A study of pediatrician's adverse childhood experiences screening workflows

May 3, 2021
Lois Levine

Adverse childhood experiences (ACEs) are associated with poor health outcomes over the course of a life, but there is still little information on clinical workflows to guide these implementation practices. At the virtual 2021 virtual Pediatric Academic Societies meeting, Julia I. Reading discussed models and variations in ACE screening workflows.

Julia Reading, medical student at the David Geffen School of Medicine at UCLA in Los Angeles, California started her session at the 2021 Pediatric Academic Societies virtual meeting with a definition of ACEs. She noted they were stressful and often traumatic experiences that included abuse, neglect, and house challenges, are associated with poor health outcomes1,2 and that despite what this could mean in terms of public health implications, screening is still not a widely adopted practice for these experiences.

For this study, individual phone interviews were conducted, questions adapted from previous surveys and barriers, and structure was adapted from prior semi-structured interviews on social risk.3 Process flow diagrams were made for each physician's ACEs screening workflow and overall groupings according to guidelines from the Institute for Healthcare Improvement.4

The aims of the study were to describe common ACEs screening workflow processes; provide examples of clinical ACEs screening workflows; and look at key informant interview study design.

The common workflow elements consisted of patient check in; question delivery (either verbally or via questionnaire by a patient portal or clinical staff at visits); and questions answered. Results included screenings based on predetermined protocolized criteria (ie, score and/or presence of symptoms) as well as primary provider intervention on an ad hoc basis, based on individual factors. The study noted substantial variations in these screening workflows, with protocolization hinging on factors that included availability of administration; beliefs about patient risk; availability of support staff; and intervention resource accessibility.

It was also noted that almost all participants conducted a screening at preventive care visits, with more than a third adding a screening if relevant symptoms were reported (using either the Adverse Childhood Experiences Questionnaire (ACE-Q) or the Pediatric Adverse Childhood Experiences abnd Related Life-Events Screener (PEARLS).

The study concluded that ACEs screening workflow variations is largely a result of differences in intervention thresholds as well as access to intervention resources. It also noted that successful screenings can be accomplished regardless of the degree of workflow protocolization; and workflows should be tailored to the needs and limitations of an individual practice.

1. Bethel CD, Solloway MR, Guinosso S, et al. Prioritizing possibilities for child and family health: an agenda to address adverse childhood experiences and foster the social anbd emotional roots of wellbeing in pediatrics. Acad Pediatr. 2017;17(7s):S36-S50. doi:10.1016/j.acap.2017.06.002
2. Bodendorfer V, Koball AM, Rasmussen C, et al. Implementation of the adverse childhood experiences conversation in primary care. Fam Pract. 2020;37(3):355-359. doi:10.1093/fampra/cmz065
3. Hamity C, Jackson A, Peralta L, Bellows J. Perceptions and experience of patients, staff, and clinicians with social needs assessment. Perm J. 2018;22:18-105. doi:10.7812/tpp/18-105.
4. Institute for Healthcare Improvement. Accessed May 3, 2021. http://www.ihi.org/resources/Pages/Tools/Flowchart.aspx