R. J. Gillespie, MD, MHPE, and Teri Pettersen, MD
Background
The American Academy of Pediatrics (AAP) Policy Statement, Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician, illuminated for the pediatrics specialty the critical role of adverse childhood experiences on lifelong health.1 However, while the policy statement expressed a commitment of the AAP to a leadership role in promoting this issue, the statement left the majority of general pediatricians asking, “What should I do now?”
Practice Characteristics and Considerations
The Children’s Clinic (TCC) is a large single-specialty pediatric practice in the metropolitan area of Portland, Oregon. Among TCC’s 28 pediatricians, several have held a long-standing interest in early childhood development; child and adolescent mental health; and screening for developmental, behavioral, and emotional problems in primary care. The providers have implemented workflows around screening for developmental disabilities, autism, postpartum depression, adolescent substance abuse, and adolescent depression. Included in each of these workflows is a provider-driven algorithm that helps formulate a responsive plan for positive screens in any of these conditions. Upon reading the AAP policy statement, several providers within the practice felt well-positioned to implement a screening protocol for ACEs in primary care.
When considering a screening protocol in primary care, it is helpful to consider four basic questions:
- Why am I looking?
- What am I looking for?
- How do I find it?
- What do I do once I’ve found it?
In addressing the first question with providers, “Why am I looking?” the impact of toxic stress is easy to explain; however, it is more challenging to justify probing parents for their history of adversity. This partly comes from providers’ fear that they will not have the skills to adequately address mental health issues that may have arisen in the parents because of their experiences. The provider champion in this project recommended a simple trigger question to focus the conversation, such as “How do you think these experiences affect your parenting now?” One of the key principles in motivational interviewing is the idea of abandoning the “righting reflex,” the belief providers often have that they have to fix, on their own, every problem that they encounter in their clinical practice.2 Often the parents are able to devise their own solutions by reflecting on their experiences and how their personal histories have affected their parenting skills.
In addressing the next question, “What am I looking for?” the provider champions considered several scenarios for screening for ACEs in the practice, including screening all children during the toddler years, focusing on specific populations such as children experiencing school problems or adolescents facing mental health concerns, and screening parents for their own experiences. After considering several potential scenarios where ACE screening could be applied, the practice decided to pilot screening parents for their ACEs. The theory behind this approach is that the majority of what people learn about parenting comes from their own experiences with their childhood and their own parents; therefore, parents who come from dysfunctional households may need additional support and counseling in terms of self-care skills, modeling conflict for their children, developmental expectations, promoting healthy development, and skills in discipline and managing challenging behaviors.
Addressing the third question, “How will I find it?” reflects the creation of the screening tool itself. The proposed screening tool contained three components: the original 10 ACEs, a questionnaire about resiliency, and a list of potential resources (see Appendix 1). Given that adversity is only a part of the conversation around toxic stress, the resiliency questionnaire helps balance the discussion with parents to highlight strengths and assets. The providers were also interested in discovering what resources parents perceive to be helpful in dealing with their own adverse childhood experiences; thus, the list of potential resources serves as a checklist for parents to mark which services they felt would be most useful.
The final question, “What do I do when I find it?” is often the most important; much has been written about the ethics of screening if there is no viable response to positive results. Therefore, providers identified resources before implementing the pilot, including selected handouts and social connectedness exercises from Connected Kids (see Appendix 2), developmental promotion materials from the website Zero to Three, and lists of parenting classes and support groups from our local 211 info network. Other developmental promotion activities come from the Ages and Stages system that is currently used in the office for developmental screening.
Pilot
The electronic medical record was manipulated in two ways to accommodate this work. First, a confidential field was created that (1) allows providers to document the results of the tool and see the results in future visits but (2) does not print into notes so that information is not inadvertently released if records are shared. Second, specific counseling points were added to the anticipatory guidance section for the well visits from four months through three years. These counseling topics, taken from the AAP’s Connected Kids materials, provide decision support for the pediatricians when addressing toxic stress as part of future well-child visits.
The original pilot was conducted with eight of the providers and has since spread to half of the practitioners. There are plans to continue to spread as the workflow continues to be refined. When parents check in for their infant’s four-month well-child check, the front desk staff hands them the screening tool along with a cover letter that explains the rationale for the tool and reminds parents that the results will be treated confidentially. Parents complete the tool while waiting for the provider, and the provider then collects the completed tool and discusses it with the family.
Results
To date, more than 500 parents have been screened for their ACEs. In TCC’s population, 7.8% of parents had an ACE score of four or higher. There were no significant differences in the publicly insured and privately insured populations. Resiliency scores generally correlated with ACE scores, with higher ACE scores correlating with lower resiliency scores; however, some parents with ACE scores of 0 or 1 still had markedly decreased resiliency scores. The majority of parents identified parenting classes and support groups as the most desired resources; others requested more information from websites or other media. Other resources requested included home visitation, relief nurseries, and support groups for fathers.
The screening has been well received by both parents and providers. Parents who experienced ACEs have vocally expressed gratitude to their providers for addressing the issue directly. Providers have felt that the screening is not burdensome, helps focus the conversations about parenting skills and developmental promotion, and sometimes changes how the providers give everyday advice to families. For example, one provider relates an encounter with a second-time mom; when discussing her own experiences of being abandoned by her mother, she related that she carries a fear of letting her own children ever feel abandoned. When the provider had recommended a “cry it out” approach with her first child’s sleep problems (before the screening tool had been implemented), she was unable to do it because of this fear. The provider feels that knowing information about the parent’s experiences allows for more useful and tailored advice that builds trust between the provider and patient. No provider has experienced a case where specific referrals for mental health services were necessary.
In the spirit of continuous quality improvement, the practice is continuing to adapt the screening to better suit the needs of the providers and families. Because of the observation that some parents with low ACE scores also had low resiliency scores, there was concern that the adversity experienced by those parents may not be adequately captured by the 10 ACE questions. As a result, they have added four questions to the screening tool to probe into food insecurity, extreme bullying and prejudice, foster care, and community violence. It is hoped that these additional questions will provide further insight into parents’ experiences. The practice is also considering formal screening for ACEs in other clinical settings, such as school failure and mental health concerns.
Conclusion
Overall, the providers feel that this screening protocol is very successful. It has enhanced the providers’ skills in understanding and addressing family dynamics. It has built trust with parents by creating a safe place for parents to discuss many topics that are not traditionally viewed as being a part of a pediatrician’s domain. Providers also feel that the care that is being delivered is more effective, in that the root of many parenting problems can be more accurately identified.
References
1. Garner AS, Shonkoff JP; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics 2012;129:e224–e231.
2. Miller, WR and Rollnick, S. Motivational Interviewing: Helping Patients Change Behavior. Guilford Press, 2012.
Resources
- Dowd D and Gillespie RJ. Practical approaches in primary care setting with patients exposed to multiple types of violence. American Academy of Pediatrics Medical Home for Children Exposed to Violence Project webinar. 2013.
- Resilience tool can be accessed at http://www.stlrhc.org/wp-content/uploads/2014/08/Resiliency-Questionnaire-2014.pdf
- Children's Resilience Initiative. Resilience Trumps ACEs.
- National Center for Infants, Toddlers and Families. Zero to Three.
- AAP’s Connected Kids resources can be purchased at http://www2.aap.org/connectedkids/material.htm
- Tools used in TCC pilot work. (See appendix)
© 2015 by Academy on Violence and Abuse
