Problem: Screening for Adverse Childhood Experiences (ACES) in pediatrics is an opportunity to address toxic stress. ACE risk factors are categorized into three areas: abuse, neglect, and household dysfunction. These directly relate, in a dose-response manner, to poor health outcomes. ACEs effects are mediated via toxic stress which leads to delays in cognitive, social-emotional and physical development in children and, as adults, to the risk of chronic disease and premature death. Most children reach their highest ACE score by age 12. Identifying scores early can support efforts to mitigate toxic stress and build resilience. They do not discriminate and effect every race and socioeconomic status. Given their nature, discussing ACEs and implementing screening can be challenging for providers. Outside support is necessary for a successful initiative. Goal: To bring universal ACEs screening to Long Island and improve provider confidence when discussing the purpose of the ACE-Q and the effects of toxic stress. Methods: Docs for Tots (DFT) incorporated a learning collaborative (LC) into their proven technical assistance and quality improvement model. An LC utilizes virtual communication, allowing them to cover a larger geographic area and bring in national experts from the Center for Youth Wellness (CYW). Four unique offices were selected: an academic institution, a private practice, a federally qualified health center (FQHC), and a physician group, providing a wide range of patients across racial and socioeconomic lines, as well as varied levels of resources and expertise. DFT served as the discussion and education facilitator on conference calls, first bi-monthly, then monthly. Monthly chart reviews provided insight on how to improve processes at each office. Providers and staff were educated on ACEs and toxic stress, discussing ACEs with patients and families, and scoring and interpreting results. The ACE-Q screening tool from CYW asks parents to identify the number of ACEs their child has experienced, not identify specific items. This can be concerning and confusing. Clinic 1 requested a patient handout explaining ACEs and the ACE-Q. DFT turned to the LC to create a cover sheet to use following their first month of screening. Prior to implementation, Clinic 3 requested assistance explaining toxic stress and the ACE-Q, so DFT and providers worked together to make and train staff on a visual aid explaining toxic stress. Conclusions: Discussing ACEs is challenging for everyone due to the inclusion of abuse and neglect. The key is to normalize the discussion around ACEs and ensure providers know how to talk about ACEs and toxic stress without judgement. Ongoing TA provides the opportunity to improve office materials and understanding of the initiative in real time, thereby improving and maintaining high screening rates.

ACEs LC Screening Rates

Figure 1

Screening rates increased after implementing QI changes at clinics one and three. Clinic 1 began screening in month 2, Clinic 3 began screening at the end of month 3, data only collected for month 4.

Figure 1

Screening rates increased after implementing QI changes at clinics one and three. Clinic 1 began screening in month 2, Clinic 3 began screening at the end of month 3, data only collected for month 4.

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