Loading

JSM Health Education & Primary Health Care

The Importance of Trauma Informed Systems in Adverse Childhood Experiences Screening

Mini Review | Open Access

  • 1. Division of General and Community Medicine, Children’s National Hospital, USA
+ Show More - Show Less
Corresponding Authors
Claire O’Connell Boogaard, Division of General and Community Medicine, Children’s National Hospital, Washington, DC, USA
Mini Review

During the Spring of 2018, our community pediatric clinic embarked on Adverse Childhood Experience (ACE) screening. We were searching for a solution to the recurrent behavioral issues, somatic concerns, and exacerbations of chronic illness that standard therapies were not providing. Some of these patients had obvious stressors in their life, but for others it was less clear, leaving us frustrated about how to help. When we read the original ACEs study [1] and consumed the emerging research on the topic, our experiences as primary care pediatricians were affirmed: strong, frequent, or prolonged toxic stress negatively impacts health [2]. Optimistic that focusing our efforts on the causative sources of illness could prevent a career of suboptimal symptomatic treatment, we set out to identify patients and families with elevated ACE scores. We reviewed the most recent studies and designed the project around lessons learned. We followed the Bayview Child Health Center-Center for Youth Wellness (BCHCCYW) Integrated Pediatric Care Model that focused on screening with an ACEs score followed by offering counseling and referral in an integrated care approach [3]. We also chose to screen in both children and parents to best understand patients’ behavior [4]. The goal was to identify individuals with elevated ACE scores and connect them with clinical and community resources to alleviate stress and build resilience.

ACES SCREENING PILOT OBJECTIVES

We knew the plan was bold and would require flexibility and innovation but were optimistic our clinic had the resources and infrastructure needed to make this a success. Our clinic is an academic community-based Patient-Centered Medical Home with onsite mental health providers, social workers, and specialty care who function as referral sources for our patients. The clinic is in an under-resourced urban neighborhood, and although ACEs touch every community, the residents of this neighborhood experience significant stressors related to racial and social injustices, putting them at greater risk for poor health outcomes. Although the topics of ACEs and toxic stress could be new conceptually to our patients and families, we hypothesized the screen would help identify risk early and educating families about the connection between adversity and health could create new avenues for healing.

ACES SCREENING PILOT DESIGN

Our team studied the available academic guidance on implementing ACEs screening and began the process. We sought approval and support from our institution and local clinic. We provided group training for all members of the care team, surveyed providers on their concerns, created scripts to standardize language and approach, educated families on the relationship between toxic stress and health to help build trust, and established referral pathways to resources at the provider’s request. Screens were incorporated in the patient’s pre-visit form packet and self-administered at age 6-month, 1-year, 2-year, and 3-year well visits. The associated EMR templates were updated for ease of ACE score documentation. We piloted the screen with a small number of parents to obtain their impressions and feedback and adjusted the language and design to increase patient comfort. We picked a small population of patients to start with and had a plan on how to quickly screen and adapt our approach as barriers presented themselves. Through our PDSA (Plan, Do Study, Act) cycles, we further adjusted the screen to include resiliency measures and continued to assess provider satisfaction with the new screening tool and available resources. According to the latest review by Kaiser Permanente Washington Health Research Institute, we targeted the 5 necessary elements required for successful ACEs screening [5]:

1) Secure broad organizational support for ACEs screening and engagement across all key stakeholders (leadership, providers, care team, IT)

2) Provide training on trauma and ACEs screening to generate support, establish a common language, increase awareness of ACEs, and build comfort with screening.

3) When starting to screen for ACEs, start small and use data to support successful implementation and spread.

4) Establish systems and practices to support staff and providers

5) Invest in building strong, trusting relationships with patients

ACEs screening: Lessons Learned

We began the process of screening and found ourselves increasingly more uncomfortable with the process. The screening tools were only filled out 28% of the time and the scores obtained did not always reflect the experiences our families had already shared with us. We were puzzled with why the screen was being underutilized and delivering inconsistent invalid results.

Organizational prioritization is needed for successful screening: After several group meetings and reflection, we discussed that although incorporating the above elements for successful screening is necessary, these elements are fragile and require a dynamic system to be executed effectively. On an institution level, this work needs approval and support but also needs prioritization in order to secure the adequate time with patients and resources to appropriately respond to the illuminated results. Screening can quickly come in conflict with productivity goals or flood the available resources already on site. Without prioritization and flexibility, the process becomes less helpful to patients and families. Prioritization also includes producing data efficiently and regularly to adjust PDSA (Plan, Do, Study, Act) cycles and improve the screening process. Our data reports were difficult to pull and implementing changes in our electronic medical record were also untimely. One year after screen implementation, the majority of the staff and provider’s lost confidence with the benefits screening, with providers reporting the intervention had no impact on patients (43%), had a negative impact because it was more paperwork to complete prior to the visit (29%), and positively impacted only those willing to discuss the screen openly, though admitting majority of patients were “not ready” to discuss or acknowledge ACEs (14%).

Discomfort with the topic of ACEs is a barrier to successful screening: Amongst our clinic staff, there is diversity in experience and comfort with ACEs that needs to be acknowledged. Although we provided staff training on ACEs screening, toxic stress, and trauma-informed care to generate support locally within our division, some staff still did not build comfort with the screen. Many people still questioned if the screen was the best way to address this topic with families, as they accurately anticipated many families would not feel comfortable completing or acknowledging their ACE score. We hoped our data would be able to show not only the prevalence of these experiences in our families, but also could show the value in recognizing it through referral outcomes. However, elevated scores were low and accepted referrals were even lower, so we were not able to capture the widespread benefit that some patients experienced from the screen.

Negative impacts of screening on staff need to be prioritized: As we embarked on this work, we assessed staff willingness and readiness to screen, but did not appropriately acknowledge the personal impact this work could have on us. Although our institution offers many wellness benefits and outreach opportunities, there was no formal assessment of the vicarious trauma this topic could bring up in staff and providers. Even for those not personally affected by the topic, incorporating a new screen, workflow, referral process, and need for therapeutic intervention results in additional tasks that increase stress and burnout in the current health care environment. The stress is compounded if this new process causes more disruptions in workflow or there is not timely closed loop communication with referrals.

System factors are barriers to successful ACEs screening: There are systematic changes we need to consider for our system to build more trust with our patients and families. As much as we try, there is a lack of continuity with patients that is a product of trying to keep access available to all. This can make it challenging for patients to trust providers with sensitive information, especially if the patient and provider differ on educational status, race/ethnicity, or perceived power. Although ACEs are universal and found in every community, patients may perceive the provider will see the ACE as a parenting problem (or worse, report it to authorities), rather than as a tool to help us better understand the context of the individual. This lack of trust is amplified if the system does not deliver care as promised. Long wait times, frequent changes in workflows, and inconsistent access to providers can make individuals lose trust in the system and be even more hesitant when it comes to sharing information with their provider.

 

THE PATH FORWARD FOR ACES SCREENING: BUILDING TRAUMA-INFORMED SYSTEMS

What can we do to improve the success of these screens in this fragile medical landscape? We need to have a universal yet personalized approach to screening. Experiences and trust vary with patients, so we need to be flexible with our approach: screening is not a “one fits all” model. Building a secure relationship with families as a system is essential if continuity with providers is not guaranteed. This relationship should be in place before the topic is introduced. The relationship may often require more than one visit to develop, as the priorities of the patient must first be addressed. Building this trusting relationship not only requires trauma-informed staff, but a trauma informed system. Even if staff have the training and education, it is vital that everything from schedule design to data collection is executed to strengthen relationships and adapt as necessary to improve care. This will require flexibility in resource allocation, possible changes to staff roles or schedules, and may interfere with other priorities of the clinic or institution. Finally, acknowledging and accommodating for the inherent stress this work places on providers and staff is crucial. This work can be fulfilling but can also be difficult, time consuming and triggering to personal experiences that should not be ignored. Lastly, although our ACEs screening journey started in the pre-COVID era, we have all witnessed increased levels of trauma and health inequities from the pandemic that disproportionally impact our under-served communities. Approaching patients with a traumainformed lens has even greater significance now and challenging our health care systems to strategize and improve our health care delivery models is critical for meaningful and impactful change.

O’Connell Boogaard C, Hippolyte J (2022) The Importance of Trauma-Informed Systems in Adverse Childhood Experiences Screening. JSM Health Educ Prim Health Care 4(1): 1048.

Received : 17 Oct 2022
Accepted : 03 Nov 2022
Published : 05 Oct 2022
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
TEST Journal of Dentistry
ISSN : 1234-5678
Launched : 2014
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X