Several years ago, pediatricians R.J. Gillespie, MD, MHPE, and Teri Pettersen, MD, piloted the use of a questionnaire about adverse childhood experiences (ACEs) and resilience at the 4-month well-child visit.
They and six other pediatricians at The Children’s Clinic in Portland, Ore., explained in a cover letter why they were posing the questions of parents, and they ended the survey by asking them about their interest in potential resources.
Today, all 28 of the pediatricians at the clinic screen for ACEs and resilience, and Dr. Pettersen , now retired from the practice, travels through the state conducting training for the Oregon Pediatric Society about the impact of ACEs in parents and their children, and how to go about identifying and addressing them.
“So many of our visits are about behavioral problems or emotional disturbances, and so often at the root of these issues is some sort of trauma the child is experiencing,” Dr. Gillespie said in an interview. “What we’re seeing in many of these cases really are coping strategies for that child to deal with the toxic stress in his or her life.”
By assessing parents’ exposure to ACEs, briefly talking with them about how ACEs might impact their parenting, and tailoring their counseling and anticipatory guidance, the pediatricians hope to prevent ACEs and consequent toxic stress from developing in children.
“We know there’s an intergenerational transmission of ACEs and traumas. If we can identify parents who are most at risk and agree to support them in a nonjudgmental way when they feel most challenged, then we can help create a healthier cycle of parenting,” Dr. Pettersen said in an interview.
The driving science
The term ACEs entered the medical lexicon after 1998, when a landmark study called the Adverse Childhood Experiences Study showed that traumatic experiences in childhood – abuse, neglect, and other severe dysfunctions in a household – not only are common among American adults but are associated with numerous poor health outcomes.
In the study and subsequent analyses, Dr. Vincent Felitti of Kaiser Permanente in San Diego and Dr. Robert Anda of the Centers for Disease Control and Prevention surveyed more than 17,000 patients about 10 types of ACEs and their current health status and behaviors. About two-thirds reported having at least one ACE, and one in eight reported four or more ( Am J Prev Med. 1998;14[4]:245-58 , www.cdc.gov/violenceprevention/acestudy/about.html ).
Adults with four or more ACEs were not only significantly more likely to report health risk behaviors (smoking, substance abuse) and poor mental health outcomes (depression, suicide attempt); they were also significantly more likely to have poor physical health outcomes, with 2.2 times the risk of ischemic heart disease, 1.9 times the risk of cancer, and 3.9 times the risk of chronic bronchitis or emphysema, for instance. There was a strong dose-response relationship between ACEs and poor outcomes.
The Felitti study spawned dozens of analyses and additional research – in children as well as adults – on the associations between early-life adversity and the incidence of poor behavioral, mental, and physical outcomes, as well as on potential mechanisms.
Some research suggested a direct link between ACEs and negative outcomes, independent of whether individuals adopt risky behavior. Other studies suggested what experts in child development and mental health have long argued – that the more ACEs a parent has, the more ACEs their child will have.
And a growing body of biomedical literature linked the extreme, frequent, or prolonged activation of the body’s stress response in childhood – what has come to be known as “toxic stress” – with disruptions of the developing nervous, cardiovascular, immune, and metabolic systems.
“We now understand the basic mechanism, which is the dysregulation of the fight-or-flight response,” said Nadine Burke Harris, MD, MPH , a pediatrician in San Francisco who started screening for ACEs in her urban clinic almost a decade ago and founded the Center for Youth Wellness in 2011 to raise awareness and advance research on ACEs and toxic stress.
While precise connections and mechanisms need to be clarified, “we now know that the repeated activation of the stress response leads to [negative] changes in the neuroendocrine immune pathways,” said Dr. Burke Harris, who coauthored a recent review of toxic stress in children and adolescents ( Adv Pediatr. 2016;63[1]:403-28 ).
In January 2012, the American Academy of Pediatrics published a policy statement titled “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health,” in which it urged pediatricians to consider actively screening for precipitants of toxic stress that are common in their communities (Pediatrics. 2011 Dec. doi: 10.1542/peds.2011-2662 ). But it stopped short of recommending particular tools or methods.
Dr. Gillespie and Dr. Pettersen did not want to wait for tools to be validated and approaches to be proven. “We’re building the plane as we fly,” Dr. Pettersen said.
The clinic’s roll-out
Dr. Pettersen learned about the ACE study and related research about 8 years ago while on a sabbatical to learn more about mental health issues. It “changed everything” about the way she viewed children and families and adversity. “I knew (we) didn’t have the infrastructure at the clinic, or the clinic’s support, to really start assessing children for what was happening to them,” she said, so she began thinking about ACE prevention and a focus on parenting.
Dr. Gillespie, in the meantime, was active in various quality improvement efforts at the state and national level, and had also become increasingly bothered by visits in which he saw children affected by maternal depression, abnormal attachment, and other problems. “I was seeing the consequences of ACEs, but I didn’t know specifically what was going on or how to talk about it,” he said.
The two pediatricians agreed to ask parents about ACEs at the 4-month well visit – a time when the families “knew us a little bit” and when “we could still influence parenting styles.”
In March 2013, they and their colleagues in the pilot group began giving parents a questionnaire that included the 10 ACE questions from Felitti’s study, questions about resilience from the Children’s Resilience Initiative , and a list of potential resources so they could understand parents’ needs.
They created a confidential field in their electronic medical record for documentation that appears during a visit, but does not print into notes and therefore will not be inadvertently released.
As they moved through the pilot phase, the pediatricians used various approaches to follow up on the assessment face-to-face. Eventually, they chose three particular questions as nonthreatening and helpful for conversation: Are there any experiences that still bother you? Of those experiences that don’t bother you, how did you get to the point where they don’t bother you? And how do these experiences affect your parenting now?
“It’s a motivational interviewing sort of style,” said Dr. Gillespie. “Parents can start identifying for themselves the solutions for the problems they’ve experienced, and they can start thinking about how their parenting might be impacted by things that have happened [or are still happening] to them.”
As the project rolled out, the physicians tweaked their process. They added four more ACE questions to address issues – community violence, extreme bullying, racism and prejudice, and foster care exposure – that they thought might lead to toxic stress in their population, for instance. And rather than ask on the written questionnaire for a “yes” or “no” to each of the ACE questions, they began asking the parent how many of the ACE questions applied to them. Moving away from the yes-no format to asking for a total count has led to more disclosures, Dr. Gillespie said.
To “keep the conversation going” in subsequent well-child visits, they developed a few questions to ask high-risk parents, like “How do you and your partner resolve conflict?” and “How did your parents resolve conflict in your household when you were a child?” And they provided training to all of the clinic’s staff on trauma-informed care and the need for support and compassion in their interactions with family members.
In the 3-plus years since incorporating ACEs assessments, the clinic’s pediatricians have made soft referrals to mental health professionals in only several cases – in each case, by suggesting that the parent contact their primary care physician. What most parents have wanted, says Dr. Gillespie, is recommendations for parenting classes and support groups. The clinic’s care manager assists the pediatricians in maintaining and providing links and handouts for various resources.
For Dr. Gillespie, the impact of the culture shift has been dramatic. “I’ve had 8-10 moms spontaneously reveal domestic violence to me in a subsequent visit, and say that they need a little help, because they’ve gotten the message that this is a safe place to talk about their experiences,” he said. “That had never happened to me in the previous 12 years of so of my career.”
Dr. Pettersen’s relationships with parents became “more intimate and more honest.” There was more trust. “If we can talk with parents [about ACEs] and not judge them for it,” she said, “then nothing is off the table.”
The ‘Two-Gen’ approach
The clinic’s approach has not been without controversy. “Dr. Gillespie was one of the very first people to screen parents for their ACEs. There’s been push-back, where some have said that you shouldn’t [ask parents about ACEs] if you don’t have anything to give people,” said Denise Dowd, MD, MPH, a pediatrician at Children’s Mercy Hospitals & Clinics in Kansas City, Mo., who chairs the AAP’s Resilience Project and has helped lead a partnership with her state’s largest early Head Start program to treat toxic stress in families.
“But I’d push back and say, parents know they have toxic stress but they don’t name it,” she said. “What we can do as trusted providers who want to advocate for families is to bear witness to their history by asking about it. Once they realize it’s not what’s wrong with [them], it’s what’s happened to [them], a shift occurs. That’s extremely validating for parents.”
That validation is part of a two-generation approach that she and Dr. Burke Harris see as part of a movement to break cycles of ACEs and toxic stress. At the California Pacific Medical Center’s Bayview Child Health Center in San Francisco, Dr. Burke Harris uses three ACE questionnaires – two of them ask parents (of children or teens) to report how many adverse experience types, or categories, apply to them and/or their child or teen, and one surveys adolescents themselves.
With the resources and clinical support of the Center for Youth Wellness, whose major funders include Google, Dr. Burke Harris can initiate a “warm hand-off” of patients with a high ACE score to a care coordinator or therapist. (The Center for Youth Wellness is beginning research to validate its ACE screening tools.) And in the meantime, the medical care she provides is trauma-informed.
“If a patient comes in for ADHD [attention-deficit/hyperactivity disorder] and has an ACE score of 6, my differential diagnosis and assessment will be different than if I see a patient sent by the school who has an ACE score of 0,” she said.
At the Portland Clinic, even though ACEs screening is now tied with the 4-month visit, pediatricians are much more attentive across the board to possible ACEs and toxic stress, and feel better able to converse with families, Dr. Gillespie said. One of his partners recently saw a 12-year-old boy who was failing in school and not making friends. Trauma-informed history-taking revealed at least several ACEs, and conversation turned to “all the resilience pieces… the connections he was missing and what he needed to cope,” he said.
References
• Resilience Project : This AAP project houses a “trauma toolkit” for primary care, case studies, and a variety of other tools.
• Center for Youth Wellness : The ACEs screening tools used by Dr. Burke Harris may be accessed at this website, along with a user guide containing sample scripts, and two white papers on ACEs and toxic stress.
• Resilience: The Biology of Stress and the Science of Hope : This documentary film, released in September 2016, is about ACEs and “a new movement” to treat and prevent toxic stress; it features the work of Dr. Burke Harris and others.
• Academy on Violence & Abuse : Various papers on ACEs screening and case finding in practice may be accessed here.
