matching money that was previously only used for out-of-home foster care to be used for preventions services given to the family with the child remaining in the home. This law requires some benchmarks in quality to be reached before using it and most states have not put it into effect yet, however, the national trend is changing toward keeping children in the home and providing services to the biological family when possible. (11)
Myth #6 I’d love to screen for ACEs but there is no way I have time during a patient visit to delve into those issues.
In most feasibility studies, practices have found that using a deidentified screening tool – one that just has the patient list the number of ACEs that are positive for them but not specify which ones – allows the physician to talk to them generally about being intermediate or high risk and what they can do to counteract those factors, rather than needing to hear the story of each one. Of course, if a patient wants to explain a positive answer, this may happen and opens the relationship to be a safe space for talking about these issues at this and future visits. When a deidentified screener was used, the time added to most visits was found to be 5 minutes or less in multiple studies. (1,9)
Myth #7 As a doctor, my focus is on my patients’ health, and knowing how many ACEs they have will not affect my diagnosis and treatment of current health issues.
The number of ACEs may not affect a specific diagnosis directly because there are other genetic and resilience factors that also play a role for each individual. However, universal screening makes it more likely that an environment or history of childhood trauma will come to your attention as you are treating chronic illnesses that have been shown to have direct correlations with childhood trauma and toxic stress, such as failure to thrive, asthma, obesity, ADHD, anxiety/depression, substance use, self-harm, and even things like syncope, headaches and chronic abdominal pain. ACEs are present in families of all socioeconomic backgrounds and you may fail to ask about such influences if the family appears to be well-functioning in your clinic.
I’d like to specifically point out the relationship between ACEs and ADHD diagnosis. Patients seem to have a dose dependent relationship between number of ACEs and likelihood of ADHD diagnosis. (10,12) It is also known that one symptom of PTSD is hypervigilance, which in a child includes behaviors such as inattention, inability to sit still, and other behaviors that mimic those of ADHD. Because the DSM-V does not allow for an ADHD diagnosis if another mental health disorder may explain the symptoms, it seems that a screening for ACEs and PTSD may be warranted in any person being screened for ADHD to further inform the diagnosis. As Guanfacine is an accepted treatment for both PTSD symptoms of hypervigilance and ADHD, it is logical that it may be a better first line treatment for a child with both ACEs and ADHD than a stimulant would be. Further research on this and elucidation of protocols are still being worked on.
Myth # 8 The ACEs screen was developed for adults and should not be used on children.
Depending on your purpose there may be value in screening both parents and children. In the case of parents there is some evidence that increased ACEs are related to developmental delays in their children. Surprisingly, there was even a stronger relationship between fathers’ ACEs and children’s developmental delays. (13) This would suggest that screening parents early on may be a way of knowing which to refer for more supports in parenting such as parenting classes or adult mental health services. Early adopters have suggested the 4-month well check visit as being a good time to screen as there are fewer other concerns at that visit. (3) Screening children, either having parents report for young children or having older children report for themselves, would be most helpful for reference when working up health and mental health conditions as stated above such as asthma, failure to thrive, ADHD, etc. These could be done either at well checks and referred back to during illness or could be done at times of work-up for these chronic conditions.
Given the many demands on physicians’ time and paperwork requirements it can be easy to be so busy in our practices that we wait for government or professional organization mandates to dictate how we practice. I hope this helps to bring some resources and research to the forefront to help us use the information that ACEs screening would provide. We should NOT be screening if we are not comfortable with what we will do with the information. And what we will do is usually just have a conversation with the caregiver or patient about the results and things they can do to combat the effects of ACEs on their child, such as getting parenting support, keeping mom healthy, trying to have high quality, safe childcare, trying out things like mindfulness and exercise in the home, leaning on extended family and friends at times of stress, coordinating with teachers, etc. Of course, we will need to have mental health professionals in place that we can refer to when needed. For help with that look back at Myth #4.
The State of California has put together a short online training for physicians and other healthcare or mental health workers to learn more about ACEs and implementing ACEs screening in the medical setting. I just did this training myself and I was impressed at how many references they include with the research and how much of the biology and physiology of stress was included. I received 2 hours of CME credit and 2 hours of MOC credit for the American Board of Pediatrics. This is the training that is being required of California physicians before they can bill for Medicaid reimbursement of administering ACEs screens. However, any healthcare provider can create a login and take the course for free. I appreciated the inclusion of the screening tools and an algorithm for how to interpret results and when referrals are recommended. Please take a look if you are a healthcare provider. It will be worth your time!
You can find it at https://www.acesaware.org/
The National Center on Safe Supportive Learning Environments has a few free online learning tools to help teachers and school administrators to learn the basics of trauma informed schools and to collaborate with their local colleagues in how to implement trauma sensitive changes in their schools. I took a quick look at them and it looked like the ones labeled Understanding Trauma and Its Impacts and Building Trauma Sensitive Schools would be best for classroom teachers. I just wanted to point out this free national resource as many are looking for tools to help with this.
Here is the LINK.