The negative impact of adverse childhood experiences (ACEs) on long-term health outcomes of children should be familiar to most pediatricians. With multiple AAP Policy Statements as recent as last summer and my prior blog discussing this topic, pediatricians have been encouraged to be aware of ACEs and help families provide safe and stable nurturing environments. But how to do that is the challenge. Screening for ACEs has been advocated as one approach and promoted throughout the state of California by their surgeon general and state law.
In this month’s Pediatrics, Loveday et al (10.1542/peds.2021-051884) published a systematic review on the evidence supporting ACEs screening. Sadly, they found very little, as only 4 studies met their criteria. And even more noteworthy, is that the screening trials they reviewed were not specific ACEs screens; they were more general social determinants of health (SDOH) screens (SEEK, WE-CARE, and an IPV intervention) that included ACEs as part of their questions. What the article cannot assess is the benefit of using the ACEs questionnaire as proposed in California. Accompanying the research paper is a commentary (10.1542/peds.2021-054624) from Drs. Lee and Forkey which places ACEs screening in context. I cannot agree more with their conclusion that, “Screening without appropriate office-based guidance and supported linkages to community resources appears to have limited evidence of benefit as noted in Loveday and colleagues’ review, and may be potentially harmful; yet pediatricians can use a resilience-informed team-based and community approach to assist families in navigating their most pressing health and social needs.”
The bottom line is, as pediatricians, we must be aware of the context surrounding our patients. This includes awareness of potential barriers to optimal health in the community (like poverty), in families (like domestic violence), and in trauma (like ACEs). Using a SDOH screening tool to better understand the context of each patient and family does have value, especially when you can couple positive screens with connections to resources in the office or community. And while using the ACEs questions for everyone doesn’t have strong evidence of utility yet, providing trauma-informed care on an individual and a child health system is important, and helping children and parents understand the impact ACEs might have on their health may be of benefit. But even more importantly, we need to advocate for the resources and policies that allow all families to be able to provide safe and stable nurturing environments for all children.